Fiser ABSITE Ch. 29 Esophagus Flashcards
What are the layers of the esophagus?
stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa
What is the blood supply of the cervical esophagus? and abdominal esophagus?
Cervical esophagus - supplied by the inferior thyroid artery
Which direction does the lymphatics of the esophagus drain?
upper 2/3 drains cephalad, lower 1/3 caudad
What kind of muscle is in the upper esophagus? lower esophagus?
striated muscle, smooth muscle
Right vagus nerve - travels on ____ portion of stomach as it exits chest; becomes ____ plexus; also has the criminal nerve of ___ > can cause persistently high acid levels postoperatively if left undivided
posterior, celiac, Grassi
Left vagus nerve - travels on ____ portion of stomach; goes to liver and biliary tree
anterior
The upper esophageal sphincter is how far from the incisors? and lower?
15 cm, 40 cm
What is the most common site of esophageal perforation (usually occurs with EGD)?
cricopharyngeus muscle
What muscle comprises the upper esophageal sphincter and prevents air swallowing?
cricopharyngeus muscle
What are the 3 anatomic areas of narrowing of the esophagus?
cricopharyngeus muscle, compression by the left mainstem bronchus and aortic arch, diaphragm
What is the surgical approach to the cervical esophagus? upper 2/3 thoracic? Lower 1/3 thoracic?
Cervical esophagus - left, Upper _ thoracic - right (avoids the aorta), Lower _ thoracic - left (left-sided course in this region)
What is the cause in primary esophageal dysfunction? secondary?
unknown in primary; secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis
What is the diagnostic procedure of choice for dysphagia and odynophagia?
barium swallow (better at picking up masses)
What is the usual cause of cervical esophageal dysphagia?
plummer-vinson syndrome
What is the 3 parts of tx for plummer-vinson syndrome?
dilation, Fe, screen for oral CA
What can occur between the cripharyngeus and pharyngeal constrictors?
Zenker’s diverticulum
What is the tx for Zenker’s diverticulum?
cricopharyngeal myotomy; Zenker’s itself can either be resected or suspended
What do you get on POD #1 after a cricopharyngeal myotomy for Zenker’s?
esophagogram
How is a traction diverticulum different from Zenker’s?
Zenker’s is a false diverticulum and lies posterior; traction is a true diverticulum is usually lateral in the mid esophagus
What is the tx for a traction diverticulum of the esophagus?
excision and primary closure; may need palliative therapy if due to invasive CA
What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?
Achalasia
What is the medical tx for achalasia (2)? what is next step?
CCB, nitrates; LES dilation (effective in 60%)
What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?
Heller myotomy
What infection can produce similar sx to achalasia?
T. cruzi
Chest pain; other sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.
Diffuse esophageal spasm
What are 4 types of tx for diffuse esophageal spasm?
CCB, nitrates, antispasmotics, Heller myotomy
Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle _ Tx: esophagectomy; Nissen may be effective in some
Scleroderma
GERD sx with bloating suggests what?
aerophagia and delayed gastric emptying
What is the best test for GERD?
pH probe
What is the surgical tx for GERD?
Nissen
The key maneuver in Nissen is identifcation of what?
left crura
What is name of the approach through the chest in a Nissen?
Belsey
During a Nissen, when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a “new” esophagus. What is this called?
Collis gastroplasty
Name the type of hiatal hernia: Sliding hernia from dilation of hiatus (most common); often associated with GERD
Type I
Name the type of hiatal hernia: Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction.
Type II
What is a Type III hiatal hernia? and type IV?
Type III - combined _ Type IV - entire stomach in the chest plus another organ (i.e., colon, spleen)
Almost all pts with Schatzki’s ring have an associated ___
sliding hiatal hernia
What is the tx for Schatzki’s ring?
dilatation of the ring usually sufficient; may need antireflux procedure
What is the transformation in pts with Barrett’s esophagus?
squamous metaplasia to columnar epithilium
Pts with Barrett’s esophagus are at 50x increased risk for what?
adenocarcinoma
Severe Barrett’s dysplasia is an indication for what?
esophagectomy
Uncomplicated Barrett’s can be treated like GERD with PPI or Nissen and surgery will decrease esphagitis and further metaplasia but it will not prevent what?
malignancy or cause regression of the columnar lining
Pts with Barrett’s esophagus who get a Nissen still need careful lifetime follow up with what?
EGD
Esophageal tumors are almost always malignant. How does it spread?
submucosal lymphatic channels
What is the best test for unresctablity in esophageal CA?
Chest/abdominal CT
What is the #1 esophageal CA? What type occurs most often in the upper 2/3?
Adenocarcinoma; Squamous cell carcinoma
Supraclavicular nodes in esophageal CA indicate what?
unresectability
Distant metastases with esophageal CA is a contraindication to what? what is the survival?
esophagectomy,
What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?
5%, 20%
What is the primary blood supply to stomach after replacing esophagus in esphagectomy?
right gastroepiploic artery (have to divide left gastric and short gastrics)
What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy -> exposes all of the esophagus; intrathoracic anasomsis
Ivor Lewis
What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.
Colonic interposition
What do you need after esophagectomy on post op day 7?
contrast study to rule out leak
Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?
5FU and cisplatin
In esophageal CA with malignant fistulas, most die within 3 months due to what?
aspiration
What is the most common benign tumor of the esophagus?
Leiomyoma
Diagnosis of Leiomyoma is esophogram, endoscopy to rule out CA. Why don’t you bx?
can form scar and make subsequent resection difficult
Tx for Leiomyoma of the esophagus is excision via thoractomy. What are the 2 indications?
> 5 cm or sx
Management for caustic esophageal injury: NG tube? Induce vomiting? Irrigation?
no, no, no
What is first step in dx in caustic esophageal injury? then what?
CXR and AXR to look for free air; endoscopy to assess lesion (but not with suspected perforation)
What is the most common cause of esophageal perforation?
EGD
What is the most common site of esophageal perforation?
cricopharyngeus muscle
How to dx esophageal perforation?
gastrograffin swallow followed by barium swallow
What is the tx for esophageal perforation that is contained, self-draining and no systemic effects?
Conservative: IVF, NPO, spit
What type of flap can be used with repair of esophageal perforation to help the area heal?
intercostal muscle pedicle flap
What is Hartmann’s sign?
mediastinal crunching on ascultation
How to dx Boerhaave’s syndrome?
gastrofrafin swallow
