Fiser Ch 29: Esophagus Flashcards
layers of the esophagus
mucosa (squamous epithelium)
submucosa
muscularis propria (longitudinal muscle layer)
NO SEROSA
blood supply of the esophagus: cervical, thoracic, abdominal
cervical: inferior thyroid aa
thoracic: directly from aorta
abdominal: left gastric and inferior phrenic aa
normal UES pressure at rest
60 mmHg
normal LES pressure at rest
15mmHg
what nerve mediates relaxation of LES?
vagus
surgical approach: cervical esophagus
left thoracotomy
surgical approach: upper 2/3 thoracic esophagus
right thoracotomy
surgical approach: lower 1/3 of esophagus
left thoracotomy
treatment of Zenker’s diverticulum?
cricopharyngeal myotomy via left cervical incision
whats plummer vinson syndrome?
- due to iron deficient anemia
- causes upper esophageal webs
tx: dilation, fe, screen for oral ca
location of zenkers diverticulum vs traction diverticulum?
zenkers: cervical esophagus and posterior
traction: mid esophagus and lateral
what an epiphrenic diverticulum? tx?
- rare, associated w esophageal motility disorders (achalasia)
- distal esophagus
tx: if symptomatic-
diverticulectomy and esophageal myotomy on opposite side
what is achalasia and cause?
- lack of peristalsis and failure of LES to relax
- 2/2 autoimmune distruction of neuronal ganglion cells in muscle wall
treatment of achalasia?
balloon dilation of LES + nitrates and CCBs initially, then heller myotomy if fails
what is a heller myotomy?
left (achalasia) or right (DES, nutcracker) thoracotomy, myotomy of lower esophagus only (achalasia) or upper and lower (DES, nutcracker) + partial nissen fundoplication
what is diffuse esophageal spasm?
frequent strong non-peristaltic unorganized contractions, LES relaxes normally
tx of diffuse esophageal spasm?
CCBs, trazodone, heller myotomy if fails (myotomy of both UPPER and LOWER
what is nutcracker esophagus?
high amplitude peristaltic contractions (>180mmHg), LES relaxes normally
best test to diagnose GERD?
pH probe
steps of nissen fundoplication
- divide short gastrics
- pull esophagus into the chest
- approximate crura
- 270 (partial) or 360 degree gastric fundus
what is a belsey fundoplication?
same as nissen but approach is through the chest
key maneuver for dissection during nissen?
finding the right crura
key maneuver for wrap during nissen
finding the left crura
what is a collis gastroplasty?
not enough esophagus to pull down into abdomen for nissen fundo so staple off stomach cardia and create a neoesophagus
treatment of dysphagia following nissen?
most likely nissen is too tight which generally resolves on its own, clear liquids for 1 week and if still there then dilation
Four different types of hiatal hernias
type I: sliding hernia from dilation of hiatus, GE jxn rises above diaphragm
type II: paraesophageal, hole in the diaphragm alongside esophagus, normal GE jxn
type III: combined type I and II
type IV: entire stomach in the chest plus another organ
management of high grade dysplasia of barrett’s?
- Esophagectomy OR
2. EGD surveillance every 3 months, 4 quadrant bx very 1cm for entire length of dysplasia
surveillance of pt w uncomplicated barrett’s
EGD every year for lifetime
esophageal cancer: best test to evaluate for resectability?
CT chest abd abdomen
esophageal cancer pathology different types
- Adenocarcinoma: most common, lower 1/3, likely to met to liver
- Squamous cell: upp 2/3, likely to met to lung
neoadjuvant chemo for esophageal ca? indication?
5FU and cisplatin, for T2 tumors+
margins for esophagectomy for esophageal cancer?
6-8cm
primary blood supply to stomach after replacing esophagus in esophagectomy?
right gastroepiploic artery
incisions for transhiatal approach esophagectomy and where is anastomosis?
neck and abdomen, cervical leak from esophageal anastomosis (cause of mortality)
incisions for Ivor Lewis approach esophagectomy, where is anastomosis?
abdominal incision and right thoracotomy, get an intrathoracic anastomosis
incisions for a 3-hole esophagectomy?
abdominal, neck and thoracotomy
most common benign esophageal tumor
leiomyoma, in the muscularis propria, mostly in lower 2/3 of esophagus (smooth muscle)
when do you remove an esophageal leiomyoma?
> 5cm or symptomatic, extra-mucosal nucleation via thoracotomy
where are esophageal polyps mostly found?
cervical esophagus
management of caustic esophageal perforations?
esophagectomy
best test to evaluate for esophageal perforation?
gastrograffin swallow
criteria for non-surgical management of esophageal perforation?
- Contained perforation by contrast
- Self draining
- No systemic effects
Management of non-contained esophageal perforation
If <24hrs and minimal contamination: primary repair with drains, muscle flaps
If >24hrs or extensive contamination:
neck- drains
chest - resection (esophagectomy), or exclusion and diversion
where is esophageal perforation often found in Boerhaave’s syndome?
left lateral wall of esophagus, 3-5cm above GE junction
what is hartmann’s sign?
mediastinal crunching on auscultation, seen in esophageal perforation likely from Boerhaave’s syndrome
Describe fundoplication: Thal: Belsey: Dor: Lind: Toupet:
Thal: 270* anterior Belsey: 270* anterior transthoracic Dor: 180*-200* anterior Lind: 300* posterior Toupet: 270* posterior
surveillance of Barett’s esophagus without dysplasia?
once daily PPI and EGD every 3-5 years w 4 quadrant biopsies every 2cm
what is a demeester score and what is considered abnormal?
Demeester score: result of 24 hour pH monitoring, composite of percent total time pH <4 in different positions, number and duration of episodes, a score >14.72 is abnormal
what is esophageal impedence used for?
for non-acid reflux (aka bile reflux), measures an electrical current
What is the origin of the thoracic duct?
cisterna chyli at L1-2
where does the thoracic duct cross midline??
right to left at T4-5
where does the thoracic duct insert?
left subclavian vein with the internal jugular vein
what does the thoracic duct carry?
chylomicrons and long chain fatty acids
