ESOPHAGUS Flashcards
Management of softgel attraction diverticulum
If asymptomatic just observe
They will in empty themselves into the esophageal lumen
Work up of esophageal leiomyoma
No biopsy!
Characteristic CT scanned findings
SUB mucosal on endoscopy
Treatment of esophageal leiomyoma
Right thoracotomy Single long ventilation Lung interior enter mediastinal pleura Blunt exposure of esophagus Longitudinal myotomy ennucleate
Guide placement of NG tube
Introduce air to ensure no leak
Zenker’s diverticulum procedure
Modified Fowler
Aspirate contents of diverticulum with soft red rubber catheter
Semi upright integration
Left ant SCM
Platysma
Strap muscles
Ligate and divide middle thyroid vein
Mobilize and retract sternocleidomastoid and carotid sheath posteriorly
manual Anterior retraction of trachea and thereby protecting recurrent laryngeal nerve in the tracheoesophageal groove
Place 56 French bougie into true lumen
Staple diverticulum at the base
(Diverticulum is cephalad to cricopharyngeal muscle)
My army of the entire length of cricopharyngeal muscle usually 8 cm and is continues down upon the muscle fibers of the esophagus
leave drain
Clears that night
Swallow study then advanced diet and pull drain.
Staging for gastric cancer
EUS
T2 equals neoadjuvant chemo
Palliotive gastrectomy for cancer?
Possibly if it obstructed
D1 nodal resection
periAortic
D2 nodal resection
Goes all the way to hilum
neoadjuvant in esophageal cancer when
chemotherapy and RT
o For any T3, T4, or N1 patient
o 4 weeks of concomitant chemotherapy and RT
(5fu and cisplatinum)
{though new reg is also considered)
followed by a 4 week break
and
then surgery
Special work of studies for esophageal cancer
Pulmonary function test
Cardiac
risk factors for esophageal cancer including:
smoking,
alcohol, Plummer Vinson syndrome, achalasia, Barrett’s, tylosis, lye injury
Tylosis
A genetic disorder
thickening (hyperkeratosis) of the palms and soles,
white patches in the mouth (oral leukoplakia),
very high risk of esophageal cancer.
This is the only genetic syndrome known to predispose to squamous cell carcinoma of the esophagus.
What is the management of a pneumomediastinum found without leak identified
Just watch them
Restudy in a couple days with thin barium again
epiphrenic diverticulum
The operative approach to the is identical to the approach for laparoscopic Heller myotomy. Five ports are placed as described previously. The short gastric vessels are divided, the left and right crus are dissected free from the esophagus, and the esophageal attachments to the mediastinum are dissected as superiorly as possible. Any adhesions between the diverticulum and esophagus are also freed to show the neck of the diverticulum. The vagus nerve, which often is overlying the diverticulum, is protected and retracted. The diverticulum is then resected with an endoscopic linear stapler (3.5-mm staple width) over a 50F lighted bougie to prevent esophageal narrowing. The Heller myotomy and fundoplication are then performed with the technique described previously. The fundoplication may be a Dor or a Toupet. It usually does not reach the area of the diverticulum, and thus, the choice has to do with the myotomy, not with the diverticulectomy. With that in mind, the principles and rationale described previously for patients with achalasia are applied. An esophagram is obtained 2 days after the operation to evaluate for esophageal leak and narrowing. If the esophagram does not show any residual diverticulum or leak, the patient is started on a liquid diet and is discharged the following day on the modified diet described previously
midesophageal diverticula
If the diverticulum is smaller than 2 cm, it can be observed. If patients progress to become symptomatic or if the diverticulum is 2 cm or larger, surgical intervention is indicated. Usually, midesophageal diverticula have a wide mouth and rest close to the spine. Therefore, a diverticulopexy can be performed where the diverticulum is suspended from the thoracic vertebral fascia. In patients with severe chest pain or dysphagia and a documented motor abnormality, a long esophagomyotomy is also indicated.
The treatment of an epiphrenic diverticulum
is similar to that of a midesophageal diverticulum. These types of diverticula also have a wide mouth and rest close to the spine. Small (
Massive G.I. bleed and esophageal varices is found–G.I. is not available to do sclerotherapy
What is your management
Two large bore IV
Typing cross
NG tube and lavage
Octreotide 15 mg bolus over 20 minutes
Repeat lavage to see bleeding has stopped
Minnesota tube
May keep the esophageal balloon inflated at 30 – 40 mmHg for 24 hours and deflated
Still no endoscopist
Tips
If note tips:
Surgery options:
EEA limited esophagectomy with ligation of the left gastric pain
Gastrotomy and perform Intrumentals six relation of varices in the esophagus
Measle cable shunt
Sugiura procedure:
Dysphasia persisting past six – eight weeks
Persistent hiatal hernia
Slipped wrap
fundus slipped behind the wrap
If neither of these are present try dilation and the scopic link
Symptomatic retreat with avoiding carbonated beverages and eating small meals five to 6 times per day
What needs to be included for preop preparation for the patient undergoing a surgical esophagectomy
PFTs
EKG/stress
Bowel prep!
At what level does the thoracic duct cross
Thoracic level IV – five
What artery feeds the transverse colon conduit for surgical esophagectomy
A sending branch of the left colic
When you giving you ad event therapy and what is it for esophageal cancer
Greater than T1 b - this goes into the submucosa - probably neoadjuvant
~T2 - this goes into the muscularis propria - new acumen for sure
Includes XRT!! 5FU Platnum (same as gastric)
Maximum esophageal stage and still go for care
T4 a! N0
T1-3 N
This includes invasion of:
The pleura
Pericardium
Diaphragm
(not D heart, aortic, vertebrae, trachea
36-year-old male with hematemesis EGD shows mucosal tear gastroesophageal junction
This is a Mallory-Weiss tear
Management is nonoperative
