Fiser Absite. Ch 29. Esophagus Stomach

Front 1

What are the layers of the esophagus?

Back 1

stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa

Front 2

What kind of muscle is in the upper esophagus? lower esophagus?

Back 2

striated muscle, smooth muscle

Front 3

What is the blood supply of the cervical esophagus? and abdominal esophagus?

Back 3

Cervical esophagus – supplied by the inferior thyroid artery
Abdominal esophagus – supplied by the left gastric artery and inferior phrenic arteries

Front 4

Which direction does the lymphatics of the esophagus drain?

Back 4

upper 2/3 drains cephalad, lower 1/3 caudad

Front 5

Right vagus nerve – travels on ____ portion of stomach as it exits chest; becomes ____ plexus; also has the criminal nerve of ___ → can cause persistently high acid levels postoperatively if left undivided

Back 5

posterior, celiac, Grassi

Front 6

Left vagus nerve – travels on what portion of stomach? and goes where?

Back 6

anterior, goes to liver and biliary tree

Front 7

The upper esophageal sphincter is how far from the incisors? and lower?

Back 7

15 cm, 40 cm

Front 8

What is the most common site of esophageal perforation (usually occurs with EGD)?

Back 8

cricopharyngeus muscle

Front 9

What muscle comprises the upper esophageal sphincter and prevents air swallowing?

Back 9

cricopharyngeus muscle

Front 10

What are the 3 anatomic areas of narrowing of the esophagus?

Back 10

cricopharyngeus muscle,
compression by the left mainstem bronchus and aortic arch,
diaphragm

Front 11

What is the surgical approach to the cervical esophagus? upper 2/3 thoracic? Lower 1/3 thoracic?

Back 11

Cervical esophagus – left
Upper ⅔ thoracic – right (avoids the aorta)
Lower ⅓ thoracic – left (left–sided course in this region)

Front 12

What is the cause in primary esophageal dysfunction? secondary?

Back 12

unknown in primary

secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis

Front 13

What is the diagnostic procedure of choice for dysphagia and odynophagia?

Back 13

barium swallow (better at picking up masses)

Front 14

What is the usual cause of cervical esophageal dysphagia?

Back 14

plummer–vinson syndrome

Front 15

What is the 3 parts of tx for plummer–vinson syndrome?

Back 15

dilation, Fe, screen for oral CA

Front 16

What can occur between the cripharyngeus and pharyngeal constrictors?

Back 16

Zenker's diverticulum

Front 17

What is the tx for Zenker's diverticulum?

Back 17

cricopharyngeal myotomy; Zenker's itself can either be resected or suspended

Front 18

What do you get on POD #1 after a cricopharyngeal myotomy for Zenker's?

Back 18

esophagogram

Front 19

How is a traction diverticulum different from Zenker's?

Back 19

Zenker's is a false diverticulum and lies posterior; traction is a true diverticulum is usually lateral in the mid esophagus

Front 20

What is the tx for a traction diverticulum of the esophagus?

Back 20

excision and primary closure; may need palliative therapy if due to invasive CA

Front 21

What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?

Back 21

Achalasia

Front 22

What is the medical tx for achalasia (2)? what is next step?

Back 22

first, LES dilation (effective in 80%)

CCB, nitrates

Front 23

What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?

Back 23

Heller myotomy

Front 24

What infection can produce similar sx to achalasia?

Back 24

T. cruzi

Front 25

sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.

Back 25

Diffuse esophageal spasm

Front 26

What are 4 types of tx for diffuse esophageal spasm?

Back 26

calcium channel blocker, trazodone; Heller myotomy if those fail (myotomy of upper and lower esophagus; right thoracotomy)

Front 27

Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle

Back 27

Scleroderma

Front 28

GERD sx with bloating suggests what?

how to dx

Back 28

aerophagia and delayed gastric emptying

may want gastric emptying study

Front 29

What is the best test for GERD?

Back 29

pH probe

also endoscopy, histology, manometry (resting LES < 6 mm Hg)

Front 30

What is the surgical tx for GERD?

Back 30

Nissen

Front 31

What is name of the approach through the chest in a Nissen?

Back 31

Belsey

Front 32

During a Nissen, when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a “new” esophagus. What is this called?

Back 32

Collis gastroplasty

Front 33

Name the type of hiatal hernia:

Sliding hernia from dilation of hiatus (most common); often associated with GERD

Back 33

Type I

Front 34

Name the type of hiatal hernia:

Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction.

Back 34

Type II

Front 35

What is a Type III hiatal hernia? and type IV?

Back 35

Type III – combined ■ Type IV – entire stomach in the chest plus another organ (i.e., colon, spleen)

Front 36

Almost all pts with Schatzki's ring have an associated ___

Back 36

sliding hiatal hernia

Front 37

What is the tx for Schatzki's ring?

Back 37

dilatation of the ring usually sufficient

PPI

dont resect

Front 38

What is the transformation in pts with Barrett's esophagus?

Back 38

squamous metaplasia to columnar epithilium

Front 39

Pts with Barrett's esophagus are at 50x increased risk for what?

Back 39

adenocarcinoma

Front 40

Severe Barrett's dysplasia is an indication for what?

Back 40

Esophagectomy

or

Endoscopic surveillance (3-month intervals; 4 quadrant Bx’s at 1-cm intervals for entire length of HGD and Bx of any suspicious areas)

Front 41

Uncomplicated Barrett's can be treated like GERD with PPI or Nissen and surgery will decrease esphagitis and further metaplasia but it will not prevent what?

Back 41

malignancy or cause regression of the columnar lining

Front 42

Pts with Barrett's esophagus who get a Nissen still need careful lifetime follow up with what?

Back 42

annual follow-up EGD

Front 43

Esophageal tumors are almost always malignant. How does it spread?

Back 43

submucosal lymphatic channels

Front 44

What is the best test for unresctablity in esophageal CA?

Back 44

Chest/abdominal CT

hoarseness (RLN invasion), Horner’s syndrome (brachial plexus invasion), phrenic nerve invasion, malignant pleural effusion, malignant fistula, invasion of another structure (eg airway invasion, vertebra, lung)

Front 45

What is the #1 esophageal CA?

What type occurs most often in the upper 2/3?

Back 45

Adenocarcinoma lower 1/3

Squamous cell carcinoma

Front 46

mets to what nodes indicate unresectability

Back 46

celiac nodes – M1 disease and Supraclavicular nodes in esophageal CA

Front 47

Distant metastases with esophageal CA is a contraindication to what? what is the survival?

Back 47

esophagectomy, < 12 mos

Front 48

What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?

Back 48

5%, 20%

Front 49

What is the primary blood supply to stomach after replacing esophagus in esphagectomy?

Back 49

right gastroepiploic artery (have to divide left gastric and short gastrics)

Front 50

What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy –> exposes all of the esophagus; intrathoracic anasomsis

Back 50

Ivor Lewis

Front 51

What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.

Back 51

Colonic interposition

Front 52

What do you need after esophagectomy on post op day 7?

Back 52

contrast study to rule out leak

Front 53

Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?

Back 53

5FU and cisplatin

Front 54

In esophageal CA with malignant fistulas, most die within 3 months due to what?

Back 54

aspiration

Front 55

What is the most common benign tumor of the esophagus?

Back 55

Leiomyoma

Front 56

Diagnosis of Leiomyoma is __, ___, and ___ to rule out CA.

Why don't you bx?

Back 56

esophogram, endoscopic u/s, CT

can form scar and make subsequent resection difficult

Front 57

Tx for Leiomyoma of the esophagus is excision via thoractomy.

What are the 2 indications?

Back 57

>5 cm or sx

Front 58

Caustic esophageal injury:
NG tube?
Induce vomiting?
drink?

Back 58

no, no, no

Front 59

What is first step in dx in caustic esophageal injury? then what?

Back 59

best test- endoscopy to assess lesion (but not with suspected perforation)

Chest and Abd CT to look for free air,

Front 60

What is the most common cause of esophageal perforation?

Back 60

EGD

Front 61

What is the most common site of esophageal perforation?

Back 61

cricopharyngeus muscle

Front 62

How to dx esophageal perforation?

Back 62

cxr initially

gastrograffin swallow followed by barium swallow

no egd

Front 63

What is the tx for esophageal perforation that is contained, self–draining and no systemic effects?

Back 63

Conservative: IVF, NPO, spit

Front 64

What type of flap can be used with repair of esophageal perforation to help the area heal?

Back 64

intercostal muscle pedicle flap

Front 65

What is Hartmann's sign?

Back 65

mediastinal crunching on ascultation

Front 66

How to dx Boerhaave's syndrome?

Back 66

gastrofrafin swallow

Front 67

What is the stomach transit time?

Back 67

3–4 hours

Front 68

Where does peristalsis occur in the stomach?

Back 68

only in the distal stomach

Front 69

What are the branches of the Celiac trunk?

Back 69

left gastric, common hepatic, splenic

Front 70

Left gastroepiploic and short gastrics are branches of what artery?

Back 70

splenic

Front 71

What is the blood supply of the greater curvature of the stomach?

Back 71

right and left gastroepiploics, short gastrics

Front 72

What is the blood supply of the lesser curvature of the stomach?

Back 72

right and left gastrics

Front 73

The right gastric is a branch of what artery?

Back 73

common hepatic

Front 74

What is the blood supply of the pylorus?

Back 74

gastroduodenal artery

Front 75

What is the mucosa of the stomach lined with?

Back 75

simple columnar epithelium

Front 76

What is the first enzyme in proteolysis and what cell secretes it?

Back 76

Pepsinogen, secreted by chief cells

Front 77

What do the parietal cells secrete?

Back 77

H+ and intrinsic factor

Front 78

What 2 things do Brunner's glands in the duodenum secrete?

Back 78

pepsinogen and alkaline mucus

Front 79

Antrectomy with gastroduodenal anastomosis?

Back 79

Billroth I

Front 80

Antrectomy with gastrojejunal anastomosis?

Back 80

Billroth II

Front 81

____ ulcer is a vascular malformation in the stomach

Back 81

Dieulafoy's

Front 82

____ disease is mucous cell hyperplasia, increased rugal folds of the stomach.

Back 82

Menetrier's

Front 83

What is the tx for gastric volvulus?

Back 83

reductiona and Nissen

Front 84

Associated with type II (paraesophageal) hernia ■ Nausea without vomiting; severe pain.

Back 84

Gastric volvulus

Front 85

Where is the tear usually located in a Mallory–Weiss tear?

Back 85

near lesser curvature of the stomach near GE junction

Front 86

What is the result of a vagotomy

Back 86

vagal denervation all forms increase liquid emptying –> vagally mediated receptive relaxation is removed, results in increased gastric pressure that accelerates liquid emptying

Front 87

In complete vagotomy (truncal or selective) there is decreased emptying of solids. In highly selective vagotomy there is normal emptying of solids. Addition of what procedure to either results in increased solid emptying?

Back 87

Pyloroplasty

Front 88

What is the most common problem following vagotomy (30–50%)?

Back 88

diarrhea

Front 89

Upper GI bleed and having trouble localizing source with EGD. What can be done next?

Back 89

tagged RBC scan

Front 90

What is the biggest risk factor for rebleeding of an upper GI bleed at the time of EGD?

Back 90

spurting blood vessel

Front 91

In a pt with liver failure, what is the most likely source of an upper GI bleed?

Back 91

esophageal varices

Front 92

What is the tx for a bleeding esophageal varices?

Back 92

EGD with sclerotherapy or TIPS, not OR

Front 93

What location of duodenal ulcers usually perforate? what location bleed from GDA?

Back 93

anterior ulcers perforate, posterior ulcers bleed from GDA

Front 94

Describe the incision and closure of a Heineke–Mikulicz pyloroplasty.

Back 94

longitudunal incision of the plyloric sphincter followed by a transverse closure

Front 95

What is the most frequent complication of duodenal ulcers?

Back 95

bleeding

Front 96

The 1st surgical option for bleeding duodenal ulcer is duodenstomy and what? what if the pt has been on PPI therapy?

Back 96

GDA ligation,

truncal vagotomy and pyloroplasty

Front 97

With GDA ligation for bleeding duodenal ulcer, it is important to avoid hitting what structure?

Back 97

common bile duct

Front 98

What is the initial treatment of choice for obstruction due to duodenal ulcer?

Back 98

serial dilation

Front 99

Pt on H–pump inhibitor develops a perforated duodenal ulcer. What is the best surgical option? what if they were not on H–pump inhibitor?

Back 99

Graham patch and highly selective vagotomy; just do Graham patch and place on omeprazole

Front 100

What is the test for Zollinger–Ellison Syndrome?

Back 100

Secretin test results in high gastrin level

Front 101

In Zollinger–Ellison syndrome, what size tumors can be enucleated?

Back 101

<2 cm

Front 102

What is the most common location for gastric ulcers? and the most common cause?

Back 102

lesser curvature; decreased mucosal defense (normal acid secretion)

Front 103

Hemorrhage is associated with higher mortality in duodenal or gastric ulcers?

Back 103

gastric

Front 104

What location in the stomach is the bx for H. pylori taken?

Back 104

antrum

Front 105

List the locations of gastric ulcers types I–V

Back 105

Type I – lesser curve along body of stomach
Type II – 2 ulcers, lesser curve and duodenal
Type III – prepyloric
Type IV – lesser curve high along cardia of stomach
Type V – associated with NSAIDs

Front 106

What is the timing after event for stress gastritis?

Back 106

3–10 days after event

Front 107

Chronic gastritis has types A and B what is their location and what are they associated with?

Back 107

Type A (fundus) – associated with pernicious anemia, autoimmune disease
Type B (antral) – associated with H. pylori

Front 108

Where are 40% of gastric cancers located?

Back 108

antrum

Front 109

What is the difference in the pain with gastric cancer vs gastric ulcer?

Back 109

gastric ulcer pain is relived by eating but recurs 30 min later.

Front 110

What blood type is a risk factor for gastric cancer?

Back 110

type A

Front 111

What is Krukenberg tumor?

Back 111

gastric cancer with mets to ovaries

Front 112

What is Virchow's nodes?

Back 112

gastric cancer with metastases to supraclavicular nodes

Front 113

What size margins in subtotal gastrectomy for gastric cancer?

Back 113

5 cm

Front 114

What is diffuse gastric cancer called?

Back 114

linitis plastica

Front 115

What is the surgical tx for linitis plastica?

Back 115

total gastrectomy

Front 116

In palliation for gastric cancer, proximal obstruction can be treated with what? and distal?

Back 116

proximal can be stented, distal lesions can be bypassed with gastrojejunostomy

Front 117

What is the most common benign gastric neoplasm? aka?

Back 117

gastric leiomyomas, also called gist tumors

Front 118

What is the chemotherapy agent and MOA for gastric leiomyomas?

Back 118

Gleevec (tyrosine kinase inhibitor)

Front 119

What is the proto–oncogene are most gastric leiomyomas positive for?

Back 119

c–kit (CD117)

Front 120

What route does gastric leiomyosarcoma spread?

Back 120

hematogenous

Front 121

What is the tx for mucosa associated lymphoid tissue lymphoma (MALT lymphoma)? and if it does not regress?

Back 121

Triple therapy abx for H. pylori; CHOP

Front 122

What are the surgical eligibility criteria for bariatric surgery?

Back 122

BMI >40 kg or BMI >35 kg with coexisting comorbiditiies

Front 123

What is the medical and surgical tx for dumping syndrome?

Back 123

octreotide may be effective. Surgery is rarely needed but includes converting a billroth I or II to a roux–en–Y gastrojejunostomy. Or increasing the gastric reserve with a jejunal pouch or increasing emptying type with a reversed jejunal loop

Front 124

What is the dietary tx for dumping syndrome?

Back 124

small, low–fat, low–carb, increased–protein meals; no liquids with meals; no lying down after meals

Front 125

What are two surgical options for treating dumping syndrome after gastrectomy?

Back 125

conversion of billroth I or billroth II to Roux–en–Y gastrojejunostomy

Operations to increase gastric reservoir (jejunal pouch) or increase emptying time (reversed jejunal loop)

Front 126

After a gastrectomy there is postprandial epigastric pain associated with N/V; pain not relived with vomiting. Evidence of bile reflux into stomach and histologic evidence of gastritis. Dx?

Back 126

Alkaline reflux gastritis

Front 127

What are 3 medical options for the tx of alkaline reflux gastritis after gastrectomy?

Back 127

H2 blockers, cholestyramine, metoclopramide

Front 128

What is the surgical option for treating alkaline reflux gastritis after gastrectomy?

Back 128

Conversion of Billroth I or Billroth II to Roux–en–Y gastrojejunostomy with afferent limb 60 cm distal to original gastrojejunostomy

Front 129

In roux–en–y which limb is the roux limb? Which is the afferent limb?

Back 129

The roux limb goes from the gastrojejunostomy to the jejunojenuostomy. The afferent limb is the portion of duodenum and jejunum feeding the jejunojenunostomy.

Front 130

What is the cause of roux stasis?

Back 130

stasis of chyme in Roux limb due to loss of jejunal motility.

Front 131

How do you dx Roux stasis?

Back 131

EGD, emptying studies

Front 132

What are 2 treatment options for Roux stasis?

Back 132

metoclopramide/prokinetics

shorten Roux limb to 40 cm

Front 133

What is caused by delayed gastric emptying after vagotomy?

Back 133

chronic gastric atony

Front 134

What is the surgical treatment for chronic gastric atony after gastrecomy?

Back 134

near total gastrectomy with Roux–en–Y

Front 135

What is the surgical option for small gastric remnant and early satiety after gastrectomy?

Back 135

jejunal pouch reconstruction

Front 136

After Billroth II or Roux–en–Y, symptoms include pain, diarrhea, malabsorption, B12 deficiency, steatorrhea. Caused by bacterial overgrowth and stasis in affarent limb.

Back 136

Blind–loop syndrome

Front 137

What is the medical and surgical treatment options for blind–loop syndrome?

Back 137

tetracycline, Flagyl, metoclopramide

reanastomosis with shorter (40 cm) afferent limb

Front 138

zenker's diverticulus true diverticulum?

Back 138

no, false diverticulum

Front 139

traction diverticulum true diverticulum?

Back 139

yes, true diverticulum

Front 140

pharyngoesophageal disorders, solids or liquids worse?

Back 140

liquids

Front 141

tx for zenkers

Back 141

Tx: cricopharyngeal myotomy (key point); Zenker’s itself can either be resected or suspended (removal of diverticula is not necessary)

Left cervical incision; leave drains in;

esophagogram POD #1

Front 142

posterior or lateral?

zenkers and traction divertiuclum

Back 142

zenkers posterior

traction lateral

Front 143

tx of traction diverticulum

Back 143

sx? excision and close

asx? nothing.

Front 144

Epiphrenic diverticulum Rare; associated with

Back 144

esophageal motility disorders(eg achalasia)

Front 145

Tx: Epiphrenic diverticulum

Back 145

Tx: diverticulectomy and esophageal myotomy on the side opposite the diverticulectomy if symptomatic

Front 146

ACHALASIA cause

Back 146

Caused by lack of peristalsis and failure of LES to relaxafter food bolus

Front 147

ACHALASIA pathophys

Back 147

Secondary to autoimmune destruction of neuronal ganglion cells in muscle wall

Front 148

imaging of ACHALASIA

Back 148

Can get tortuous dilated esophagus and epiphrenic diverticula; bird’s beak appearance

Front 149

if dilation and medication fail in ACHALASIA

Back 149

Heller myotomy (left thoracotomy, myotomy of lower esophagus only; also need partial Nissen fundoplication)

Front 150

can get what cancer in achalasia

Back 150

Can get esophageal CA late (squamous cell most common)

Front 151

infection that can cause achalasia

Back 151

T. cruzi can produce similar symptoms

Front 152

medical tx for DIFFUSE ESOPHAGEAL SPASM

Back 152

: calcium channel blocker, trazodone;

Front 153

if meds fail for DIFFUSE ESOPHAGEAL SPASM

Back 153

Heller myotomy if those fail (myotomy of upper and lower esophagus; right thoracotomy)

Front 154

what is dx of CHEST pain +/- dysphagia

Back 154

NUTCRACKER ESOPHAGUS

Front 155

manometry of NUTCRACKER ESOPHAGUS

Back 155

high-amplitude peristaltic contractions (> 180 mm Hg);

LES ok

Front 156

tx of NUTCRACKER ESOPHAGUS

Back 156

same as diffuse esophageal spasm

calcium channel blocker, trazodone; Heller myotomy if those fail (myotomy of upper and lower esophagus; right thoracotomy)

Front 157

sx of scleroderma esophagus

Back 157

Heartburn, massive reflux, dysphagia

Front 158

how is LES tone?

reflux?

Back 158

loss of LES tone

massive refluxand strictures

Front 159

tx SCLERODERMA

Back 159

Tx: PPI and Reglan; esophagectomy usual if severe

Front 160

dx GERD?

Back 160

Dx: pH probe (best test), endoscopy, histology, manometry

Front 161

(resting LES in GERD?

Back 161

(resting LES < 6 mm Hg)

Front 162

GERD

Key maneuver for dissection is __

Key maneuver for wrap is__

Back 162

Key maneuver for dissection is finding the right crura

Key maneuver for wrap is identification of the left crura

Front 163

sx of Type II –HIATAL HERNIA

Back 163

Symptoms: chest pain, dysphagia, early satiety

Front 164

best way to dx schatzki's ring

Back 164

Front 165

what to do if have dysphagia after nissen

Back 165

wrap too tight

(generally resolves on its own;

give clears for 1st week;

can dilate after 1 week)

Front 166

pt with chest pain, retching without vomiting, can’t pass NG tube;

what is it? what to do

Back 166

paraesophageal hernia II-IV..

risk for incarceration

usually need repair

may want to avoid repair in the elderly and frail if minimal symptoms

Front 167

adenoca of esophagus met to where?

Back 167

liver mc

Front 168

SCC of esophagus met to where?

Back 168

lung mc

Front 169

Most important prognostic factor in patient devoid of systemic metastases

Back 169

nodal spread

Front 170

primary blood supply to stomach after replacing esophagus in ca resection

Back 170

Right gastroepiploic artery

(have to divide left gastric and short gastrics)

Front 171

to resect esophageal ca- can use what approaches

Back 171

Transhiatal approach-cervical anastomosis (mortality from esophageal leaks)

Ivor Lewis – intrathoracic anastomosis

3-Hole esophagectomy - abdominal, thoracic, and cervical incisions

Front 172

need to als perform __ in these 3 procedures

Back 172

pyloromyotomy

Front 173

when to Thoracic duct ligation

where at?

Back 173

> 2 L/day or is refractory to medical Tx

right side, low in the mediastinum)

Front 174

Post-op chemo? (indicated for node-positive disease)

Back 174

cisplatin and 5FU

Front 175

complication of esophageal ca resection-- die w/i 3 mo

Back 175

Malignant fistulas

Tx – esophageal stent for palliation

Front 176

After esophagectomy how to r/o leak

Back 176

→ need contrast study on postop day 7 to rule out leak

Front 177

Esophagectomy margins

Back 177

Need 6–8 cm margins

Front 178

ESOPHAGEAL POLYPS Symptoms

Back 178

dysphagia, hematemesis

Front 179

2nd most common benign tumor of the esophagus

where aT?

Back 179

ESOPHAGEAL POLYPS

cervical esophagus

Front 180

alkali ingestion- ____necrosis

acid ingestion- ___ necrosis

Back 180

deep liquefaction necrosis

coagulation necrosis;

Front 181

Degree of injury:Primary burn looks like

tx?

Back 181

hyperemia

Conservative Tx: IVFs, spitting, antibiotics, oral intake after 3–4 days; may need future serial dilation for strictures (usually cervical)

Front 182

Degree of injury: secondary burn looks like

tx?

Back 182

ulcerations, exudates, and sloughing

Tx: prolonged observation and conservative therapy as above; TPN

Indications for esophagectomy – sepsis, peritonitis, mediastinitis, free air, mediastinal or stomach wall air, crepitance, contrast extravasation, pneumothorax, large effusion

Front 183

Degree of injury: Tertiary burn looks like

tx?

Back 183

deep ulcers, charring, and lumen narrowing

Tx: as above; esophagectomy usually necessary

Front 184

Degree of injury:Primary burn complication...

Back 184

Can also get shortening of esophagus with GERD (Tx: PPI)

Front 185

Caustic esophageal perforations are repaired?

Back 185

NO- esophageal perforations require esophagectomy (are not repaired due to extensive damage)

Front 186

tx for if esophageal perf not contained

< 24 hours or minimal contamination :

Back 186

primary repair with drains

Need longitudinal myotomy to see the full extent of injury

Front 187

tx for if esophageal perf not contained

>48 or extensive contamination :

Back 187

Neck – just place drains (no esophagectomy) → will eventually heal

Chest – 1) resection (esophagectomy, cervical esophagostomy) or

2) exclusion and diversion (cervical esophagostomy, staple across distal esophagus, washout mediastinum, place chest tubes – late esophagectomy at time of gastric replacement)

Gastric replacement of esophagus late when patient fully recovers