STS Benchmark - Esophagus

Question 1

Small cell carcinoma of the esophagus.
Where is it usually located?

Answer 1

Distal third. Rare.

Question 2

What is the most common extrapulmonary site of primary small cell carcinoma?

Answer 2

Esophagus

Question 3

What is the gross and pathological appearance of primary small cell carcinoma of the esophagus?

Answer 3

often appears as a submucosal mass, and central ulceration is common with growth. Histologic examination reveals small, lymphocyte-like cells and immunohistochemical analysis may demonstrate neuron-specific enolase or other neuroendocrine markers.

Question 4

When localized, small cell carcinoma of the esophagus is best treated how?

Answer 4

Initially with a local modality (resection or radiotherapy) followed by systemic therapy (cytotoxic chemotherapy). With aggressive contemporary treatment nearly one-third of such patients are expected to survive five years.

Question 5

What are some advantages and challenges of using jejunum for your conduit after an esophagectomy?

Answer 5

A jejunal interposition has several advantages in esophageal reconstruction, including preserved peristalsis and minimal risk of reflux. However, an adequate length of jejunum with an intact pedicle cannot always be mobilized to reach the cervical esophagus. A recent innovation described is the “supercharged” pedicle, which maintains an inferior vascular pedicle but adds second arterial and venous microvascular anastomoses in the neck as well. A retrosternal pathway may expand the utility of the single-pedicled jejunal option for reconstruction, but the more routine alternative is the free interposed segment (jejunal “autograft”) with microvascular anastomoses. Division of the jejunal pedicle in this way probably eliminates the peristaltic advantages. Postoperative manometric evaluations routinely show no peristalsis for denervated jejunal segments.

Question 6

A patient is to undergo transhiatal esophageal resection for failed previous reflux procedures. Reconstruction with a long colon interposition based on the left colic artery is planned. The operative detail which best prevents gastrocolic reflux is?

Answer 6

10 cm intra-abdominal colon segment (infradiaphragmatic high pressure region) to create a barrier to reflux.

Question 7

What are some of the surgical considerations when using colon for interposition after esophagectomy?

Answer 7

• Colon may be favored as the conduit of choice when the esophagus is resected for benign conditions.
• It is used when the stomach is inadequate or absent.
• When the anastomosis is in the neck, the left colon based on the left colic artery is the best choice of conduit.
• All colon interpositions should be oriented in the isoperistaltic position. The colon graft has delayed emptying. Contractive waves between meals probably help empty food saliva and mucous secretions from the graft.
• After mobilization of the left colon, the conduit is placed through the lesser sac in a retrogastric position. The posterior mediastinal route is favored for transposition as it is the shortest route and best avoids tension and rotation.
• A lower posterior cologastric anastomosis protects the vascular pedicle against tension and angulation. One should plan on at least a 10 cm intra-abdominal colon segment (infradiaphragmatic high pressure region) to create a barrier to reflux.

Question 8

Fluoro-deoxy-glucose positron emission tomography (FDG-PET) is more useful than endoscopic ultrasound and CT in the assessment or determination of which clinical stage of esophageal cancer?

Answer 8

IV

Question 9

What diagnostic study is best for determining N1 for esophageal cancer?

Answer 9

EUS

Question 10

What are Barrett ulcers?
How often do they occur in Barrett esophagus?
Are they malignant?
Do they require surveillance?
Does antireflux surgery help heal them?

Answer 10

Barrett’s ulcer is an uncommon complication of Barrett’s esophagus, occurring in 10%-15% of cases. It is a deep, sharply circumscribed ulcer surrounded by columnar epithelium. Like any ulcer, it can penetrate and produce chest pain radiating to the back, bleed, or perforate into the mediastinum or other structures. Barrett’s ulcers are rarely malignant. However, these patients must remain under endoscopic surveillance even after documented healing of the ulcer since the columnar lining continues to have malignant potential. Although initial intensive medical treatment is justified, there is a high failure rate. Antireflux surgery is followed by healing in most cases.