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General Surgery > Esophagus > Flashcards

Esophagus Flashcards

1
Q

Criteria for undergoing endoscopic mucosal resection for Barrett’s

A
  • Focal high-grade dysplasia (HGD) or stage T1a intramucosal lesion <2cm
  • No evidence of lymph node involvement or systemic disease
  • Flat or polypoid lesions without ulceration
  • Lesions without lymphovascular invasions
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2
Q

What is the rate of progression of high-grade dysplasia to esophageal adenocarcinoma?

A

6%

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3
Q

What is the recommended surveillance in patients with low-grade dysplasia? Frequency and technique

A

Frequency: Every 6-12mo
Technique: Four quadrant biopsies every 2cm

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4
Q

What is the recommended surveillance in patients with high-grade dysplasia? Frequency and technique

A

Frequency: Every 3mo (if has never undergone ablative therapy)
Technique: Four quadrant biopsies every 1cm

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5
Q

What is the annual rate of neoplastic transformation in Barrett’s patients?

A

0.5%

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6
Q

What is the cutoff between long- and short-segment Barrett’s?

A

3cm

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7
Q

What percentage of (American) patients with GERD will develop Barrett’s?

A

6-15%

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8
Q

DeMeester score cutoff for physiologic reflux

A

14.72

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9
Q

Bravo probe location placement

A

5cm above LES

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10
Q

Indications for surgical management of GERD: (6)

3 medication-related, 2 endoscopic-related, 1 symptom-related

A
  • Failed optimal medical management
  • Noncompliance with medical therapy
  • Unwillingness to take lifelong medications
  • Severe esophagitis on endoscopy
  • Complications of GERD (benign stricture, Barrett’s, bleeding, ulceration)
  • Extraesophageal atypical reflux symptoms
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11
Q

Absolute contraindications for surgical management of GERD (5)

A
  • Presence of esophageal cancer
  • Barrett’s with high-grade dysplasia
  • Inability to tolerate anesthesia
  • High surgical risk as a result of comorbidities
  • Portal hypertension and uncorrectable coagulopathy
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12
Q

Relative contraindications for surgical management of GERD (2)

A
  • BMI >35 (should get bariatric surgery instead)

- Surgeon experience

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13
Q

Preop evaluation prior to antireflux procedure

A

-Endoscopy (to evaluate for Barrett’s)
-Manometry (to evaluate for disorders of peristalsis)
-Ambulatory pH monitoring (DeMeester >14.72)
PRN:
-UGI series (to evaluate for hiatal hernia)

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14
Q

Which patients do not require ambulatory pH testing?

A
  • Typical reflux symptoms
  • Histologic evidence of esophagitis
  • Good response to PPIs
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15
Q

Nissen fundoplication

A

360 degree wrap

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16
Q

Toupet fundoplication

A

Posterior 270 degree wrap

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17
Q

Dor fundoplication

A

Anterior 90 or 180 degree wrap

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18
Q

Nissen operative procedure (7)

A
  • Division of gastrohepatic ligament (look for replaced L hepatic artery)
  • Identify R crus and open phrenoesophageal ligament
  • Mobilize R crus off esophagus, dissect anteriorly and circumferentially to the L crus (identify anterior vagus nerve)
  • Divide short gastrics for better visualization of the L crus
  • Create posterior window (identify posterior vagus nerve)
  • Close crura with nonabsorbable pledgeted sutures
  • Perform fundoplication over a 56Fr bougie with 2.5cm length of intra-abdominal esophagus.
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19
Q

Surgical management of gas bloat syndrome

A

Convert full fundoplication to a partial wrap

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20
Q

Medical management of gas bloat syndrome

A

Dietary modification (avoidance of carbonated beverages, avoiding aerophagia) and prokinetic agents

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21
Q

Atypical symptoms of GERD (9, 6 pulmonary, 3 non-pulmonary)

A

Pulmonary:

  • Asthma
  • Chronic cough
  • Idiopathic pulmonary fibrosis
  • Recurrent pneumonia
  • Aspiration
  • Recurrent bronchitis

Non-pulmonary

  • Chest pain
  • Hoarseness
  • Dental erosions
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22
Q

Criteria for mechanically defective LES

A 
Pressure (<6mmHg)
Total length (<2cm)
Abdominal length (<1cm)
23
Q

Do typical or atypical symptoms respond better to anti-reflux procedures?

A

Typical

24
Q

Endoscopic finding of “trachealization” of the esophagus

A

Eosinophilic esophagitis

25
Q

Endoscopic finding of salmon-colored mucosa

A

Barrett’s

26
Q

Most common esophageal motility disorder

A

Achalasia

27
Q

Schatzki’s ring type A

A

Narrowing of lower esophagus that can be asymptomatic or cause dysphagia, may be treated endoscopically if symptomatic. Usually due to mucosal overgrowth.

Type A: Above the GEJ

28
Q

Schatzki’s ring type B

A

Narrowing of lower esophagus that can be asymptomatic or cause dysphagia, may be treated endoscopically if symptomatic. Usually due to mucosal overgrowth.

Type B: at the squamocolumnar junction

29
Q

Type II achalasia

A

Achalasia with esophageal compression:

  • mean integrated relaxation pressure > upper limit of normal
  • no normal peristalsis
  • panesophageal pressurization with >20% of swallows
30
Q

Type I achalasia

A

Classic achalasia:

  • mean integrated relaxation pressure > upper limit of normal
  • 100% failed peristalsis
31
Q

Type III achalasia

A
  • Mean integrated relaxation pressure > upper limit of normal
  • no normal peristalsis but with preserved fragments of distal peristalsis or premature spastic contractions with >20% of swallows
32
Q

Typical reflux symptoms (3)

A

Heartburn
Dysphagia
Regurgitation

33
Q

Workup for achalasia (3)

A
  • Esophagram (classic bird’s beak finding)
  • Endoscopy (to rule out pseudoachalasia, especially malignancy)
  • Manometry (gold standard, classically shows failure of LES relaxation and aperistalsis)
34
Q

T/F: Nissen fundoplication is associated with regression of low-grade dysplasia in non-dysplastic Barrett’s esophagus?

A

True, although no data to support that anti-reflux procedures prevent esophageal cancer

35
Q

In what percentage of patients undergoing esophagectomy for high-grade dysplasia are there foci of unsuspected esophageal cancer?

A

25-75%, probably on the lower end

36
Q

Type I hiatal hernia

A

Sliding hiatal hernia

37
Q

Type II hiatal hernia

A

True paraesophageal hernia, rarest of PEHs

38
Q

Type III hiatal hernia

A

Combination of true paraesophageal hernia and sliding hernia. Accounts for majority of paraesophageal hernias.

39
Q

Type IV hiatal hernia

A

Another abdominal organ joins stomach in the hernia sac (spleen, colon, etc). Usually has an abnormal location of the GEJ.

40
Q

Giant paraesophageal hernia

A

30% or more of the stomach is herniated into the thorax

41
Q

Cameron ulcers

A

Gastric ulcers within a paraesophageal hernia from friction between opposing, engorged gastric walls

42
Q

Borchardt’s triad

A

Epigastric/chest pain
Retching without vomiting
Inability to pass an NGT

(Gastric volvulus)

43
Q

T/F: An asymptomatic large paraesophageal hernia in a patient >65yo should be repaired

A

False, the risk of elective repair exceeds any benefit

44
Q

Laimer’s membrane

A

Phrenoesophageal membrane

45
Q

Zenker’s diverticulum definition

A

Posterior outpouching of pharyngeal mucosa just proximal to the cricopharyngeal muscle through Killian’s triangle

46
Q

Zenker’s diverticulum herniates proximal or distal to cricopharyngeus?

A

Proximal

47
Q

Symptoms of Zenker’s diverticulum (5)

A 
Dysphagia
Regurgitation
Cough
Choking episodes
Globus sensation
48
Q

Extent of Heller myotomy for achalasia

A

5cm on anterior esophagus, 2 cm on stomach

49
Q

Los Angeles grade A esophagitis

A

One or several erosions limited to the mucosal folds and no larger than 5mm in extent

50
Q

Los Angeles grade B esophagitis

A

One or several erosions limited to the mucosal folds and larger than 5mm in extent

51
Q

Los Angeles grade C esophagitis

A

Erosion(s) extending over mucosal folds but overall less than 3/4s of the circumference

52
Q

Los Angeles grade D esophagitis

A

Confluent erosions extending over more than 3/4s of the circumference (“circular defects”)

53
Q

What is the surgical approach for a Zenker’s diverticulum?

A

Left cervical incision. (This makes sense since the esophagus bulges to the left on thyroid ultrasounds.)

General Surgery (12 decks)

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