-
layers of esophagus
mucosa, submucosa, muscularis propria
-
blood supply to the esophagus
inf thyroid, branches from aorta, left gastric/inf phrenic
-
becomes celiac plexus and has criminal nerve of grassi
right vagus (posterior)
-
the thoracic duct crosses the midline where
t4 t5
-
normal pressures of upper esophageal sphincter
60/15
-
normal pressures of lower esophageal sphincter
15/0
-
lower esophageal sphincter pressure with gerd
<5
-
length of esophageal sphincter
30 cm
-
aspiration with brainstem stroke is 2/2
failure of cricopharyngeus muscle to relax
-
best initial test for dysphagia/odynophagia
barium swallow
-
best initial test for suspected perf
gastrograffin followed by thin barium
-
dysphunction of esophagus in achalasia
inability for les to relax and loss of peristalsis
-
pathophys of achalasia
loss of neuronal ganglion cells in auerbachs
-
sxs of achalasia
dysphagia to liquids and solids with regurgitation of food
-
suspected achalasia but difficulty passing scope past GE junction
pseudoachalasia from GE junction malignancy
-
burned out esophagus defined as
- >50% non-pulsatile contractions
- <30 mmhg with each contraction
-
significance of finding burned out esophagus in achalasia
Heller wont work need esophagectomy
-
achalasia at risk of
squamous cell ca of esophagus
-
medical tx for achalasia
relax sphincter with balloon dilation, Ca blocker, nitrates
-
length of incision of for a heller
7cm proximally or up to inf pulm vein and 1-2cm below egj
-
treatment of late leak after heller
- define location of fluid collection with ct, drain
- abx
- npo
- tpn
- r/o distal obstruction with gastrograffin
- surgery if no closure in 6-8 weeks
-
best test for DES
manometry
-
tx of des
ca blocker, trazadone(psych)
-
surgey for des
right vats/thorocatomy with long esophageal myotomy plus belsy
-
how does the manometry findings differ in nutcracker vs des
waves are high amplitude just like des but are peristaltic
-
CREST
- seen in scleroderma
- Calcinosis
- Rayndauds
- Esophageal dysmotility
- Sclerodactyly
- Teleangiectasis
-
most common affected organ in scleroderma
esophagus
-
most important clinical finding with associated with esophageal dysphunction
raynauds
-
operation for scleroderma of affecting the esophagus
partial wrap + collis gastroplasty or for very dilated esophagus- esophagectomy
-
epiphrenic diverticula most commonly seen with
achalasia
-
tx for epiphrenic diverticula
fix the underlying problem- tight les sphincter with baloon dilation or peptic stricture with GERD
-
indications to resect epiphrenic diverticulum
narrow neck, inflammation, large size
-
tx of traction diverticula
- nothing if asx otherwise:
- excision and primarily closure
- stent for palliation if advance lung ca
-
initial w/u for zenker's should not consist of what
EGD due to risk of perforation
-
open surgical treatment of zenkers
- left neck incision ant border of scm
- ligate inf thyroid aa. and middle thyroid vein for exposure
- cricopharyngomyotomy 3cm below on cervical esophagus and 3cm above hypopharynx
-
chest pain, dysphagia with subcu emphysema
esophageal perf
-
sites of esophageal perf
UES, indentation of aortic arch, LES
-
infxn from perforated esophagus allows access to mediastinum through what avenues
- post mediastinum: retropharyngeal/retroviscer through alar fascia
- ant mediastinum: pre tracheal fascia
-
tx of cervical esphageal perf
explore primary repair and leave drains
-
while operating for an a cervical esophageal perf you cannot find the site of perforation, what do you do
just leave drains
-
important aspect of repair/management of esophageal perforations at all locations
look for and treat any site of distal obstruction
-
tx of perforated esophagus in a non septic pt with minimal contamination without mediastinitis within 24 hrs of perf
primary repair using longitudinal myotomy to see full length of injury, 2 layer closure, tissue coverage, and treat any distal obstruction
-
tx for esophageal perf >48hrs, septic, large contamination, mediastinitis
- esophagectomy and diversion:
- cervical esophagostomy (spit fistula)
- stapled esophagus above GE junction
- washout mediastinum and place chest tubes
- esophagectomy if not too sick otherwise can leave in place
-
esophageal perforation in a pt with achalasia
- if contained than conservative but make sure LES has been dilated
- non-contained:
- left thoracotomy, repair perf, longitudinal myotomy on opposite side
- if burned out esophagus:
- esophagectomy and gastric pull up at the same time if no mediastinitis
-
Tx for esophageal dissection/intramural hematoma from TEE
NPO x 7days, abx
-
mediastinal abscess following foreign body removal without sepsis
ct guided drainage
-
difference between grade IIa adn IIb esophageal caustic injury
circumferential ulcerations
-
difference between IIIa and IIIb esophageal caustic injury
extensive necrosis
-
tx of grade I and IIa caustic injuries
npo until able to handle saliva then liquids times 1 week then mechanical soft x 3 weeks
-
tx for grade IIb or higher caustic injuries
gastrostomy and feeding J tube
-
when and where do strictures usually take place in caustic injuries
3 weeks and at aortic indentation
-
perforation after trying to repair stricture secondary to remote caustic injury
likely will need esophagectomy
-
tx of disk batteries or coins in stomach
remove if they do not move in 48 hours
-
size criteria of removal of foreign body found in stomach
> 2 x 5cm
-
what senarios need f/u esophagram or manometry following removal of foreign body in the esophagus
- anything below the cervical esophagus
- meat/food impaction
- repeated episode
- battery removal (r/o perforation)
-
most common cause of an edible or non edible object stuck in the esophagus below the UES
peptic stricture
-
what needs to be r/o child presents with food lodging in the UES
retrobulbar palsies
-
criteria for GERD with pH probe
>4.5% of total time with pH < 4
-
In a w/u before proceeding with a Nissen the patient is found to have some esophageal contractions with an amplitude<30 mmHg without transmission
if secondary esophageal dysmotility than needs partial wrap if primary then need treatment for that specific disorder
-
diagnostic study used in w/u of GERD with with worried about a paraesophageal hernia
barium swallow
-
what is the adequate length of the LES
5cm
-
what is the adequate length of intraabdominal LES
2cm
-
most common cause of esophageal bleeding
esophagitis from gerd
-
why do pts with GERD and stricture need a collis gastroplasty instead of a Nissen
shortened esophagus
-
esophageal shortening is suggested when
EGJ lies 4 to 5cm above diaphragm
-
surveillance of barrets requires
4 quadrant biopsies at 1cm intervals 3-6 months initially
-
where should you avoid the anastomosis when doing an esophagectomy in a patient with Barrets
intrathoracic
-
schatzki's ring found where and associated with what
squamocolumnar junction and associated with GERD and hiatal hernia
-
webs are not associated with
motility disorders
-
when does a pt with GERD need an EGD
if recurrent, persistent, or suspicion of complications
-
what is the key to hiatal dissection
finding right crura
-
what is the key to performing the wrap
finding left crura
-
-
phrenoesophageal membrane is an extension of
transversalis fascia
-
most common complication following redo nissen
wrap herniation
-
dysphagia and heartburn following nissen
slipped fundoplication
-
study of choice with early dysphagia following nissen
barium esophagram
-
type II hiatal hernia is caused by
weakness in phrenoeophageal membrane
-
triad of chest pain, inability to vomit, inability to pass ngt
borchardt's triad
-
retching without vomiting in a pt who has no hx of a fundoplication
incarcerated paraesophageal hernia
-
indications for surgery of leiomyoma
- >5cm
- symptomatic
- unsure of diagnosis
- intraluminal, pedunculated or mobile
-
indications for surgery for fibrovascular polyp
all need surgery secondary to risk of airway obstruction but can resect with EGD if <8cm
-
single best test for resectability of esophageal ca
chest ct
-
in esophageal cancer r/o mets to where
- lungs- bronchoscopy/ct
- liver- lfts/ct
- adrenals
- celiac, sma and supraclavicular nodes
-
-
single worst tumor marker for prognosis
EGFR
-
most common site of mets in squamous esophageal cancer
lung
-
how is barret's confirmed
if squamocolumnar junction is 3cm above GE junction (confirmed by manometry
-
mucosa stains blue with what
Toludine blue
-
what agents are used in pre op chemo/xrt
cisplatin and 5-FU
-
who gets preop chemo/xrt
anything greater than a T1 lesion
-
whats the importance of a pt undergoing preop xrt when undergoing esophagectomy
increase risk of leak so must perform anastomosis outside chest
-
margins needed in esophageal cancer
10cm
-
most common complication with lymphadenectomy in esophageal cancer
recurrent nerve injury
-
blood supply in colonic interposition is dependent on
marginal vessles
-
incidental m1a disease found during resection
continue with resection and resect involved LNs
-
lymph node involvement is at least what stage in esophageal ca
IIb
-
greater than three nodes involved is atleast what stage
III
-
air leak discovered during esophageal resection
likely tear in distal trachea or left mainstem, need to intubate uninjured side
-
bleeding during esophageal resection
- high and dark- azygoes, needs right thoracotomy
- low and bright red- branch of aorta need left thoracotomy
-
positive margins found when doing ivor lewis
resect additional esophagus and perform anastomosis in neck
-
when do you need to operate for chylothorax
if no improvement after 3 weeks or > 2L per day
-
tx necrosis of stomach following gastric pull through
- resect necrotic part
- place residual stomach in abdomen
- g and j tube
- cervical esophagostomy
- colonic interposition in 3 months
-
tx of perforated unresectable esophageal cancer
stent
-
adjuvant chemo used for
tull thickness or node positive
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