ESOPHAGUS Flashcards
scleroderma of esophagus
Patients with scleroderma have manifestations in many different organ systems.
Esophageal dysmotility
low amplitude,
simultaneous contractions
NORMAL or LOW lower esophageal sphincter (LES) pressures
Treatment centers around treating scleroderma with secondary improvement of the esophageal symptoms.
Achalasia shows similar findings with the difference being achalasia has a high LES pressure Similar to scleroderma, achalasia shows low amplitude, simultaneous contractions.
Leiomyomas treatment
Standard:
Leiomyomas Extramucosal enculeation with subsequent closure of the myotomy
Esophageal resection is used for greater than 8 cm or annular in character.
Non-operative surveillance is used only for asymptomatic patients with a small leiomyoma (<3
cm).
Esophageal pH monitoring
two methods:
Wireless pH monitoring
or
by an intraluminal tube with nasopharyngeal catheter.
With wireless monitoring, a single Bravo pH probe is placed 5 cm above the lower esophageal sphincter (LES) and 48 hours of measurements are obtained.
Patients indicate when they experience symptoms as well as their change in position.
Nasopharygeal catheters measure pH for only 24 hours, however, and are considered to be more accurate due to the presence of multiple pH probes along the catheter allowing for larger sampling of pH changes.
Esophageal acid exposure may be physiologic, therefore, measurements include percent total time of pH <4 while upright, supine and overall.
Also the number and duration of each episode are monitored.
A composite score (DeMeester) is calculated based on these parameters. A score greater than 14.72 (95th percentile) is considered abnormal.
Esophageal impedance is an adjunct (does not measure pH). A low voltage current is applied to multiple electrodes within the probe which determine the presence of liquid, food bolus or esophageal tissue via impedance.
With multiple electrodes along a probe, direction of bolus transport may also be determined. This allows for detection of non-acid (bile) reflux and may be used to determine reflux even with the presence of PPIs.
Belsey Mark IV
done through left thoracotomy
continued symptoms of GERD post Nissen now with shortened esophagus
Advantages of the Belsey Mark IV include
the ability to free up the esophagus,
all the way to the level of the aortic arch.
tension-free return of the terminal esophagus to the abdomen is especially important when the esophagus has been shortened by transmural esophagitis.
Also, surgery in an obese patient is more easily accomplished through the chest.
direct mediastinal approach when it is filled with fibrous tissue owing to previous esophageal surgery and more than 75% of patients retain the capacity for normal swallowing, belching and vomiting.
Bottom Line: The Belsey Mark IV technique is often used to treat complications of laparoscopic fundoplications. It is a wise choice to use in the patient with a shortened esophagus, the obese patient, and/or the patient with coexisting disease in the left chest wall, lung or upper abdomen.
what is the maximum depth of invasion on EUS in esophageal cancer and still go for cure
endoscopic ultrasound indicates that the tumor has not invaded adjacent organs,
and/or
fewer than five enlarged lymph nodes are imaged.
This means that if tumor has invaded outside of the esophagus perforated and there are 4 positive nodes you can still go for cure!!
The main purpose of cross-sectional imaging studies in patients with known esophageal carcinoma is to stage the disease as accurately as possible to determine which patients may be suitable candidates for surgical resection.
Computed tomography (CT) (choice D) is considered complementary to endoscopy and barium
Treatment of local esophageal carcinoma
roughly divided into those with a high probability of mucosal confined disease (T1)
and
those with possible regional disease (T2-3).
Disease confined to the mucosa (T1a) is unlikely to have systemic involvement and may be treated by resection alone.
Treatment for extension into the submucosa (T1b) is somewhat controversial as there is a significant chance for nodal disease (15-25%), even with a negative EUS.
Many would give chemotherapy in this scenario.
Invasion of the muscularis propria (T2) indicates a high probability of regional disease.
Chemotherapy is usually given.
According to CROSS trial, neoadjuvant chemotherapy with paclitaxel and carboplatin improves five year survival vs surgery alone (47% vs 34%). While 35%-50% of patients will receive a complete clinical response from chemotherapy alone, many will still have viable tumor obtained after resection. For this reason, surgical resection is still recommended after neoadjuvant treatment.
While both esophagectomy and endoscopic mucosal resection (EMR) are considered acceptable options, most centers now perform EMR followed by radiofrequency ablation due to similar outcomes by case-control studies with few complications.
is appropriate for lesions confined to the mucosa (T1a).
Bottom Line: Esophageal adenocarcinoma is treated by EMR for lesions limited to mucosa.
Resectable lesions which invade the muscularis propria require neoadjuvant chemoradiation followed by esophagectomy.
ABS Qualifying Exam Insight: Many questions about malignancy are about chemotherapy indication and options for a more limited resection. Know the stages that dictate changes in treatment.
Barrett’s esophagus occurs where
distal esophagus proximal to the GE junction
Barrett’s esophagus conformational change
secondary to chronic reflux
from squamous to columnar
cells seen with Barrett’s esophagus
On EGD, it has the appearance of
Goblet cells - evil goblins in this case
salmon colored mucosa
inflammation and erosions - of mucosal inflammatio (not full thickness)
Barrett’s esophagus increases the risk of developing
adenocarcinoma;
however the overall risk remains quite low at less than 1% per year.
Schatzki’s ring
narrowing of the esophagus
occurs at the GE junction
comprised of mucosa, submucosa, and connective tissue. NO muscular component to these rings.
Patients often present with symptoms of obstruction following meals and are diagnosed with a barium esophagram performed in the prone position for better visualization.
Treatment is only warranted for symptomatic patients (choice B), and usually consists of serial dilations.
Persistent symptoms are treated with a Nissen fundoplication. Surgical resection is contraindicated (choice D) as this will result in severe strictures.
Bottom Line: Symptomatic Schatzki’s rings that fail to improve with dilations are treated with a Nissen fundoplication.
For more information, see: Sabiston’s Textbook of Surgery, 18th Edition, Chapter 41, Electronic Publication.
mid-esophageal diverticulum
The patient is presenting with a mid-esophageal diverticulum. These are traction diverticulum that involve all layers of the esophageal wall and can be due to inflammation, granulomatous disease, or even cancer. The treatment is with a diverticulectomy and primary closure.
Answer E: Manometry testing is not required for the diagnosis of esophageal diverticulum.
BUT - ruling out cancer is
Zenker’s diverticulum
occur near the cricopharyngeus muscle in an area known as Killian’s triangle. Only the mucosa herniates with a Zenker’s or a distal esophageal diverticulum and these are due to pulsion forces. Pulsion diverticulum will require a myotomy for surgical treatment.
Answer A: Zenker’s diverticulum are found in Killian’s triangle. Answer B: Mid-esophageal diverticulum are due to traction or inflammation.
what distance is considered mid esophagus
20 cm
sophageal adenocarcinoma is known to spread aggressively through the
The correct answer is: A lymphatic channels (choice A).
The likelihood of nodal invasion increases with the depth of the tumor (choice E). For this reason, most tumors that are T2-T4 are treated with neoadjuvant therapy to decrease this disease burden.
T1 tumors extend into the submucosa (choice D) and are treated with surgical resection alone (choice B).
If N1 disease is present, then an en bloc resection is indicated (choice C). Bottom Line: Esophageal adenocarcinoma spreads via submucosal lymphatic
channels.
A zenker’s diverticulum is defined as
blowout of the mucosa on the posterior wall at the transition zone between the hypopharynx and the esophagus (Kilian triangle).
The mucosal herniation occurs through an anatomical weakness near the cricopharyngeus muscle
(most likely due to failure of relaxation of the UPPER esophageal sphincter during swallowing)
It is a false diverticulum.
Normally, at rest, the upper esophageal sphincter (UES) is closed due to tonic contraction.
After swallowing, within milliseconds, the UES relaxes as a result of a transient interruption of the muscle contraction, allowing the passage of the bolus into the upper esophagus.
During this process, the larynx moves forward and upward to facilitate the opening of the relaxed sphincter.
