Esophagus

Question 1

Laparoscopic Anti-reflux surgery

Answer 1

• More cost effective than lifelong medical therapy

- Temporary dysphagia common (not behind 3 months post-op)

Question 2

Hiatal hernia surgery indicated for?

Answer 2

Type II, III, IV (all paraesophageal)

Type I is a sliding and should be controlled with medical management

Question 3

Neoadjuvant therapy for esophageal cancer

Answer 3

• cisplatinum and fluorouracil (5-FU) given concomitantly with 40 to 60 cGy directed at the mediastinum
• T2, T3 or nodal mets
• EUS: Only good test for identifying LN mets

Question 4

Esophagectomy for cancer

Answer 4

• Highgrade dysplasia or cancer
• If patient has cardiac/pulmonary dysfunction, do not do esophagectomy because patient cannot tolerate general anesthesia. Do endoscopic mucosal resection for high grade or stage I instead

Question 5

Collis Gastroplasty

Answer 5

When you can’t do Nissen because sub diaphragmatic portion of esophagus is too short.
- Create vertical incision on top of stomach so you can wrap funds all around the new esophagus

Question 6

Zenker

Answer 6

• AKA “pharyngoesophageal diverticulum”
• MC diverticulum of the esophagus
• At an anatomic weakness in the posterior pharyngeal constrictor muscle just above the cricopharyngeus muscle
• A pulsion-type pseudodiverticulum
• Anatomic weakness + underlying motility disorder
• Symptoms are indications for surgery. Must address motility issue also, therefore diverticulectomy is not good bc it will recur
• cricopharyngeal myotomy is required
• A small diverticulum (

Question 7

The transhiatal esophagectomy

Answer 7

The gastric remnant based on the right gastroepiploic artery is used to reestablish gastrointestinal continuity.

Question 8

Ivor-Lewis esophagectomy

Answer 8

• 2 stage procedure
  1- Laparotomy and mobilization of the stomach,
  2- 10 to 15 days later: right thoracotomy, resection of the esophagus, and esophagastric anastomosis.
• Intracthoracic anastamosis vs. transhiatal esophagectomy which is a cervical anastomosis (If leak occurs, can do a bedside neck drainage)

Question 9

Leiomyoma of esophagus

Answer 9

• MC benign tumor of esophagus
• mid to distal (from cmooth muscle)
• Barium swallow, CT chest/abd, EGD

Question 10

Achalasia

Answer 10

• degeneration or absence of ganglion cells of the Auerbach plexus in the esophagus
• Manometry
• In response to swallowing, abnormal simultaneous contractions occur in the esophageal body instead of normal coordinated peristaltic waves.
• LES pressure increased at rest, fails to relax with swallowing
• Nonsurgical Tx: pharmacotherapy and enodoscopic balloon dilatation; Botulinum neurotoxin injection
• Sx: Heller myotomy: muscles of LES and cardia are cut

Question 11

Esophageal SCC

Answer 11

• RF: smoking, EtOH
• Nitrosamines and other nitrosyl compounds found in smoked meats
• ## achalasia, caustic strictures, Plummer-Vinson syndrome, and tylosis

Question 12

LES tone

Answer 12

– Increase by alpha, gastrin and motilin

– Decrease by beta, cholecystokinin, estrogen, glucagon, progesterone, somatostatin, and secretin

Question 13

Most deleterious esophageal mucosal injury is caused by?

Answer 13

Gastric acid & pepsin

Question 14

Barrett’s Esophagus

Answer 14

– Metaplsia: Squamous to Columnar
– Pre–cursor to Adenocarcinoma
– 4 categories: none, indeterminate, low–grade dysplasia, and high–grade dysplasia (50% will need esophagectomy or Lap. mucosal resection. fundoplication CI because doesn’t cause regression)
– Only need to perform surveillance EGD. No surgery
– Role of H. Pylori not established
– Can do Nissen then PPI and surveillance for low–grade dysplasia (6–10% malignancy risk per year)
– Dysplasia and adenocarcinoma are most common in the gastric mucosa type with intestinal metaplasia

Question 15

Recurrent hiatal hernia diagnostic imaging

Answer 15

UGI

Question 16

Laparoscopic Fundoplication

Answer 16

– Crural dissection, preservation of both vagi (hepatic branch of anterior vagus) – dissect both crura and close posteriorly behind esophagus – Mobilize fundus, divide short gastrics – Finally, a short, loose fundoplication is created by enveloping the lower esophagus with the anterior and posterior walls of the fundus
– MC error: pulling anterior portion of fundus behind esophagus

Question 17

24 hour pH monitoring

Answer 17

– Most sensitive test for GERD (GS). pH

Question 18

MCC esophageal perforation

Answer 18

– iatrogenic (EGD)
– Primary repair making sure to incise the muscularis over the perforation to cover defect – 2 layer closure & buttressed with a flap of pleura or intercostals muscle – chest tube placed & removed until a contrast study done at day 6 or 7 postoperatively demonstrates no leakage.

Question 19

cervical esophagus

Answer 19

– 5cm; C6–T1, curve left down, incision left anterior SCM;

Question 20

MC site of spontaneous perforation

Answer 20

– The lower part of the esophagus is covered only by flimsy mediastinal pleura on the left, and this portion is most commonly the site of spontaneous perforation in Boerhaave syndrome

Question 21

phrenoesophageal ligament

Answer 21

– Fibroelastic membrane, arises from sub diaphragmatic fascia. Lower limit of of this membrane anteriorly is marked by a fat pad corresponding to GE junction

Question 22

Aspiration after transmittal esophagectomy

Answer 22

Serious episodes of aspiration following recurrent nerve injury are caused not only by cricopharyngeal dysfunction, but also inability to close the glottis during swallowing and loss of the protection afforded by effective coughing.

Question 23

Achalasia

Answer 23

– failure of the lower esophageal sphincter to relax
– Dysphagis. Solids then liquids
– Weight loss later in the course
– Barium swallow study

Question 24

Esophagus muscle

Answer 24

– Striated upper halg

– Smooth lower half

Question 25

Lower LES

Answer 25

– Secretin, somatostatin, glucagon, CCK, Ethanol

Question 26

Increasie LES

Answer 26

– Aceytlcholine, gastrin, motilin, bombesin