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104 Cards in this Set
- Front
- Back
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Esophagus distances |
Teeth to UES ~ 15 cm UES to LES 25 - 30 cm C6 - T11 (30 cm long) |
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Best access incision |
Neck - left neck Mid - right Lower - left chest |
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Embryology |
Squamous epithelium: endoderm Muscularis: mesoderm |
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Layers |
Mucosa: Squamous (Z line - where transitions to columnar)
Submucosa 2 layers of muscle (striated to smooth) |
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3 indentations |
At CP muscle (Most narrow) Aortic arch Left mainstem bronchus |
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Upper esophageal sphincter |
High pressure zone Resting pressure 60 Should relax to 12 with food |
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Killian’s triangle |
Thyropharyngeal oblique fibers Cricopharyngeus muscle horizontal fibers |
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Lower esophageal sphincter |
Not true sphincter 2-5 cm high pressure zone Resting pressure 6 - 26 mmHg |
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↑ LES tone |
Gastrin Motilin |
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↓ LES tone |
Estrogen CCK Secretin Ca2+ blockers Caffeine Diazepam Theophylline |
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Blood supply |
Cervical: inferior thyroid artery Thoracic: branches off aorta and bronchial Abdominal: left gastric, phrenic |
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Venous drainage |
Mirrors arteries Submucosal venous plexus Azygous runs along right Hemazygous rights along left Abdominal: coronary vein to portal system |
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Lymphatics |
Significant submucosal lymphatics Little barrier to longitudinal spread of cancer Upper ⅔ drains cephalad Lower ⅓ both |
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Sympathetic |
Cervival / thoracic / splanchnic trunks |
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Parasympathetic |
Vagus |
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Subclavian ring |
Abnormal R subclavian ring from descending aorta behind esophagus |
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Subclavian ring Tx |
Asymptomatic - reassurance Weight loss / dysphagia: Reimplant / bypass subclavian |
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Pulmonary artery sling |
Left pulmonary artery off right pushes between trachea and esophagus |
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Pulmonary artery Tx |
Can lead to tracheal stenosis and left pulmonary artery stenosis Tx: Sternotomy, bypass, reposition vessels |
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Schatzki’s ring |
Low by squamocolumnar junction Rarely significantly obstructive RF: Plummer Vinson (anemia, fingers) |
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Zenker’s |
Pharyngoesophageal False @ Killian's triangle between thyro- & crico- pharyngeus |
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Zenker's Dx |
Barium swallow |
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Zencker's Tx |
Traditionally left neck - resect or pexy + myotomy If small or ill patient, don’t need to resect - just myotomy |
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Dolman approach for Zencker's |
Endoscopic Over 3 cm - results same Under 3 cm - surgery superior |
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Midesophageal Diverticula |
Usually asymptomatic / incidental Right side |
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Midesophageal Diverticula Dx |
Barium swallow CT Endoscopy r/o cancer Manometry - rule out motility disorder |
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Midesophageal Diverticula Tx |
Under 2 cm - observe Over 2 cm or symptomatic - diverticulopexy |
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Epiphrenic Diverticula |
Pulsion / false Common with NEM, DES, achalasia - related to high LES pressure |
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Epiphrenic DiverticulaDx: |
Barium swallow Endoscopy r/o cancer |
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Dysphagia |
Always needs a work up #1: esophagram / Upper GI series #2 endoscopy if concern for mass |
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Achalasia |
LES cannot relax Eventually NO PERISTALSIS Dysphagia with liquids & solids GERD 76% |
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Achalasia Causes |
Immunologic - Lymphocytes in LES enriched for anti-HSV Genetic Lack of inhibitory neurons Have exaggerated responses to Ach & CCK Infectious |
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Achalasia Dx |
#1 test: Manometry Barium swallow - bird’s beak Endoscopy RO mass |
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Achalasia Tx good surgical candidate |
Myotomy is best / most effective option Begin above LES and continue few cm down anterior gastric wall Usually paired with antireflux procedure |
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Achalasia Tx poor surgical candidate |
1) Ca channel blockers 2) Botox Symptoms recur in 50% within 6 months 3) Dilation“Rupture LES”Usually 60% effective @ 10 years |
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Achalasia SCC risk |
7% |
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Diffuse Esophageal Spasm |
Normal peristalsis interrupted by strong spasms Chest pain / similar to angina RF: IBS, sexual dysfunction, urinary disturbances |
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Diffuse Esophageal Spasm Dx |
Manometry Consistent intermittent contractions mixed with normal peristalsis High Amplitude over 30 mmHg (2 groups: + or - effective peristalsis) |
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Diffuse Esophageal Spasm Tx |
Rule out GERD symptoms with PPI trial Ca channel blockers - shown in trials to improve manometry but not chest pain Nitrates - may help with pain Trazodone / TCAs Last resort - long myotomy including all regions that were abnormal on + Dor |
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Esophageal hypermotility |
Spastic / nutcracker esophagus / LES HTN Chest pain 50% dysphagia |
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Esophageal hypermotility Dx |
Manometry Mean amplitude over 180 mm Hg Duration over 6 cm |
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Esophageal hypermotility Tx |
Medical management as above |
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Esophageal hypomotility |
Peristalsis under 30 mm Hg not effective Severe reflux |
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Esophageal hypomotility |
Scleroderma (due to diffuse vasculititis) - also have LES below 10 RA SLE Amyloidosis Myxedema MS |
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GERD |
⅓ have nonspecific symptoms Often get respiratory complications30% have normal endoscopy Screening systems miss atypical symptoms Compensate by swallowing a lot → aerophagia → belching |
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RF |
BMI Hiatal hernia Especially nonreducing |
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Antireflux barrier |
Frequency of swallow / non-swallow induced LES relaxations LES structural integrity Pressure (high pressure zone less than 6 mm Hg too weak) Overall length (length less than 2 cm too short) Average length in stomach (less than 1 cm too short) Length exposed to positive pressure of abdomenCrura / GE flap valve as represented by angle of HIS**** why hiatal hernias play a role |
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GERD Sequelae - Esophagitis |
Mucosal - esophagitis / stricture (due to gastric acid + pepsin) Worse: Time exposed to pH under 4, pH 7 + bilirubin???? Presence / size of hiatal hernia (shorter LES and lower resting P) Better: PPI |
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GERD Sequelae |
Esophagitis → Stricture Over time LES can become permanently defective Extraesopagheal - pulmonary issues Metaplastic - Barrett’s → adenocarcinoma |
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GERD Dx |
24 hours pH probe - “gold standard” (pH under 4 considered exposure) Endoscopy |
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GERD Tx |
PPI, but most will require life-long treatment Anti-reflux procedure indicated for severe GERD not relieved by meds, complicated by esophagitis, stricture, Barrett, GERD + paraesophageal hernia, PPI dependent for life (especially if young or prefer), cannot take PPI |
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PPIs |
80-90% effective, still have some breakthrough Unlikely to work if: Nocturnal reflux Major LES abnormality Gastric + duodenal Mucosal injury at endoscopy AE: osteoporosis |
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Choosing a fundoplication |
Always get manometry to determine what kind of fundoplication best Generally Nissen is best unless patients have severe esophageal dysmotility |
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Nissen fundoplication |
Crural dissection, identification and preservation of both vagi including the hepatic branch of the anterior vagus Circumferential dissection of the esophagus Crural closure + strattice less recurrence Fundic mobilization by division of short gastric vessels Creation of a short, loose fundoplication by enveloping the anterior and posterior wall of the fundus around the lower esophagus If esophagus very short can perform collis gastroplasty If lacerate esophagus during operation, repair defect and add fundoplication over |
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Nissen outcomes |
80-90% successful at 5 years Best success in patients with: Low pH on monitor Typical symptoms Improvement with PPI |
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Nissen complications |
Early wrap herniation into the chest 1.3% - Substernal pain + no regurg Dysphagia - wrap is too tight Gas bloat syndrome Causes: Vagus injury, disordered gastric motility Tx: #1 dietary modifications, prokinetic agents Hemorrhage rare - short gastrics, trauma to liver or phrenics |
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Toupet |
270 partial posterior Patient feel more comfortable but 50% may still have pathologic acid exposure |
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Dor |
180 anterior Only for severe achalasia with Heller myotomy |
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Morbidly obese + GERD |
RYGB |
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If hiatal hernia |
Fix at time of fundoplication |
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Larger hernia |
More acid exposure to esophagus |
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Hiatal herniaType |
I: sliding of GEJ into the chest, attenuated phrenoesophageal ligament II TRUE: GEJ in place but fundus covered by peritoneal sac herniates into chest III: both (I+II) IV: stomach + another organ in the chest |
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Hiatal hernia Dx |
Usually incidental on upper GI or endoscopy Manometry pH monitoring |
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Hiatal hernia Tx |
If Type I and asymptomatic, can observe, otherwise: repair + usually antireflux procedure (but not necessary) Gastric volvulous: repair + Nissen has least recurrence (270 if motility issues) |
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Concern hiatal hernia recurred |
Upper GI |
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Barrett’s |
Squamous → columnar metaplasia |
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Barrett’s RF |
Early onset GERD Abnormal lower esophageal and body physiology Mixed reflux of gastric / duodenal contents |
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Barrett's Sequelae |
5 - 10% get dysplasia each year 0.5 - 1% get adenocarcinoma If high grade dysplasia - up to 50% have adenocarcinoma within |
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Can PPIs improve GERD but not Barrett's? |
YES |
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Barrett's Tx |
No dysplasia → medical therapy or Nissen, repeat in a year Indefinite dysplasia → High dose PPI, repeat biopsy in 3 months, and repeat Low-grade: → medical therapy or Nissen, repeat in 6 months (Nissen stops progression but no regression) High grade → esophagectomy is classic standard Endoscopic mucosal resection if sick Must continue surveillance after Nissen |
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Leiomyoma |
⅔ of all benign Intramural in muscularis propria layer Usually distal because derived from smooth muscle |
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Leiomyoma Dx |
EGD with EUS shows smooth mucosa, mass underneath CT scan to rule out malignant appearance / spread If unclear if GIST or sarcoma, can EUS-FNA cautiously |
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Leiomyoma Tx |
Enucleate if symptomatic or question of malignancy or over 8 cm |
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Fibrovascular polyps |
? |
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Esophagus cancer |
Adenocarcinoma more common than SCC now SCC 5X black men ACC 3X white men (annual rate of increase = ) Overall very low in women |
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SCC RF |
Smoking + EtOH Nitrites Achalasia Caustic strictures PV syndrome Tylosis |
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AdenoCA RF |
GERD / Barrett’s |
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Esophageal Cancer WU |
Barium swallow Esophagoscopy with EUS - very accurate for T stage, can see LN + FNA nodes PET scan to RO mets |
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T Stage |
T1 - submucosal T2 - intramuscular T3 - into perisophageal tissue T4 - into other structures |
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N Stage |
N |
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Siewest tumor classifications |
I: AdenoCa of lower esophagus (Barrett’s) II: GE junction III: Below GE junction |
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Esophageal Cancer neoadjuvaant |
T2 and more |
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aLkali |
Liquefactive necrosis → ulceration → cicatrization |
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aCid |
Coagulation |
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Grades |
I Superficial mucosa burn / edema / hyperemia IIA: Slughing mucosa, patchy ulcers IIB: Circumferential ulcer III: Full thickness necrosis |
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Caustic injury management |
Asymptomatic - wait 24 hours and scope Symptomatic - rule out perforation with CXR, then scope I/IIA - NPO, AAT IIB/III - Abs, NPO, gastrostomy or jejunostomy depending on if stomach involved |
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Foreign body ingestion |
Often stuck at cervical esophagus @ CP muscle indentation, some at second indentation (aortic arch) |
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Foreign body Dx / Tx |
Dx:CXR / scope Tx:Rigid esophagoscopy & retrieval Upper GI to rule out perforation |
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Perforation |
#1 iatrogenic @ CP muscle Spontaneous / barogenic (Boerhaave) Foreign body Trauma Cancer Caustic ingestion |
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Specific signs by location |
Cervical - dysphagia, neck pain, ephysema Intrathoracic - mediastinitis Intraabdominal - peritonitis |
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Perforation Dx |
Upper GI / CT |
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Perforation Tx |
Surgical approach depends on how contaminated |
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Uncontained cervical perforation |
left neck, drain, NPO, feeding tube, reevaluate in 1-2 weeks |
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Uncontained Intrathoracic perforation Uncontaminated |
Debride perforation Vertical myotomy to expose mucosa 2 layer repair Intercostal muscle patch |
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Uncontained Intrathoracic perforation Contaminated / tissues look bad |
Cervical esophagostomy, stapled division of GE junction Chest tubes / feeding tubes Re-evaluate in 6-8 weeks for restoring continuity Delayed recon options: gastric pull up, interpositions |
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Mallory Weiss Tear |
Violent emesis → bloody Tear is at junction of esophagus and gastric cardia |
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Mallory Weiss Tear Dx |
Endoscopy |
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Mallory Weiss Tear Tx |
Resuscitate / support →Treat endoscopically → OR |
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Esophagectomy Approaches |
McKeown Ivor Lewis Hiatal |
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Esophagectomy Morbidities |
Leak (? ) Conduit necrosis Insufficient conduit length Thoracic duct injury / Chylothorax Dysphagia / aspiration |
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Thoracic duct injury / Chylothorax |
(4%) #1 cause of chylothorax |
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Chylothorax Dx |
3-4 g protein / 100 mL, high triglycerides |
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Chylothorax Tx |
Very low can try high protein low fat diet Under 500 mL / day: NPO / TPN 500 - 1000: can try NPO / TPN Over 1000: Ligate |
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Dysphagia / aspiration after esophagectomy |
Can occur as a result of RLN injury (ascends in TE groove - innervates CP and cervical esophagus) |
