Esophagus

Question 1

Endoscopic findings of esophageal stricture is predictive of what?

Answer 1

shortened esophagus

Question 2

Barret’s esophagus treatment if:

1. No dysplasia?
2. Low grade dysplasia
3. High grade dysplasia or intramucosal cancer?

Answer 2

1. No dysplasia - treat like GERD. Try PPI’s first. If asymptomatic with medical management then no surgery
   If symptomatic despite medical management then consider anti-reflux surgery (Nissen)
   Surgery or PPI does not decrease risk of cancer due to Barret’s esophagus
2. Increased surveillance, q6 months with 4 quadrant biopsies every 2 cm for 2 years. If negative after then can do less frequent, q3yr?
3. EMR + ablation

Question 3

Esophageal Cancer
Where is it most common?
Types more common in AA vs white men?
Staging?

Answer 3

Greater in Asia.

SCC of esophagus incidence has been stable and is still more common than adenocarcinoma overall but adeno incidence has been increasing.

SCC predominates in black men (not adenocarcinoma)

Adenocarcinoma is more common in white men

Staging 
T1a - mucosa 
T1b - into submucosa
T2 - into muscularis propia 
T3 - into adventitia 

N1 - 1-2 LNs
N2 - 3-6 LNs
N3 - 7 or more LNs

Question 4

Treatment for for upper GI bleeding due to Mallory-weiss tears

Answer 4

if no active extravasation on initial endoscopy then no follow-up endoscopy needed

Question 5

Treatment for esophageal tears?

Answer 5

primary repair with buttress (patch) is okay but not okay to only buttress like a duodenal ulcer

Question 6

For esophagitis, mucosal break classification:

Answer 6

Class A - one or more breaks < 5mm that does not extend between the tops of two mucosal folds

Class B - one or more breaks > 5mm that does not extend between the tops of two mucosal folds

Class C - one or more breaks continuous between the tops of two or more mucosal folds but < 75% around

Class D - one or more breaks continuous between the tops of two or more mucosal folds but > 75% around

Question 7

What are 2 ways to monitor Esophageal pH?

Answer 7

Wireless monitoring via Bravo sensor placed 5 cm from LES

Nasopharyngeal catheter - more sensing points but only 24 hours

Question 8

Esophageal impedance testing can detect what?

Answer 8

alkaline / bile reflux

Question 9

American Society for Gastrointestinal Endoscopy recommends endoscopic surveillance _____ years after the caustic ingestion.

Answer 9

15 to 20 years

Question 10

Massive hemoptysis due to esophagus, variceal bleeding:
Mortality?
Treatment?

Answer 10

Mortality 20%

Large bore IV’s
Transfusion - goal Hct 25-30%, over resuscitating can worsen portal hyeprtension
Intubation, correct coagulopathy, Start vasopressin and nitroglycerin

EGD and banding
If bleeding controlled then consider surgical shunt or TIPS
If not controlled then Blakemore or Minnesota tube
Blakemore - distal port for suctioning GI luminal contents
Minnesota - distal port + proximal port (suctioning secretions

Question 11

Cervical esophagus access:

Answer 11

Left neck incision

Platysma is entered and strap muscles are released.

Stay anterior to SCM

Retract SM, IJV and CCA laterally

May encounter middle thyroid artery, can ligate

Beware the recurrent laryngeal nerve in the tracheosophageal groove

Question 12

For children, the _____ is the most commonly used organ for esophageal substitution.

MC reason for esophageal replacement in kids is what?

2nd MC reason in kids is what?

Answer 12

Colon.

A long gap esophageal atresia.

Caustic stricture

Question 13

How to treat contained esophageal perforations?

Answer 13

Treated non-operatively - give abx

Question 14

Effects on LES tone:

What increases tone?

Decreases tone?

Answer 14

Increases tone
Alpha agonists and beta-blockers
Gastrin and motilin

Decrease tone
Alpha blocker and beta agonists decrease tone
Estrogen and progesterone
Glucagon, CCK, secretin, somatostatin,

Question 15

Esophageal manometry findings:
Normal UES resting pressure?
Normal LES resting pressure?
Pressures when swallowing?

Abnormal findings:
1. Normal amplitude, normal contractions, high LES pressure = ?

2. Low amplitude, simultaneous contractions, high LES = ?
3. Low amplitude, simultaneous, normal or low LES = ?
4. Low amplitude, non-transmitted contractions, normal LES = ?
5. High amplitude, long contractions, normal LES = ?

Answer 15

Normal UES resting pressure is 50-70mmHg

Normal LES resting pressure is 10-20mmHg

Pressures when swallowing approach 0mmHg

Abnormal findings:
1. Hypertensive LES

2. Achalasia
3. Scleroderma (treat the scleroderma first)
4. Ineffective esophagus motility
5. Nut-cracker esophagus
   Can have pressure > 180mmHg
   Tx with Diltiazem

Question 16

Transthoracic heller myotomy

steps

Answer 16

Position patient right lateral decubitus

Left thoracotomy at the level of 7th intercostal space. Ligate left inferior pulmonary ligament to mobilize left lung.

Retract the lung medially and cephalad.  Incise the mediastinal pleura.  Encircle the esophagus with a penrose drain.  Identify both vagus nerves.  Perform the esophagomyotomy.  This procedure is often used for DES (diffuse esophageal spasm) as the length required for myotomy is longer than what can be accessed via an abdominal approach.

Question 17

How to diagnose suspected foreign body

Answer 17

XR then endoscopy

Question 18

Zenker’s diverticulum are due to ______ ?

Type of diverticulum?

Treatment based on size?

Answer 18

Tight cricopharyngeal muscle

Pulsion type of diverticulum.
NOT a true diverticulum.

< 2cm can just do myotomy through left neck incision

> 5cm may need to resect

For diverticulum > 3cm endoscopic and surgical results are the same

Question 19

Need __________ with esophagectomies?

Answer 19

Pyloromyotomy

Question 20

Transhiatal esophagectomy steps

Answer 20

Starting with a laparotomy, the liver is mobilized and retracted laterally.  The phrenoesophageal ligament is then taken down and the esophagus mobilized at the hiatus.  The short gastric vessels are ligated.  Care must be taken to preserve the right gastroepiploic artery as this will serve as the blood supply for the conduit. The pars flaccida is then taken down and the left gastric artery ligated.  The vagus nerves are then ligated. The esophagus is then mobilized.  The distal third of the dissection may be done under direct visualization, while the proximal two-thirds must be done bluntly.  Only a limited and blind thoracic lymphadenectomy is able to be performed. A left cervical incision is made along the border of the sternocleidomastoid.  The carotid sheath is retracted laterally.  The cervical esophagus is then isolated.  After completion of mobilization of the entire esophagus, it is ligated in the neck and brought through the laparotomy incision.  The stomach is divided, usually taking a portion of the lesser curvature with it. The gastric conduit is then passed through the chest and a cervical anastomosis is performed.

Question 21

Ivor-Lewis esophagectomy

Answer 21

Upper abdominal incision and right thoracotomy

Thoracic anastomosis is performed

Thoracic duct is ligated due to extensive lymphadenectomy

Question 22

Management of suspected Leiomyoma of the esophagus

Answer 22

Not biopsied since biopsy of the lesion would cause scarring and make follow-up resection more difficult.

Correct treatment is excision.

Right thoracotomy for mid-esophagus

Left thoracotomy for distal-esophagus

Question 23

MCC of TEF in adults is _________?

What is 2nd and 3rd?

Answer 23

Malignancy.

Trauma is second and infection is 3rd.