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Oral Boards > Esophagus > Flashcards

Esophagus Flashcards

1
Q

Reflux DDx?

A

DES, Motility d/o, Reflux, PES, HH

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2
Q

Reflux Hx?

A

ask about heartburn. regurgitation of food or dysphagia, NSAID, H.Pyori, ETOH, Smoking

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3
Q

Reflux work up?

A

imaging- swallow r/o HH, tic, tumor
Studies-
EGD doc barrets
Manometry r/o motility d/o when considering Nissen
24 hr ph probe ph15 = reflux For patients without erosive dz and atypical sx in which surgery is being considered

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4
Q

reflux treatment?
PPI vs H2 blocker mech?
Surgery indications?

A

Medical Management
Antacids, H2 Blockers (reversible inhibit histamine receptor decreasing acid production) PPI (K/ Na channel irreversible), Carafate (Ulcers), Small meals
r/o H. Pylori test if you see an ulcer or gastritis
Indications for Nissen
heartburn and regurgitation add esophagitis
failed meds for 6 mo, dc meds,
complications
Barrets, stricture, HH x 6mo

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5
Q

Laparoscopic fundoplication description?

A

position supine c SCDs, periop abx in mod lithotomy and reverse Tberg
open hasson 10mm, L mid abdomen 1/3 b/w xiphoid and umbilicus, camera port
5mm port level of umbilicus left of midline to retract stomach
10mm port in left midclavicular line at costal margin (right hand working)
5mm subxiphoid port right of midline (left hand working)
5 mm subcostal port in r mid clavicular line for liver retraction
divide gastrohepatic ligament at pars flacida c harmonic, divide to level of medial border of right crus
divide phrenoesophageal ligament of left crus
divide gastrophrenic ligament to mobilize cardia
develop plane b/w esophagus and right crus bluntly (ID post vagus) and sweep mediastinal tissue away from esophagus
contine dissection of right crus until junction of left crus is seen at base
mobilize off left crus sparing (anterior vagus)
mobilize gastric fundus- take short gastrics with harmonic take posterior vessels as well . mobilize from inferior pole of spleen to angle of His
determine length of intraabdominal esophagus, need at least 3 cm if not may need collie gastroplasty
place babcock from R to L in retroesophageal space and grasp funds and pull to right of Esophagus
check for tension- if released and does not retract back its ok then
shoeshine manuever to make sure not twisted
reappx crura in retroesophageal space using 2-0 ethibond (don’t forget)
have anesthesia place bougie 50F
2cm wrap with 2-0 ethibond and to grab esophageal muscle to prevent slip, remove dilator
close

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6
Q

nissen complication and treatment

A

nissen strictures dilation q6 wks x3 after a barium swallow
Gas bloat. - avoid carbonation

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7
Q

Barrets definition

A

Definition-

Can see on EGD metaplasia (columnar epithelium) of at least 3 cm of the distal esophagus, salmon color on EGD

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8
Q

when to treat Barrets with surgery?

A

indication for nissen

only to control symptoms doesn’t prevent dev cancer

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9
Q

Patient with stricture preop?

A

Note- strictures need to be dilated prior to nissen

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10
Q

Barrets EGD?

A

When seen on EGJ need to do 4 quadrant biopsy at 2 cm intervals from 1 cm below EGJ to 1 cm above metaplasia. Need to r/o dysplasia

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11
Q

What % of Barrets develop into LGD and HGD?

A

Note- 10% dev LGD, 2 % dev HGD

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12
Q

Barrets Surveillance? LGD?

A

Barrets w/o dysplasia q2/yr,

LGD q1yr until no dysplasia

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13
Q

Barrets Treatment?
LGD tx?
HGD tx?

A

Barrets without symptoms then just meds
Barrets with symptoms or not responding to meds then Nissen
LGD treat with meds unless symptomatic then needs nissens surv q6 x2 yrs and if dz is stable q 3yrs
HGD (THE) (should be confirmed by two pathologist) 33% have associated cancer at time of dx
photodynamic ablation, endoscopic mucosal ablation, endoscopic laser ablation
esophagectomy
HGD
un-dilatable stricture
Perforation of Barrets esophagus
Burnt out esophagus
develop cancer

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14
Q

Perforated Barrets or bleeding Barrets?

A

Complication
emergent cases of perforated Barrets or bleeding Barrets after failed attempts of controlling need segmental esophagectomy
They need endoscopic follow up afterwards

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15
Q

Motility disorder DDx, HX and PE?

A

Hx - ask about heartburn. regurgitation of food or dysphagia, NSAID, H.Pyori , smoking ETOH
DDx- PNA, Cardiac w/u
gurguling in neck = tic needs a myotomy

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16
Q

Acalasia sx Ddx, causes, manometry findings?

A

Acalasia= regurg, dysphagia, odynophagia weight loss progressive symptoms
dysphagia to solids and liquids regurgitation of undigested foods
DDx- dysmotility, spasm, peptic stricture, zenkers, diverticulum
neural degeneration dorsal motor myenteric plexus lose vagal innervation
megaesophagus need to r/o malignancy and achalasia
barium swallow -birds beak
esophageal manometry - Achalasia -aperistaltic body with incomplete or absent relaxation of LES (>30mmHg)
no scope for tics, ok for achalasia cuz you need to r/o malignancy

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17
Q

Achalasia treatments?

A

Meds- CCB, Nitrates, cause smooth muscle relaxation and decrease LES
short lived effectiveness and have s/e
should be used only to temporize or for those who are poor candidates for surgery
Botox- endoscopically can improve sx only last transhiatal esophagectomy
balance b/w relieving obstruction and not worsening GERD

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18
Q

Achalasia surgery description?

A

Laparoscopic Heller Myotomy c Dor Fundiplication (reduces reflux)
NGT to remove large amounts of indigestive food, prevent aspiration
position supine c SCDs, periop abx in mod lithotomy and reverse Tberg
open hasson 10mm, L mid abdomen 1/3 b/w xiphoid and umbilicus, camera port
5mm port level of umbilicus left of midline to retract stomach
10mm port in left midclavicular line at costal margin (right hand working)
5mm subxiphoid port right of midline (left hand working)
5 mm subcostal port in r mid clavicular line for liver retraction
retract left lateral segment of liver
Dissect the upper 1/3 of the fundus taking the short gastrics along the upper portion of the greater curvature with harmonic scalpel in preparation for anterior fundoplication
Expose the GE junction by beginning on the lesser curvature and continue obliquely to the angle of HIS. The gastroesophageal fat pad is then dissected from right to left gradually rolling the anterior vagus to the right.
Divide any venous branches with harmonic scalpel
Clear the GE junction for 6-9 cm for myotomy
Perform myotomy by initially using hook cautery to mark the muscular layer. Grasp the 2 sides and gently apply traction in order to split the esophageal muscle fibers (longitudinal and circular until mucosa visible).
Extend myotomy 4-5 cm proximal until muscles thin out and alleast 2-3 cm only stomach (don’t forget this!). Separate fibers for about 40-50% circumference.
Test myotomy to confirm absence of mucosal violation with leak test and irrigation. If leak open and repair with 4-0 vicryl. And perform open myotomy on opposite (posterior) side.
Anterior Partial Fundo (Dor) Since fundus was mobilized, lay anterior fundus over myotomy and suture L fundus to L crus and cu t edge o f myotomy and suture R fundus to R crus and cut edge of myotomy. Use 2-0 silk.

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19
Q

Perforated nissen?
Megaesophagus?
Perforate esophagus during nissen?

A

Complications
If perforated- need to NPO, TPN, Primary repair and buttress
Megaesophagus - need to r/o distal esophageal cancer vs achalasia
perforate - esophagus while performing myotomy- repair with absorbable suture and cover c wrap

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20
Q

Hiatal hernia Hx and PE?

A

Hx-post prandial fullness not related to type of food, epigastric pain with some degree of dysphagia, vomiting, anemia (ulcer need to EGD prior and r/o barrets) and manometry, swallow check GE jxn
PE- listen to chest for BS

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21
Q

Hiatal hernia classifications?

A

Classifications
Type 1- Sliding, EGJ is in chest (same tx as GERD)
Type 2- Paraesophageal hernia, EGJ is in abdomen
all need surgery to avoid gastric volvulus, ulceration, anemia
Type 3- (Advanced type 2) shortened esophagus and EGJ is in the chest
Type 4- large where additional organ involved

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22
Q

Complications of hiatal hernia?

A

T 2 and 3 30% risk of perf, strangulation, hemorrhage

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23
Q

Hiatal hernia work up?

A

CBC r/o anemia, H.pylori
CXR (gas behind cardiac silhouette), UGIS
EGD bx and brushings- r/o Barrets, check for ulcerations and biopsy em
Esophageal manometry if considering surgery (partial fundo)

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24
Q

Hiatal hernia treatment?

A

Medical management- H2 blockers, PPI, H.Pylori, avoid things that lower LES Chocolate, peppermint
If acute obstruction gastric valvulus then ngt
Surgery

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25
Q

Hiatal hernia surgery description?

A

Surgery
laparoscopic for HH is much more difficult than for regular reflux so any difficulty of bleeding, difficult anatomy convert to open
may consider thoracic approach if prior surgeries or shortened esophagus
reduce sac divide all the phrenoesophageal ligaments to avoid recurrence
close diaphragmatic defect (needs to be tension free crural approximation)
try primary repair first and if isn’t possible then a absorbable mesh (avoid erosion into esophagus)
anchor lesser curve to arcuate ligament
+- nissen floppy, (avoiding the common complication of reflux after surgery)
collis gastroplasty if needed usually for T3 (through the left chest 2/2 shortened esophagus)
60 french

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26
Q

Hiatal hernia post op? and complications?

A

post op
diet really slow, clears, full, soft, slippery then regular weeks
Comp
if tachy or sob get a swallow to r/o leak
too tight of a fundoplication, or excessive tension -> reoperate

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27
Q

Diffuse esophageal spasm H&P and imaging and treatment?

A

H&P- Intermittent CP with negative cardiac w/u.
Imaging: Barium Swallow-corkscrew esophagus
Treatment: Medical- nitrates, calcium channel blockers.

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28
Q

Zenkers definition?

A

Zenkers-lower pharyngeal constrictor is contracting against unyielding cricopharnygeus muscle (problem) causing mucosal out pouching Killings triangle (Cervical diverticulum) usually left posterolateral wall

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29
Q

Zenkers H&P?

A

Usually elderly, with upper Dysphagia. regurgitation undigested food, gurgling in neck, sensation of something stuck in throat, halitosis, H/O PNAs
PE- usually uneventful, do a neuro exam to r/o Bulbar Palsy

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30
Q

Zenkers labs and imaging?

A

Labs- nutritional, cardiac enzymes if chest pain
Imaging:
EKG, CXR
Barium Swallow- shows diverticulum. Usually left sided. No need for EGD unless you want to r/o Barrets but should not be the first (high association with HH and GERD)
manometry possible

31
Q

Zenkers treatment options?

A

Treatment
two options staple vs open surgery
endoscopic is an option if diverticulum is 2-5cm
doesn’t remove the diverticulum

32
Q

Zenkers surgery?

A

Diverticulectomy and Crycopharyngeus myotomy
indicated to avoid life threatening respiration insufficiency
preop- pulm, cardiac (check coats, is he on anti platelet) , nutrition for this elderly patient, ABX
I have never done this procedure before but the key aspects are the following
Place NGT. Usually Left cervical incision over anterior border of the SCM at level of cricoid
Retract SCM and carotid sheath laterally
Retract omohyoid medially
Divide middle thyroid vein and retract thyroid medially.
Identify and protect recurrent nerve
Expose esophagus behind trachea by palpation
Identify diverticulum- if cannot find it have anesthesia insufflate air or transilluminate with fiberotpic scope.
Grasp diverticulum and rotate esophagus so posterior aspect is visible.
Put right angle clamp under cricopharyngeus and superficial to mucosa and divide muscle fibers for 3- 5 cm.
If diverticulum doesn’t flatten out transect with TA stapler after placing 40F bougie to prevent narrowing of esophagus.
Place small soft suction drain and close layers.

33
Q 
Zenkers complications?
pharyngeal leak or abscess?
cervical esophagus perf?
RLN injury?
Lymphocele?
Stricture?
A

pharyngeal leak or abscess- (open and drain)
cervical esophagus perforation- (treat conservatively, NPO and broad spectrum ABX ,spit and open and drain any abscess) if contained and not septic
RLN injury- (repair if ID intraoperatively, if found post op generally not repaired for at least 6 mo if sx haven’t improved)
lymphocele
stricture - dilate and if found late may need bx to r/o cancer

34
Q

Epiphrenic w/u and treatment?

A

check for associated d/o GERD (EGD), Achalasia (BS and manometry)
difficult surgery high M&M, reserve for severely symptomatic pts
diverticulectomy and non obstructive fundo and heller if associated motility d/o

35
Q

Caustic injury what do you?

A

ABCs- airway first
if intact gather hx to find out where the perf might be? retrosternal pain? Peritonitis?
crepitus? breath sounds effusions?
labs, CXR, Gastrograffin study first
if no obvious perf then EGD to capture the degree of it 1,2,3rd?
IVF, NPO, ABX

36
Q

Caustic injury first degree treatment?

A

First degree (erythema)
NPO till no sx then start diet slowly
EGD in 3 weeks

37
Q

Caustic injury 2nd and 3rd degree treatment?

A

2nd or 3rd (frank necrosis, ulceration, circ)
NPO, IVF, ABX, suction of saliva
if stable after 5-6 days then clears
Gastrograffin in 3 weeks to r/o strictures and if found then every 3 months
if still stricture after 12 months then esophagectomy
also consider jejunostomy to initially help with feeding for few weeks followed by esophagectomy

38
Q

Indications for surgery for caustic esophageal injury?

A

Indications for Surgery
Sepsis, peritonitis, met acidosis, mediastinitis, free air under diaphragm, med air, crepitant, extravasation, PTX, Pleural effusion, air in stomach wall
intraabdominal perforations approach through abdomen

39
Q

Strictures after caustic injury

A

Strictures-
start weekly dilations increasing in size with 22 F.
if persist then surgery is indicated with resection and gastric pull up
Perforations - see above- may need resection and reconstruction

40
Q

Boarhaaves DDx?

What to do right away?

A 
Life threatening
DDx- iatrogenic, trauma, malignancy, FB, caustic injury, inflammation GERD, infection
dont rush in r/o
acute MI,
aortic dissection
gastric volvulus
perf PUD
ABC!
41
Q

Boarhaaves PE, Labs, Imaging?

A

PE- subq emphysema, vomiting and chest pain (Macklers triad Pathognomonic esophageal perforation)
Labs- EKG, CBC, Renal, Amylase, Lipase, ABG
Image- 3 way film (left pleural effusion and mediastinum crepitus)
if shows above then get gastrograffin swallow
left posterolateral wall
dx- plain radiograph
esophagography CXR AP and lateral view emphysema, pleural effusion, pneumomediastinum, hyrothorax, PTX or sub diaphragmatic air, if normal needs more w/u
CT with oral study of choice! gastrograffin (water soluble rapid absorption after extravasation) then serial dilute barium, barium contrast
labs
some cases EGD confirm diagnosis

42
Q

Goals of treatment for Boarhaaves?

A

Goals of tx

prevent further contantimation, eliminate infection, restore GI tract and establish nutrition

43
Q

What does Boarhaaves surgery depend on?

A

Surgery dependent upon age, health, tissues, pathology
debridement, drainage of pleural spaces, ctrl leak, complete reexpansion of lung, prevent gastric reflux, nutritional support, abx
primary repair with buttressing repair
esophagectomy c immediate versus delayed reconstruction
esophageal exclusion and diversion, T-tube placement and drainage, vs drainage alone
remember scenario can apply to esophageal anastomotic leaks after resection or pull up

44
Q

Patient with a perforated esophagus with in 24 hrs relatively clean with minimal contamination?
Postop?

A

Primary repair c drains
Indication-normal thoracic esophageal perforation
low perforation
right lateral decubitus position
single lung ventilation (helpful if patient can tolerate it)
left thoracotomy 7th rib interspace
once exposed mobilize and the necrotic tissue is debrided careful to viable tissue
vertical esophageal myotomy open longitudinal and circular muscles to fully expose mucosa
two layer closure mucose c vicryl and muscle interrupted silks
reinforce using intercostal muscle, mental onlay graft
NGT placed just above the repair while the closure is submerged in saline, test repair c insufflating air and occlude distal esophagus
then advance NGT into stomach
gastrostomy vs jejunostomy
chest tube
drain
Postop
NPO, NGT until BF returns, start orals,
post op day 10, Swallow before removal of CT

45
Q

Esophagus perforated Presents after 24 hrs if septic and shock and wouldn’t tolerate lengthy procedure

A

place chest tubes,
NGT above the perforation,
NPO, TPN, ABX

46
Q

Esophagus perforated Presents after 24 hrs shock but resuscitated

A

left thoracotomy
debride esophagus- leave it open
ligate the EG junction with 2 ties of #2 chromic
place an NGT above the tear
consider Jejunostomy for feeds vs just TPN
Postop
high volume irrigation with NS through NGT
NPO/TPN.ABX

47
Q

Esophagus perforated Presents after 24hrs is reasonable shape and stable med condition

A 
Resection and diversion
indication-
when primary repair not possible or path is less desirable
megaesophagus from achalasia
carcinoma
caustic ingestion
Exclusion and Diversion
severe devitalized tissue
patient can’t tolerate definitive repair
options-
resect with immediate or delay repair 
Ivor Lewis
exclusion and diversion
closure of perforation
esophageal diversion
pleural drainage (chest tube)
creation of cervical esophagostomy for proximal diversion
drainage by T tube distal to  esophageal perforation (long arm toward stomach, short arm proximal esophagus
T tube brought out separate incision 
place jejunostomy
follow the primary repair if done with esophogram
if leak place pigtail catheter
48
Q

Thoracic Esophageal tears superficial?

A

if superficial c limited mediastinitis, no pleural effusion (only thin collection of contrast parallel to esophageal lumen without significant spillage into mediastinum) and no systemic symptoms
conservative treatment
NGT, NPO, ABX, Close observation

49
Q

Leak after an esophageal repair?

A

Complication-

leak after repair - divert

50
Q

Cervical esophageal perforation treatment

A

cervical leak-
can usually treat conservatively if contained and not showing systemic signs
difficult to find
make an incision in left neck along SCM unless visualized on right
retract SCM and carotid sheath literally, ligate middle thyroid and omohyoid muscle divided and trachea and esophagus retracted medially
bluntly dissect posterior tissue to esophagus to access infectious tracts
myotomy
NGT and close in two layers 4-0 PDS mucosa, 3-0 silk on muscular layer, irrigate, wash, buttress c strap muscles, test,
leave a JP drain loosely close

51
Q

Upper 2/3 chest esophageal perforation? Lower 1/3 rd?

Abdominal esophageal perforation?

A

R posterolateral

Left
take down inferior pulmonary ligament
move lung medially
myotomy prn, debride, irrigate, buttress, test, drains

midline incision
Dor or Thal procedure

52
Q

Esophageal perforation unstable and greater than 24hrs? Not horrible and horrible tissue?

A 
Left thoractomy,
debride esophagus and leave open
ligate GE JXN
NGT above perforation
Chest tube
start irrigation through NGT, NPO, TPN, ABX
not horrible tissue
T tube in chest, then go into abdomen for g tube and feeding J tube
if really bad tissue
Esophageal exclusion
cervical esophagostomy
open gtube, feed jtube, wide drainage
reconstruct esophagus in 6-8 weeks
53
Q

esophageal perforation reasonable and greater than 24 hrs?

A 
L thoractomy
Segmental esophagectomy/ Chest tube
end Esophagostomy, 
Stapled distal esophagus
Gastrostomy tube
54
Q

Describe Stable patient with perforation while dilation for achalasia may attempt primary repair and Belsy Mark IV (240 degree) and thoracic esophagomyotomy.

A

Repair perforation in two layers and dissect esophagus from aortic arch to hiatus.
Ligate esophageal arteries.
Incise phrenoesophageal ligament and respect fat pad to expose esophagus.
perform myotomy from arch to stomach 1 cm.
Belsey Mark- bring GEJ/cardia into chest.
plicate the cardia of the stomach to the thickened esophageal muscle using 2 rows of 2 horizontal mattress sutures.
2 heavy sutures are then used to suture either side of the myotomy to the crura from abdomen to thoracic side of the diaphragm.
return GEJ/Cardia back to abdomen

55
Q

Esophageal cancer ddx, RF, Hx?

A

DDx- Benign stricture, achalasia, motility d/o, Schatzki’s ring (dilatable benign mucosal or submucosal ring at the jxn of the columnar and squamous esophageal mucosa), squamous, adenocarcinoma (usually lower)
RF- Smoking, ETOH
Hx-hemetemesis, weight loss, caustic injury, dysphagia (sticking food)
PE- Virchows node (left supraclavicular) needs FNB to confirm stage 4 ->no surgery

56
Q

Esophageal cancer dx and how to stage?

A 
Dx, Stage, Preoop, Tx
Barium Swallow (need to visualize thoracic esophagus)
EGD c bx and brushings,
Bronch if upper 2/3
EUS c FNA to visualize depth of intramural tumor and paraesphogeal and upper abdominal LN
CT C/A/P
c/s if colon for conduit
PET
57
Q

Esophageal staging

A

(three layers lamina propria, muscularis propria, adventia)
resectable
Stage 1 - T1 submucosa 70% survival
Stage 2a- T2 muscularis propria or T3 adventitia RESECTABLE (IVOR LEWIS) 50% survival
Preop PFTs, Cardiac w/u, nutrition
Unresectable
Stage 2b T1,T2N1- (paraesophageal nodes) - Neoadjuvant
Stage 3 T3N1 or T4 (adj organ) -Neoadj (5FU, cisplatin, mitomycin and XRT 4500 rads) almost like nigro.chemo to downstage and surgery 25% survival
Feeding J-tube

58
Q

what rules out surgery for esophageal cancer?

A 
Hoarseness (RLN involvement)
Horners sx
Malignant Pleural Effusion
Vertebral invasion
Mets dz (FNA) Virchows node
Enlarged Mediastinum or Paratracheal or Celiac nodes
Awy fistula
Most Upper 1/3 esophageal cancers are unresectable
esophageal varices- relative CI
59
Q

How to palliate esophageal cancer?

A

Palliation-
if not a candidate need to reestablish lumen- dilate and stent (metal), feeding tubes, neoaduvant chemo and radiation (5FU and Mitomycin best for Squamous Cell), Adeno less responsive to radiation, laser to restore lumen (5% perforation rate) and if none works then palliative surgery typically for bleeding GEJ tumors requiring transfusions

60
Q

Esophageal cancer preop?

A

Pulmonary -PFT (spirometry and diffusion capacity),
Cardiac -ECHO,
Nutrition- 2 weeks of TPN
no cigarette smoking and use incentive spirometer for minimum
3 weeks and walking program,

61
Q

Esophageal neoadj tx?

A

Neoadjuvant chemoradiation
40% of lesions are missed by EUS
Give preop chemo (cisplatin and 5FU) c External RT (4500 rads) over 35 days has increased survival in most resectable esophageal cancers

62
Q

goals of esophagectomy?

A

achieve complete R0 resection

restore ability to swallow comfortably

63
Q

Describe Ivor lewis?

A

CVP, A line, Double lumen to deflate R lung
prep neck chest abdomen and supine in slight lateral decubitus position
dx lap
ex lap (exploration)
gastric tube, save gastroepiploics R
kocher
pyloroplasty (you eventual cut vagus nerves)
deflate r lung
Right 5th intercostal posterolateral thoracotomy, pleura divided and lung swept medially
thoracic duct and azygous vein ligated
lyphadenectomy,
transect esophagus need 2 cm margins (FROZENS)
intrathoracic anastomosis best if done higher up around azygous vein to avoid reflux
Hand sewn, can do it anywhere single layer prolene running
chest tube
feeding J tube ?
Note- (left thoracoabdominal incision if very distal tumor) Left 6th to 7th ICS thoracotomy preferred for distal esophageal tumor retract lung cephalad

64
Q

Stage 4 discovered during esophagectomy?

A

Stage 4 discovered during operation (omental implant or liver mets don’t proceed with surgery is not justified to palliate dysphagia with such poor survival

65
Q

Postop esophagectomy?

A

postop
Note- no proven benefit of postop chemo radiation
Incentive spirometer, ice chips, NGT for 3 days, diet is then progressed barium swallow on day 7 to doc anastomosis integrity and gastric emptying
nocturnal j tube feeds are administered if oral intake is inadequate
jtube is removed 3-4 weeks

66
Q 
Esophagectomy complications?
If it leaks?
Saliva from chest tube?
total disruption of anastomosis?
chylothorax?
gastric emptying delayed?
tear to trachea during repair?
find a celiac node?
find a mediastinal node?
find a paratracheal LN?
A

if leak and needs resection do not do anastomosis until 6-12 mo to see if esophageal cancer recurs early
Saliva comes out of chest tube or necrosis of gastric tube- drain mediastinum, perform partial and total resection of gastric tube with diversion and J tube
total disruption of anastomosis - cervical esophagostomy, feeding J tube
chylothorax - 50% resolve spontaneously- use chest tube to drain pleural space, parentral nutrition or fat restricted diet c medium chain FA, Octreotide
persistent use lymphangiography or blue dye to localize the leak, persistent may require thoracic duct ligation b/w 8th and 12th rib on right thoracotomy
Gastric emptying - administer erthromycin, inject botox, balloon dilate or stent across
Tear to trachea- pass ETT balloon distal to it, may have to spit sternum to do it, primary repair
Find a celiac, mediastinum or paratracheal LN enlargement send for frozens palliative measures only, radiation, chemo, dilation laser, stent, feeding tube
Note do not place a G tube preop for nutrition will destroy ability to make a conduit

67
Q

Esophageal variceal bleeding DDx?

A

DDx- Other causes of UGIB= PUD, Varices, MW, Diffuse gastritis

68
Q

Esophageal variceal bleeding what to do?

A 
ABCs
resuscitate,
CVP, Foley, T&C, FFP
NGT, lavage
ABX
69
Q

Esophageal variceal bleeding Hx and PE and Labs?

A

Hx- alcohol use
PE-Hepatomegaly, ascites
Labs- LFTs, Lytes, Coags, T&C

70
Q

Esophageal variceal bleeding treatment?

A

Vasopressin 0.04 units/min
Octreotide to decrease portal pressure
Sengstaken-Blakemore tube (needs to be intubated and know how to use it)
BB keep HR below 100, PPI
endoscopy once stabilized
Sclerotherapy, banding (neither will work)
TIPS (good for refractory bleeds and ascites)
hepatic vein accessed through IJV and tunneled to portal vein, coated stent then placed across the tract to decrease portal pressure below 12mmHg
Emergency Portosystemic Shunts
Mesocaval - 8 mm PTFE shunt b/w SMV and IVC
ID MCV and follow distally to SMV (to the right of SMA)
ID the IVC through right colonic mesentery adjacent to duodenum
anastomose to the IVC first the to side of SMV (can use left IJV if contaminated)
Note - this tech doesn’t compromise the potential for future liver txp
Other options- gastric devascularization, gastrostomy and suture ligation

71
Q

Complications of esophageal variceel bleeding?

A

Complication- postop encephalopathy - check CT/MRI to r/o intracranial lesion, start lactulose and rifaximin, reevaluate shunt

72
Q

patient has thrombosed splenic vein and bleeding gastric varices

A

(needs only a splenectomy)

73
Q

patient develops hepatic failure or hepatorenal sx postop

A

same pharm support with dopamine for support measure

consider diuretic

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