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Surgery > Esophagus > Flashcards

Esophagus Flashcards

1
Q

Esophagus develops during gestation

A

4th week

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2
Q

Failure of separation of dorsal foregut from laryngotracheobronchial tree during development

A

TEF fistula

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3
Q

Failure of recanalization of tubular lumen

A

Esophageal atresia, web, stenosis

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4
Q

5-6cm

Extends from cricopharyngeus (C6) to thoracic inlet (T1)

A

Cervical esophagus

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5
Q 
15cm
From TO (T1) to esophagea hiatus of diaphragm (T10)
A

Thoracic esophagus

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6
Q

Short 5-6cm

Absent in patients with hiatal hernia or esophageal shortening from chronic inflammation

A

Abdominal esophagus

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7
Q

Cricopharyngeus (UES) innveration

A

recurrent laryngeal nerve

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8
Q

Functional zone not an anatomic structure

A

LES

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9
Q

Anatomic sites of esophageal narrowing

Most common sites of foreign body impaction

A

Aortic arch
left main stem Bronchus
Cricopharyngeus
Diaphragm

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10
Q

Esophageal wall layers

A

Mucosa
Submucosa
Muscularis

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11
Q

Esoohagus lacks this layer so healing is poor after insult

A

Serosa

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12
Q

Mucosa of esopahgus

A

Non keratinizing SSE

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13
Q

Muscularis layer is divided into

A

Outer longitudinal

Inner circular

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14
Q

Upper 1/3 of esophageal muscle

Lower 2/3

A

striated

smooth

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15
Q

Esophageal landmark by endoscopic distance from incisor

UES

Thoracic inlet

Aortic arch/LMB

LES/GEJ

A

UES 15cm

TI 18cm

Aortic arch/LMB 25cm

LES/GEJ 40cm

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16
Q

Upper 1/3 of esophagus blood supply

A

Inferior thyroid artery

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17
Q

Middle 1/3 esophagus blood supply

A

Descending thoracic aorta

Bronchial arteries

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18
Q

Lower 1/3 esophagus blood supply

A

Left gastric artery

Inferior phrenic artery

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19
Q

Parasympathetic inn to esophagus

A

Vagus nerve

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20
Q

Innervates cricopharyngeus and cervical region

A

recurrent laryngeal nerve

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21
Q

sympathetic fibers for the esophagus arise from

A

Cervical

Thoracic chain ganglia

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22
Q

Contains nonsegmented network of lymphatics

A

Submucosa

Upper 2/3 cephalad drain
Lower caudad

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23
Q

Site of cricopharyngeal weakness

Most common location to find pseudodiverticula or iatrogenic perforation

A

Killian’s triangle

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24
Q

35 y/o female
progressive heartburn, regurgitation of undigested food
barium swallow: bird beak tapering of distal esoph
manometry reveals:

A

Achalasia
Lack of peristalsis
Failure of LES relaxation

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25
Q

Strongest layer of esophagus

Primary importance for surgical repair

A

submucosa

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26
Q

Most common esophageal motility disorder
25-60 years equal distribution
Aperistalsis
Failure of LES relaxation during swallowing
Not a primary disorder but neural degeneration

A

Achalasia

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27
Q

Patients with achalasia present with

A

Progressive dysphagia to solids and liquids
Heartburn, chest paun
Regurgitation of undigested food
Techniques to ameliorate dysphagia by maintaining upright, keeping arms elevated over head, consuming liquid

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28
Q

Achalasia dx: finding

A

Barium swallow: bird beak with dilation if proximal segment

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29
Q

Dx mandatory to rule out obstructing mass or stricture

A

Esophagoscopy

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30
Q

Manometry in achalasia reveals

A

lack of peristalsis and failure LES relxation

resting LES pressure may be normal or high

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31
Q

UES pressure (resting)

A

50-70

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32
Q

UES pressure (bolus)

A

12-14

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33
Q

LES pressure (resting)

A

10-20

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34
Q

Medical management of achalasia

A

Nitrates
Ca ch blocker
Botox

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35
Q

Symptomatic improvement but recurrence is high and risk of perforation at 5% in achalasia repair

A

Pneumatic dilation

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36
Q

Definitive therapy: achalasia

A

Heller myotomy

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37
Q

Long standing severe achalasia

Dilated and non functional esophagus called

A

sigmoid esophagus

tx: esophagectomy

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38
Q

smooth muscle degeneration
LES failure
disordered peristalsis of distal esophagus
esophageal dysmotility in 80% women 40-50
sparing of:

A

Scleroderma

proximal striated

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39
Q

Scleroderma s and sx

A

severe reflux esophagitis
dysphagia
scleroderma (calcinosis, Raynaud, esophageal dysmo, sclerodactyly, skin change, telangiectasia, renal impairment, pulmonary HTN)

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40
Q

Scleroderma dx: finding

A

Barium: dilated esophagus with DISTAL NARROWING

Manometry: dysmotility, aperistalsis of distal esophagus with inc LES

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41
Q

Medical mx of scleroderma

Sx

A

H2 blocker
PPI
HOB elevation

severe with loss of function (fundoplicariob and gastroplasty)

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42
Q

Primary motility disorder
Disordered high amplitude motility
Substernal chest pain radiating to neck or upper ex
Dysphagia with solid and liquid

A

Diffuse esophageal spasm

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43
Q

DES dx: finding

A

Barium: corkscrew esophagus and segmentation

Manometry: frequent, high amp, simultaneous contraction (>/= 20% of 10 simultaneous waveform)
LES normal

44
Q

DES medical mx

A

nitrate
Ca ch blocker
Botox

45
Q

Most common primary motility disorder
Chest pain, dysphagia
Manometry: continuous, high amp (>/=2 SD above normal) peristalsis

A

Nutcracker esophagus

Tx:
Nitrate
Ca ch blocker

Sx: Heller if nonrefractory

46
Q

Found at Killian’s triangle as a result of discoordination of UES relaxation and swallowing

A

Pharyngoesophageal

Zenker’s or Pulsion diverticulum

47
Q

Either pulsion (motility disorder) or traction bec of extra esophageal disease such as cancer or granulomatous infection

A

Middle esophageal diverticula

48
Q

Most commonly by motility d/o, achalasia
Associated with GERD
Within 10cm of GEJ

A

Epiphrenic diverticula

49
Q 
Regurgitation
Halitosis
Aspiration
Chest pain
Dysphagia
Asymptomatic
A

Diverticulum

50
Q

Diverticulum dx

A

Barium
Manometry and pH studies: motility disorder with reflux
Esophagoscopy to rule out mechanical obstruction

51
Q

Sx for diverticula

A

Diverticulectomy with myotomy

Transoral stapled repair

52
Q

Congenital incomplete recanalization but may be acquired
Trans or mucosal and submucosal
Asymptomatic but sometimes dysphagia with solid food
Associated with GERD or IDA (Plummer Vinson)

A

Esophageal web, ring

53
Q

Ring at the GEJ due to GERD

A

Schatzki’s ring

54
Q

Majority of paraesophageal hernias are

A

Type I sliding hiatal

55
Q

Ulcer in sliding hiatal hernia
Lesser curve
Chronic blood loss but rarely with perforation

A

Cameron’s ulcer

56
Q

Borchardt’s triad

A

Severe chest pain
Painful retching without emesis
Inability to pass NGT

incarcerated paraesophageal hernia

57
Q 
Incidenta on upper endoscopy or CT
Bowel sounds on chest
CXR air fluid level in chest
Coiled intrathoracic NGT
Barium swallow is dx
A

Esophageal hernia

58
Q

Chest
Contains GEJ with or without fundus
No volvulus

A

Type I Sliding Hiatal

59
Q

Abdomen
Contains fundus
Organoaxial volvulus

A

Type II rolling paraesophageal

60
Q

Chest
Contains GEJ, fundus, body
Organoaxial and mesoaxial volvulus

A

Type III mixed paraesophageal

61
Q

Chest
Contains GEJ, fundus abdominal organ
Organoaxial or mesoaxial volvulus

A

Type IV mixed paraesophageal

62
Q

Chest pain and paraesophageal hernia is emergency surgery bec of

A

risk of incarceration or strangulation

63
Q

Sliding hernia sx

64
Q

Preferred surgery for chronic hernia

A

Transthoracic

65
Q

Classic teaching for asymptomatic paraesophageal hernia

A

surgical repair for all

66
Q

Paraesophageal hernia repairs must be

A

hernia reduction
Sac excision
Tension free closure of crural defect

67
Q

Longitudinal mucosal tear near GEJ due to repeated retching and high intraluminal pressure

Common in alcoholics

Dx:

A

Mallory Weis tear

Endoscopy

68
Q

Most common cause of esophageal perforation

A

iatrogenic

69
Q

Spontaneous rupture of esophagus resulting from inc intraabdominal pressure against closed glottis during bouts of retching

Perforation by malignancy or infection (TB)

Elderly, delibiltated

A

Esophageal perforation

70
Q 
Severe chest and back pain
Dyspnea
Dull percussion at left chest
Subcutaneous emphysems
Tachycardia
Hypotension
Severe sepsis with instability
A

Esophageal perforation

71
Q

Esoph perforation dx: finding

A

CXR: pneumomediastinum, subcutaneous emphysema, left hydropneumothorax, simple effusion

72
Q

Demostrates leak in esophageal rupture

A

Gastograffin swallow

73
Q

Localizes site of esophageal perforation

A

Esophagoscopy

74
Q

Esophageal rupture tx

A

Broad spec antibiotics
NPO
Fluid resuscitation
Drainage of effusion decompression of pneumothorax

75
Q

Esoph perforation operative therapy:

A

Irrigation and drainage of pleural cavity with primary repair of perforation
Reinforce with intercostal, pleural, pericardial flap

76
Q

Alkali agents cause

A

liquefactive necrosis

77
Q

Acids cause

A

coagulation necrosis

78
Q

Caustic injury mx

A

Dx: flexible esophagoscopy

Assess and secure airway
Do not neutralize agent
Observe if asymptomatic 
Mildd admit NPO for 1-2 days
Full thickness: NPO, TPN, antibiotic

Resect

79
Q

Caustic injury complications

A

stricture

SCC

80
Q

58 y/o,M
Hx of GERD
Endoscopy with biopsy: mild dysplasia

Ff up:

A

Endoscopic surveillance with biopsy every 2 years to monitor dysplasia

81
Q

Premalignant condition by intestinal metaplasia

Primary risk factor: GERD (5-10)

A

Barett’s

82
Q

If severe dysplasia is present perform

A

esophagectomy

83
Q

Resected Barrett’s specimen with severe dysplasia have adenocarcinoma:

84
Q

SCC risk factors

A 
Tobacco
Alcohol
Achalasia
Alkali injury 
Plummer Vinson
85
Q

Dx for SCC

A

Esophagoscopy with biopsy

staging: CT, PET, endoscopic uts

86
Q

Most common esophageal malignancy

A

Adenocarcinoma

87
Q

Adenocarcinoma rf

A

GERD

Barrett’sc

88
Q

Benign lesions and motility disorders appear

A

smooth narrowing

89
Q

Malignant lesions demonstrate

A

irregular apple core

appearance

90
Q

Stage I and IIA sx

T3NO

A

Surgery +/- neoadjuvant

91
Q

Stage IIB, III tx

A

chemoradiation (neoadjuvant) w/

surgery

92
Q

stage IV tx

A

palliation: esophageal stent

93
Q

Most common mortality and morbidity in postesophag

A

Postesohagectomy pneumonia

pulmo complication

94
Q

Incision: laparotomy, neck
Anastomosis: neck

A

Transhiatal

95
Q

Incision: laparotomy, right thoracotomy
anastomosis: chest

A

Ivor-Lewis

96
Q

Incision: left thoracotomy
Anastosmosis: chest

A

Thoracoabdominal

97
Q

Incision: laparotomy, right thoracotomy, neck
Anastomosis: neck

A

three hole

98
Q

Worst outcomes occur in leaks from

A

chest rather neck

99
Q

Majority of patients with esophageal ca present at stage

100
Q

Layer essential in anastomotic repair

101
Q

Most common site of esophageal perforation during endoscopy

After repeated vomiting

A

Killian triangle

Distal thoracic esophagus

102
Q

Order of preference of conduit for esophageal reconstruction

A

Stomach>colon>jejunum

103
Q

45 y/o
progressive dysphagia to solid
first dx?

A

barium swallow

104
Q

determines resectability of esophageal malignancy

A

freedom from distant metastases or distal nodal involvement, ability to resect adjacent involved structure

105
Q

80 y/o
dysphagia with aspiration pneumonia
esophageal study contrast agent of choice?

A

Nonionic H20 soluble agent to minimize risk of pneumonitis

106
Q

Benefits of lap Heller and partial fundoplication vs left thoracoscopic myotomy for achalasia

A

Dec length of stay

Dec post op reflux

Surgery (17 decks)

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