Esophagus Flashcards
Zenker Diverticulum…asymptomatic… < 1cm diverticulum…preferred treatment?
observation
Zenker Diverticulum …symptomatic … < 2cm… treatment options?
- Transoral intraluminal approach
- Diverticulopexy alone OR cricopharyngeal myotomy alone
- Peroral endoscopic myotomy (in high volume center)
Zenker Diverticulum… with 2 to 5 cm diverticulum…. what are your treatment options? which one is preferred?
- cricopharyngeal myotomy and diverticulopexy [preferred]
- Cricopharyngeal myotomy and diverticulectomy
NCCN guidelines - For esophagectomy for esophageal cancer… at least how many Lymph Nodes should you remove?
15 lymph nodes
In early stage esophageal cancer, which cancer has more early lymphatic spread - esophageal adenocarcinoma or esophageal squamous cell?
esophageal squamous cell
Barrett’s esophagus without dysplasia… endoscopic surveillance recommendation?
EGD every 3 to 5 YEARS with 4 quadrant biopsies taken every 2 cm along the esophagus
Barrett’s esophagus with dysplasia… endoscopic surveillance recommendation?
EGD every 3 to 6 MONTHS with 4-quadrant biopsies every 1cm along the length of the segment
Layers of esophagus (inside to outside)
mucosa
submucosa
muscularis propria
NO serosa
What is the esophageal blood supply (cervical vs. thoracic vs. abdominal)
Cervical - inferior thyroid artery
Thoracic - vessels directly off aorta
Abdominal - left gastric/Inferior phrenic arteries
What are the boundaries of Killian triangle?
What’s the significance of Killians triangle?
It is a triangular area in the wall of the pharynx:
- Inferior border: cricopharyngeus muscles
- Superior borders: inferior constrictor muscles
Killian triangle is a weak spot where a pharyngeoesophageal diverticulum (Zenker’s diverticulum) is more likely to occur.
Concern for esophageal perforation…
- Study of choice?
- MC site of perforation?
- MC site of iatrogenic perforation?
- Study of choice: contrast esophagography (use gastrografin [water soluble], followed by dilute barium). IF at ASPIRATION risk, use dilute barium
- MC site of perforation - distal esophagus in left posterolateral aspect, 2-3 cm above GE junction.
- MC iatrogenic location - cricopharyngeus
Treatment for esophageal perforation if its….
isolated cervical esophageal injury?
open neck and drain it
Treatment for esophageal perforation if its….
Stable patient + Thoracic perforation with leakage? [please list primary steps]
Is there anything you would do if its from achalasia?
Primary repair:
- Left thoracotomy
- Debridement of devitalized tissue
- [MUST DO] myotomy to visualize full extent of mucosal injury
- Repair in two layers (inner absorbable, outer permanent)
- Cover with well vascularized tissue (intercostal/omental/latissimus flap)
- Leak test
- Place NGT past repair
- Drain chest
- Close
IF from achalasia - include CONTRALATERAL myotomy
Treatment for esophageal perforation if its….
unstable patient + Thoracic perforation with leakage? [please list primary steps]
exclusion and diversion
- closure of perforation
- Drainage
- Cervical ESOPHAGOSTOMY for proximal diversion
- T tube into defect and drain externally as controlled fistula
- J-tube enteral access
Achalasia
- Cause?
- Manometry findings (3)?
- Sign on imaging?
- Treatment?
- Cause: degenerative loss of nitric oxide producing inhibitory neuron w within LES (autoimmune vs. genetic vs. infectious)
- Manometry findings: 1) high/normal LES basal pressure; 2) incomplete LES relaxation, 3) hypotonic or absent peristalsis
- Imaging: birds beak sign on barium swallow w/ esophageal dilation
- Tx: Heller myotomy with partial fundoplication (6cm on esophagus; 2cm onto stomach)
What is pseudoachalasia?
Achalasia caused by malignancy
Organism causing Chagas disease that can lead to achalasia?
Trypanosoma cruzi
What is the manometry findings for isolated hypertensive LES?
Treatment?
Manometry findings:
- HIGH Basal LES pressure
- Complete LES relaxation
- Normal Peristaslsis
Treatment: Calcium channel blockers, nitrates, Heller myotomy
What is the manometry findings for diffuse esophageal spasm?
Treatment?
Manometry findings:
- Normal LES pressure
- Normal LES relaxation
- High amplitude, uncoordinated esophageal contractions (30>mmHg simultaneous contractions in >10% of swallows)
Treatment: Calcium channel blockers, nitrates. Surgery less effective (needs long segment myotomy in extreme cases)
What is the manometry findings for nutcracker esophagus?
Treatment?
- Normal LES pressure
- Normal relaxation
- High amplitude, coordinated esophageal contractions
Tx: calcium channel blockers, nitrates. Surgery less effective (needs long segment myotomy in extreme cases).
Epiphrenic esophageal diverticula
- Type of diverticulum?
- Associated with?
- Treatment?
- Type: pulsion diverticulum
- Associated with: esophageal motility disorders
- Tx: Diverticulectomy and treatment of underlying motility disorder (may meed heller myotomy)
Thoracic/Mid-esophageal diverticula
- Type of diverticulum?
- Often seen with what diseases?
- When and what treatment?
- Type: Traction diverticulum (a TRUE)
- Seen with inflammatory diseases (TB, malignancy)
- Treatment if symptomatic: VATS diverticulectomy and myotomy
Define Barrett’s esophagus.
What cancer are you at increased risk of getting and how increased is your risk?
Intestinal metaplasia of the lower esophagus from squamous cell to columnar cells
30-60x increased risk for esophageal ADENOCARCINOMA
Barrett’s esophagus with high grade dysplasia on biopsy.
Next step?
repeat biopsy. Confirm with experg GI pathologist.
ENDOSCOPIC MUCOSAL RESECTION if high grade dysplasia confirmed.
TNM for Esophageal cancer?
Where are the important clinical distinctions?
T1a- invades lamina propria/muscularis mucosa
T1b - invades submucosa***
T2 - invades muscularis propria
T3 - invades adventitia
T4a - invades resectable surrounding structures (pleura/pericardium diaphragm)
T4b - invades unresectable surrounding structures (aorta, vertebrae, trachea)
N1: 1-2 nodes
N2: 3-6 nodes
N3: 7+ nodes
M1: +distant mets
