Score - Esophagus Flashcards
A 45-year-old woman with a history of caustic esophageal injury from a previous suicide attempt is sent to your clinic. She has a distal esophageal stricture as a result of her injury. The woman complains of recurrent dysphagia despite endoscopic dilations. She says that after each dilation, her symptoms develop more quickly. She is worried that soon she will have no relief. From which of the following treatments could she benefit?
Mitomycin C
For patients with strictures undergoing dilation, mitomycin C has been shown in randomized trials to provide symptomatic improvement and reduced frequency of periodic dilations.
A 62-year-old man presents with the results of a recently completed esophagogastroduodenoscopy (EGD), which reveal a mass in the distal esophagus. Biopsy of the mass at the time of the EGD indicated esophageal adenocarcinoma. To evaluate this man for advanced local regional disease, which of the following imaging modalities is preferred?
CT of the chest with fluorodeoxyglucose positron emission tomography
Fluorodeoxyglucose positron emission tomography (PET)–computed tomography (CT) of the chest is the preferred imaging modality in the evaluation of patients for locoregional disease—both for initial imaging and determination of the response to initial treatment. Overall, PET-CT appears to allow for better staging by providing additional information in up to 22% of cases when compared to CT of the chest alone. Also, CT is usually combined with PET for the evaluation of hypermetabolic areas, which may correspond to local regional disease. Transesophageal echocardiography and magnetic resonance imaging of the chest are not commonly used in the preoperative workup of esophageal carcinoma.
A 20-year-old woman, a college student, presents to the emergency department after an apparent suicide attempt. She drank approximately 500 mL of an unknown liquid from a chemistry laboratory. She is speaking in complete sentences without respiratory distress and has mild epigastric discomfort. After establishment of airway patency and hemodynamic stability, as well as placement of intravenous access, which of the following is the next best management step?
Urgent endoscopy
Endoscopy should be performed as soon as possible after caustic ingestions, ideally within 24 hours, to assess the magnitude and extent of injury. Blind nasogastric tube insertion is contraindicated. Forced emesis is contraindicated. Therapeutic administration of diluents is not recommended after caustic ingestions. The role of glucocorticoids in preventing future esophageal strictures is controversial and typically reserved for high-grade injury, if used at all.
A 70-year-old man with dysphagia of recent onset and a 30-lb weight loss in the past year presents to your office for evaluation. Workup demonstrates a T2N1M0 distal esophageal adenocarcinoma. What is the best predictor of long-term survival in this man?
Number of regional nodes involved
A thorough staging workup is mandatory in all patients with esophageal cancer. The extent of nodal involvement is the best predictor of long-term survival and an important guide for therapeutic approaches. Necessity of neoadjuvant therapy is influenced by T stage and N stage both, but survival overall is most influenced by the number of nodes found to be involved. The size of the lesion is not a factor in the survival statistics.
A 37-year-old woman presents after failed medical therapy for acid reflux. She undergoes an appropriate workup that reveals a DeMeester score of 16, endoscopy findings of mild esophagitis, and no significant manometry findings. She is interested in magnetic sphincter augmentation (MSA). As a part of counseling her about this procedure, it is important to note which of the following?
After surgery, it is important to eat solid foods immediately to prevent scarring that will keep the device in a closed position.
MSA is a viable option for patients who have gastroesophageal reflux disease (GERD). The MSA device is indicated in the treatment of any patient with adequate esophageal motility and an appropriate workup confirming a diagnosis of GERD. Early initiation of diet is extremely important. Patients should eat frequent solid meals postoperatively to prevent capsule formation and subsequent dysphagia.
Long-term data on MSA indicate that there are similar rates of control of symptoms of GERD when compared to the Nissen procedure, with more than 80% of patients not requiring proton pump inhibitors at 5 years. Erosion is a significant concern with this technique, although it rarely occurs (< 1% of cases). But erosion does mandate removal of the device. Finally, the device is placed circumferentially around the esophagus, with care being taken to exclude the posterior vagus. However, proper technique includes minimal dissection of the phrenoesophageal ligament.
During an Ivor Lewis esophagectomy, while in the abdomen, you notice that there is no pulse in the right gastroepiploic artery. What is the best course of action?
A. Close the patient, and discuss other conduit options such as left colon interposition or jejunal free graft.
Using a stomach without a solid blood supply is a poor choice. The “safe” option is to use another conduit after further discussion. Resecting the esophagus and using the unprepared left colon as a conduit would be a major undertaking, and using the unprepared colon is not recommended. The stomach will not reach high enough into the chest to perform a reasonable resection if it is based on the left gastric artery. The right gastric will not be sufficient to provide enough blood flow to the gastric conduit in the chest.
A 58-year-old patient presents for evaluation of paraesophageal hernia. Your attending asks whether you think mesh should be used for the hiatal hernia repair if it is large. What would you reply?
Short-term recurrence rates are decreased with the use of mesh repair at the hiatus compared to hiatoplasty alone.
Mesh reinforced hiatoplasty appears better in the short term with a decreased incidence of recurrence. However, three different randomized controlled clinical trials have not shown this to be true for long-term outcomes. Patients have equivalent recurrence rates at long-term follow-up (5 years) whether mesh reinforcement is or is not used at the hiatus. Regarding mesh placement, this should always be placed as an onlay, with underlying hiatal closure. An absorbable mesh should be used, given the risk of esophageal erosion from permanent mesh. If the hiatus cannot be closed, then permanent mesh must be used as a bridge, as absorbable mesh is not indicated in bridging repairs.
A 40-year-old man underwent Nissen fundoplication 1 week ago. He calls the office with complaints of dysphagia. How would you best manage this?
Check for adherence to appropriate postoperative diet
A liquid diet is important in postoperative week 1 or 2 to allow for postoperative inflammation and edema to resolve. However, if shortly after this, symptoms do not improve, then further evaluation is warranted.
A 68-year-old man wishes to discuss surgical treatment of a Zenker diverticulum. He presents with dysphagia, regurgitation of foul-smelling contents, halitosis, and a nagging cough. He has undergone a workup including a barium esophagram and esophagogastroduodenoscopy, which demonstrated a 2.5-cm diverticulum. What is the best operative approach?
Open myotomy with diverticulopexy
This patient has a diverticula that is smaller than 3 cm in size, making an open approach the ideal approach. Patients with diverticula smaller than 3 cm are at risk for an incomplete myotomy with endoscopic approaches such as the Dohlman technique, (which consists of diverticulectomy and myotomy that is performed via rigid endoscopy), and with a flexible endoscopic repair. For open approaches, myotomy is generally sufficient for small diverticula (< 2 cm). Excision of the sac is indicated in cases of a persistent sac, or when > 5 cm. In this particular patient, a diverticulopexy can be performed to prevent entry of food and secretions.
A 72-year-old male with prior history of a stroke was referred to your clinic for symptoms of dysphagia. He reports difficulty swallowing his food. He feels like the food gets stuck in the back of his throat. He has been hospitalized three times in the past year for recurrent pneumonia. He often coughs after eating. Which would be the most appropriate NEXT diagnostic test?
Modified barium swallow
This patient’s symptoms are concerning for oropharyngeal dysphagia rather than esophageal dysphagia given his history of cough with eating and recurrent aspiration events. The feeling of food getting stuck in his throat may be consistent with Zenker’s diverticulum. The modified barium swallow is the best test to distinguish oropharyngeal dysphagia from Zenker’s diverticulum, which is caused by cricopharyngeal dysfunction. Other tests may be helpful, but it is first important to determine whether the patient’s symptoms are related to oropharyngeal dysfunction.
You are called to the recovery room to evaluate a 54-year-old man who just underwent an esophagogastroduodenoscopic dilation of a midesophageal stricture. He is complaining of worsening chest pain, dyspnea, and dysphagia. What would be your surgical approach to repair his esophageal perforation?
Right posterolateral thoracotomy
Right posterolateral thoracotomy is the approach used for repair of perforation of the middle third of the esophagus. Because this patient already had a known midesophageal stricture, this would be his most likely site of esophageal perforation. Left posterolateral thoracotomy is the approach used for repair of perforation in the lower third of the esophagus.
A 54-year-old man with gastroesophageal reflux disease presents to your clinic with recent symptoms of dysphagia, on upper endoscopy he is diagnosed with a 9-mm distal esophageal benign peptic stricture. What is the appropriate treatment for the stricture?
Serial esophageal dilations until symptoms resolve
Peptic strictures can be dilated using a freely passing bougie (Maloney or Hurst), over-the-wire (Savary or Balloon), or through-the-scope (balloon) dilators. The stricture should be dilated no more than 2 mm each session to avoid perforation, with serial dilations until symptoms resolve.
Less invasive therapeutic options than esophageal stricturoplasty are available. Excision is not a recommended treatment for peptic stricture. A proton pump inhibitor should be started to prevent recurrence of the stricture, but the drug itself is not a treatment for peptic stricture. Finally, per oral endoscopic myotomy is not a recommended treatment for peptic stricture.
During a laparoscopic vertical sleeve gastrectomy being performed for morbid obesity, you find a hiatal hernia anterior to the esophagus. How do you proceed?
Complete the operation with the addition of a hiatal hernia repair.
During any procedure performed for morbid obesity, a hiatal hernia diagnosed preoperatively or intraoperatively should be repaired to prevent postoperative complications.
