Esophagus and Diaphragmatic Hernia

Question 1

Locations of anatomic narrowing of the esophagus

Answer 1

• Cricopharyngeal muscle
  
  • narrowest (1.5cm)
• Crossing of the left mainstem bronchus and aortic arch
  
  • 1.6 cm
• Lower esophageal sphincter
  
  • 1,6 to 1,9 cm

Question 2

The cervical esophagus receives it blood supply primarily fron the

Answer 2

Inferior thyroid artery

• Thoracic portion
  
  • bronchial arteries, with 75% of infividuals having one right sided and 2 left sided branches
  • two esophageal branches arise directly from the blood supply
• Abdominal portion
  
  • ascending branch of the left gastric artery
  • inferior phrenic arteries

Question 3

Cranial nerves involve in the swallowing mechanism

Answer 3

V, VII, X, XI, XII

• motor neuronms : C1 to C3

Question 4

PArts of the human antireflux mechanism

Answer 4

• mechanically effective LES
• Efficient esophageal clearance
• adequately functioning gastric reservoir

If the pharyngeal swallow does not initiate a peristaltic contraction, the coincident relaxation of the lower esophageal sphincter is unguarder and reflux of gastric juice can occur

Question 5

Physiologic reflux happens most commonly when a person is

Answer 5

Awake and upright

• Reflux episodes occur in healthy volunteers primarily during transient lisses of the gastroesophageal barriers, which may be due to a relaxatin of LES or intragastric pressure overcoming sphincter pressure (LESS IN ASLEEP AND SUPINE)
• In the upright position, there is a 12 mmHg pressure gradient between the resting positive intra-abdominal pressure and the most negative intrathoracic pressure. This gradient favors the flow of gastric juice up into the thoracic esophagus when upright
• The LES pressure is significantly higher in the supine position. due to the apposition of the hydrostatic pressure of the abdomen to the abdominal portion of the sphincter

Question 6

Hormones that decrease LES tone

Answer 6

Estrogen, somatostatin, CCK, glucagon, progesterone

Question 7

The msot common cause of a deficient LES is

Answer 7

Inadequate intrabdominal length

• Permanently defective sphincter is defined by 1 or more of the ff characteristics
  
  • An LES with a mean resting pressure of <6 mmHg
  • an overall sphincter length of < 2cm
  • intrabdominal sphincter length of < 1cm

Question 8

Maximal esophageal mucosal damage is caused by exposure to

Answer 8

Acidic fluid + pepsin + Bile salts

Question 9

The incidnece of metaplastic Barrett esophagus progressing to adenocarcinoma is

Answer 9

0.2 to 0.5%

• 2 sequale if reflux is allowed to persist and susrained or repetitive esophageal injury
  
  • Luminal stricture from the submucosal and eventually intramural fibrosis
  • tubular eesophagus may become replaced with columnar epithelium
• Endocopically BE can be quiescent or associated with complications of esophagitism stricturem Barret Ulceration and dysplasia

Question 10

The histologic hallmark of BE is

Answer 10

Goblet cells

• Traditionally, BE was identified by the presence of columnar mucosa extending at least 3 cm into the esophagus.

Question 11

Relied from respiratory symptoms can be expected in approximately what percent of patients with reflux associated asthma with medical therapy

Answer 11

50%

• Antireflux surgery improves respiratory symptoms in nearly 90% of children and 70% of aduts with asthma and reflux disease

Question 12

Candidates for antireflux surgery

Answer 12

• objectively proven gastroesophageal reflux disease
• typical symptoms of GERD despite adequate medical management
• younger patient unwilling to take life ling medication

In addition, a structurally defective LES can also predict which patiets are more likely to fail with medical therapy

Question 13

Preoperative testing for antireflux surgery

Answer 13

• Contrast esophagram
  
  • esophageal shortening is present when a barium swallow Xray identifies a sliding hiatal hernia that will not reduce in the upright position or that measures more than 5cm in length at endoscopy
• 24 hour pH probe
• Esophageal manometry
  
  • Patient swith normal peristaltic contractions can be considered for a 360 degrees Nissel fundoplication or partial fundoplication
  • if not = partial
• esophagogastoduodenostomy

Question 14

The valve created during antireflux procedure should be at least

Answer 14

3 cm

• this not only augments sphincter characteristics in patients in whome they are reduced before surgery but prevents unfolding of a normal sphincter in response to gastric distention

Question 15

A toupet fundoplication involves

Answer 15

A 270 degree posterior wrap

• Partila fundoplication were developed as an alternative to the Nissen procedure in an attempt to minimize the risk of postfundoplication side effects,
• a 270 degree gastric fundoplication around the distal 4cm of the esophagus.
• Usually stabilzed by anchoring the wrap posteriorly to the hiatal rim

Question 16

What percentafe of patients should be expected to have relief of symptoms at 5 years out from antireflux surgery

Answer 16

80-90%

Question 17

An upward dislocation of both the cardia and gastric fundus is which type of hiatal hernia?

Answer 17

Type III

• Type I : characterized by an upward dislocation of the cardia in the posterior mediastinum
  
  • sliding hernia
• Type II : characterized by an upward dislocation of the gastric fundus alongside a normally positioned cardia
  
  • rolling or paraesophageal
• Type III : characterized by an upward dislocation of both the cardia and gastric fundus
  
  • mixed

Question 18

The msot common form of esophageal cancer

Answer 18

Adenocarcinoma

• more then 50% of esophageal cancer

Question 19

Squamous cell carcinomas of the esophagus most commonly occur

Answer 19

In the cervical and upper thoracic esophagus

Question 20

The preopertaive test most heavily correlated with the ability to tolerate an esophagectomy

Answer 20

FEV1

• Ideally should be 2L or more
• any patient with FEV1 of <1.25 L is a poor candidate for thoracotomy
  
  • 40% risk of dying from respiratory insufficiency within 4 years
  • tranhiatal esophagectomy should be considered

Question 21

Which test most accurately assess the T-stage of esophageal cancer?

Answer 21

Endoscopic ultasonography

Question 22

Esophagectomy

Answer 22

• If tumor invades the submucos, without visible LN
  
  • esophagectomy with LN dissection
• EUS demostrates spread through the wall of the esophagus especially if LN are enlarged
  
  • induction chemoradiation therapy
• EUS demonstrates invasion of the trachea, bronchus, aorta, or spine
  
  • surgical resection is rarely indicated
• Invasion in the pleura (T4a)
  
  • surgical resection can be considered in the absence of a malignant effusion

Question 23

The technique of resecting an esophageal cancer which remains symptomatic after definitive chemoradiotherapy

Answer 23

Salvage esophagectomy

• performed usually with an open two-field approach
• most technically challenging of all esophagectomy techniques

Question 24

Patients with dysphagia secondary to esophageal cancer treated with radiation can expect the benefir to last

Answer 24

2-3 months

Question 25

How long after completion of neoadjuvant chemoradiatherapy should esophagectomy performed>

Answer 25

6-8 weeks

• after 8 weeks, edema in the periesophageal tissue starts to turn to scar tissue, making dissection more difficult

Question 26

The optimal treatment of an incidentally discovered 3cm leiomyoma of the upper esophagus in a 45 year old otherwise healthy man

Answer 26

Enucleation

• Lesions proximal and middle esophagus require a right thoracotomy
• distal esophageal lesion require left thoracotomy
• Large lesions or those involving the GEJ may require esophageal resection

Question 27

Following a night of heavy drinking, a 43 year old other wise healthy man has sudden onset of severe chest pain after vomiting. Esophagram confirms, esophageal rupture just proximal to the GEJ. What is the preferred operative exposure

Answer 27

Left thoracotomy

Question 28

A 34 year old man presents to the emergency departmetn after an episode of hematemesis. EGD confirms a Mallory weis tear, with no residual bleeding. Treatment should consists of

Answer 28

Observation

• In majority of aptients, the bleeding will stop spontaneously with non operative management.
• The stomach shouldbe decompressed and antiemetics administered,
• Endoscopic injection of epinephrine may be therapeutic if bleeding does not stop spontaneously
• Surgery may be required to stop blood loss
  
  • laparotmy and high gastronomy with oversewing of the linear tear

Question 29

Successful treatment of a zenker diverticulum involves

Answer 29

Either diverticulopexy or resection with cricopharyngeal myotomy

Question 30

SImultaneous contractions of the esophagus

Answer 30

Diffuse esophageal spasm

• The LES in DES usually shows a normal resting pressure and relaxation on swallowing. A hypertensive sphincter with poor relaxation may also be present
• Corkscrew esophagus or psudodiverticulosis