Esophagus

Question 1

Normal manometry

Answer 1

note relaxation of LES, normal progression of contraction

Question 2

Manometry for achalasia

Answer 2

note no relaxation of LES and aperistalsis

Question 3

Chicago classification of Achalasia

Answer 3

Type II responds best to treatment

Question 4

Success rate for pneumatic dilation for achalasia

Answer 4

60-75% (suitable for patients who are not good surgical candidiates - should also consider Botox)

Question 5

Indications for esophagectomy in patients with Achalasia

Answer 5

Mega esophagus (up to 12 cm diameter), sigmdoi esophagus.

Question 6

Keys to laparoscopic heller myotomy

Answer 6

1. Divide the longintudinal and circular fibers for 6 cm proximal and 2 cm distal to GE junction
2. Separate muscle fibers from mucosa for 180 degrees
3. Leak test
4. Dor fundoplication
5. If perforation, repair mucosa and then muscle and perform contralateral myotomy with Toupet fundoplication.
6. POD 1 esophagram
7. Esophageal diet.

Question 7

Work up for concern for esophageal mass and subsequent diagnosis of esophageal cancer

Answer 7

1. EGD with biopsy
2. CT C/A/P
3. PET CT
4. EUS
5. CBC, BMP, LFTs, INR, albumin
6. Bronchoscopy if airway involvement
7. HER2 testing if adenocarcinoma

Question 8

Definitive treatment for cervical esophageal cancer

Answer 8

(> 5 cm from cricopharyngeus) chemoradiation

Question 9

Esophageal cancers possibly in consideration for upfront esophagectomy (no pre op chemradiation)

Answer 9

1. T1a (deep submucosa)
2. T1b (no high risk features)
   
   1. < 3 cm
   2. no LVI
   3. well differentiated

Question 10

Siewart classification

Answer 10

1. Lower esophageal (5 above to 1 above) - esophageal
2. True cardia (1 above to 2 below) - esophageal
3. Subcardial (2 below to 5 below) - gastric

Question 11

Indications for staging laparoscopy in esophageal cancer

Answer 11

1. T3, N+ Siewart 2 or 3
2. Positive washings without visible peritoneal mets is still M1 disease

Question 12

Esophageal T4a (resectable)

Answer 12

Pericardium, pleura, diphragm

Question 13

Esophageal T4b (unresectable)

Answer 13

heart, great vessls, trachea, liver, spleen, lung, pancreas

Question 14

Esophageal cancer with positive supraclavicular node

Answer 14

Unresectable (also if nonregional LN are positive)

Question 15

Tylosis

Answer 15

AD

Punctate lesions on palms and soles

Risk of esophageal cancer

Question 16

Genetic syndromes associated with Esophageal cancer

Answer 16

1. Tylosis
2. Familial Barrett’s esophagus
3. Bloom syndrome (also get AML)
4. Fanconi anemia (pancytopenia)

Question 17

Surveillance after ER

Answer 17

1. H&P, EGD every 3 months for 1 years, every 6 months for 1 years after, then annually
2. Imaging annually for 3 years

Question 18

Cross trial median OS in chemoradiation plus surgery vs surgery alone

Answer 18

49 months vs 24 months (SCC 81 vs 21; adeno 43 vs 27)(DFS and pCR was also better in chemoradiation group)

Question 19

Hill esophagogastropexy

Answer 19

Used if someone needs anti-reflux procedure, but has had a fundal resection previously.

Lesser curve around the right side of the esophagus with pexy to the arcuate ligament.

Question 20

Mallory Weis tear is usually above or below the GE junction ?

Answer 20

below

Question 21

Malignanent transformation of Barrett’s esophagus

No dysplasia

LGD

HGD

Answer 21

0. 25% per year; annual surveillance
1. 5% per year; surveillance Q3-6mo or RFA ablation

4-8 % per year: RFA ablation or esophagectomy

Question 22

Nutcracker esophagus has amplitudes > than…

and duration > than…

Answer 22

> 180 mm Hg

> 6 sec

Question 23

Modified LA classification for esophagitis

Answer 23