Surgery of the Esophagus

Question 1

What tissue layer does the Esophagus lack?

Answer 1

SEROSA

Question 2

Long-standing FB can lead to the developmet of ____ in the esophagus

Answer 2

Strictures

Question 3

What is the holding layer of the esophagus?

Answer 3

Submucosa

Question 4

3 Principles of Esophageal SX?

Answer 4

• GENTLE tissue handling
• Minimal tension on suture lines
• Close in either 1 or 2 layers

Question 5

How do you perform 1 layer closure of the esophagus?

Answer 5

• Simple interrupted suture pattern
• Knots on the EXTRALUMINAL surface
• Encompass all 4 tissue layers

Question 6

How do you perform 2 layer closure of the Esophagus?

Answer 6

• 1^st Layer
  
  • Simple interuppted pattern in mucosa & submucosa
  • Knots on INTRALUMINAL surface
  • Inner layer will slough off when it heals and be digested
• 2^nd Layer
  
  • Simple interuppted pattern in submucosa, muscularis & adventitia
  • Prolene or PDS can be used

Question 7

List the Approaches for Esophageal SX

Answer 7

• Cervical esophagus → ventral midline
• Thoracic esophagus (CRANIAL to <3) → R lateral thoracotomy @ 3^rd, 4^th, or 5^th interspace
• Thoracic esophagus (CAUDAL to <3) s→ R or L lateral thoracotomy @ the 10^th, 11^th or 12^th interspace
• Dorsal recumbency
• Prop behind neck to arch it upwards
• Tie front legs in a caudal direction or cross (if a large dog)

Question 8

Indications for Esophageal Resection & Anastomosis

Answer 8

• Severe trauma or necrosis
• Esophageal stricture < 3-5 cm
• Esophageal neoplasia (rare in SAs)

Question 9

What portion of the thoracic esophagus can be safely resected?

Answer 9

up to 1/3

Question 10

What should you do when resecting > 3-5 cm of esophagus?

Answer 10

Utilize tension relieving techniques

Question 11

List the layers of the esophagus in the order that they must be sutured close in a Esophageal Resection & Anastomosis

Answer 11

1. Seromuscularis (180 degree line)
2. Mucosa & Submucosa
3. Remnants of mucosa & submucosa
4. Finish w/ Front portion of Muscularis layer (go a circle)

Question 12

What can be used for Esophageal Patching?

Answer 12

• Muscle pedical graft
  
  • sternohyoid mm, sternalthyroid mm., or diaphragm
• Omentum
• Pericardium or gastric wall (on occasion)

Question 13

Post-op TX for Esophageal SX?

Answer 13

• NPO→ 24 hrs-10 d.
• Liquid diet for 3-5 d. if feeding PO
• Bypass the esophagus (i.e. gastrostomy)
  
  • Slurry via stomach tube
• Thoracostomy tube for 24-48 hrs.
  
  • longer if pleuritits/mediastinitis is present (until negative pressure is regained)
• ABX until drains are removed

Question 14

Complications of Esophageal SX?

Answer 14

• leakage or rupture along the suture line
• stricture

Question 15

What factors predispose the Esophagus to rupture post-op?

Answer 15

• LACK OF SEROSA
• Pressure gradient changes due to respiration
• Rapid dilation associated w/ swallowing

Question 16

List the 4 most common sites of Esophageal Obstruction by FB.

Which 2 sites allow for the easiest retrievel of FBs?

Answer 16

1. Thoracic Inlet
2. Base of Heart (pull FB back or push FB forward)
3. Esophageal hiatus (pushing w/ an endoscope is best)
4. Pharyngeal esophagus (not common)

• Pharygneal esophagus or Thoracic inlet

Question 17

List Radiographic Findings that point towards Esophageal FBs.

Answer 17

• Abnormal intraluminal density
• Esophageal distension
• Tracheal displacement
• Abnormalities of the Mediastinum
• Abnormalities of the Lung fields + pleura

Question 18

What contrast material should be used if rupture is suspected?

Answer 18

Iodine

Question 19

Which contrast agents can cause pulmonary edema?

Why?

Answer 19

Iodinated contrast agents

b/c are hyperosmolar

Question 20

Which 2 methods should be used to remove Esophagel FBs

as much as possible?

Answer 20

• Esophagoscopy
• Balloon catheter retrieval

(Non-surgical techniques)

Question 21

Post-Op TX for Non-Surgical FB Retrieval?

Answer 21

• No perforation → soft diet + ABX
• Minor perforation → gastrostomy tube feeding + ABX
• Significant perforation → Thoracotomy, Thorascostomy + gastrostomy tube feeding & ABX

Question 22

Etiology of Esophageal Strictures

Answer 22

• 2° to inflammation & trauma
• Esophageal SX complication
• 2° to Gastroesophageal Reflux Dz (GERD)
• Anesthesia ?
• Antacid TX

Question 23

Describe the Bouginage or Balloon Dilation

for treating Esophageal Strictures

Answer 23

• Progressively larger dilators are used
• Requires GA
• May require multiple procedures to achieve adequate dilation
• Guarded to fair PX → stricutures often recur

Question 24

Who most often presents w/ Cricopharyngeal Achalasia?

How do they present?

Answer 24

• puppies at weaning
• problems begin once start eating solid food
• Gagging, retching, forceful expulsion of bolus of food
• Regurgitation immediately after swallowing

Question 25

DDX for Cricopharyngeal Achalasia

Answer 25

PRAA

Megaesophagus

Pyloric Stenosis

Question 26

TX for Cricopharyngeal Achalasia

Answer 26

Cricopharyngeal myectomy

(contraindicated for phyaryngeal dyshagia)

Question 27

What “tool” can help animals suffering from Megaesophagus?

Answer 27

Bailey Chair

(gravity helps food pass to stomach)

Question 28

What parasite causes granulomatous rxns in the esophagus?

Answer 28

Spirocerca lupi

Question 29

How can you TX Hypertrophic Osteopathy due to S. lupi?

Answer 29

Surgical removal of a single tumor in the thorax or abdomen → regression of dz in long bones

Question 30

Where should a Esophagostomy Tube be placed?

Why?

Answer 30

Cranial to the Esophageal Hiatus

Don’t want to cause Gastroesophageal reflux by having the tube too close to the stomach

Question 31

What should you ALWAYS do when using an Esophagostomy Tube?

Answer 31

Flush w/ water → feed patient→ flush with water