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55 Cards in this Set

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Why does the esophagus command more respect from the surgeon?
Does not tolerate surgery as well as most other tissues
-esophagotomy avoided if any other treatment available
*What are 6 reasons that the esophagus heals poorly after surgery?
1) Contaminated site
2) Absence of a complete serosal layer
-none in cervical area
-in thorax mediastinum only goes against the esophagus on either side
3) Absence of omentum
4) Possibly poor blood supply (debatable)
-weakest in thoracic esophagus
5) Tension, motion and distention
-moves boluses of food
6) Movement of ingesta past the surgical site
-ingesta= very contaminated
What are Halstead's 7 principles?
1) Gentle tissue handling
2) Accurate hemostasis
3) Preservation of adequate blood supply
4) Strict asepsis
5) No tension on sutures
-be careful about this w/ esophagus
6) Careful approximation of tissue planes
7) Obliteration of dead space
-can't really do for esophagus
Historically the mucosa was believed to be the holding layer of the esophagus and suturing was always performed as a two-layer suture. How is the esophagus closed now?
Now we know that the sub-mucosa is the holding layer, so we know that a single layer is fine as long as we get the sub-mucosa
What is the two-layering suture technique that is/was used for the two-layer technique on the esophagus?
Do submucosa first and then musulcaris and adventitia together on top of it
-layers starting in lumen: mucosa, submucosa, muscularis externa, adventitia
How is the single-layer technique done to suture the esophagus?
Ideally non penetrating, but same as the bladder that we would rather make sure to get the submucosa and enter the lumen then not get a good bite of the submucosa
what type of suture should be used to close the esophagus? what suture pattern?
Monofilament
-simple interrupted or simple continuous, but lots of tension use interrupted
How do you approach the esophagus when using a stapling instrument?
Depends on the location:
If you're in the neck and patient is big dog can enter through the oral cavity, if caudal enough can come through the stomach so don't have to make an incision in esophagus
Is stapling a very effective method used to anastamose the esophagus?
Yes, shown to have better healing, fast, and creates an inversion
What approach do you use when there's an issue with the cervical esophagus? Where is esophagus located?
A ventral midline approach to the neck
-esophagus is slightly to the left and dorsal to the trachea so retract trachea to the right
-can pass large tube in esophagus- makes it easier to find
When approaching the esophagus from the cranial thorax do we prefer to incise on the right or left? why?
Left because that's where the esophagus favors
How do you approach the esophagus when there's an issue in the esophagus at the base of the heart?
Do a right lateral thoracotomy thoracotomy bc the aorta is to the left of the esophagus and aortic arch isn't going to be moved out of the way so to get to esophagus need to go to the right side where vena cava anad azygos is located- can move these out of the way
-if caudal to heart we go back to a left sided thoracotomy
What is a general rule of what IC space to use for a thoracotomy if you are in doubt?
Always use the more caudal IC space because the ribs can be moved cranially but not caudally
What are 4 principles to remember when performing an esophagotomy?
1) Occlude lumen cranial and caudal to surgical site
2) Avoid vagus nerve
3) Use stay sutures
-something to hold onto
4) Make longitudinal incision
Where is the vagus nerve located in the cranial thorax?
Initially lateral on left and right side and then as reach the caudal thorax it moves to dorsal and ventral on the esophagus
What do you call it when you remove a portion of the esophagus?
Esophagectomy
What are the 2 most common reasons for performing an esophagectomy?
Tumor or stricture
What kind of forceps do you want to use when performing an esophagectomy?
Non-traumatic
-like Doyen clamps
What type of closure do you use when performing an esophagectomy?
Single or double layered closure
What is different about the approach when performing an esophagectomy compared to an esophagotomy?
Esophagectomy you use a circumferential incision not longitudinal like an esophagotomy
How much of the esophagus that can be removed is variable from one patient to the next, what can you do if you go to anastomose the esophagus and there's too much tension?
can do a myotomy cranial and caudal to anastomosis site. The muscularis has two layers: longitudinal and transverse layer, longitudinal layer of muscularis is superficial (outside) so can make an incision through adventitia then cut through longitiduinal muscularis and releases some tension on anastomosis site.
What are 2 support or patching techniques used on the esophagus?
1) Muscular graft in the neck
2) Use omentum
-if caudal enough
What 3 muscles can be used for a muscular graft in the esophagus?
sternohyoideus, sternothyroideus, sternocephalicus
**Keep one end attached so has blood supply
What's the purpose of patching the esophagus with omentum?
Provides blood supply, just makes sure not to strangle the omentum and lose blood supply
What do you have to be careful about when using the omentum to support the esphophagus?
Make sure not to create a hiatal hernia and end up with abdominal contents in chest
-have omentum use entire lumen cut into the diaphragm
-incise near esophageal hiatus
What are 4 common complications of an esophagectomy?
1) Dehiscence
2) Leakage
3) Stenosis
4) Esophageal fistulas
What does the amount of collagen laid down on the esophagus after an esophagectomy depend on?
How much tension is put on it, more tension the more collagen that is laid down to try and keep it together, so almost always get strictures if lots of tension
What are 8 clinical signs of esophageal disease?
**1) Regurgitation
2) Coughing
-at greater risk for aspiration pneumonia
3) Dysphagia
4) Dyspnea
5) Ptyalism
6) Pyrexia
7) Altered appetite
8) Weight loss
What are 4 components used to diagnose esophageal disease?
1) Signalment
2) History
3) Radiographs
4) Endoscopy
What are the 4 most common sites of foreign bodies in the esophagus?
1) Upper esophageal sphincter
-right at entry of esophagus
2) Thoracic inlet
-2 ribs stop expansion
3) Base of heart
-heart gets in the way
4) Very caudal end of esophagus at the cardia
*all these areas either have a sphincter or can't dilate as much
What are some ways to try and remove a foreign body in the esophagus without having to incise into the esophagus?
-Can use a balloon catheter
be prepared to performing thoracotomy if something like fish hook bc risk of pneumothorax
-Endoscopy
What can cause a stricture in the esophagus (not surgery related)?
Abdominal contents can sit in esophagus and be very damaging- can occur and weeks down the road you have a bad stricture form collagen lay down (caudal esophagus)
-Foreign bodies
-esophagectomy
What are some conservative treatments for esophageal disease?
Have animals sit upright when they eat and make them sit upright for 5 minutes after meal
-lets gravity help push food down
-Use a bougienage: balloons of different sizes to keep stretching out the esophagus
What are the 5 most common types of neoplasia in the esophagus?
1) Squamous cell carcinoma
2) Leiomyosarcoma
3) Leiomyoma
4) Fibrosarcoma
5) Osteosarcoma (extraskeletal)
What are the characteristics of malignant neoplasia of the esophagus?
Locally invasive
-metastasize to lymph nodes and lungs
Most sarcomas of the esophagus in dogs are associated with ___________.
Spirocerca lupi
What is the prognosis of malignant esophageal neoplasia?
Poor prognosis for survival bc surgical resection is very difficult
Hiatal hernias (gastroesophageal) are more common in what breed?
Brachycephalics
What are 3 examples of gastroesophageal intussussception?
1) Paraesophageal herniation
-fundus moving through hiatus next to esophagus
2) Combination of fundus and paraesophageal herniation
3) Gastroesophageal intussusception
-very rare
Why are hiatal hernias difficult to diagnose?
Because they are a dynamic problem so animal may be fine when brought into your clinic
What is the classic history of an animal with a hiatal hernia?
Salivation, burping, looks nauseas, lasts for an hour and then they're fine
What are the 3 surgical steps/options to correcting a hiatal hernia?
1) Close hiatal opening
-make sure to not make too tight bc issues of food getting into stomach
2) Can pexy the esophagus to the diaphragm
3) Pexy stomach to abdominal wall
-he likes to do both R and L side so not going anywhere
*Usually end up doing all 3 steps
What is cricopharyngeal achalasia? How common is it?
Failure of the upper esophageal sphincter to relax (usually congenital)
-rare
When do you usually notice cricopharyngeal achalasia in an animal?
When they switch to solid food
What is the correction used for cricopharyngeal achalasia?
Cricopharyngeal myectomy
How do you perform a cricopharyngeal myectomy?
-Ventral midline approach to pharynx
-Remove a part of the cricopharyngeal muscle and suture it together
How do you place an esophagostomy tube?
use a hemostat and put into esophagus poke against skin make an incision in chin (not over jug) grab tube and pull out through mouth and then grab through mouth and push it back down; if just grabbed it at C and went down into esophagus you could be in subQ so if come up through mouth and push it back in its definitely in the esophagus -we do contrast study to ensure proper placement
What are 3 possible complications of an esophagostomy tube?
1) Skin irritation
2) Hemorrhage
-if cut into jugular v.
3) Mediastinitis
-if tip isn't in esophagus can go down through mediastinum
What are 6 advantages of an esophagostomy tube?
1) Fast
2) Only simple equipment required
3) Cost less than gastrostomy tube placement
4) Relatively non-invasive
5) complications are decreased
6) Tube can be removed at any time
-gastrotomy tube= have to stay in 7-10 days
What causes vascular ring anomalies? What do they cause?
Congenital
Constriction of the esophagus
The esophagus is normally located ______ relative to the aortic arch.
Right
**95% of animals with a vascular ring anomaly have _________.
Persistent right aortic arch
How does a persistent right aortic arch cause esophageal constriction?
right aortic arch persists so aortic arch goes to right instead of left and goes around esophagus and ligamentum arteriosum has to go from right side to left side = where vascular anomaly occurs
What is the classic signs of a vascular ring anomaly on an x-ray?
**Dilation of esophagus that stops at the base of the heart
What is the treatment for a persistent fourth aortic arch?
Perform left thoracotomy and cut ligament arteriosum and ligate it bc it could still have flow (was ductus arteriosus during development)