Esophagus and Diaphragm Flashcards

Question

Which test most accurately assess the T stage of esophageal cancer? A. High-resolution CT scan B. Magnetic resonance imaging (MRI) C. Echocardiography D. Endoscopic ultrasonography (EUS) E. Esophagogastroduodenoscopy (EGD)

Answer 1

Answer: D For years, clinical staging, contrast radiography, endoscopy, and CT scanning formed the backbone of esophageal cancer staging. More recently, preoperative decision making is guided by endoscopic ultrasonography (EUS) and positron emission tomography (PET) scanning. EUS provides the most reliable method of determining depth of cancer invasion. In the absence of enlarged LNs, the degree of wall invasion dictates surgical therapy. (See Schwartz 10th ed., p. 1008.)

Answer 2

Answer: B If the tumor invades into the submucosa, without visible LN involvement, most individuals would suggest esophagectomy with LN dissection, as positive nodes can be found in 20 to 25% of those with cancer limited to the mucosa and submucosa. If EUS demonstrates spread through the wall of the esophagus, especially if LNs are enlarged, then induction chemoradiation therapy (neoadjuvant therapy) should be strongly considered. Lastly, when the EUS demonstrates invasion of the trachea, bronchus, aorta, or spine, then surgical resection is rarely indicated. If there is invasion into the pleura (T4a), then surgical resection can be considered in the absence of a malignant effusion. Thus, it can be seen that the therapy of esophageal cancer is largely driven by the findings of an endoscopic ultrasonography. It is difficult to provide modern treatment of esophageal cancer without access to this modality. (See Schwartz 10th ed., p. 1008.)

Answer 3

Answer: B Salvage esophagectomy is the nomenclature applied to esophagectomy performed after failure of definitive radiation and chemotherapy. The most frequent scenario is one in which distant disease (bone, lung, brain, or wide LN metastases) renders the patient nonoperable at initial presentation. Then, systemic chemotherapy, usually with radiation of the primary tumor, destroys a foci of metastasis, as demonstrated by CT and CT-PET, but the primary remains present and symptomatic. Following a period of observation, to make sure no new disease with become evident, salvage esophagectomy is performed, usually with an open two-field approach. Surprisingly, the cure rate of savage esophagectomy is not inconsequential. One in our patients undergoing this operation will be disease free 5 years after, despite the presence of residual cancer in the operative specimen. Because of the dense scarring created by radiation treatment, this procedure is the most technically challenging of all esophagectomy techniques. (See Schwartz 10th ed., p. 1011.)

Answer 4

Answer: B Primary treatment with radiation therapy does not produce results comparable with those obtained with surgery. Currently, the use of radiotherapy is restricted to patients who are not candidates for surgery, and is usually combined with chemotherapy. Radiation alone is used for palliation of dysphagia but the benefit is short-lived, fasting only 2 to 3 months. Furthermore, the length and course of treatment are difficult to justify in patients with a limited life expectancy. Radiation is effective in patients who have hemorrhage from the primary tumor. (See Schwartz 10th ed., p. 1012.)

Answer 5

Answer: C The timing of surgery after chemoradiation induction is generally felt to be optimal between 6 and 8 weeks following the completion of induction therapy. Earlier than this time, active inflammation may make the resection hazardous, and the patients have not had time to recover fully from the chemoradiation. After 8 weeks, edema in the periesophageal tissue starts to turn to scar tissue, making dissection more difficult. With chemoradiation, the complete response rates for adenocarcinoma range from 17 to 24%. No tumor is detected in the specimen after esophagectomy. Patients demonstrating a complete response to chemoradiation have a better survival rate than those without complete response, but distant failure remains common. (See Schwartz 10th ed., pp. 1012–1013.)

Answer 6

Answer: C Despite their slow growth and limited potential for malignant degeneration, leiomyomas should be removed unless there are specific contraindications. The majority can be removed by simple enucleation. If, during removal, the mucosa is inadvertently entered, the defect can be repaired primarily. After tumor removal, the outer esophageal wall should be reconstructed by closure of the muscle layer. The location of the lesion and the extent of surgery required will dictate the approach. Lesions of the proximal and middle esophagus require a right thoracotomy, whereas distal esophageal lesions require a left thoracotomy. Videothoracoscopic and laparoscopic approaches are now frequently used. The mortality rate associated with enucleation is low, and success in relieving the dysphagia is near 100%. Large lesions for those involving the GEJ may require esophageal resection. (See Schwartz 10thed., pp. 1017–1018.)

Answer 7

Answer: C The key to optimum management is early diagnosis. The most favorable outcome is obtained following primary closure of the perforation within 24 hours, resulting in 80 to 90% survival. The most common location for the injury is the left lateral wall of the esophagus, just above the GEJ. To get adequate exposure of the injury, a dissection similar to that described for esophageal myotomy is performed. A flap of stomach is pulled up and the soiled fat pad at the GEJ is removed. The edges of the injury are trimmed and closed primarily. The closure is reinforced with the use of a pleural patch or construction of a Nissen fundopication. (See Schwartz 10th ed., pp. 1018–1019.)

Answer 8

Answer: B Mallory-Weiss tears are characterized by arterial bleeding, which may be massive. Vomiting is not an obligatory factor, as there may be other causes of an acute increase in intraabdominal pressure, such as paroxysmal coughing, seizures, and retching. The diagnosis requires a high index of suspicion, particularly in the patient who develops upper gastrointestinal (GI) bleeding following prolonged vomiting or retching. Upper endoscopy confirms the suspicion by identifying one or more longitudinal fissures in the mucosa of the herniated stomach as the source of bleeding. In the majority of patients, the bleeding will stop spontaneously with nonoperative management. In addition to blood replacement, the stomach should be decompressed and antiemetics administered, as a distended stomach and continued vomiting aggravate further bleeding. A Sengstaken-Blakemore tube will not stop the bleeding, as the pressure in the balloon is not sufficient to overcome arterial pressure. Endoscopic injection of epinephrine may be therapeutic if bleeding does not stop spontaneously. Only occasionally will surgery be required to stop blood loss. The procedure consists of laparotomy and high gastrotomy with oversewing of the linear tear. Mortality is uncommon, and recurrence is rare. (See Schwartz 10th ed., p. 1020.)

Answer 9

Answer: D When a pharyngoesophageal diverticulum is present, localization of the pharyngoesophageal segment is easy. The diverticulum is carefully freed from the overlying areolar tissue to expose its neck, just below the inferior pharyngeal constrictor and above the cricopharyngeus muscle. It can be difficult to identify the cricopharyngeus muscle in the absence of a diverticulum. A benefit of local anesthesia is that the patient can swallow and demonstrate an area of persistent narrowing at the pharyngoesophageal junction. Furthermore, before closing the incision, gelatin can be fed to the patient to ascertain whether the symptoms have been relieved, and to inspect the opening of the previously narrowed pharyngoesophageal segment. Under general anesthesia, and in the absence of a diverticulum, the placement of a nasogastric tube to the level of the manometrically determined cricopharyngeal sphincter helps in localization of the structures. The myotomy is extended cephalad by dividing 1 to 2 cm of inferior constrictor muscle of the pharynx, and caudad by dividing the cricopharyngeal muscle and the cervical esophagus for a length of 4 to 5 cm. If a diverticulum is present and is large enough to persist after a myotomy, it may be sutured in the inverted position to the prevertebra fascia using a permanent suture (ie, diverticulopexy). If the diverticulum is excessively large so that it would be redundant if suspended, or if its walls are thickened, then a diverticulectomy should be performed. This is best performed under general anesthesia by placing a Maloney dilator (48F) in the esophagus, after controlling the neck of the diverticulum and after myotomy. A linear stapler is placed across the neck of the diverticulum and the diverticulum is excised distal to the staple line. The security of this staple line and effectiveness of the myotomy may be tested before hospital discharge with a water soluble contrast esophagogram. Postoperative complications include fistula formation, abscess, hematoma, recurrent nerve paralysis, difficulties in phonation, and Horner syndrome. The incidence of the first two can be reduced by performing a diverticulopexy rather than diverticulectomy. (See Schwartz 10th ed., p. 989.)

Answer 10

Answer: B The classic manometric findings in these patients are characterized by the frequent occurrence of simultaneous waveforms and multipeaked esophageal contractions, which may be of abnormally high amplitude or long duration. Key to the diagnosis of diffuse esophageal spasm (DES) is that there remain some peristaltic wave forms in excess of those seen in achalasia. A criterion of 30% or more peristaltic wave forms out of 10 wet swallows has been used to differentiate DES from vigorous achalasia. However, this figure is arbitrary and often debated. The LES in patients with DES usually shows a normal resting pressure and relaxation on swallowing. A hypertensive sphincter with poor relaxation may also be present. In patients with advanced disease, the radiographic appearance of tertiary contractions appears helical, and has been termed corkscrew esophagus or pseudodiverticulosis. Patients with segmental or DES can compartmentalize the esophagus and develop an epiphrenic or midesophageal diverticulum between two areas of high pressure occurring simultaneously. MANOMETRIC CHARACTERISTICS 1) ACHALASIA - Incomplete lower esophageal sphincter (LES) relaxation (<75% relaxation) - Aperistalsis in the esophageal body - Elevated LES pressure ≤26 mmHg - Increased intraesophageal baseline pressures relative to gastric baseline 2) DIFFUSE ESOPHAGEAL SPASM (DES) - Simultaneous (nonperistaltic contractions) (>20% of wet swallows) - Repetitive and multipeaked contractions - Spontaneous contractions - Intermittent normal peristalsis - Contractions may be of increased amplitude and duration 3) NUTCRACKER ESOPHAGUS - Mean peristaltic amplitude (10 wet swallows) in distal esophagus ≥180mmHg - Increased mean duration of contractions (>7.0 s) - Normal peristaltic sequence 4) HYPERTENSIVE LOWER ESOPHAGEAL SPHINCTER - Elevated LES pressure (≥26 mmHg) - Normal LES relaxation - Normal peristalsis in the esophageal body 5) INEFFECTIVE ESOPHAGEAL MOTILITY DISORDERS - Decreased or absent amplitude of esophageal peristalsis (<30 mmHg) - Increased number of nontransmitted contractions

Answer 11

The esophagus lacks a serosa.

Answer 12

1) Meissner's - Submucosa 2) Auerbach's - Between muscle layers - Responsible for peristalsis

Answer 13

1) Cricopharyngeal muscle - Uppermost narrowing - 1.5cm (narrowest) - Main contributor to the Upper Esophageal Sphincter. 2) Crossing of left mainstem bronchus and aortic arch - 1.6cm 3) Diaphragmatic hiatus - 1.6 to 1.9cm These normal constrictions tend to hold up swallowed foreign objects, and the overlying mucosa is subject to injury by the slow passage of corrosive liquids.

Answer 14

The UES is a high-pressure zone that can reach 90mmHg, and return to average resting pressure of 60mmHg when swallowing.

Answer 15

The LES has a resting pressure zone of 6 to 26mmHg. It is 2-5cm long, and vagus-mediated relaxation occurs during normal food transit. Pressure is increased by GASTRIN and MOTILIN. Pressure is decreased by CCK and SECRETIN.

Answer 16

1) Cervical Esophagus - Inferior thyroid artery 2) Proximal Thoracic Esophagus - Bronchial arteries 3) Distal Thoracic Esophagus - Aortic branches 4) Intraabdominal Esophagus - Ascending branch of the left gastric artery - Inferior phrenic arteries

Answer 17

Esophageal contractions are coordinated in the medulla. 1) Oral - Voluntary - Medial temporal lobes and limbic system 2) Pharyngeal - Involuntary (once initiated, swallowing is an entirely reflex act.) - Larynx closes. 3) Esophageal - Initiated by pharyngeal activity in swallowing. - Primary peristalsis: Becomes involuntary after initiation - Secondary: Triggered by distension/irritation; reflux contents back. - Tertiary: Nonprogressive, nonperistaltic, spasm

Answer 18

Vagus nerves

Answer 19

The cervical esophagus has more direct segmental lymph drainage into the regional nodes. In the upper 2/3 of the esophagus, the lymph flow is mostly cephalad. In the lower 2/3, caudad. In the thoracic portion, the submucosal lymph plexus extends over a long distance in a longitudinal direction before penetrating the muscle layer to enter lymph vessels in the adventitia. Consequently, a primary tumor can extend for a considerable length superiorly or inferiorly in the submucosal plexus. Free tumor cells can follow the submucosal lymphatic plexus in either direction for a long distance before they pass through the muscularis and on into the regional LNs.

Answer 20

Cervical: Drain into the paratracheal and deep cervical LNs. Upper thoracic: Empty mainly into the paratracheal LNs. From the lower esophagus: Into the subcarinal nodes and inferior pulmonary ligament nodes Superior gastric nodes receive lymph not only from the abdominal portion of the esophagus, but also from the adjacent lower thoracic segment.

Answer 21

1. Elevation of tongue 2. Posterior movement of tongue 3. Elevation of soft palate (closing passage between oropharynx and nasopharynx) 4. Elevation of hyoid 5. Elevation of larynx 6. Tilting of epiglottis

Answer 22

1) Glossopharyngeal nerve (CN IX) 2) Superior laryngeal branch of the vagus nerves Once aroused by stimuli entering via these nerves, the swallowing center in the medulla coordinates the complete act of swallowing by discharging impulses through CN V, VII, X, XI and XII, as well as motor neurons of C1 to C3.

Answer 23

1) A mechanically effective LES 2) Efficient esophageal clearance 3) An adequately functioning gastric reservoir

Answer 24

When awake and in the upright position. Reflux occurs in healthy volunteers primarily during transient losses of the gastroesophageal barrier, which may be due to a relaxation of the LES or intragastric pressure overcoming sphincter pressure. Gastric juice can also reflux when a swallow-induced relaxation of the LES is not protected by an oncoming peristaltic wave. The average frequency of these unguarded moments or of transient losses of the gastroesophageal barrier is far less while asleep and in the supine position than while awake and in the upright position. Hence there are fewer opportunities for reflux in the supine position. Second, in the upright position, there is a 12mmHg pressure gradient between the resting, positive intraabdominal pressure measured in the stomach and the most negative intrathoracic pressure measured in the esophagus at midthoracic level. This gradient favors the flow of gastric juice up into the thoracic esophagus when upright. The gradient diminishes in the supine position. Third, LES pressure in normal subjects in significantly higher in the supine position than in the upright position. This is due to the apposition of the hydrostatic pressure of the abdomen to the abdominal portion of the sphincter when supine.

Answer 25

INCREASE LES Pressure: - Alpha-adrenergic neurotransmitters or beta-blockers - Gastrin and motilin - Bombesin, l-enkephalin, substance P - Antacids, cholinergics, agonists, domperidone, metoclopramide, prostaglandin F2 DECREASE LES Pressure: - Alpha-blockers and beta-stimulants - CCK, estrogen, glucagon, progesterone, somatostatin, secretin - Calcitonin gene-related peptide, gastric inhibitory peptide, neuropeptide Y, vasoactive intestinal polypeptide - Anticholinergics, barbiturates, calcium channel blockers, caffeine, diazepam, dopamine, meperidine, prostaglandin E1 and E2, theophylline - Peppermint, chocolate, coffee, ethanol, fat

Answer 26

1) Endoscopic evaluation - First diagnostic test (UGI Endoscopy) in any patient complaining of DYSPHAGIA. - For initial assessment, flexible fiberoptic esophagoscope is the instrument of choice. - GERD: Esophagitis, Barrett's columnar-lined esophagus (CLE-- columnar instead of normal squamous epithelium; histologically, intestinal metaplasia). - Abnormalities of the gastroesophageal flap (via retroflexion): Grading of I-IV - Hiatal hernia: Pouch lined with gastric rugal folds lying 2cm or more above the margins of the diaphragmatic crura, identified by having the patient sniff. A prominent sliding hiatal hernia is associated with increased exposure to gastric juice. - Paraesophageal hernia: Exclude gastric (Cameron's) ulcers or gastritis within the pouch. (Intragastric retroflex or J maneuver) - Esophageal diverticulum: Exclude ulceration or neoplasia. Biopsy is NOT usually performed for submucosal lesions. 2) Radiographic evaluation - Barium swallow: Assess anatomy and motility - Hiatal hernias: Best observed prone because increased intraabdominal pressure promotes displacement of the esophagogastric junction above the diaphragm. - Lower esophageal narrowing (rings, strictures): Fully distended views of the esophagogastric region - Circumferential carcinomas, peptic strictures, large ulcers, hiatal hernias: Full-column technique - Small esophageal neoplasms, mild esophagitis and esophageal varices may be missed, hence the full-column technique must be supplemented by mucosal relief or double-contrast films - Motion recording techniques aid in evaluating functional disorders or pharyngoesophageal and esophageal phases of swallowing. - The radiographic assessment of the esophagus is not complete unless the entire stomach and duodenum have been examined. A gastric/duodenal ulcer, partially obstructing gastric neoplasm, or scarred duodenum and pylorus may contribute to symptoms.

Answer 27

LA Grade A - Mucosal break(s) ≤5 mm, without continuity across mucosal folds LA Grade B - Mucosal break(s) >5 mm, without continuity across mucosal folds LA Grade C - Mucosal break(s) continuous between ≥2 mucosal folds, involving <75% of the esophageal circumference LA Grade D - Mucosal break(s) involving ≥75% of the esophageal circumference When a stricture is observed, the absence of esophagitis above a stricture suggests the possibility of a chemical-induced injury or a neoplasm. The latter should always be considered and is ruled out only by evaluation of a tissue biopsy of adequate size.

Answer 28

Multiple biopsy specimens should be taken in a cephalad direction to confirm the presence of intestinal metaplasia. The earliest sign of malignant degeneration is high grade dysplasia or intramucosal adenocarcinoma. These dysplastic changes have a patchy distribution, so a minimum of 4 biopsy samples spaced 2cm apart should be taken from Barret's lined portion of the esophagus. Tumors occur in an area of specialized columnar epithelium near the squamocolumnar junction in 85% of patients, and within 2cm of the squamocolumnar junction in virtually all patients.

Answer 29

Have the patient swallow a barium-impregnated marshmallow, a barium-soaked piece of bread, or a hamburger mixed with barium. This may bring out a functional disturbance in esophageal transport that can be missed when liquid barium is used.

Answer 30

1) Esophageal motility study (EMS) - Motor function and sphincters are evaluated - Dysphagia, odynophagia, noncardiac chest pain, and when the barium swallow/endoscopy does not show a clear structural abnormality. - Confirms dx of primary esophageal motility disorders (achalasia, DES, nutcracker esophagus, hypertensive LES). - Confirms dx of motility disorders secondary to systemic disease (scleroderma, dermatomyositis, polymyositis, mixed connective tissue disease). - GERD: Mechanically defective LES, evaluate esophageal peristalsis and contraction amplitude. - A rise in pressure above the gastric baseline is the beginning of the LES. 2) High-Resolution Manometry - Multiple circumferential recording sites are used to create a "map" of the esophagus and its sphincters. - LES is a high-pressure zone that should relax at the inception of swallowing, and contract after the water or solid bolus passes through the LES. - May detect overlooked focal motor abnormalities, predict bolus propagation and measure pressure gradients. 3) Esophageal Impedance - Intraluminal electrical impedance catheter is used to measure GI function. - Impedance: ratio of voltage to current, and is a measure of the electrical conductivity of a hollow organ and its contents. - Intraluminal electrical impedance is inversely proportional to the electrical conductivity of the luminal contents and the cross-sectional area of the lumen. - Air has very low electrical conductivity, and therefore has high impedance. - Selectively used for dx of GERD. (24h pH monitoring has limitations-- insensitive to higher pH values, can only detect abnormal acid reflux at pH <4, which is altered in those taking PPIs. 4) Esophageal Transit Scintigraphy - Esophageal transit of a 10mL water bolus containing technetium-99m sulfur colloid can be recorded with a gamma camera. Using this technique, delayed bolus transit has been shown in patients with a variety of esophageal motor disorders, including achalasia, scleroderma, DES, and nutcracker esophagus. 5) Video and Cineradiography - Allows re-evaluation by reviewing the studies at various speeds. - More useful than manometry in evaluating the pharyngeal phase of swallowing. - Manofluorography: Simultaneous computerized capture of videofluoroscopic images and manometric tracings (for complex functional abnormalities).

Answer 31

The respiratory inversion point is identified when the positive excursions in the abdominal cavity that occur with breathing change to negative deflections in the thorax. This serves as a reference point at which the amplitude of the LES pressure and the length of the sphincter exposed to abdominal pressure are measured. As the pressure-sensitive station is withdrawn into the body of the esophagus, the upper border of the LES is identified by the drop in pressure to the esophageal baseline. From these measurements, the pressure, abdominal length, and overall length of the sphincter are determined. To account for the asymmetry of the sphincter, the pressure profile is repeated with each of the five radially oriented transducers, and the average values for sphincter pressure above gastric baseline, overall sphincter length, and abdominal length of the sphincter are calculated.

Answer 32

A mechanically defective sphincter is identified by having one or more of the following: 1) Average LES pressure of <6mmHg 2) Average length exposed to the positive-pressure environment in the abdomen of ≤1cm 3) Average overall sphincter length of ≤2cm

Answer 33

1) 24h Ambulatory pH Monitoring - 48H* esophageal pH monitoring is the Gold standard for the diagnosis of GERD. - the most direct method of measuring increased esophageal exposure, via an indwelling pH electrode or a radiotelemetric pH monitoring capsule - measures the actual time the esophageal mucosa is exposed to gastric juice - measures the ability of the esophagus to clear refluxed acid - correlates esophageal acid exposure with the patient's symptoms - measurements made over 1-2 circadian cycles (24-48h) - should NOT be considered a test for reflux, but a measurement of esophageal exposure to gastric juice, 2) Radiographic Detection of GERD - 40% patients with classic symptoms: Spontaneous reflux - In most patients who show spontaneous reflux on radiography, the diagnosis of increased esophageal acid exposure is confirmed by 24h esophageal pH monitoring. - Hence the radiographic demonstration of spontaneous regurgitation of barium into the esophagus in the upright position is a reliable indicator that reflux is present. - Failure to see this does not indicate the absence of the disease, hence this test is rarely used for clinical diagnosis.

Answer 34

1) Cumulative time the esophageal pH is below a chosen threshold, expressed as percentage of total, upright, and supine monitored time 2) Frequency of reflux episodes below a chosen threshold, expressed as number of episodes per 24h 3) Duration of the episodes, expressed as number of episodes >5 minutes per 24h, and the time in minutes of the longest episode recorded.

Answer 35

Esophageal disorders are frequently associated with abnormalities of duodenogastric function: reflux of alkaline duodenal juice, including bile salts, pancreatic enzymes, and bicarbonate, is thought to have a role in the pathogenesis of esophagitis and complicated Barrett's esophagus. Functional disorders are also not confined to the esophagus but are associated with those of the rest of the foregut. 1) Gastric Emptying Study - Radionuclide-labeled meals - After ingestion, gamma camera images of the stomach are obtained at 5 to 15 minute intervals for 2-4hours. - After correction for decay, the counts in the gastric area are plotted as the percentage of total counts at the start of imaging. - The resulting emptying curve can be compared with data obtained in normal volunteers. - Normal subjects will empty 59% of a meal within 90minutes.

Answer 36

Dysphagia It can be a sign of underlying malignancy and should be aggressively investigated until a diagnosis is established. Oropharyngeal - Difficulty transferring food out of the mouth into the esophagus, nasal regurgitation, and/or aspiration. Esophageal - Sensation of food sticking in the lower chest or epigastrium - May or may not be accompanied by pain (odynophagia) relieved by passage of the bolus

Answer 37

The loss of the high pressure zone and a decrease in the resistance it imparts to the retrograde flow of gastric juice into the esophageal body.

Answer 38

1) Resting LES pressure 2) Overall length 3) Intraabdominal length As the sphincter becomes shorter, a higher amount of pressure is needed to prevent a given amount of reflux. Much like the neck of a balloon as it is inflated, as the stomach fills and distends, sphincter length decreases. Therefore, if the overall length of the sphincter is permanently short from repeated distention of the fundus secondary to large volume meals, then with minimal episodes of gastric distention and pressure, there will be insufficient sphincter length for the barrier to remain competent, and reflux will occur.

Answer 39

1) An LES with a mean resting pressure of <6mmHg 2) An overall sphincter length of <2cm; 3) Intraabdominal sphincter length of <1cm

Answer 40

It is believed that GERD has its origins within the stomach. Distension of the fundus occurs because of overeating and delayed gastric emptying secondary to a high-fat diet. The resultant distension causes "unrolling" of the sphincter by the expanding fundus, and this exposes the squamous epithelium in the region of the distal LES to gastric juice. Repeated exposure results in inflammation and development of columnar epithelium at the cardia. This is the initial step in the development of carditis and explains why in early disease, esophagitis is mild and commonly limited to the very distal aspect of the esophagus. The patient attempts to compensate by increased swallowing, allowing the saliva to neutralize the refluxed gastric juice and thus, alleviate discomfort. Increased swallowing leads to aerophagia, bloating and belching, and creates a vicious cycle of repetitive injury. Additionally, this can lead to a fibrotic mucosal ring at the squamocolumnar junction, called a "Schatzki ring" which may result in dysphagia. This explanation for the pathophysiology of GERD is supported by the observation that severe esophagitis is almost always associated with a defective LES.

Answer 41

1) A mechanically defective LES | 2) Increased esophageal exposure to fluid containing duodenal content, that includes bile and pancreatic juice

Answer 42

0.2 - 0.5% per year

Answer 43

The presence of intestinal goblet cells

Answer 44

Long-term relief of symptoms | Secondary goals: healing of esophageal mucosal injury and prevention of disease progression

Answer 45

It occurs at approximately 0.2 - 0.5% per year of follow-up, which represents a risk 40x that of the general population. Most, if not all cases of adenocarcinoma of the esophagus arise in Barrett's epithelium. About 1/3 of all patients with BE present with malignancy.

Answer 46

1) Laryngopharyngeal reflux-type symptoms 2) Adult-onset asthma 3) Idiopathic pulmonary fibrosis

Answer 47

1) Reflux theory - Symptoms are the direct result of laryngopharyngeal exposure and aspiration of gastric contents - Vagal-mediated afferent fibers result in bronchoconstriction during episodes of distal esophageal acidification. 2) Ambulatory pH testing - Acid exposure within the proximal esophagus is more frequently identified in those with gastroesophageal reflux and respiratory symptoms, than those with gastroesophageal reflux symptoms alone. 3) Impedance testing - A correlation between proximal fluid movement and laryngopharyngeal symptoms such as cough can be demonstrated. 4) Bronchoconstriction occurs with the infusion of acid into the distal esophagus. There is a shared embryologic origin of the tracheoesophageal tract and vagus nerve, and this reflex is though to be an afferent fiber-mediated reflex that protects the aerodigestive system from the aspiration of refluxate.

Answer 48

First-line: When initially identified with mild symptoms of uncomplicated GERD, patients can be placed on 12 weeks of simple antacids before diagnostic testing is initiated. Patients should be counseled to elevated the head of the bed, avoid tight-fitting clothing, eat small frequent meals, avoid eating the nighttime meal immediately prior to bedtime, and avoid alcohol, coffee, chocolate, and peppermint, which are known to reduce resting LES pressure and may aggravate symptoms. Other supplements: 1) Alginic acid: may augment the relief of symptoms by creating a physical barrier to reflux, as well as by acid reduction; reacts with sodium bicarbonate in the presence of saliva to form a highly viscous solution that floats like a raft on the surface of gastric contents. When reflux occurs, this protective layer is refluxed into the esophagus, and acts as a protective barrier. 2) Metoclopramide or Domperidone: Meds to promote gastric emptying are beneficial in early disease but of little value in more severe disease. Persistent symptoms: Mainstay is acid suppression. High-dose regimens of hydrogen potassium PPIs, such as omeprazole (up to 40mg/d), can reduce gastric acidity by as much as 80-90%. This usually heals mild esophagitis. In severe esophagitis, healing may occur in only one-half of the patients. In patients who reflux a combination of gastric and duodenal juice, acid-suppression therapy may give relief of symptoms, while still allowing mixed reflux to occur. This can allow persistent mucosal damage in an asymptomatic patient. Within 6 months of discontinuation of any form of medical therapy for GERD, 80% of patients have a recurrence of symptoms, and 40% of individuals with daily GERD eventually develop symptoms that breakthrough adequately dosed PPIs. Once initiated, most patients will require lifelong treatment. Suggested approach: First-line therapy entails antisecretory medication, usually PPIs, in most patients. Failure of medication to adequately control GERD symptoms suggests either that the patient may have relatively severe disease, or a non-GERD cause for symptoms. Endoscopic evaluation is recommended to assess degree of injury and presence of BE. Treatment options entails either long term PPI use vs. antireflux surgery. Laparoscopic antireflux surgery in these patients achieves long-term control of symptoms in 85-90%. The measurement of esophageal acid exposure via 24h pH should be done when patients are considered for surgery. The status of the LES and esophageal body function should also be performed.

Answer 49

1) Objectively proven gastroesophageal reflux disease 2) Typical symptoms of gastroesophageal reflux disease (heartburn/ regurgitation) despite adequate medical management 3) Younger patient unwilling to take lifelong medication (ie, <49yo) 4) Severe endoscopic esophagitis in a symptomatic patients with a structurally defective LES 5) Development of a stricture in a patient-- represents failure of medical therapy (malignancy and drug-related etiology must be ruled out, and the stricture should be progressively dilated up to a 50-60F bougie prior to surgery. If dysphagia is relieved and the amplitude of esophageal contractions is adequate, an antireflux procedure should be performed; if there is a global loss of esophageal contractility, caution should be exercised in performing an antireflux procedure, and a partial fundoplication should be considered). A structurally defective LES can also predict which patients are more likely to fail with medical therapy. Patients with normal sphincter pressures tend to remain well-controlled with medical therapy, whereas patients with a structurally defective LES may not respond as well and often develop recurrent symptoms within 1-2 years.

Answer 50

Treatment should be directed at the BE and the lesion, using either evaluation endoscopic ablation, endoscopic resection, or esophageal resection.

Answer 51

1) Reflux objectively confirmed by 24h pH monitoring or by the presence of ulcerative esophagitis 2) Propulsive force of body of esophagus evaluated by esophageal manometry (if it has sufficient power to propel a bolus of food through a newly-constructed valve) - Normal peristaltic contractions: consider for a 360deg Nissen fundoplication or a partial fundoplication - Absent peristalsis: Partial fundoplication, if achalasia has been ruled out 3) Hiatal anatomy should be assessed - Smaller hiatal hernias: Endoscopy is sufficient - Larger hiatal hernias: Contrast radiology

Answer 52

To safely create a new antireflux valve at the gastroesophageal junction, while preserving the patient's ability to swallow normally and belch to relieve gaseous distention. The aim of any fundoplication is to create a loose wrap and to maintain the position of the gastric fundus close to the distal intraabdominal esophagus, in a flap valve arrangement. The efficacy of this relies on the close relationship between the fundus and esophagus, not the tightness of the wrap.

Answer 53

1) Operation should create a flap valve which prevents regurgitation of gastric contents into the esophagus. This will result in an increase in the pressure of the distal esophageal sphincter region. 2) Operation should place an adequate length of the distal esophageal sphincter in the positive-pressure environment of the abdomen by a method that ensures its response to changes in intraabdominal pressure. The permanent restoration of 2 or more cm of abdominal esophagus ensures the preservation of the relationship between the fundus and the esophagus. All of the popular antireflux procedures increase the length of the sphincter exposed to abdominal pressure by an average of at least 1cm. 3) Operation should allow the reconstructed cardia to relax on deglutition. In normal swallowing, a vagally mediated relaxation of the distal esophageal sphincter and the gastric fundus occurs. The relaxation lasts for approximately 10 secs and is followed by a rapid recovery to the former tonicity. 4) The fundoplication should not increase the resistance of the relaxed sphincter to a level that exceeds the peristaltic power of the body of the esophagus. The resistance depends on the degree, length, and diameter of the gastric fundic wrap, and on the variation in intraabdominal pressure. A 360deg wrap should be no longer than 2cm and constructed over a large (50-60F) bougie. This will ensure that the relaxed sphincter will have adequate diameter with minimal resistance. A bougie is not necessary when constructing a partial wrap. 5) The operation should ensure that the fundoplication can be placed in the abdomen without undue tension and maintained there by approximating the crura of the diaphragm above the repair. Leaving the fundoplication in the thorax converts a sliding hernia into a PEH, with all the complications associated with that condition. Maintaining the repair in the abdomen under tension predisposes to an increased incidence of recurrence.

Answer 54

1) Only the fundus of the stomach should be used to buttress the sphincter, because it is known to relax in concert with the sphincter. 2) The gastric wrap should be properly placed around the sphincter and not incorporate a portion of the stomach or be placed around the stomach itself, because the body of the stomach does not relax with swallowing. 3) Damage to the vagal nerves during dissection of the thoracic esophagus should be avoided because it may result in failure of the sphincter to relax.

Answer 55

A 360degree fundoplication around the lower esophagus for a distance of 4-5cm, without division of the short gastric vessels (now modified-- with division of vessels). Elements common to both lap and open procedures: 1) Hiatal dissection and preservation of both vagi along their entire length 2) Circumferential esophageal mobilization 3) Hiatal closure, usually posterior to the esophagus 4) Creation of a short and floppy fundoplication over an esophageal dilator

Answer 56

Partial fundoplications were developed as an alternative to the Nissen procedure in an attempt to minimize the risk of postfundoplication side effects, such as dysphagia, inability to belch, and flatulence. The commonest approach has been a posterior partial or TOUPET fundoplication. 270-degree gastric fundoplication around the distal 4cm of esophagus.

Answer 57

Following posterior hiatal repair, the anterior fundus is rolled over the front of the esophagus and sutured to the hiatal rim and the esophageal wall. Division of the short gastric vessels is NOT needed. 180-degree anterior partial fundoplication provides a more robust wrap and achieves an excellent longer-term outcome in 90% of patients at follow up of at least 10 years. The fundus and esophagus are sutured to the right side of the hiatal rim to create a flap valve at the gastroesophageal junction and to stabilize a 3-4cm long intraabdominal esophagus.

Answer 58

1) Transoral incisionless fundoplication (TIF) - Totally endoscopic procedure for performing a partial fundoplication using T-bar fasteners - 270 to 290deg wrap - Approved for hernias >2cm. - ARS remains an option in case of TIF failure. - Does NOT provide cruroplasty. 2) Belsey-Mark IV - Recreates the LES while reducing an intrathoracic stomach and closing a hiatal defect. - Approached via a left thoracotomy hence may avoid a hostile abdomen. - Useful in the dissection of large and giant chronic paraesophageal hernias. - 240-deg partial wrap; imbricating cardia against the distal esophagus. 3) Toupet - 270 degree, posterior partial wrap. 4) Dor - 180 degree, anterior partial warp. 5) Hill - Creation of a gastroesophageal flap valve, in an attempt to recreate normal anatomy. 6) Gastropexy - For highest risk patients with hernias at risk for volvulus. - May include a percutaneous endoscopic gastrostomy tube.

Answer 59

1) Low-grade dysplasia - Biopsy specimens should be repeated after 12 weeks of high-dose acid suppression therapy. 2) High-grade dysplasia or Intramucosal cancer in >1 biopsy specimen - If invasive CA (stage T1b or deeper) is present, or for multifocal long segment BE in younger and fit patients, in whom endoscopic treatments are unlikely to be adequate: ESOPHAGEAL RESECTION. - For smaller intramucosal tumors to be removed with clear pathology margins, to obtain better pathological staging as a "big biopsy", or to excise shorter segments of BE piecemeal: ENDOSCOPIC MUCOSAL RESECTION. - To reduce the rate of progression from high grade dysplasia to invasive cancer by 50%: RF ABLATION. 3) Indeterminate/lower grade - Suppress dysplasia by a course of acid suppression therapy in high doses for 2-3 months, followed by rebiopsy of the Barrett's segment.

Answer 60

Placement of the wrap around the stomach

Answer 61

Herniation of repair into the chest

Answer 62

When dysphagia is associated with poor motility and multiple previous repairs, further revision fundoplication is unlikely to be successful, and in otherwise fit patients it is appropriate to seriously consider esophageal resection.

Answer 63

Type I: Sliding hernia - Upward dislocation of the cardia in the posterior mediastinum - 48 years old Type II: Rolling or Paraesophageal Hernia (PEH/Giant hiatal hernia) - Upward dislocation of gastric fundus alongside a normally positioned cardia - 61 years old - women > men (4:1) Type III: Combined sliding-rolling/mixed hernia - Upward dislocation of both cardia and gastric fundus - The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180deg around its longitudinal axis, with the cardia and pylorus as fixed points (intrathoracic stomach). Type IV: When an additional organ, usually the colon, herniates as well. Types II-IV are also known as paraesophageal hernias, as a portion of the stomach is situated adjacent to the esophagus, above the gastroesophageal junction.

Answer 64

Traditionally, it is believed that dysphagia and postprandial fullness are caused by compression of the adjacent esophagus by a distended cardia, or twisting of the GEJ by the torsion of the stomach that occurs as it becomes progressively displaced in the chest. Respiratory complications ensure from aspiration. New research demonstrates that the cause of dyspnea in the presence of a giant PEH is more likely to be left atrial compression, decreasing cardiac output, than a restrictive pulmonary effect.

Answer 65

This is reflected by a double-humped high-pressure zone at the GEJ. The first pressure rise is due to diaphragmatic impingement on the herniated stomach. The second is due to the true distal esophageal sphincter.

Answer 66

1) Upright CXR - Air fluid level behind the cardiac shadow - Caused by a PEH or intrathoracic stomach 2) Upper GI barium study - Greater accuracy for a paraesophageal hernia (sliding hernias can spontaneously reduce) 3) Fiber-optic esophagoscopy - Sliding: Gastric pouch lined with rugal folds extending above the impression caused by the crura of the diaphragm (or measuring at least 2cm between the crura), identified by having the patient sniff, and the squamocolumnar junction on withdrawal of the scope. - PEH: On retroversion of the scope, there is a separate orifice adjacent to the GEJ into which gastric rugal folds ascend. - Sliding-Rolling/Mixed: Gastric pouch lined with rugal folds above the diaphgram, with the GEJ entering about midway up the side of the pouch.

Answer 67

24h esophageal pH monitoring shows that - PEH: 60% with increased esophageal exposure to gastric acid - Sliding: 71% with increased esophageal exposure to gastric acid Hence it is now recognized that paraesophageal hiatal hernia can be associated with pathologic gastroesophageal reflux. The competency of the cardia depends on an interrelationship between: 1) distal esophageal sphincter pressure 2) length of sphincter exposed to positive-pressure environment of abdomen 3) overall sphincter length A deficiency in any one of these is associated with incompetency of the cardia regardless of whether a hernia is present.

Answer 68

Patients with PEH are generally counseled to have elective repair, especially if symptomatic.

Answer 69

1) Physiologic testing with 24h esophageal pH monitoring has shown increased esophageal exposure to acid gastric juice in 60-70% of patients with a PEH, and 71% in those with a sliding hernia. 2) There is no relation between symptoms experienced by the patient with a PEH and the competency of the cardia. 3) A dissection of the gastroesophageal esophagus may lead to postoperative reflux despite a negative preoperative pH score.

Answer 70

The failure to achieve 2.5cm of intraabdominal esophagus with standard mediastinal dissection techniques.

Answer 71

A procedure to achieve esophageal lengthening by the creation of a neoesophagus using the gastric cardia.

Answer 72

Recurrent hiatal hernia (5-10%)

Answer 73

Asymptomatic recurrent hernias, like primary PEH, do not need to be repaired. The risk of incarceration, strangulation, or obstruction is minimal.

Answer 74

Schatzki's ring is a thin submucosal circumferential ring in the lower esophagus at the squamocolumnar junction, often associated with a hiatal hernia. Stiennon believed the ring to be a pleat of mucosa formed by infolding of redundant esophageal mucosa due to shortening of the esophagus. Others believe it to be congenital, and still others suggest it is an early stricture resulting from inflammation of the esophageal mucosa caused by chronic reflux. Symptoms include brief episodes of dysphagia during hurried ingestion of solid foods. Majority of Schatzki's ring patients without proven reflux have a history of ingestion of drugs known to be damaging to the esophageal mucosa.

Answer 75

The best form of treatment of a symptomatic Schatzki's ring in patients who do not have reflux consists of esophageal dilation for relief of the obstructive symptoms. In patients with a ring who have proven reflux and a mechanically defective sphincter, an antireflux procedure is necessary to obtain relief and avoid repeated dilation.

Answer 76

Scleroderma is a systemic and primarily neurogenic disorder, involving small vessel inflammation and subsequent perivascular deposition of normal collagen, leading to vascular compromise. It is accompanied by esophageal abnormalities in 80% of patients. In the GI tract, the predominant feature is smooth muscle atrophy. In early scleroderma, an adrenergic overactivity may be present that causes parasympathetic inhibition, supporting a neurogenic mechanism for the disease. Clinically, this manifests in the patient as having a poor esophageal pump and a poor valve.

Answer 77

The diagnosis of scleroderma can be made manometrically by the observation of normal peristalsis in the proximal striated esophagus, with absent peristalsis in the distal smooth muscle portion. LES pressure is progressively weakened as the disease advances. Gastroesophageal reflux occurs in patients with scleroderma because they have both hypotensive sphincters and poor esophageal clearance. This combined defect can lead to severe esophagitis and stricture formation. The typical barium swallow shows a dilated, barium-filled esophagus, stomach, and duodenum, or a hiatal hernia with distal esophageal stricture and proximal dilatation..

Answer 78

Traditionally, esophageal symptoms have been treated with PPIs, antacids, elevation of the head of bed, and multiple dilations for strictures, with unsatisfactory results. Scleroderma patients have frequently had numerous dilations before they are referred to the surgeon. The surgical management is controversial, but majority recommend a partial fundoplication (anterior or posterior) performed laparoscopically. Esophageal shortening may require a Collis gastroplasty in combination with a partial fundoplication. If esophagitis is severe, or there has been a previous failed antireflux procedure and the disease is associated with delayed gastric emptying, a gastric resection with Roux-en-Y gastrojejunostomy has proved the best option.

Answer 79

A condition with immunologic similarity to asthma, a form of allergic esophagitis. Normally presents with chest pain (often postprandial) and dysphagia, most commonly to solids. Unlike GERD, it does not respond to proton pump inhibitors. A barium swallow should be the first test obtained in the patient with dysphagia. EE has a characteristic finding called the "ringed esophagus" or the "feline esophagus" as the esophageal rings are felt to look like the stripes of a housecat. Histologically, the pathologist should see a minimum of 15 eosinophils per hpf, usually at the base of the epithelium.

Answer 80

Treatment is symptomatic, and includes testing for food allergies and elimination of identified items from the diet. Second-line therapy includes inhaled or ingested corticosteroids as would be used to treat asthma. If dysphagia is not relieved by steroids, it may be necessary to dilate the esophagus.

Answer 81

Termed transit dysphagia, this is usually congenital or results from acquired disease involving the central and peripheral nervous system (CVA, brainstem tumors, poliomyelitis, multiple sclerosis, Parkinson's disease, pseudobulbar palsy, peripheral neuropathy, and operative damage to cranial nerves involved in swallowing). They can be categorized into one or a combination of the ff abnormalities: 1) inadequate oropharyngeal bolus transport 2) inability to pressurize the pharynx 3) inability to elevate the larynx 4) discoordination of pharyngeal contraction and cricopharyngeal relaxation 5) decreased compliance of the pharyngoesophageal segment secondary to neuromuscular disease

Answer 82

1) Adequate oropharyngeal bolus transport 2) Intact swallowing reflex 3) Reasonable coordination of pharyngeal pressurization with cricopharyngeal relaxation 4) Cricopharyngeal bar, Zenker's diverticulum, or a narrowed pharyngoesophageal segment on videoesophagogram and/or presence of excessive pharyngoesophageal shoulder pressure on motility study.

Answer 83

Zenker's diverticulum signifies cricopharyngeal dysfunction, enlarging progressively due to the decreasing compliance of the skeletal portion of the cervical esophagus that occurs with aging. Symptoms include dysphagia associated with spontaneous regurgitation of undigested, bland material, often interrupting eating or drinking. Occasionally this can be severe enough to cause debilitation and significant weight loss. Chronic aspiration and repetitive respiratory infection are common. Once suspected, the diagnosis is established by a barium swallow.

Answer 84

The low morbidity and mortality associated with cricopharyngeal and upper esophageal myotomy have encouraged its use for almost any problem in the oropharyngeal phase of swallowing. If a diverticulum is large enough to persist after a myotomy, it may be sutured in the inverted position to the prevertebral fascia using a permanent suture (ie, diverticulopexy). If the diverticulum is excessively large, or if its walls are thickened, a diverticulectomy should be performed. Endoscopic stapled cricopharyngotomy and diverticulotomy are also effective for larger diverticular (>2cm).

Answer 85

Recurrence of a Zenker's diverticulum may occur with long follow-up and is more common after diverticulectomy without myotomy, presumably due to persistence of the underlying loss of compliance of the cervical esophagus when a myotomy is not performed.

Answer 86

Esophageal motility disorders should be looked at as a spectrum of abnormalities that reflect various stages of destruction of esophageal motor function. These result from abnormalities in the propulsive pump action of the esophageal body or relaxation of the LES. They result from either primary esophageal abnormalities, or from generalized neural, muscular, or collagen vascular disease. ``` PRIMARY ESOPHAGEAL MOTILITY DISORDERS Achalasia, "vigorous" achalasia Diffuse and segmental esophageal spasm Nutcracker esophagus Hypertensive lower esophageal sphincter Nonspecific esophageal motility disorders ``` SECONDARY ESOPHAGEAL MOTILITY DISORDERS Collagen vascular diseases: progressive systemic sclerosis, polymyositis and dermatomyositis, mixed connective tissue disease, SLE Chronic idiopathic intestinal pseudoobstruction Neuromuscular diseases Endocrine and metastatic disorders

Answer 87

6 in 100,000 population per year

Answer 88

Although complete absence of peristalsis in the esophageal body has been proposed as the major abnormality, present evidence indicates achalasia is a primary disorder of the LES. The pathogenesis of achalasia is presumed to be a neurogenic degeneration, which is either idiopathic or due to infection. This degeneration leads to hypertension of the LES, a failure of the sphincter to relax on swallowing, elevation of intraluminal esophageal pressure, esophageal dilatation, and a subsequent loss of progressive peristalsis in the body of the esophagus. The esophageal dilatation results from the combination of a nonrelaxing sphincter, which causes a functional retention of ingested material in the esophagus, and elevation of intraluminal pressure from repetitive pharyngeal air swallowing. With time, the functional disorder results in anatomic alterations seen on radiographic studies, such as a dilated esophagus with a tapering "bird's beak"-like narrowing of the distal end. There is usually an air-fluid level in the esophagus from the retained food and saliva, the height of which reflects the degree of resistance imposed by the nonrelaxing sphincter. As the disease progresses, the esophagus becomes massively dilated and tortuous.

Answer 89

A subgroup of patients with otherwise typical features of classic achalasia has simultaneous contractions of their esophageal body that can be of high amplitude. This manometric pattern has been termed vigorous achalasia, and chest pain episodes are a common finding in these patients. Since the development of high resolution esophageal manometry technology, the term vigorous achalasia has been replaced with Chicago type 3 achalasia. Differentiation of type 3 achalasia from DES can be difficult. In both diseases, videographic examination may show a corkscrew deformity of the esophagus and diverticulum formation.

Answer 90

Diffuse Esophageal Spasm (DES) is characterized by substernal chest pain and/or dysphagia. It differs from classic achalasia in that it is primarily a disease of the esophageal body, produces a lesser degree of dysphagia, causes more chest pain, and has less effect on the patient's general condition. Nonetheless, it is impossible to differentiate achalasia from DES on the basis of symptoms alone. Esophagogram and esophageal manometry are required to distinguish these two entities. True symptomatic DES is a rare condition, occurring about 5x less frequently than achalasia.

Answer 91

The cause and neuromuscular pathophysiology of DES are unclear. The basic motor abnormality is rapid wave progression down the esophagus secondary to an abnormality in the latency gradient. Hypertrophy of the muscular layer of the esophageal wall and degeneration of the esophageal branches of the vagus nerve have been observed in this disease, although these are not constant findings. Manometric abnormalities in DES may be present over the total length of the esophageal body, but are usually confined to the distal 2/3. In segmental esophageal spasm, the manometric abnormalities are confined to a short segment of the esophagus.

Answer 92

ACHALASIA 1) Incomplete LES relaxation (<75% relaxation) 2) Aperistalsis in the esophageal body 3) Elevated LES pressure ≤26mmHg 4) Increased intraesophageal baseline pressures relative to gastric baseline

Answer 93

DES 1) Simultaneous nonperistaltic contractions >20% of wet swallows 2) Repetitive and multipeaked contractions 3) Spontaneous contractions 4) Intermittent normal peristalsis 5) Contractions may be of increased amplitude and duration Key to the diagnosis of DES is that there remain some peristaltic waveforms in excess of those seen in achalasia. The LES shows a normal resting pressure and relaxation on swallowing. In patients with advanced disease, the radiographic appearance of tertiary contractions appears helical and has been termed "corkscrew esophagus" or "pseudodiverticulosis" (patients with segmental or diffuse esophageal spasm can compartmentalize the esophagus and develop an epiphrenic or midesophageal diverticulum between two areas of high pressure occuring simultaneously).

Answer 94

NUTCRACKER ESOPHAGUS 1) Mean peristaltic amplitude (10 wet swallows) in distal esophagus ≥180mmHg 2) Increased mean duration of contractions (>7.0s) 3) Normal peristaltic sequence

Answer 95

HYPERTENSIVE LES 1) Elevated LES pressure ≥26mmHg 2) Normal LES relaxation 3) Normal peristalsis in the esophageal body

Answer 96

INEFFECTIVE/NONSPECIFIC ESOPHAGEAL MOTILITY DISORDERS 1) Decreased or absent amplitude of esophageal peristalsis (<30mmHg) 2) Increased number of nontransmitted contractions 3) Increased number of multipeaked/repetitive contractions 4) Contractions of prolonged duration 5) Contractions of low amplitude The finding of a nonspecific esophageal motility disorder may represent only a manometric marker of an intermittent, more severe esophageal motor abnormality. High amplitude peristalsis (nutcracker esophagus) and low-amplitude peristalsis (ineffective esophageal motility) are frequently associated with GERD. Surgery plays no role in these disorders, unless there is an associated diverticulum.

Answer 97

Nutcracker Esophagus

Answer 98

Nutcracker or supersqueezer esophagus is a manometric abnormality in patients who are characterized by peristaltic esophageal contractions with peak amplitudes greater than two SDs above the normal values. Contraction amplitudes can easily be above 400mmHg. Treatment should be aimed at the treatment of GERD. Chest pain symptoms (at the lower end of peak pressure) may be related to GERD rather than intraluminal hypertension. At the high end (peak pressures >300mmHg), chest pain may be the result of the nutcracker physiology, as treatment directed at reducing intraluminal pressure is more effective than when used for those with lower peak pressures.

Answer 99

Hypertensive LES is characterized by an elevated basal pressure of the LES with normal relaxation and normal propulsion in the esophageal body. About one-half of these patients, however, have associated motility disorders of the esophageal body, particularly hypertensive peristalsis and simultaneous waveforms. In the remainder, the disorder exists as an isolated abnormality. Dysphagia in these patients may be cause by a lack of compliance of the sphincter, even in its relaxed state. Myotomy of the LES may be indicated in patients unresponsive to medical therapy of dilation. When the symptom contribution of the hypertensive sphincter is in doubt, it is possible to inject the LES with botulinum toxin, endoscopically. If symptoms are relieved (temporarily) with this technique, then it is likely that myotomy will provide more permanent benefit.

Answer 100

Connective tissue disease (scleroderma, CREST syndrome) and infants treated for Esophageal atresia often develop motility disorders that manifest later in life. Symptoms include heartburn and dysphagia. The latter may be a result of a peptic stricture rather than the esophageal dysmotility. An esophageal motility study will usually show severely reduced or absent LES pressure. The role of antireflux surgery under these conditions is controversial but if performed, should be limited to partial fundoplication, as full Nissen fundoplication may result in severe dysphagia.

Answer 101

Pulsion diverticula are those associated with motor disorders. They occur most commonly with nonspecific motility disorders, but can occur also with primary motility disorders. In primary motility disorders, the motility disorder is usually diagnosed before the development of the diverticulum. When associated with achalasia, the development of a diverticulum may temporarily alleviate the symptom of dysphagia by becoming a receptacle for ingested food and substitute the symptom of dysphagia for postprandial pain and regurgitation of undigested food. If a motility abnormality of the esophageal body or LES cannot be identified, a traction or congenital cause for the diverticulum should be considered.

Answer 102

Traditionally, diverticula were considered a primary abnormality. Hence they were categorized based on location. Epiphrenic diverticula arise from the terminal third of the thoracic esophagus and are usually found adjacent to the diaphragm. They have been associated with distal esophageal muscular hypertrophy, esophageal motility abnormalities, and increased luminal pressure. They are pulsion diverticula and are associated with diffuse spasm, achalasia, or nonspecific motor abnormalities in the esophageal body.

Answer 103

When diverticula are associated with esophageal motility disorders, esophageal myotomy from the proximal extent of the diverticulum to the stomach should be combined with diverticulectomy. (If diverticulectomy alone is performed, one can expect a high incidence of suture line rupture due to the same intraluminal pressure that initially gave rise to the diverticulum.) If the diverticulum is suspended to the prevertebral fascia of the thoracic vertebra, a myotomy is begun at the neck of the diverticulum and extended across the LES. If the diverticulum is excised by dividing the neck, the muscle is closed over the excision site, and a myotomy is performed on the opposite esophageal wall, starting just above the level of the diverticulum or at the proximal extent of the spastic segment of the esophagus if high resolution motility is used. If complete, the myotomy will cross the LES, reducing distal esophageal peak pressure, and it will increase the likelihood that dysphagia will be replaced with GERD symptoms. Increasingly, partial fundoplication is performed after LES myotomy to decrease the frequency of disabling GERD developing after myotomy and diverticulectomy. When a large diverticulum is associated with a hiatal hernia, then hiatal hernia repair is added.

Answer 104

Midesophageal or traction diverticula were theorized to come from adhesions forming between the inflamed mediastinal nodes and esophagus of TB patients. By contraction, the adhesions exerted traction on the esophageal wall and led to a localized diverticulum. Most of these are asymptomatic and incidentally discovered during investigation of nonesophageal complaints. In such patients, the radiologic abnormality may be ignored. Those with dysphagia, regurgitation, chest pain, or aspiration should be thoroughly investigated for an esophageal motor abnormality. Occasionally, a patient will present with a bronchoesophageal fistula manifested by a chronic cough on ingestion of meals. The diverticulum in such patients is most likely to have an inflammatory etiology.

Answer 105

The indication for surgery is dictated by the degree of symptomatic disability. Usually, midesophageal diverticula can be suspended due to their proximity to the spine. If a motor abnormality is documented, a myotomy should be performed as described for an epiphrenic diverticulum.

Answer 106

Used for motor disorders of the esophageal body. Indicated for dysphagia caused by any motor disorder characterized by segmental or generalized simultaneous waveforms in a patient whose symptoms are not relieved by medical therapy. Diffuse and segmental esophageal spasm, vigorous or type 3 achalasia, and nonspecific motility disorders associated with a mid- or epiphrenic esophageal diverticulum.

Answer 107

Peroral Endoscopic Myotomy (POEM) allows a long myotomy to be performed entirely from the lumen of the esophagus with an endoscope. It is minimally invasive and can be done outpatient. This procedure may be used for those with type 3 achalasia (vigorous achalasia), where it is necessary to divide the esophagogastric circular muscle on both sides of the diaphragm to the extent that might not be possible with laparoscopy or thoracoscopy alone. The major downside of POEM is that an effective antireflux valve cannot be created, exposing the patient to a 40-50% risk of GERD post procedure.

Answer 108

Heller Myotomy or Myotomy of the Lower Esophageal Sphincter (LES) aims to relieve the functional outflow obstruction secondary to loss of relaxation and compliance of the LES in achalasia (ie, reducing sphincter pressure to <10mmHg). Other options for addressing LES include hydrostatic balloon dilation (similar outcome with surgical myotomy), botulinum toxin injection.

Answer 109

MEDICAL OR SURGICAL? For newly diagnosed patients, pneumatic dilation achieves adequate relief of dysphagia and pharyngeal regurgitation in 50-60% of patients. If dilation fails, myotomy is indicated. For those with a dilated and tortuous esophagus or an associated hiatal hernia, balloon dilation is dangerous and surgery (surgical myotomy) is the better option. The best treatment for achalasia is a laparoscopic Heller myotomy with partial fundoplication. APPROACH In the absence of a previous upper abdominal surgery, most surgeons prefer the abdominal approach (less pain, shorter length of stay). It is also a bit easier to ensure a long gastric myotomy when the approach is transabdominal. ARS Excellent results have been reported following meticulously performed myotomy without an antireflux component. If an antireflux procedure is used as an adjunct to esophageal myotomy, a complete 360-deg fundoplication should be avoided. Rather, a 270-deg Belsey fundoplication, a Toupet posterior 180-deg fundoplication, or a Dor anterior 180-deg fundoplication should be used to avoid the long term esophageal dysfunction secondary to outflow obstruction afforded by the fundoplication itself. PROGNOSIS The earlier an effective reduction in outflow resistance can be accomplished, the better the outcome will be, and the more likely some esophageal body function can be restored.

Answer 110

1) Complete division of all circular and collar-sling muscle fibers 2) Adequate distal myotomy to reduce outflow resistance 3) Undermining of the muscularis to allow wide separation of the esophageal muscle 4) Prevention of postoperative reflux

Answer 111

Either an anterior hemifundoplication augmenting the angle of His (Dor) or posterior partial fundoplication (Toupet) can be performed. The Dor type is slightly easier to perform, and does not require disruption of the normal posterior gastroesophageal attachments (theoretical advantage in preventing postoperative reflux). In most RCTs, laparoscopic Heller myotomy and partial fundoplication was superior to the alternative treatments.

Answer 112

Squamous carcinoma of the esophagus

Answer 113

Additives (nitrous compounds in pickled vegetables and smoked meat) Mineral deficiencies (zinc and molybdenum) Smoking Alcohol Long-standing achalasia Lye strictures Tylosis (autosomal dominant disorder with keratosis of palms and soles) HPV

Answer 114

Metaplastic, columnar-lined or Barrett's esophagus | occurs in 10-15% of patients with GERD

Answer 115

Dysphagia usually presents late in the natural history of the disease because the lack of a serosal layer on the esophagus allows the smooth muscle to dilate with ease. As a result, the dysphagia becomes severe enough for the patient to seek medical advice only when more than 60% of the esophageal circumference is infiltrated with cancer.

Answer 116

Esophageal cancer is diagnosed with endoscopic biopsy and is staged with CT of the chest and abdomen, EUS, and PET scan for all patients with CT or EUS evidence of advanced disease (T2 or greater, N1-2 or NX). T in situ, T1a, intramucosal cancer - Endoscopic treatment (EMR) T1-T2, N0: Confined to esophagus (submucosal invasion) - Esophagectomy with LN dissection T1-T3, N1: Locally advanced - Multimodality approach (neoadjuvant chemo + surgery) (chemoRT + surgery) Any T, Any N, M1: Disseminated - Palliation (RT, endoscopic placement of expandable esophageal stent)

Answer 117

``` Lung Liver Peritoneal surfaces Omentum Small bowel mesentery ```

Answer 118

EUS provides the most reliable method of determining cancer depth of invasion. A curative resection should be encouraged if EUS indicates that the tumor has not invaded adjacent organs (T4b), and/or fewer than 6 enlarged LNs are imaged.

Answer 119

TX: Primary tumor cannot be assessed. T0: No evidence of primary tumor. Tis: High-grade dysplasia T1: Tumor invades lamina propria, muscularis mucosae, or submucosa. - T1a: Tumor invades lamina propria or muscularis mucosae. - T1b: Tumor invades submucosa T2: Tumor invades muscularis propria. T3: Tumor invades adventitia. T4: Tumor invades adjacent structures. - T4a: Resectable tumor invading pleura, pericardium, or diaphragm. - T4b: Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc. ``` NX: Regional LN cannot be assessed. N0: No regional LN mets. N1: Mets in 1-2 regional LNs. N2: Mets in 3-6 regional LNs. N3: Mets in ≥7 regional LNs. ``` M0: No distant mets. M1: Distant mets.

Answer 120

Esophageal SCC Stage 0: Tis N0 M0 I: T1 N0-1 M0 II: T2 N0-1 M0 T3 N0 M0 III: T3 N1 M0 T1-3 N2 M0 IVA: T4 N0-2 M0 Any T N3 M0 IVB: Any T Any N M1

Answer 121

Esophageal AdenoCA Stage 0: Tis N0 M0 I: T1 N0 M0 IIA: T1 N1 M0 IIB: T2 N0 M0 III: T2 N1 M0 T3 N0-1 M0 T4a N0-1 M0 IVA: T1-4a N2 M0 T4b N0-2 M0 Any T N3 M0 IVB: Any T Any N M1

Answer 122

8% of primary malignant tumors of the esophagus occur in the cervical portion, and are almost always SCC. They are more common in females. The efferent lymphatics from the cervical esophagus drain completely differently from those of the thoracic esophagus. The latter drain directly into the paratracheal and deep cervical or internal jugular LNs with minimal flow in a longitudinal direction. Cervical esophageal CA is frequently unresectable because of early invasion of the larynx, great vessels, or trachea. Hence stereotactic radiation with concomittant chemotherapy is the most desirable treatment.

Answer 123

These are mostly SCC, and are frequently associated with LN mets. Generally, T1 and T2 cancers without LN mets are treated with resection only, but there is more and more data to suggest LN involvement or transmural cancer (T3) warrants treatment with neoadjuvant chemoradiation therapy followed by resection. Although some surgeons prefer a transhiatal esophagectomy, most surgeons believe that resection of midesophageal cancer should be performed under direct vision with either thoracoscopy (VATS) or thoracotomy.

Answer 124

These are usually adenocarcinomas. Unless staging demonstrates an incurable lesion, resection in continuity with a LN dissection should be performed. Because of the propensity of GI tumors to spread for long distances submucosally, long lengths of grossly normal GI tract should be resected. The longitudinal lymph flow in the esophagus can result in skip areas, with small foci of tumor above the primary lesion, which underscores the importance of a wide resection of esophageal tumors. (*Wong has shown that local recurrence at the anastomosis can be prevented by obtaining a 10cm margin of normal esophagus above the tumor. Also, there is no submucosal lymphatic barrier between the esophagus, stomach and cardia, hence 50% of local recurrences post resection occur in the intrathoracic stomach along the line of gastric resection.)

Answer 125

A curative resection requires a cervical division of the esophagus and a >50% proximal gastrectomy in most patients with carcinoma of the distal esophagus or cardia.

Answer 126

Resection for cure of esophageal CA in a patient older than 80 years old is rarely indicated because of the additional operative risk and the shorter life expectancy. However octogenarians with a high-performance status and excellent cardiopulmonary reserve may be considered candidates for esophagectomy.

Answer 127

``` Cervical 8% Upper thoracic 3% Middle thoracic 32% Lower thoracic 25% Cardia 32% ```

Answer 128

I: Eating normally (11%) II: Requires liquids with meals (21%) III: Able to take semisolids but unable to take solid food (30%) IV: Able to take liquids only (40%) V: Unable to take liquids, but able to swallow saliva (7%) VI: Unable to swallow saliva (12%) Grades I-III can generally be palliated with RT, in combination with chemotherapy (definitive chemoradiation therapy, meaning surgery is not anticipated in the future). Radiation is increased from 45 Gy to 60 Gy, administered over 8 weeks, rather than 4 weeks for induction therapy. Grade IV and higher necessitates additional treatment, the mainstay of which is indwelling esophageal stents. However, if cancers involve the GEJ, a stent may cause disabling reflux and heartburn; hence RT may be preferable for cancers at this level. If feeding access is desirable, laparoscopic jejunostomy is the procedure of choice.

Answer 129

Cardiopulmonary reserve is assessed with FEV in 1 second (≥ 2L). A patient with an FEV in 1 second of <1.25L is a poor candidate for esophageal resection. Poor pulmonary reserve: TRANSHIATAL Esophagectomy (less pulmonary morbidity) Most individuals who can climb 3 flights of stairs without stopping will do well with two-field open esophagectomy especially with an epidural catheter for postoperative pain relief.

Answer 130

Nutritional status. Profound weight loss (>20lb) with hypoalbuminemia (albumin <3.5g/dL) is associated with a much higher rate of complications and mortality. Because most malnourished patients have locally advanced esophageal cancer, placement of a feeding tube prior to induction chemoRT should be considered.

Answer 131

``` Recurrence nerve paralysis Horner's syndrome Persistent spinal pain Paralysis of the diaphragm Fistula formation Malignant effusion Tumor >8cm in length Abnormal axis of the esophagus on barium >4 enlarged LNs in CT Weight loss >20% Loss of appetite ```

Answer 132

Open transhiatal esophagectomy

Answer 133

Ivor-Lewis (En Bloc) Esophagectomy The operation is started in the abdomen with an upper midline laparotomy and extensive LN dissection. Following closure of the abdominal incision, the patient is placed in the left lateral decubitus position, and an anterolateral thoracotomy is performed through the 6th ICS. Because this is the most radical of dissections, complications are most common, including pneumonia, respiratory failure, AF, chylothorax, anastomotic leak, conduit necrosis, fistula, recurrent laryngeal nerve injury. However this also has a long-term outcome with the greatest survival.

Answer 134

Salvage esophagectomy is the term used for esophagectomy performed after failure of definitive RT and chemotherapy. This is often done when distant disease renders the patient nonoperable at initial presentation. Then, systemic chemo destroys all foci of mets as shown by CT and PET, but the primary remains symptomatic and present. 1 in 4 patients undergoing this operation will be disease-free 5 years later. Because of dense scarring by radiation treatment, this is the most challenging technically among all esophagectomy techniques.

Answer 135

Leiomyomas constitute more than 50% of benign esophageal tumors. The average age at presentation is 38, and these are twice as common in males. These are usually solitary and usually intramural, with 90% located in the lower 2/3. The overlying mucosa is freely movable and normal in appearance, with dysphagia and pain as the most common complaints. A barium swallow is the most useful method to demonstrate a leiomyoma of the esophagus (smooth, semilunar, or crescent-shaped filling defect that moves with swallowing, sharply demarcated, covered and surrounded by normal mucosa). Esophagoscopy should also be performed to exclude the reported observation of a coexistence with carcinoma. Biopsy should NOT be done (increased chance of mucosal perforation). Endoscopic ultrasound is also a useful adjunct in the workup of leiomyomas. Leiomyomas should be removed by simple enucleation.

Answer 136

Lesions of the proximal and middle esophagus require a right thoracotomy, whereas distal esophageal lesions require a left thoracotomy. Large lesions or those involving the GEJ may require esophageal resection.

Answer 137

Congenital cysts are lined wholly or partly by columnar ciliated respiratory-type epithelium, glandular gastric-type epithelium, squamous epithelium, or transitional epithelium. Acquired retention cysts also occur probably secondary to obstruction of the excretory ducts of the esophageal glands. Enteric and bronchogenic cysts are the most common secondary to developmental abnormalities during the formation and differentiation of the lower respiratory tract, esophagus and stomach from the foregut. Cysts are usually located intramurally in the middle to lower third of the esophagus, and present clinically similar to leiomyomas. Surgical excision by enucleation is the preferred treatment. During removal, a fistulous tract connecting the cysts to the airways should be sought, especially in patients with repeated bronchopulmonary infections.

Answer 138

Perforation of the esophagus constitutes a true emergency. Spontaneous perforation, known as Boerhaave's syndrome, comprises only 15% of cases of esophageal perforation (14% FB, 10% trauma). Pain is a striking and consistent symptom and strongly suggests rupture (cervical area following instrumentation of the esophagus, or substernally in a patient with a history of resisting vomiting). If subcutaneous emphysema is present, the diagnosis is almost certain. CXR may show air or an effusion in the pleural space (abnormalities may differ based on time interval, site of perforation, and integrity of mediastinal pleura): TIME Mediastinal emphysema, strong indicator of perforation, takes at least 1 hour to be demonstrated and is present in only 40% of patients. Mediastinal widening secondary to edema may not occur for several hours. Air in the deep muscles (erector spinae) of the neck is often the earliest sign of perforation and can be present without evidence of air in the mediastinum. SITE Cervical perforation: Cervical emphysema Thoracic perforation: Mediastinal emphysema ``` INTEGRITY OF MEDIASTINAL PLEURA Pleural rupture results in a PNEUMOTHORAX (77%) 2/3: Left-sided perforation 1/5: Right-sided perforation 1/10: Bilateral ``` Intact pleura results in MEDIASTINAL EMPHYSEMA A pleural effusion secondary to inflammation of the mediastinum occurs late. In 9% of patients, CXR is normal. Diagnosis is confirmed with a CONTRAST ESOPHAGOGRAM (Extravasation in 90% of patients). The use of a water-soluble medium such as Gastrografin is preferred (ideally in right lateral decubitus position-- if upright, there is a 10% false negative rate as the passage of contrast can be too rapid). Elevation of pleural amylase may occur from extrusion of saliva through the perforation.

Answer 139

Into the left pleural cavity or just above the GEJ. The most common location is the left lateral wall of the esophagus, just above the GEJ. 50% of patients have concomitant GERD, suggesting that minimal resistance to the transmission of abdominal pressure into the thoracic esophagus is a factor in the pathophysiology of the lesion.

Answer 140

When a hiatal hernia is present and the sphincter remains exposed to abdominal pressure, the lesion produced is usually a Mallory-Weiss mucosal tear, and bleeding rather than perforation is the problem. This is due to the stretching of the supradiaphragmatic portion of the gastric wall. In this situation, the hernia sac represents an extension of the abdominal cavity, and the GEJ remains exposed to abdominal pressure.

Answer 141

Early diagnosis is key. The most favorable outcome is obtained following primary closure of the perforation with in 24hours, resulting in 80-90% survival. For adequate exposure, a dissection similar to a myotomy is performed. A flap of stomach is pulled up and the soiled fat pad at the GEJ is removed. The edges of the injury are trimmed and closed primarily. Closure is reinforced with a pleural patch or construction of a Nissen fundoplication. If the time delay before closing a perforation approached 24h and the tissues are inflamed, division of the cardia and resection of the diseased portion of the esophagus are recommended. The remainder of the esophagus is mobilized, and as much normal esophagus as possible is saved and brought out as an end cervical esophagostomy. If retained esophagus is so long that it loops down into the chest, the contaminated mediastinum is drained and a feeding jejunostomy tube is inserted. Nonoperative management has been advocated in select situations. The choice of conservative therapy requires skillful judgment and necessitates careful radiographic examination of the esophagus. This follows an injury occurring during dilation of esophageal strictures or pneumatic dilations of achalasia. Conservative management should NOT be used on patients who have free perforations into the pleural space.

Answer 142

Mortality associated with immediate closure varies between 8 and 20%. After 24h, survival decreases to <50%, and is not influenced by the type of operative therapy. The recovery from sepsis is often immediate, dramatic, and reflected by a marked improvement in the patient's condition over a 24-hour period. On recovery from sepsis, the patient is discharged and returns on a subsequent date for reconstruction with a substernal colon interposition. Failure to apply this aggressive therapy can result in a mortality rate in excess of 50% in those with a delayed diagnosis.

Answer 143

Conservative management should NOT be used on patients who have free perforations into the pleural space. Cameron proposed three criteria for NOM of esophageal perforation: 1) Esophagogram must show the perforation to be contained within the mediastinum and drain well back into the esophagus. 2) Symptoms should be mild, and 3) There should be minimal evidence of clinical sepsis. If these are met, it is reasonable to treat the patient with hyperalimentation, antibiotics, and cimetidine to decrease acid secretion and diminish pepsin activity. Oral intake is resumed in 7-14 days, dependent on subsequent radiographic examinations.

Answer 144

Acute upper GI bleeding following vomiting, which is considered to be the cause of up to 15% of all severe upper GI bleeds. The mechanism is similar to spontaneous esophageal perforation: an acute increase in intraabdominal pressure against a closed glottis in a patient with a hiatal hernia. The tears are characterized by arterial bleeding, which may be massive. The diagnosis needs a high index of suspicion, particularly in the patient who develops upper GI bleeding following prolonged vomiting or retching. Upper endoscopy confirms the suspicion by identifying one or more longitudinal fissures in the mucosa of the herniated stomach as the source of bleeding. In majority of patients, bleeding stops spontaneously with nonoperative management. In addition to blood replacement, the stomach should be decompressed and antiemetics administered, as a distended stomach and continued vomiting aggravate further bleeding. A Sengstaken-Blakemore tube will not stop the bleeding, as the pressure is not sufficient to overcome arterial pressure. Endoscopic injection of epinephrine may be therapeutic if bleeding does not stop spontaneously. Only occasionally will surgery be required to stop blood loss (laparotomy and high gastrostomy with oversewing of the linear tear). Mortality is uncommon, and recurrence is rare.

Answer 145

Children: Most likely accidental Adults/teenagers: Most likely deliberate Alkalis are more frequently swallowed accidentally than acids, because strong acids cause an immediate burning pain in the mouth.

Answer 146

Acute injury entails care to focus on controlling immediate tissue injury and potential for perforation. The degree and lesion's extent depends on: the nature of caustic substance, concentration, quantity swallowed, and time the substance is in contact with tissues. Chronic injury entails a focus on treatment of strictures and disturbances in pharyngeal swallowing. ALKALIS Dissolve tissue and penetrate more deeply. ACIDS Cause a coagulative necrosis that limits their penetration. The esophagus is more severely and preferentially affected at the level of striated-muscle-smooth-muscle interface (weakest point of contractions, slower clearance).

Answer 147

The lesions caused by lye injury occur in 3 phases. 1) Acute necrotic phase: 1-4 days post injury - Coagulation of intracellular proteins results in cell necrosis, and living tissue develops an intense inflammatory reaction. 2) Ulceration and granulation phase: 3-5 day post injury - Superficial necrotic tissue sloughs, leaving an ulcerated, acutely inflamed base, and granulation tissue fills the defect left by the sloughed mucosa. - Lasts 10-12 days - Esophagus is weakest at this period. 3) Cicatrization and Scarring (starts 3rd week post-injury) - formed connective tissue begins to contract, resulting in narrowing of esophagus - Adhesions betweeen granulating areas occur, resulting in pockets and bands. - Efforts must be made at this time to reduce stricture formation.

Answer 148

Initial/acute phase - Pain in the mouth and substernal region - Hypersalivation - Pain on swallowing - Dysphagia - Fever (consider esophageal lesion) - Bleeding - Vomiting Ulceration and granulation - Complaints disappear Cicatrization and scarring - Dysphagia reappears secondary to fibrosis and retraction, leading to narrowing of the esophagus - Of those who develop stricture formation: 60% do so in 1 month, and 80% do so in 2 months - If dysphagia does not develop within 8 months, it is unlikely that a stricture will occur. - Serious systemic reactions such as hypovolemia and acidosis resulting in renal damage can occur in cases in which the burns have been caused by strong acids. - Respiratory complications secondary to aspiration can happen.

Answer 149

Consider that esophageal burns can be present without apparent oral injuries. Hence early esophagoscopy is advocated to identify injuries (within 12 h). Radiographic examination is not a reliable means to identify the presence of early esophageal injury, but it is important in later follow-up to identify strictures.

Answer 150

First degree: Mucosal hyperemia and edema Second degree: Limited hemorrhage, exudate ulceration, and pseudomembrane formation Third degree: Sloughing of mucosa, deep ulcers, massive hemorrhage, complete obstruction of lumen by edema, charring, perforation

Answer 151

ACUTE PHASE - Correct hypovolemia - Broad spectrum antibiotics - Do an esophagoscopy within 12hours, and manage accordingly: 1st degree burn - Lye/alkali: Neutralize with 1/2 strength vinegar, lemon juice, or orange juice - Acid: Neutralize with milk, egg white, or antacids - Feeding jejunostomy tube for nutrition as necessary - Oral feeding can be started when the dysphagia of the initial phase has regressed. 2nd and 3rd degree burns - Exploratory laparotomy: a) Viable esophagus and stomach: - - Intraluminal esophageal stent - - Posterior gastric wall biopsy - - Jejunostomy b) Questionable esophagus and stomach - - Second look at 36hours c) Full thickness necrosis of esophagus and stomach - - Esophagogastric resection - - Cervival esophagostomy - - Jejunostomy - - Resection of adjacent involved organs - Extensive necrosis: resection - Extensive gastric involvement: Total gastrectomy and near-total esophagectomy - Air in the esophageal wall-- sign of muscle necrosis and impending perforation, and is a strong indication for esophagectomy - Intraluminal esophageal stent: For those operated on with no evidence of extensive esophagogastric necrosis. A biopsy of the posterior gastric wall should be done to rule out occult injury, and any questionable viability by histology should prompt a second look operation within 36h. The stent should be maintained for 21 days and removed after a satisfactory barium esophagogram. *CONTRAINDICATED: Sodium bicarbonate is NOT used because it generates CO2, which might increase the danger of perforation. - Emetics (vomiting renews contact of caustic substance with esophagus)

Answer 152

Antegrade dilation with a Hurst or Maloney bougie, and retrograde dilation with a Tucker bougie. An adequate lumen should be re-established within 6 months to 1 year, with progressively longer intervals between dilations. Otherwise operative intervention should be considered.

Answer 153

Surgical intervention is indicated when: 1) Complete stenosis, in which all attempts from above and below have failed to establish a lumen 2) Marked irregularity and pocketing on barium swallow 3) Development of a severe periesophageal reaction, or mediastinitis with dilatation 4) Fistula 5) The inability to dilate or maintain the lumen above a 40F bougie 6) A patient who is unwilling or unable to undergo prolonged periods of dilation.

Answer 154

In order of preference: 1) Colon 2) Stomach 3) Jejunum

Answer 155

When the cervical esophagus is destroyed, and a pyriform sinus remains open, the anastomosis can be made to the hypopharynx. When the pyriform sinuses are completely stenosed, a transglottic approach is used to perform an anastomosis to the posterior oropharyngeal wall.

Answer 156

Most acquired esophageal fistulas are to the tracheobronchial treee and secondary to either esophageal or pulmonary malignancy. Traumatic fistulas and those associated with esophageal diverticula account for the remainder. Fistulas associated with traction diverticula are usually due to mediastinal inflammatory disease, and traumatic fistulas usually occur secondary to penetrating wounds, lye ingestion, or iatrogenic injury.

Answer 157

Paroxysmal coughing following ingestion of liquids Recurrent or chronic pulmonary infections Onset of cough immediately after swallowing suggests aspiration, whereas brief delay suggests a fistula.

Answer 158

Surgical treatment of benign fistulas consists of division of the fistulous tract, resection of irreversibly damaged lung tissue, and closure of the esophageal defect. To prevent recurrence, a pleural flap should be interposed. Treatment of malignant fistulas is difficult especially post radiation. Generally, only palliative treatment is indicated, via a specially-designed esophageal endoprosthesis that bridges and occludes the fistula, allowing the patient to eat. A salivary tube is also a good option for proximal esophageal fistulas. This tube has a proximal "lip" that rests on the cricopharyngeal muscle and thereby directs the saliva into the tube and past the fistula. Last resort (rarely) is esophageal diversion with placement of a feeding jejunostomy.

Answer 159

Malignant and end-stage benign disease (reflux/drug-induced stricture formation that cannot be dilated without damage to the esophagus, a dilated and tortuous esophagus from severe motility disorders, lye-induced strictures, and multiple previous antireflux procedures).

Answer 160

The jejunum is a dynamic graft and contributes to bolus transport, whereas the stomach and colon function more as a conduit.

Answer 161

d. Esophagectomy

Answer 162

c. Gastrografin swallow study in 48 hours

Answer 163

B. Gastrografin esophagogram *Boerhaave's Syndrome: Violent retching, perforation at distal left wall

Answer 164

D. There are high amplitude pressures during manometry

Answer 165

E. Esophagectomy

Answer 166

D. Nissen fundoplication

Answer 167

E. Esophagectomy with cervical esophagostomy, gastrostomy and feeding jejunostomy

Answer 168

B. Esophagectomy alone

Answer 169

C. Gastrografin swallow study in 48 hours

Answer 170

A. Endoscopic Ultrasound (EUS)

Answer 171

Mucosa and muscularis propria (the esophagus has no serosa)

Answer 172

Inferior thyroid arteries (branch of thyrocervical trunk on the left and subclavian artery on the right)

Answer 173

Direct blood supply from 4 to 6 esophageal arteries off of the aorta; esophageal branches off of right (R) and left (L) bronchial arteries; supplemented by descending branches off the inferior thyroid arteries, intercostal arteries, and ascending branches of the paired inferior phrenic arteries

Answer 174

Left gastric artery and the paired inferior phrenic arteries

Answer 175

The submucosal venous plexus drains into the inferior thyroid veins (tributaries of L subclavian vein and R brachiocephalic vein)

Answer 176

The submucosal venous plexus of the thoracic esophagus joins with the more superficial esophageal venous plexus and the venae comitantes that surround the esophagus at this level This plexus then drains into the azygos veins on the right and the hemiazygos veins on the left.

Answer 177

Drains into both the systemic and portal venous systems through the Land R phrenic veins and the L gastric (coronary) vein and short gastric veins

Answer 178

Cervical esophagus receives branches from the cervical sympathetic trunk (from superior ganglion in the neck); the thoracic esophagus receives branches from the thoracic sympathetic trunk (from the stellate ganglion). which form an esophageal plexus that envelops the thoracic esophagus anteriorly and posteriorly; the distal thoracic esophagus receives innervation from the greater and lesser splanchnic nerves

Answer 179

Vagus nerve

Answer 180

Inner circular and outer longitudinal

Answer 181

Striated muscle (voluntary)

Answer 182

Smooth muscle (involuntary)

Answer 183

Cricopharyngeus muscle; compression by the left mainstem bronchus and aortic arch; diaphragm

Answer 184

The transition of the distal 1 to 2 cm of esophageal mucosa to cardiac mucosa/junctional columnar epithelium

Answer 185

The collar of Helvetius (loop of Willis) and the gastroesophageal fat pad

Answer 186

1) The squamocolumnar epithelial junction (Z-line), provided the patient does not have Barrett esophagus 2) The transition from the smooth esophageal lining to the rugal folds of the stomach

Answer 187

1) Elevation of the tongue, 2) Posterior movement of the tongue, 3) Elevation of the soft palate, 4) Elevation of the hyoid, 5) Elevation of the larynx, 6) Tilting of the epiglottis

Answer 188

Progressive contractions (2 to 4 cm/s) that move down the esophagus and reach the LES after the initiation of swallowing (-9 seconds)

Answer 189

Progressive contractions generated from distention/irritation of the esophagus or from an independent local reflex to clear the esophagus of material that was left behind after a primary peristaltic wave rather than voluntary swallowing

Answer 190

Uncoordinated contractions of smooth muscle that are nonprogressive, nonperistaltic, monophasic, or multiphasic simultaneous waves that can occur either after voluntary swallowing or spontaneously between swallows

Answer 191

50 to 70mmHg

Answer 192

12 to 14 mm Hg

Answer 193

Zenker diverticulum and epiphrenic diverticulum

Answer 194

Parabronchial (midesophageal) diverticulum.

Answer 195

Barium esophagram

Answer 196

Typically present on the right secondary to the overabundance of structures in the midthoracic region of the left chest

Answer 197

If a symptomatic patient with inflamed mediastinal lymph nodes from tuberculosis or histoplasmosis, treat medically with anti-tuberculin or antifungal agents; if diverticulum <2 cm, observe; if patient symptomatic or diverticulum >2 cm, perform diverticulopexy (suspend from thoracic vertebral fascia). and a long esophagomyotomy is indicated in patients with severe chest pain or dysphagia and a documented motor abnormality

Answer 198

If diverticula <2 cm, perform diverticulopexy; in patients with severe chest pain, dysphagia, or a documented motor abnormality, perform long esophagomyotomy: if diverticulopexy, begin long esophagomyotomy at the neck of diverticulum and extend onto LES; and if diverticulectomy, perform esophagomyotomy on opposite esophageal wall, extending from the level of the diverticulum onto the LES; if large associated hiatal hernia, perform diverticulectomy, long esophagomyotomy, and repair of hiatal hernia

Answer 199

Point of potential weakness at the transition between the oblique fibers of the thyropharyngeus muscle and the horizontal fibers of the cricopharyngeus muscle

Answer 200

If diverticulum > 3 cm, do a cricopharyngeal myotomy with diverticulectomy with TA stapler versus invert and perform diverticulopexy to precervical fascia through a left neck incision If <2 cm - leave alone

Answer 201

Cricopharyngeus muscle, iatrogenic

Answer 202

(1) Treatment of contamination with broad-spectrum antibiotics and antifungals. (2) Wide local drainage. (3) Source control with covered esophageal stents or VATS. (4) Enteric feeding access with G or Jtubes.

Answer 203

Gastrografin esophagram

Answer 204

Barium esophagram

Answer 205

Regurgitation. globus sensation. dysphagia. GERD, noncardiac chest pain. esophageal neoplasm

Answer 206

Pressure < 6 mm Hg total length < 2 cm abdominal length < 1 cm

Answer 207

LES with a sphincter pressure above the ninety-fifth percentile of normal

Answer 208

Hypertensive LES resting pressure, incomplete or nonrelaxing LES, aperistalsis of the esophageal body, esophageal pressurization, and elevated lower esophageal baseline pressure

Answer 209

Esophageal manometry

Answer 210

Primary destruction of nerves to the LES with secondary degeneration of the neuromuscular function of the body of the esophagus from idiopathic or infectious neurogenic degeneration

Answer 211

Dysphagia, regurgitation, weight loss

Answer 212

Squamous cell carcinoma

Answer 213

Heller myotomy

Answer 214

Simultaneous, multipeaked contractions of high amplitude(> 120 mm Hg) or long duration (>2.5 seconds)

Answer 215

Medical treatment or endoscopic intervention (nonsurgical)

Answer 216

Incapacitating chest pain or dysphagia after failure of medical and endoscopic therapy or presence of a pulsion diverticulum of the thoracic esophagus

Answer 217

Long esophagomyotomy with the proximal extent high enough to include the entire length of the abnormal motility as determined by manometric measurements and the distal extent of the myotomy down onto the LES, with or without extension onto the stomach through a left tboracotomy or a left video-assisted technique; Dor fundoplication can be performed to provide protection from reflux and prevent healing of the myotomy site.

Answer 218

Manometry demonstrating high-amplitude peristaltic contractions with normal relaxation of LES Peristaltic esophageal contractions 2 standard deviations above the normal values on manometric tracings (amplitudes >400 mm Hg)

Answer 219

Medical (calcium channel blockers, nitrates, and antispasmodics) for temporary relief during acute spasms; avoidance of caffeine, cold, and hot foods

Answer 220

Elevated LES pressure (> 26 mm Hg) and normal relaxation of the LES

Answer 221

Initially endoscopically with Botox injections and hydrostatic balloon dilation; surgery indicated in symptomatic patients who fail interventional treatments

Answer 222

Laparoscopic modified Heller esophagomyotomy with a partial antireflux procedure (Dor, Toupet) in patients with normal esophageal motility

Answer 223

The sum total of the number of low-amplitude contractions ( <30 mm Hg) and nontransmitted contractions exceeds 30% of wet swallows

Answer 224

Prevention with effective treatment of GERD; altered motility is irreversible

Answer 225

Acid suppression medication and EGD every 3 to 5 years

Answer 226

Acid suppression medication and surveillance endoscopy performed at 6 to 12 months

Answer 227

Confirmation of pathology by two experienced pathologists. ( 1) Esophagectomy or (2) endoscopic mucosal resection with radiofrequency ablation or (3) endoscopic surveillance every 3 months. Choice of treatment will depend on if patient is a surgical candidate.

Answer 228

Right subclavian artery arising from the descending aorta and traveling behind the esophagus in its course to the right upper extremity

Answer 229

An anomaly of the pulmonary arterial trunk where the left pulmonary artery arises from the right pulmonary artery (instead of the main pulmonary artery trunk) and courses between the trachea and the esophagus with resultant significant anterior compression of the esophagus

Answer 230

Tracheal stenosis and left pulmonary artery narrowing

Answer 231

Open sternotomy with cardiopulmonary bypass and anatomic repositioning of the great vessels

Answer 232

A result of reflux esophagitis versus overcontractility of the circular esophageal musculature of the inferior esophageal sphincter combined with the sliding gastric mucosa of a hiatal hernia results in persistent apposition of the 2 mucosal layers and fibrosis of the submucosal layer below

Answer 233

Barium esophagram

Answer 234

No treatment

Answer 235

Administration of oral papain (2.5% solution) in 5-mL aliquots every 30 minutes for a total of 4 doses for proteolytic digestion of impacted protein food; intravenous (IV) meperidine (25-50 mg) to encourage spontaneous dislodgment of the impacted food bolus; esophagoscopy with the use of an overtube (rigid or flexible) for extraction

Answer 236

Disruption of the ring by oral dilation (SO-French tapered Maloney bougie) with sequential bougienage dilation as symptoms recur

Answer 237

Patients who fail bougienage or have intractable reflux, intraoperative bougienage followed by a Nissen fundoplication is recommended, but excision of the ring is not indicated

Answer 238

Intraoperative bougienage followed by Nissen fundoplication without excision of the ring

Answer 239

Esophageal web has squamous cell epithelium above and below the web. Schatzki ring is composed of esophageal epithelium above and gastric epithelium below the ring.

Answer 240

Membranous disruption through an endoscope or bougie, versus piecemeal excision with biopsy forceps, versus laser lysis, versus balloon dilation

Answer 241

Surgical mucosal resection via a transcervical or transthoracic approach, longitudinal myotomy created and circumferential excision of the web performed, mucosa is circumferentially reapproximated with interrupted absorbable sutures, and muscle is closed longitudinally

Answer 242

A smooth, well-defined, noncircumferential mass with distinct borders

Answer 243

Surgical enucleation; observation acceptable in patients with significant comorbidities or with small ( <2 cm) asymptomatic tumors

Answer 244

Sliding hiatal hernia; simple herniation of GE junction into chest

Answer 245

GE junction remains at esophageal hiatus and gastric fundus herniates alongside the esophagus into the chest

Answer 246

Combination of type I and type II hiatal hernia; GE junction and gastric fundus/body in chest

Answer 247

Advanced stage of hiatal hernia with entire stomach and other intraabdominal content herniated into the chest

Answer 248

Liquefaction necrosis

Answer 249

Coagulation necrosis

Answer 250

1) Acute necrosis, ulceration and granulation 2) Cicatrization 3) Scarring

Answer 251

Superficial mucosal burn, mucosal edema, and hyperemia

Answer 252

Transmucosal injury, patchy ulcerations, exudates, sloughing mucosa

Answer 253

Transmucosal injury, circumferential injury

Answer 254

Transmural injury with periesophageal/perigastric extension; deep ulcerations; black/gray discoloration; full-thickness necrosis

Answer 255

Grades IIB and III

Answer 256

Neutralization with half-strength vinegar or citrus juice

Answer 257

Neutralization with milk, egg whites, or antacids

Answer 258

Observation and oral nutrition when the patient can painlessly swallow saliva

Answer 259

48 hours of observation and oral nutrition when the patient can painlessly swallow saliva; repeat endoscopy and barium esophagram are performed in follow-up at intervals of 1, 2, and 8 months

Answer 260

Monitor in the ICU and keep NPO with IV fluids; start IV antibiotics and a proton pump inhibitor; if evidence of acute airway involvement, airway obstruction can be relieved with aerosolized steroids with the possible need for fiber-optic intubation

Answer 261

Exploratory laparoscopy in stable patients or laparotomy in unstable patients

Answer 262

The viable stomach and esophagus are left in situ, and a feeding jejunostomy tube is placed with endoscopic placement of an esophageal stent

Answer 263

The questionable esophagus and stomach are left in situ with a second-look operation performed in 36 hours, with further management based on the findings

Answer 264

Resection of the esophagus, stomach, and all affected surrounding organs and tissues; creation of an end-cervical esophagostomy; and placement of a feeding jejunostomy

Answer 265

After re-epithelialization, aggressive treatment with bougie dilation, regardless of symptoms; dilations performed daily for 2 to 3 weeks, then every other day for 2 to 3 weeks, then weekly for months and lengthening the interval as time passes

Answer 266

Gastric pull-up, jejunal interposition, colon interposition

Answer 267

Adenocarcinoma

Answer 268

Lower one-third of the esophagus

Answer 269

Upper two-thirds of the esophagus

Answer 270

Bleeding, airway injury, insufficient conduit length, thoracic duct injury, respiratory (pneumonia), esophageal conduit necrosis, anastomotic leak, anastomotic stricture, hoarseness, chylothorax, transhiatal herniation of abdominal contents

Answer 271

``` Turbid, milky white fluid; specific gravity 1.020 to 1.030; protein content 3 to 4 g/100 mL; fat content 1 to 4 g/ 100 mL; triglyceride content > 110 mg/dL ```

Answer 272

Nonoperative management (should stop spontaneously)

Answer 273

Initially, nonoperative management; if not resolved or significantly improved in 5 to 7 days, perform operative duct ligation

Answer 274

Early duct ligation

Answer 275

Answer: D. The thoracic duct ascends in the mediastinum parallel to the esophagus and can easily be injured during mobilization for esophagectomy. Lymphatic leaks from lymph node dissections are often trivial and will usually seal on their own with no intervention.

Answer 276

Answer: D In a patient with reflux symptoms and Barrett epithelium, this is an indication for antireflux surgery, that is, Nissen fundoplication.

Answer 277

Answer: B. Barrett esophagus is an acquired condition thought to be caused by chronic reflux. It is associated with ulceration and stricture and has a higher rate of malignant degeneration than normal esophageal endothelium.

Answer 278

Answer: B. Patients with anastomotic leaks at the cervical area need to be made NPO; given antibiotics; and have the neck wound explored, debrided, and drained. Revising the anastomosis is unlikely to be successful due to inadequate length and friability of the tissues. In cases of catastrophic conduit necrosis, the esophagus can be diverted proximally and reconstruction performed in a delayed fashion with alternative conduits (jejunum, colon)

Answer 279

Answer: D. Boerhaave ruptures normally occur in this area after periods of coughing or retching. The patient will normally present with severe chest pain, fever, and subcutaneous emphysema.

Answer 280

Answer: D. Symptoms may vary, but this is largely a progressive disease. Smaller diverticuli may be left in situ; however, the key aspect to the procedure is to release the cricopharyngeal muscle by performing an adequate myotomy. The patient is at a higher risk for recurrence if an appropriate myotomy is not made.

Answer 281

Answer: B. Caustic injuries can cause catastrophic damage to the esophagus; aggressive management is necessary. An EGD should be the first invasive test to assess the degree of damage to the esophageal mucosa and needs to be serially repeated throughout the healing process. There is no role for exploratory surgery in the absence of perforation or sepsis.

Answer 282

Answer: D. An aberrant right subclavian artery is a common anomaly. Normally, it doesn't cause any symptoms and the patient can be reassured. In a patient with no symptoms of dysphagia and concomitant morbid obesity, there is little doubt that food intake is a problem and no specific treatment is necessary. In patients who present with dysphagia and weight loss, this can be termed "dysphagia lusoria" and consideration is made for reimplantation or bypass of the subclavian artery to provide relief of the esophageal obstruction.

Answer 283

Answer: B. A patient with a contained esophageal perforation may be treated conservatively, provided there are no systemic signs of sepsis or peritonitis. These patients often heal within 2 weeks. Surgery should be reserved for patients who develop peritoneal signs, a leukocytosis, or an uncontained perforation. Esophageal stenting is a novel approach, but it would be difficult to place at the GE junction to create a good seal without creating significant reflux. The role of endoluminal repair is evolving and is not currently a standard approach.

Answer 284

Answer: A. In a septic patient with conduit necrosis, the best choice is a damage control-type procedure: resect the obviously necrotic gastric conduit and perform an esophageal diversion (Spit fistula). Presumably, the patient already has a Jtube for enteral feeds from the first operation. This will allow for resuscitation and stabilization, and delayed reconstruction can be considered with alternative conduits. There is no role for a complex operation in a septic patient with a failed bypass.

Answer 285

Answer: C. Schatzki ring is a fibrous thickening in the esophagus that causes narrowing. It is nonmalignant in nature. Biopsies reveal stratified squamous cells above the ring and columnar cells distally. The treatment of choice is esophageal dilation.

Answer 286

Answer: C. The symptoms he presents with are consistent with a Zenker diverticulum, especially given his history of recurrent pneumonia. The best initial test for diagnosis of a suspected Zenker diverticulum is a barium esophagogram

Answer 287

Answer: C.? Stricture is a known late complication of esophagectomy. If patients are symptomatic with dysphagia to solids and having issues maintaining weight, the treatment of choice is esophageal dilation.

Answer 288

Answer: A. Patients found to have Barrett esophagus with low-grade dysplasia should undergo screening EGD in 6 to 12 months with 4-quadrant biopsy every 1 cm in concerning areas. B is appropriate for Barrett esophagus without dysplasia. C is appropriate for Barrett esophagus with high-grade dysplasia. D is appropriate for esophageal carcinoma.

Answer 289

Answer: A. Based on her esophagram findings, she has achalasia. Achalasia is associated with a hypertensive LES with a diffuse dilation of the intrathoracic esophagus that is aperistaltic. B is a manometry finding associated with scleroderma. C is associated with nutcracker esophagus. D is associated with diffuse esophageal spasm.

Answer 290

ANSWER: B COMMENTS: The esophagus is a two-layered muscular tube, and it is approximately 25 to 30 cm in length. The esophagus is unique from the other parts of the alimentary tract in its lack of a serosal layer. The inner circular muscle is an extension of the cricopharyngeus muscle. Two nerve plexuses, the Meissner’s and Auerbach’s plexuses, are found in the submucosa and between the muscle layers of the esophagus, respectively. They comprise the intrinsic autonomic nerve system of the esophagus and are responsible for peristalsis. Three distinct anatomic constrictions of the esophagus occur at the level of the cricopharyngeus muscle (approximately 14 mm), left mainstem bronchus (15 to 17 mm), and the diaphragmatic hiatus (16 to 19 mm), in order of increasing diameter.

Answer 291

ANSWER: C COMMENTS: The upper and LESs are high pressure zones rather than actual anatomic landmarks. The cricopharyngeus muscle is thought to be the main contributor to the upper high-pressure zone. When swallowing, UES pressure can reach 90mmHg and return to an average resting pressure of 60 mmHg. The LES is characterized by a resting pressure zone of approximately 6 to 26 mmHg and measures 2 to 5 cm in length. Vagus-mediated relaxation of the LES occurs during normal food transit. Gastrin and motilin increase LES pressure, whereas cholecystokinin and secretin decrease LES pressure.

Answer 292

ANSWER: C COMMENTS: The blood supply to the cervical esophagus arises from the inferior thyroid arteries, a branch from the thyrocervical trunk of the right subclavian artery. The proximal thoracic esophagus receives its blood supply from the bronchial arteries. The distal thoracic esophagus receives its blood supply from direct branches arising from the aorta. The intraabdominal esophagus receives its blood supply from the inferior phrenic arteries. The short gastric arteries cross the gastrosplenic ligament arising from the end of the splenic artery and anastomosing with the branches of the left gastric and left gastroepiploic arteries.

Answer 293

ANSWER: D COMMENTS: Esophageal contractions are controlled by the swallowing center located in the medulla. Swallowing is a complex series of coordinated events, which can be broken down into the oral, pharyngeal, and esophageal phases. The oral phase is voluntary and controlled by the medial temporal lobes and limbic system of the cerebral cortex. When a food bolus is passed to the pharyngeal phase, it becomes involuntary. This phase involves the closure of the larynx, protecting the airway, via elevation of the hyoid among other coordinated events. The food bolus eventually passes through the UES to begin the esophageal phase. Esophageal peristalsis is separated into primary, secondary, and tertiary peristalsis as delineated on manometry. Primary peristalsis is triggered voluntarily after swallowing but becomes involuntary after initiation. Waves travel the entire length of the esophagus and work to propel the food bolus toward the stomach. Secondary peristalsis is involuntary and triggered by esophageal distension or irritation. They are thought to have defensive purposes working to propel reflux contents back toward the stomach. Tertiary peristalsis involves uncoordinated waves that are nonprogressive and nonperistaltic, representing smooth muscle contractions and related to motility disorders and spasm.

Answer 294

ANSWER: A COMMENTS: A number of lifestyle factors have been found to be associated with GERD, including acidic liquids and foods, smoking, drinking, obesity, supine sleeping, and certain medications. Although modification of these associated risk factors is plausible and has proven benefits in symptoms of GERD patients, they are limited and often provide inconsistent relief. Smoking has been proven to cause decreased pressure of the LES on high resolution manometry immediately after smoking; the pressure returns to baseline several minutes after completion. Cigarettes also lead to decreased saliva production and decreased contractility, leading to prolonged acid secretion, and impair the pharyngeal/UES reflex during deglutition.

Answer 295

ANSWER: A COMMENTS: The principles of antireflux surgery (ARS) that have been studied and accepted are hiatal dissection and closure, lengthening of the intraabdominal esophagus, division of the short gastric vessels, creation of a short (2 cm) and floppy fundoplication, and the use of a bougie. Common techniques often used by many surgeons but not well established are fixation of wrap, use of pledgets, bougie size, and number of sutures used.

Answer 296

ANSWER: D COMMENTS: The indications for ARS are severe esophageal injury, incomplete resolution of symptoms with medical therapy, patient preference against long-term pharmacologic therapy, or complications from a hiatal hernia. The success of ARS depends on the accuracy of diagnosing GERD, which can be enhanced by monitoring pH. The DeMeester score is used to assess the degree of abnormality (>14) of the pH study. The presence of a short esophagus requires a lengthening procedure such as a Collis gastroplasty in addition to fundoplication, but it is not a contraindication to ARS. The presence of high-grade dysplasia within a Barrett’s esophagus requires resection and is a contraindication to ARS.

Answer 297

ANSWER: C COMMENTS: The long-term success rate of ARS approaches 90% with approximately a 1%-per-year failure rate. The most common operative finding on repeated fundoplication is a herniated fundoplication (33%) above the diaphragm, followed by a disrupted wrap (18%), a tight wrap (13%), and a slipped wrap (10%) onto the body of the stomach.

Answer 298

ANSWER: C COMMENTS: TIF is a totally endoscopic procedure for performing a partial fundoplication using T-bar fasteners. This wrap is usually performed as a 270-degree to 290-degree wrap. It is not approved as a modality to treat hiatal hernias >2 cm but is approved to reduce hernias <2 cm. This is performed using a suction traction device to pull the stomach downward. Several studies with 12-month follow-up data have reported more than 90% of patients remaining off proton pump inhibitors (PPIs). No trial has compared TIF to surgical ARS, and longer-term follow-up studies are required. ARS remains an option after TIF if the wrap has failed. Radiofrequency ablation is a therapeutic modality utilized in the treatment of Barrett’s esophagus with high-grade dysplasia and is an endoscopic treatment option (Stretta). This technique is thought to bulk the LES with fibrotic reaction changes thus decreasing reflux. TIF does not provide a cruroplasty as part of the repair of small hiatal hernias.

Answer 299

ANSWER: E COMMENTS: A 2-cm floppy wrap is recommended, providing adequate control of reflux. Longer wraps may control reflux better but have been associated with increased symptoms of dysphagia. The intrathoracic esophagus is mobilized to lengthen the intraabdominal portion in an attempt to relocate the LES at its physiologic level. This typically requires at least 2 to 3 cm of mobilization. Pneumoperitoneum during laparoscopic dissection can artificially make this length appear longer intraoperatively. Use of mesh to buttress hiatal hernia repairs is typically used in large defects, defined as >5 cm, or when crural dissection has left much of the peritoneum stripped. There is no consensus on the use of mesh; however, the use of permanent mesh has been largely abandoned due to problems with erosion. Often, dissection of large hernias results in the entering of one or both of the pleural spaces. Carbon dioxide is rapidly resorbed and does not require repair or tube thoracostomy. Shortened esophagus is relatively uncommon in smaller hiatal hernias with a higher incidence in large hiatal hernias, peptic strictures, and reoperative ARS. Insufficient mobilization of intraabdominal esophagus can result in high rates of recurrence, up to 40% in large and giant hernias. Creation of a tension-free wrap then requires lengthening of the esophagus via Collis gastroplasty. This involves excising a portion of the cardia, creating a “neo-esophagus,” and thus moving the gastroesophageal junction (GEJ) and angle of His into the abdominal cavity.

Answer 300

ANSWER: D COMMENTS: The Belsey Mark-IV operation recreates the LES while reducing an intrathoracic stomach and closing a hiatal defect. This operation is approached via a left thoracotomy, allowing the surgeon to avoid a hostile abdomen and is typically reserved for redo situations in the current era of laparoscopic Nissen fundoplication. This approach can also be useful in the dissection of large and giant chronic paraesophageal hernias. The Belsey Mark-IV provides a 240-degree partial wrap, imbricating cardia against the distal esophagus. Each of the other operations requires an abdominal approach. The Toupet is a 270-degree, posterior partial wrap, while the Dor is a 180-degree anterior partial wrap. The Hill operation focuses on the creation of a gastroesophageal flap valve in an attempt to recreate normal anatomy. Gastropexy is reserved for the highest-risk patients with hernias at risk for volvulus and can include a percutaneous endoscopic gastrostomy tube. This, however, should not be considered in patients with significant abdominal surgical histories.

Answer 301

ANSWER: C COMMENTS: Benign tumors of the esophagus are rare and represent less than 1% of esophageal neoplasms. Leiomyomas account for 60% of these lesions and are often found in the distal two-thirds of the esophagus. Most of these tumors are asymptomatic. Pain and dysphagia are the most common complaints. They have a characteristic smooth filling defect on contrast-enhanced study and are described as a hypoechoic mass within the submucosa or muscularis propria on EUS. Recently, they have been classified as a gastrointestinal stromal tumor. Most of these tumors occur from mutations of the c-KIT oncogene. Leiomyomas are removed by enucleation, and biopsy should be avoided because of the increased risk for perforation.

Answer 302

ANSWER: C COMMENTS: Factors that contribute to the failure of the intrinsic antireflux mechanism are intraabdominal LES length less than 1 cm, LES resting pressure less than 6 mmHg, the presence of esophageal dysmotility, LES total length less than 2 cm, and a low attachment of the phrenoesophageal ligament

Answer 303

ANSWER: A COMMENTS: This patient has achalasia, an esophageal motility disorder affecting 1 in 10,000. Its exact etiology is unknown, and it results from an uncontrolled balance of excitatory and inhibitory signals. Symptoms may be vague but typically involve dysphagia, regurgitation, and weight loss. Its diagnosis can be made by a characteristic distal narrowing on esophagogram, creating the classic “bird’s beak” appearance. Manometry is required to confirm the diagnosis and typically displays aperistalsis with a hypertensive resting LES that fails to relax with deglutition (Table 20.1 and Fig. 20.1). High-amplitude waves, pressure, and prolonged contraction waves are characteristic of Nutcracker esophagus. These waves result in typically complete propagation and in LES relaxation. Uncoordinated peristalsis is present in diffuse esophageal spasm (DES). The normal resting pressure of the LES is between 15 and 25 mmHg.

Answer 304

ANSWER: B COMMENTS: Heller myotomy remains the most common surgical treatment for achalasia. This can be performed open or laparoscopically and begins with hilar dissection and mobilization of intrathoracic esophagus for visualization. A myotomy is performed to release the LES to provide symptomatic relief and typically begins just proximal to the GEJ anteriorly and extends a minimum of 5 cm cephalad and 2 to 3 cm caudad. It is important that both longitudinal (outer) and circular (inner) muscle layers be released. An antireflux component is routinely added as postoperative reflux can be disabling after myotomy. Typically, a partial wrap, either the Dor or Toupet, is used because of fear of recurrent dysphagia with complete Nissen wrap, although this has been successfully utilized. No wrap has been proven to be superior. Entrance into the esophageal lumen requires repair with the creation of a new myotomy site. Nonsurgical options include Botox injections and pneumatic dilation. Botox injections provide good relief but lack durability with recurrent symptoms typically occurring 1 to 4 months after injection. Additionally, Botox can significantly increase the difficulty of surgical myotomy and should only be reserved for nonsurgical candidates. Pneumatic dilation provides good relief of dysphagia but lacks durability, often requiring repeat dilations with up to half of the patients at 5 years having recurrent symptoms. The most devastating complication of dilation is esophageal perforation, and it occurs in up to 4% of patients. Peroral endoscopic myotomy, POEM, is an interesting endoscopic approach to performing a surgical myotomy and has been shown to have good results.

Answer 305

ANSWER: C COMMENTS: The rate of esophageal perforation after endoscopic pneumatic dilation is low (4%). Early diagnosis plus treatment of esophageal perforation is associated with improved survival. In stable patients with a contained perforation, there is a role for nonoperable management consisting of nothing by mouth and intravenous antibiotics. If the perforation is because of an underlying pathology that causes distal obstruction (e.g., achalasia, esophageal cancer, or stricture), the operative treatment must address the underlying disease. A myotomy should be performed in patients with achalasia and esophagectomy considered only in those with a sigmoid esophagus or megaesophagus.

Answer 306

ANSWER: B COMMENTS: Vascular rings are a known cause of tracheoesophageal compressive symptoms. They typically present the children as diet is transitioned from milk to solids but can vary widely in presentation. A left pulmonary artery arising from the right pulmonary artery and a double aortic arch may form a sling around the esophagus and cause symptoms of dysphagia but typically present at a younger age. The left common carotid arising from the brachiocephalic artery is a normal variant of arch anatomy; it is asymptomatic and referred to as a bovine arch. An aberrant right subclavian artery that arises from the descending aorta and travels posterior to the esophagus can present as dysphagia in the adult. Surgical correction is required in the symptomatic patient and involves ligation at its origin and reimplantation on the right common carotid artery.

Answer 307

ANSWER: A COMMENTS: DES is a poorly understood motility disorder of the esophagus. Chest pain and dysphagia are often present. The diagnosis is made by esophagography demonstrating a classic picture of a corkscrew esophagus (Fig. 20.2). Manometry will show simultaneous multipeaked contractions similar to those seen in achalasia; however, the LES will have normal receptive relaxation. A variant of achalasia in which amplitude pressure is normal or elevated is also known as vigorous achalasia. Pharmacotherapy (nitrates, calcium channel blockers, and phosphodiesterase inhibitors) aimed at smooth muscle relaxation is the first-line treatment of DES. Bougie or pneumatic dilations are used with variable results for severe dysphagia with documented LES hypertension. Surgery, which involves a long esophagomyotomy from the level of the aortic arch to the LES, is reserved for patients who fail pharmacologic and endoscopic therapies.

Answer 308

ANSWER: E COMMENTS: Esophageal diverticula may be classified by type (true or false), location, and pathophysiology (traction or pulsion). Parabronchial diverticula are the only true diverticula and result from traction associated with inflamed mediastinal lymph nodes. Epiphrenic diverticula are false resulting from pulsion and occur in the distal esophagus. Zenkers, or pharyngoesophageal, diverticula occur in Killian’s triangle at the level of the cricopharyngeus and are thought to be the result of increased pressure and pulsion during swallowing. Symptoms involve dysphagia, halitosis, and regurgitation. Symptomatic Zenkers requires surgical therapy. Diverticulopexy and myotomy remain the preferred approaches, minimizing potential salivary fistulas that diverticulectomy predisposes. For small diverticula, myotomy alone has proven sufficient. Videoendoscopic stapling via esophagodiverticulostomy combines the myotomy and enlarges the pouch but is contraindicated in diverticula <3 cm. This is because there is insufficient room for placement of the stapler jaws.

Answer 309

ANSWER: D COMMENTS: Esophageal mucosal injuries result from reflux of gastric juice that may contain bile salts from the duodenum. Within a pH range of 2 to 6.5, bile salts are soluble and nonionized; they are therefore better absorbed by esophageal mucosa cells and cause the greatest cell damage. Barrett’s esophagus is a condition in which intestinal columnar epithelium replaces the esophageal squamous epithelium as a result of inflammation secondary to chronic reflux. The metaplastic cells are more resistant to injury from reflux but are more prone to malignant transformation. Barrett’s esophagus is found in 10% of patients with GERD, and more than 70% of cases are found in men aged 55 to 63 years. Patients with Barrett’s esophagus have a 40-fold increased risk for esophageal carcinoma.

Answer 310

ANSWER: E COMMENTS: The treatment of Barrett’s esophagus varies depending on the presence or absence of dysplasia and whether it is low or high grade. The differentiation between low-grade dysplasia (LGD) and high-grade dysplasia (HGD) is purely histologic and subjective with reported interobserver variability (LGD < 50% agreement vs. HGD 85% agreement). Barrett’s without dysplasia may be observed every 3 to 5 years via endoscopy with biopsies. Treatment consists of managing the acidic reflux and includes medical therapy with PPI and ARS. LGD requires initial 6-month surveillance endoscopies with biopsies performed in four quadrants every 1 cm with subsequent endoscopies yearly. HGD should be treated; if it is not treated, it should be surveilled every 3 months. Endoscopic therapies for dysplasia include radiofrequency ablation and PDT; however, no head-to-head trial has been performed to show superiority. Endoscopic mucosal resection, EMR, is a less invasive option for evaluation of the depth of lesions as well as resection of HGD and early adenocarcinoma, T1a lesions <2 cm. The risk of progression of HGD to adenocarcinoma is 6% per year; for nondysplastic Barrett’s esophagus, it is approximately 0.5% per year, which is similar to colon polyps.

Answer 311

ANSWER: C COMMENTS: Mallory-Weiss tears are linear tears in the esophagogastric mucosa that cause bleeding in patients with repeated emesis. The diagnosis is made by endoscopy, and most bleeding stops spontaneously. Because the source of the bleeding is arterial, pressure tamponade is not helpful and may lead to perforation of the esophagus. For refractory bleeding, endoscopic injection or cautery can be used, but definitive treatment requires a gastrotomy and suture ligation.

Answer 312

ANSWER: A COMMENTS: Schatzki rings are concentric constrictions of the distal end of the esophagus (Fig. 20.3) occurring at the squamocolumnar junction; as a result, there is esophageal mucosa above and gastric mucosa below. The rings consist of muscularis mucosa, connective tissue, and submucosal fibrosis. Treatment involves oral dilation, which can provide relief for up to 18 months. Excision of the rings should be avoided because the esophageal strictures that result from resection are much more difficult to manage.

Answer 313

ANSWER: A* COMMENTS: Esophageal cancer is the sixth most common malignancy and has an incidence of 20 per 100,000 in the United States. Worldwide, squamous cell carcinoma is the most common type; however, in the United States, adenocarcinoma accounts for up to 70% of patients with esophageal cancer. The male-to-female ratio is 3:1 for squamous cell carcinoma and 15:1 for adenocarcinoma. In addition, squamous cell carcinoma mainly affects African-American men, whereas adenocarcinoma mainly affects white men. Alcohol and tobacco smoking increase the risk for esophageal cancer fivefold each and 25-fold to 100-fold in combination. Additives such as nitrosamines in pickled and smoked foods have been implicated in the risk for cancer.

Answer 314

ANSWER: E COMMENTS: Many imaging modalities are available for the characterization of esophageal cancers. Barium esophagography is a good first test for patients with dysphagia and a history suspicious for cancer. Although CT is accurate for M staging, it is only 57% accurate for T staging. PET is an excellent tool that can be used to evaluate N and M staging but should not be used as a single diagnostic modality. MRI is excellent for detecting metastatic and T4 lesions. EUS is the most important diagnostic tool in esophageal cancer staging. Tissue samples can be obtained from lymph nodes, as well as from the primary lesion. EUS is more sensitive and specific than CT in evaluating the celiac lymph nodes.

Answer 315

ANSWER: C COMMENTS: The risk of lymph node involvement is directly proportional to tumor depth or T stage. The incidence of positive lymph nodes is: 18% for T1a intramucosal, 55% for T1b submucosal, 60% for T2 not beyond the muscularis propria, 80% for T3 with the involvement of paraesophageal tissue but not adjacent structures, and 100% for T4 with the involvement of adjacent structures. This is related to the anatomy of lymphatic drainage in the esophagus. The lymph channels travel within the submucosa in an axial fashion, allowing cancer to travel significant distances in cranial and caudal directions before causing an obstruction or draining beyond the muscularis.

Answer 316

ANSWER: A COMMENTS: Treatment of esophageal cancer is complex, and multiple modalities are often necessary. The decision regarding treatment options depends on whether the intent is curative or palliative. Squamous cell carcinoma is much more radio responsive than adenocarcinoma, although with the latter, a complete histologic response is seen in approximately 25% of patients undergoing neoadjuvant chemoradiation therapy. Neoadjuvant radiation therapy is limited to 4500 cGy to avoid the surgical morbidity associated with high-dose radiation. Cisplatin, in combination with 5-fluorouracil and epirubicin, is an established chemotherapy regimen, but the use of mitomycin C, etoposide, and paclitaxel as third agents is gaining favor. Stage I disease is best treated with curative surgical resection.

Answer 317

ANSWER: B COMMENTS: Transhiatal esophagectomy was first described by Wolfgang Denk in 1913 and popularized by Orringer in the 1980s. Incisions on the left side of the neck and abdomen are used, and a thoracotomy is avoided. The esophagus is bluntly dissected, and the tabularized stomach is pulled through the posterior mediastinum to create a cervical esophagogastric anastomosis. The blood supply to the gastric conduit is based on the right gastroepiploic artery. A gastric pull-up procedure, based on the right gastroepiploic artery, in the posterior mediastinal position has the best functional result. Alternative routes (subcutaneous, substernal, or right pleural space) or conduits (colon or jejunum) can be used but result in an inferior function. Thoracic anastomosis, as the result of an Ivor-Lewis esophagectomy, results in a lower leak rate but carries a much higher morbidity and mortality as a result of associated mediastinitis. Thoracic esophagectomy is also associated with a greater lymphadenectomy due to direct access of the mediastinum for dissection. This has not been equivocally proven to yield improved disease-free or overall survival. When all three incisions are combined (cervical, thoracotomy, and laparotomy), this is referred to as a three hole, or a McKeown.

Answer 318

ANSWER: C COMMENTS: The goal of palliative care is to relieve suffering and improve the overall quality of life by reducing tumor burden and restoring nutritional access. Chemotherapy, radiation therapy, PDT, laser treatment, stenting, and feeding tubes are options for palliation. Dysphagia is the most common initial symptom of patients with esophageal cancer, especially in those with advanced disease. Endoscopic laser fulguration with the Nd:YAG laser is 75%–80% successful in treating dysphagia, but multiple treatments may be required, and the risk of perforation is highest at 10%. PDT, an alternative form of laser therapy, is also an excellent tool for palliation in patients suffering from dysphagia. A photosensitizing drug [porfimer (Photofrin)] is injected intravenously before treatment and is selectively taken up by neoplastic cells. Activation of Photofrin with a red light at 630 nm releases singlet oxygen, which kills the host cell. The depth of penetration is limited to 5 mm and thus not great for deep lesions or extrinsic compression. Self- expanding metal stents (SEMS) provide good immediate relief from dysphagia. Covered stents prevent ingrowth of cancer into the stent, which can lead to subsequent recurrent stenosis. Covered stents also have a high incidence of migration compared with uncovered stents. In general, stents cannot be used for cervical lesions due to difficulty in swallowing after placement and for GEJ lesions due to severe reflux after placement. PDT may work best for GEJ lesions, and Nd:YAG ablation works well in cervical lesions that cannot be stented. Chemotherapy is used to treat systemic disease and reduce overall tumor burden but needs to be administered with radiation therapy to control local disease and can take weeks to be effective. As such it should be reserved for patients with a longer life expectancy.

Answer 319

ANSWER: A COMMENTS: Iatrogenic causes account for the largest cause of esophageal perforation, typically as the result of instrumentation including esophagoscopy, transesophageal echocardiography, and dilation (pneumatic and bougie). Boerhaave’s syndrome is the most common cause of spontaneous esophageal perforation, accounting for 15% of cases. Cancer only accounts for 1% of esophageal perforations.

Answer 320

ANSWER: D COMMENTS: Esophageal perforation carries a high morbidity and between a 10% and 40% mortality. Traditional teaching is that repair of esophageal perforation should only occur if identified early; however, modern studies have reported great success with repair of delayed injuries as well. Esophageal repair should involve a two-layer repair with an onlay buttress, typically of pericardium, pleural fat, or a pedicle intercostal muscle flap. The cervical esophagus is best approached via a left neck incision anterior to the sternocleidomastoid. Perforations here are most commonly found at the cricopharyngeus/UES as this is the highest pressure zone. The upper two-thirds of the thoracic esophagus is best approached via a right thoracotomy and the distal one-third via a left thoracotomy. The intraabdominal esophagus is best approached via an upper midline laparotomy. In achalasia, most perforations are the result of pneumatic dilation and can be managed with repair and myotomy at a different location; however, resection is not required. For patients with perforation associated with a malignancy, resection should be considered if feasible. Recently covered stent placement with wide mediastinal drainage allows temporization and an oncologic operation to occur under more elective circumstances. Cervical esophagostomy as a diversion with wide mediastinal drainage and feeding tube placement should be reserved for those with prohibitive risk to resection, short life expectancy, or significant gross contamina- tion and sepsis.

Answer 321

ANSWER: E COMMENTS: Caustic injury to the esophagus can be attributed to the ingestion of acidic or alkaline liquids. Alkaline substances (lye) produce liquefactive necrosis of tissue and can cause deep tissue penetration. If diagnosed within the first hour of ingestion, half-strength vinegar or citrus juice can be used to neutralize the ingested alkali. After careful examination of the oropharynx, airway, chest, and abdomen, endoscopy should be performed to grade the burn. Serial esophagograms should be performed to evaluate for stricture formation rather than waiting for symptoms of obstruction to develop. Early stent placement or bougie dilation is effective in preventing long-term strictures; however, dilation should be performed only after reepithelialization has been confirmed with endoscopy. For long-segment strictures requiring resection, colonic interposition is the preferred graft.

Answer 322

E. Endoscopy

Answer 323

C. Peritoneal lavage with fluid cytology

Answer 324

D. Pain on swallowing

Answer 325

D. Intravenous fluid resuscitation

Answer 326

E. Diffuse esophageal spasm

Answer 327

E. Presence of squamous mucosa extending at least 3cm into the esophagus

Answer 328

E. Transhiatal esophagectomy with pyloromyotomy, gastric pull-up, and anastomosis to the cervical esophagus

Answer 329

A. Typical longitudinal mucosal tear with overlying fibrinous exudate extending from the proximal esophagus to the gastric cardia

Answer 330

E. Endoscopic ultrasound

Answer 331

A. Adenocarcinoma

Answer 332

D. Esophageal cancer is associated with parasitic infections

Answer 333

E. Colon interposition if esophagus will be removed.

Answer 334

A. Adenocarcinoma is most common in the middle third

Answer 335

C. The morbidity and mortality rates for cervical esophagogastric anastomotic leak are substantially less than those associated with intrathoracic esophagogastric anastomotic leak.

Answer 336

D. Endoscopy

Answer 337

B. Gastrograffin esophagogram Boerhaave's Syndrome

Answer 338

D. There are high amplitude pressures during manometry

Answer 339

E. Esophagectomy

Answer 340

D. Nissen fundoplication

Answer 341

E. Esophagectomy with cervical esophagostomy, gastrostomy, and feeding jejunostomy

Answer 342

B. Esophagectomy alone

Answer 343

C. Gastrograffin swallow study in 48hours (esophagogram)

Answer 344

A. Endoscopic ultrasound (EUS)

Answer 345

I: Eating normally II: Requires liquids with meals III: Able to take semisolids but unable to take solids IV: Liquids only V: Able to swallow saliva VI: Unable to swallow saliva

Answer 346

Locoregional disease Stage I-III - Esophagectomy. - Others: Endoscopic therapy (eg mucosal resection), Preoperative chemoradiation ``` Metastatic disease Stage IV - Unresectable - ECOG less than or equal to 2: Chemo+palliation - ECOG >2: Palliation ```

Answer 347

``` Age >75yo FEV1 <1.25 and EF <40% >20% weight loss Locally advanced tumor — Horner syndrome — RLN paralysis — Paralysis of diaphragm — Malignant pleural effusion — Length >9cm — >4 LN involved ``` Distant Mets

Answer 348

Current standard for non-surgical management of locally advanced disease. CIS+ 5FU For advanced resectable disease: neoadjuvant chemo radiation is the current approach

Answer 349

1) Vagal-sparing esophagectomy - reserved for patients with esophageal cancer limited to the intramucosal layer without the need for lymphadenectomy 2) Transhiatal (Orringer and Sloan) - Performed via upper midline laparotomy and left cervical incision - Gastric conduit based on the right gastroepiploic artery is used to establish GI continuity (if stomach is unusable, a colonic interposition can be performed) 3) Transthoracic (Ivor-Lewis) - Upper midline abdominal incision and a right thoracotomy is done - Esophagus is dissected out of its bed, stomach is pulled up into the thorax through esophageal hiatus and divided at its cardiac portion to allow creation of an anastomosis between the distal end of the esophagus and the fundus of the stomach. 4) Three-field (McKeown) - Carried out through separate laparotomy, right thoracotomy, and cervical incisions 5) Left thoracoabdominal (Akiyama) - Performed by making an oblique incision from the midpoint between the xiphoid and umbilicus across the costal arch to the tip of the scapula. - Abdomen is opened, the costal arch is divided, and the chest is entered through the 7th ICS - Diaphragm is opened in a circumferential manner along the chest wall 6) Minimally Invasive - Include laparoscopic, hand-assisted, thoracoscopic and robot-assisted esophagectomy

Answer 350

Siewert I: Esophageal TTE + two-field LAD Siewert II: Cardia TTE or THE (R0) Siewert III: Subcardiac Total Gastrectomy + D2 LAD

Answer 351

T1 Invaded lamina propria, muscularis mucosae, or submucosa T1a Lamina propia/ muscularis mucosae T1b Submucosa T2 Invades muscularis propria T3 Invades adventitia T4 Invades adjacent structures T4a Resectable tumor invading pleura, pericardium/diaphragm T4b Unresectable tumor invading other adjacent structures, such as aorta, vertebral body, trachea, etc. N1 1-2 LN N2 3-6 LN N3 >7 regional LN

Answer 352

1) Paraesophageal, peritumoral, subcarinal LN | 2) Aortopulmonary window along mainstream bronchi and along L recurrent nerve.

Answer 353

42. (D) A Zenker’s (pharyngoesophageal) diverticulum is a mucosal outpouching through the triangular bare area between the cricopharyngeus muscle and the inferior constrictor muscle of the pharynx (Killian’s triangle). Most present on the left side of the neck.

Answer 354

43. (E) The current surgical treatment for a symptomatic pharyngoesophageal diverticulum is myotomy. If the diverticulum is >2 cm, it should be resected. Small asymptomatic diverticula require no treatment. Failure of relaxation of the cricopharyngeus muscle is thought to result in the development of the diverticulum.

Answer 355

44. (E) An epiphrenic (supradiaphragmatic) diverticulum is a pulsion diverticulum and is associated without any obvious lesions (35%) or with hiatal hernia (30%), diffuse esophageal spasm (DES) (20%), achalasia (10%), and miscellaneous causes (5%). It is located with 10 cm of the cardia. An epiphrenic diverticulum is commonly asymptomatic and should not be treated surgically unless symptoms are clearly related to it. Parabronchial lymphadenopathy can cause traction diverticulae (which are located at a higher level).

Answer 356

45. (A) The appearance of unexplained dysphagia in adults requires urgent evaluation. Esophageal carcinoma is particularly prevalent in certain parts of Africa and Asia, but the incidence is increasing in Western countries. In achalasia there is initially a greater tolerance for solids over liquids. In carcinoma, dysphagia for solids is noted initially, and later there is difficulty in swallowing liquids as well. Esophagoscopy is required in the workup of dysphagia. It is imperative to rule out an underlying carcinoma.

Answer 357

46. (B) In addition to the presence of an upper esophageal web leading to dysphagia, the Plummer-Vinson syndrome is characterized by atrophic oral mucosa, spoon-shaped brittle nails (koilonychia), and iron deficiency anemia. Endoscopy reveals a fibrous web just below the cricopharyngeus muscle. There is an increased risk of developing cancer of the esophagus.

Answer 358

47. (D) Nonoperative therapy is the initial treatment of GERD. The treatment is weight loss, avoidance of fatty meals, smoking cessation, abstinence from alcohol, positional awareness, avoidance of lying supine, and avoidance of certain foods (e.g., chocolate) and drugs (e.g., theophylline, anticholinergic agents, a-adrenergic antagonists). Dysphagia requires special attention to rule out a stricture, cancer, or a motility disorder. Poor results are more likely when previous surgery has failed and in patients with scleroderma.

Answer 359

48. (B) The cardia is displaced into the posterior mediastinum. The term sliding hernia (Fig. 5–8) indicates that a part of the peritoneum slips or slides with the hernia into the posterior mediastinum. The wall of the sac is formed medially by the stomach and laterally by the peritoneum. Reflux esophagitis is more likely to occur with this type of hernia. The sliding hiatal hernia may be entirely symptomatic or lead to reflux esophagitis and possibly esophageal stricture.

Answer 360

49. (C) Benign peptic strictures of the esophagus are submucosal fibrotic rings that narrow the lumen and obstruct the passage of food. They present with dysphagia. They tend to be between 1 and 4 cm in length. GERD is the most common cause. Other associated motility disorders often occur. Heartburn may improve because of the obstruction to refluxed bile.

Answer 361

50. (D) The present treatment is aimed at preventing esophagitis. Barrett’s esophagus is regarded as a premalignant condition and is characterized by columnar metaplastic of the normal squamous epithelial lining of the esophagus. The cancer risk is increased 20–50-fold. About one-third of patients present with malignancy, and many cases of adenocarcinoma of the esophagus arise from Barrett’s mucosa. There is an increased risk for the development of squamous carcinoma. It is found in 8–10% of patients with long standing reflux.

Answer 362

51. (D) This is a type 4 hiatal hernia (Fig. 5–9). In the classic case of a paraesophageal “rolling” hernia, the GE junction remains below the hiatus, allowing the stomach and sometimes other viscera to migrate upward into the chest alongside the esophagus. Paraesophageal hernias are prone to obstruction, bleeding, and volvulus (either mesoaxial or organoxial rotation). Chronic symptoms include pain and postprandial fullness, with heartburn in 90% of cases. Gastric ulcers develop in as many as 30% of cases and they may cause acute or chronic (MISSING BOTTOM LINE) indicated and effective to relieve symptoms and to prevent complications, which may be catastrophic.

Answer 363

52. (B) Schatzki’s ring is a thin, circumferential scar in the lower esophagus, more common in men (65) or greater. It is acquired and probably results from repeated trauma to the mucosa with chronic inflammation and fibrosis. Endoscopic dilation is the usual treatment. It is usually successful but antireflux surgery is occasionally necessary for severe GERD, especially if it is worsened by dilatation. Associated hiatal hernia is very common.

Answer 364

53. (A) Dysphagia in esophageal achalasia is described as paradoxical in that it is more pronounced for liquids than solids. There are numerous reports of an increased incidence of carcinoma in achalasia, ranging from 3% to 10%. In 1975, Belsey reported a 10% incidence in 81 patients in whom symptoms tended to occur at a younger age. Recurrent lung infections from aspiration of esophageal contents are a troublesome complication. The treatment is surgical myotomy or endoscopic dilatation.

Answer 365

54. (D) A Mallory-Weiss tear is characterized by acute and sometimes massive UGI hemorrhage. It accounts for up to 10% of UGI bleeds. It is due to arterial bleeding following repeated vomiting (which causes mucosal tears at the GE junction). The cause is the same as that for spontaneous rupture of the esophagus (i.e., an increase in intra-abdominal pressure against a closed glottis). Causes other than vomiting such as paroxysmal coughing or retching, may sometimes lead to this condition. Upper endoscopy confirms the diagnosis. Surgery may occasionally be necessary to stop the bleeding.

Answer 366

55. (B) Spontaneous rupture of the esophagus, or Boerhaave’s syndrome, is most common in men between 35 and 55 years of age. The usual presentation is severe pain in the precordium, lower thorax, or epigastrium. Classically it follows an episode of violent vomiting. A chest film shows hydropneumothorax usually on the left side, but it may be on the right side or bilateral. Free air below the diaphragm is not a usual finding. The tear is usually located above the diaphragm and is longitudinal on the left posterolateral wall. Air passes around the mediastinum, which results in subcutaneous emphysema.

Answer 367

56. (D) Spontaneous rupture of the esophagus is an acute emergency. It requires efforts to establish a rapid diagnosis followed by an emergency operation. Rapid resuscitation and antibiotics should be instituted prior to surgery. Shock is not a contraindication to surgery because it is unlikely that the patient’s condition will improve until surgery has been performed. The surgical approach is usually thoracic, but the abdominal approach may also be used.

Answer 368

57. (E) The esophagus is a posterior mediastinal structure in much of its course. The thymus gland is located in the anterior mediastinum. The recurrent laryngeal nerve runs between the trachea and the esophagus. The aorta loops backward over the left side of the esophagus. At this level the thoracic duct is on the left side of the esophagus. The brachiocephalic vein is the most anterior structure in the superior mediastinum.

Answer 369

58. (D) Leiomyoma is the most common benign tumor encountered in the esophagus. Malignant transformation is thought to be rare. Less than 10% of alimentary tract leiomyomas are found in the esophagus. They are composed of spindle cells and grow slowly and may progressively cause obstructive symptoms. Leiomyomas are not referred to as a benign GIST. Other benign lesions are congenital or acquired cysts, adenomatous polyps, papillomas, lipomas, neurofibromas, and hemangiomas.

Answer 370

59. (C) The gastroesophageal zone of elevated pressure is 3–4 cm long and has a resting pressure of 15-cm H2O. Pregnancy, obesity, and gastric dilatation, all result in increased intra-abdominal pressure and can result in reflux. Alkalinization of the stomach, gastrin, epinephrine, cholinergic agents (bethanecol), and a-adrenergic agents (metoclopromide) increase the resting pressure of the LES. Anticholinergic agents (atropine), glucagon, and secretin decrease the resting pressure, and is released by the vagus nerve and it stimulates the production of acid in the stomach.

Answer 371

60. (E) The history of GERD coupled with these findings is highly suggestive of an adenocarcinoma arising in a Barrett’s esophagus. Squamous carcinoma is more likely to occur higher up in the middle third of the esophagus. Endoscopy and biopsy prove the diagnosis. The patient should be treated surgically by esophagectomy if carcinoma is confirmed. Inoperable upper esophageal squamous cell carcinomas can be treated with chemoradiation (survival outcomes are similar to surgery with less morbidity).

Answer 372

61. (D) Surgical resection of the esophagus remains the recommended treatment for patients with carcinoma of the lower esophagus, provided that there is no metastatic disease and the patient’s overall medical condition is compatible with a major operation. This offers the best palliation and the only hope for cure. The 5-year survival rates vary between 15 and 25%. Radiation and chemotherapy, in combination with surgery in selected patients, may improve these statistics. There are four types of esophagectomy—transthoracic, en bloc, transhiatal, and video-assisted. Regardless of whatntype of operation is performed, complete macroscopic and microscopic removal of tumor, is the goal.

Answer 373

62. (A) Blunt trauma is the most common cause of diaphragmatic rupture. Associated injuries are common. In blunt trauma, the left diaphragm is ruptured more frequently than the right. The stomach, spleen, colon, and omentum may enter the left pleural cavity. Diaphragmatic injury without herniation of abdominal contents is difficult to diagnose. Patients may present with symptoms many years after the initial trauma. Early surgery is indicted.

Answer 374

63. (B) Subhepatic (intrahepatic) space infection usually occurs after surgery or peritonitis in the supracolic compartment. It is an unlikely complication of biliary pancreatitis. Infections in the subhepatic space may extend to the infracolic compartment via the paracolic gutter (of Morrison). In addition to the stomach, the subhepatic space may be involved with infection secondary to injury or diseases of the gallbladder, the first part of the duodenum, the anterior portions of the pancreas, or the liver. The uncinate lobe of the pancreas is the part of the head located posteriorly to the superior mesentric artery vein.

Answer 375

64. (D) Oral fluids and solid foods can usually be started several days after the injury. Feeding at this stage is encouraged if the patient continues to show favorable improvement. If the caustic injury is superficial, stricture formation is unlikely to occur. Endoscopy to the proximal extent of the injury is recommended unless perforation is suspected. No attempt should be made to pass the endoscope beyond the proximal portion of the inflammatory segment. Emetics should not be administered because the esophagus will be reexposed to the agent when the patient vomits.

Answer 376

65. (C) Esophageal perforation has occurred. Caustic alkali ingestion results in liquefactive necrosis while acid ingestion causes caogulation necrosis. The esophagus is more often involved than the stomach during alkaline ingestion (and conversely, the stomach is more often involved than the esophagus during acid ingestion). Features on x-ray suggesting esophageal perforation include pneumothorax, pneumomediastinum, and pleural effusion. Ewald tubes or nasogastric tubes should be avoided because of the risk of perforation.

Answer 377

85. (C) The symptoms and radiologic findings in this patient suggest achalasia. Evaluation includes endoscopy to rule out a stricture or cancer. Barium swallow will show a dilated esophagus, failure of the LES to relax during swallowing, and a lack of peristalsis. Nonoperative management is of limited usefulness but may be considered in high-risk patients who are not candidates for surgery.

Answer 378

86. (C) A healthy patient with achalasia who has failed nonoperative management should be considered for surgical intervention. Pneumatic dilatation is first-line therapy. It causes disruption of the muscular layers of the LES. A balloon is placed endoscopically at the level of the LES. Fluoroscopy is used to visualize the balloon as it is inflated to pressures no higher than 10 psi. If pneumatic dilatation fails, or if symptoms return after successful dilation, surgery should be considered. The procedure may be done open or endoscopically. The operation involves a myotomy that divides the circular and longitudinal muscle fibers. It extends from the distal 6 cm of the esophagus, through the LES, and the proximal gastric cardia. A partial fundoplication is usually included to prevent gastroesophageal reflux.

Answer 379

87. (A) It is important to rule out coronary artery disease in patients who have DES because the symptoms may be similar. Barium swallow and endoscopy are used to evaluate the esophagus. A corkscrew esophagus is highly suggestive of DES, however, it is not always seen. Manometry is the diagnostic study of choice. Medical management includes nitrates and calcium channel blockers.

Answer 380

88. (C) Barrett’s esophagus is a metaplastic change found in 10–15% of GERD patients. The normal squamous cells of the esophagus are transformed into columnar cells. It is more commonly seen in men. Patients with Barrett’s esophagus (without dysplasia) require lifelong surveillance. Patients with severe dysplasia have a 40–50% chance of developing adenocarcinoma of the esophagus. Prophylactic esophagectomy is recommended.

Answer 381

92. (D) Candida is the most common cause of infectious esophagitis. Predisposing factors include malignancy, AIDS, and antibiotic use. A double contrast esophageal swallow or esophagogastroduodenoscopy (EGD) can be used to make the diagnosis. Not all patients with oral thrush have candida esophagitis; cytomegalovirus (CMV) esophagitis can also occur in these patients. Other infecious causes include tuberculosis (TB) and herpes. Antibiotics can be effective. A superficial spreading carcinoma of the esophagus may have a similar appearance in diagnostic studies.

Answer 382

95. (A) Duplication cysts are congenital. Communication with the true lumen is uncommon. They are usually asymptomatic. Symptoms and complications can include dysphagia, infection, perforation, and bleeding. Malignant degeneration is rare. Symptomatic cysts can be removed by open thoracotomy or videoassisted thoracoscopic (VATS) techniques.

Answer 383

96. (B) Vascular rings are congenital. They can encircle the trachea and esophagus and cause compressive symptoms. The two most common types are double aortic arch and right aortic arch with left ligamentum arteriosum. Diagnostic studies include chest x-ray, barium study, Echo, CAT scan, MRI, and angiogram. Surgery involves division of the ring.