1. Describe anatomy of esophagus
    • - squamous epithelium
    • - circular inner muscle layer
    • - outer longitudinal muscle layer
    • - no serosa
  2. What is the major blood supply to the esophagus:
    vessels directly off the aorta are the major blood supply to the esophagus
  3. Blood supply:
    Cervical esophagus:
    Abdominal esophagus:
    Cervical esophagus- supplied by the inferior thyroid artery

    Abdominal esophagus- supplied by the left gastric artery and inferior phrenic arteries
  4. Lymphatics:
    upper 2/3 drains cephalad

    lower 1/3 caudad
  5. What kind of muscle is the upper + lower esophagus?
    Upper esophagus- striated muscle

    Lower esophagus- smooth muscle
  6. Right vagus nerve:
    travels on posterior portion of stomach as it exists chest; becomes celiac plexus; also has the criminal nerve of Grassi --> can cause persistently high acid levels postoperatively if left undivided
  7. Left vagus nerve-
    travels on the anterior portion of the stomach; goes to the liver and biliary tree
  8. Thoracic duct:
    travels from right to left in the chest at upper 1/3 of mediastinum; inserts into left subclavian vein
  9. Upper esophageal sphincter
    • (15cm from incisors)
    • cricopharyngeus muscle (circular muscle, prevents air swallowing); has recurrent laryngeal nerve innervation

    • - normal UES pressure with food bolus- 12-14mmHg
    • - normal UES pressure at rest- 50-70mmHg

    Cricopharyngeus muscle- most common site of esophageal perforation (usually occurs with EGD)
  10. Aspiration with brainstem stroke
    failure of UES (cricopharyngeus) to relax
  11. Lower esophageal sphincter:
    • 1) 40cm from incisors
    • 2) relaxation mediated by inhibitory neurons
    • 3) muscle is normally contracted at resting state --> prevents reflux
    • 5) normal LES pressure at rest 10-20mmHg
  12. Anatomic areas of narrowing:
    • 1) cricopharyngeus muscle
    • 2) compression by the left mainstem bronchus and aortic arch
    • 3) diaphragm
  13. Swallowing stages:
    1) CNS initiates swallow

    2) normal esophageal pressure with food bolus- 70-120mmHg

    3) primary peristalsis- occurs with food bolus and swallow initiation

    4) secondary peristalsis- occurs with incomplete emptying and esophageal distention, propagating waves

    5) tertiary peristalsis- nonpropagating, nonperistalsing (dysfunctional)

    UES and LES are normally contracted between meals
  14. Swallowing mechanism:
    • 1) soft palate occludes the nasopharynx
    • 2) larynx rises and airway opening is blocked by epiglottis
    • 3) cricopharyngeus relaxes
    • 4) pharyngeal contraction moves food into esophagus
    • 5) LES relaxes soon after initiation of swallow
  15. Important clinical endoscopic measurements of the esophagus in adults
    see pg. 207 for pic
  16. surgical approach:
    Cervical esophagus- left

    Upper 2/3 thoracic- right (avoids the aorta)

    Lower 1/3 thoracic- left (left-sided course in this region)
  17. Hiccoughs
    • causes:
    • 1- gastric distention
    • 2- temperature changes
    • 3- EtOH
    • 4- tobacco

    • Reflex arc-
    • - vagus
    • - phrenic
    • - sympathetic chain T6-T12
  18. Esophageal dysfunction:
    • Primary-
    • unknown cause

    • Secondary-
    • 1- systemic disease
    • 2- gastroesophageal reflux disease (GERD; most common)
    • 3- scleroderma
    • 4- polymyositis
  19. What is the procedure of choice for heartburn
    Endoscopy- procedure of choice for heartburn --> can visualize esophagitis, etc.
  20. Whats procedure of choice for dysphagia and odynophagia:
    barium swallow- procedure of choice for dysphagia and odynophagia (better at picking up masses)
  21. Whats the dx/tx of meat impaction:
  22. Pharyngoesophageal disorders
    1) trouble in transfering food from mouth to esophagus

    • 2) Most commonly neuromuscular disease
    • 1- myasthenia gravis
    • 2- parkinsons
    • 3- polymyositis
    • 4- muscular dystrophy
    • 5- zenker's diverticulum
    • 6- lye ingestion
    • 7- stroke

    3) liquids worse than solids

    • 4) Cervial esophageal dysphagia-
    • 1- plummer-vinson syndrome; usually due to web; fe-deficient anemia
    • Treatment: dilation, Fe; need to screen for oral Ca
  23. Zenker's Diverticulum:
    1) Zenker's diverticulum- caused by increased pressure during swallowing.

    • 2) Is a false diverticulum- posterior
    • 1- occurs between the cricopharyngeus and pharyngeal constrictors
    • Symptoms: upper esophageal dysphagia, choking, halitosis

    • Dx:
    • 1- barium swallow studies
    • 2- manometry
    • 3- risk for perforation with EGD and Zenker's

    • Treatment: cricopharyngeal myotomy (key point); zenker's itself can either be resected or suspended (removal of diverticula not necessary)
    • - left cervical incision
    • - leave drains in
    • - esophogram POD #1
  24. Traction diverticulum
    1) is a true diverticulum

    2) usually lies lateral

    • 3) Due to:
    • - inflammation
    • - granulomatous disease
    • - tumor

    4) usually found in the mid-esophagus

    • 5) Symptoms:
    • 1- regurgitation of undigested food
    • 2- dysphagia

    • 6) Treatment:
    • 1- excision and primary closure
    • 2- may need palliative therapy (ie XRT) if due to invasive Ca
  25. Epiphrenic diverticulum
    1) rare, associated with esophageal motility disorders

    2) most common in the distal 10cm of the esophagus

    3) most are asymptomatic; can have dysphagia and regurgitation

    4) Diagnosis: esophagram and esophageal monometry

    • 5) Treatment:
    • - diverticulectomy and long esophageal myotomy on the side opposite the diverticulectomy
  26. Achalasia
    • 1) Symptoms:
    • 1- dysphagia
    • 2- regurgitation
    • 3- weight loss
    • 4- respiratory symptoms

    2) Caused by failure of peristalsis and lack of LES relaxation after food bolus

    3) secondary to neuronal degeneration in muscle wall

    • 4) Manometry-
    • 1- increased LES pressure
    • 2- incomplete LES relaxation
    • 3- no peristalsis

    5) Can get tortuous dilated esophagus and epiphrenic diverticula; birdbeak appearance

    • 6) Treatment:
    • 1- calcium channel blocker
    • 2- nitrates
    • 3- LES dilation--> effective in 60%
    • 4- If medical treatment and dilation fail --> heller myotomy- left thoracotomy, transect circular layer of muscle lower esophagus; also need partial nissen fundoplication

    7) T. Cruzi can produce similar symptoms
  27. Diffuse esophageal spasm
    1) chest pain; other symptoms can be similar to achalasia. Many have psychiatric history

    • 2) Manometry-
    • 1- frequent strong body contractions of increased amplitude and duration
    • 2- normal LES tone
    • 3- strong unorganized contractions

    3) surgery better at resolving dysphagia than pain

    4) nutcracker esophagus has similar symptoms

    • 5) Treatment:
    • - calcium channel blocker
    • - nitrates
    • - antispasmodics
    • - Heller myotomy (transect circular layer of upper and lower esophagus)

    6) treatment usually less effective for diffuse esophageal spasm than for achalasia
  28. Scleroderma
    • 1- causes dysphagia
    • 2- loss of LES tone
    • 3- most have strictures
    • 4- fibrous replacement of smooth muscle

    Treatment- esophagectomy; nissen may be effective in some
  29. Gastroesophageal reflux disease:
    1) normal anatomic protection from GERD- need LES competence, normal esophageal body, normal gastric reservoir

    2) increased acid exposure to esophagus from loss of the normal gastroesophageal barrier

    3) get heartburn symptoms 30-60 minutes after meals

    4) can also have asthma symptoms (cough), choking, PNA

    5) symptoms worse lying down

    • 6) Need to make sure patient does not have another cause for pain
    • - dysphagia/odynophagia- need to worry about tumors
    • - bloating- suggests aerophagia and delayed gastric emptying (Dx: gastric emptying study)
    • - epigastric pain- suggests peptic ulcer, tumor

    • 7) dx:
    • 1- endoscopy
    • 2- pH probe (best test)
    • 3- manometry (resting LES<6mmHg)
    • 4- histology

    8) Medical therapy 1st: omeprazole for 12 weeks

    • 9) Surgical indications:
    • 1- GERD on pH monitoring
    • 2- failure of medical Tx
    • 3- complications of GERD (stricture, barrett's esophagus, cancer)

    • 10) Treatment: Nissen --> divide short gastics, pull esophagus into abdomen, repair defect in phrenoesophageal membrane; 270- (partial) or 360-degree gastric fundus wrap
    • 1- phrenoesophageal membrane is an extension of the transversalis fascia
    • 2- key manuver is identification of the left crura
    • 3- Belsey- approach is through the chest.
    • 4- Collis gastroplasty- when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a "new" esophagus
    • 5- most common cause of dysphagia following Nissen- wrap is too tight
  30. Hiatial Hernia
    Type I- sliding hernia from dilation of hiatus (most common); often associated with GERD

    Type II- paraesophageal; hole in the diaphragm alongside the esophagus, normal GE junction. Symptoms:chest pain, dysphagia, early satiety

    Type III- combined

    Type IV- entire stomach in the chest plus another organ (i.e. colon, spleen)

    - with type II, still need Nissen as diaphragm repair can affect LES; also helps anchor stomach

    - paraesophageal hernia (type II)- all need repair --> high risk of incarceration

    - most patients with type I hiatal hernia do not have reflux

    - most patients with significant reflux do have type I hiatal hernia
  31. Schatzki's ring:
    1) almost all patients have an associated sliding hiatal hernia

    2) symptoms: short episodes of dysphagia following rapid swallowing

    3) Treatment: dilatation of the ring usually sufficient; may need antireflux procedure
  32. Barrett's esophagus
    1) squamous metaplasia to columnar epithelium

    2) occurs with long-standing exposure to gastric reflux

    3) cancer (adenocarcinoma) risk increased 50x

    4) severe barrett's dysplasia is an indication for esophagectomy

    • 5) uncomplicated barrett's can be treated like GERD (i.e. PPI or Nissen)- surgery will decrease esophagitis and further metaplasia but will not prevent malignancy or cause regression of the columnar lining
    • - need careful follow-up with EGD for lifetime, even after Nissen
  33. Esophageal Cancer
    • 1) esophageal tumors are almost always malignant, early invasion of nodes
    • 2) spreads quickly along submucosal lymphatic channels
    • 3) symptoms: difficulty swallowing solids, dysphagia, weight loss
    • 4) Risk factors:
    • - achalasia
    • - caustic injury
    • - EtOH
    • - tobacco
    • - nitrosamines

    5) Diagnosis: esophagram diagnostic procedure of choice in patients with dysphagia, odynophagia, or suspected mass lesions

    - chest/abdominal CT best test for unresectability

    • 7) Adenocarcinoma #1 esophageal cancer- not squamous
    • 1- adenocarcinoma- most often occurs in lower 1/3 of esophagus
    • 2- squamous cell carinoma- most often occurs in upper 2/3 of esophagus

    8) Supraclavicular nodes- M1 disease, unresectable

    • 9) Distant metastases- most got to lung or liver, contraindications to esophagectomy
    • - survival <12 months

    10) nodal disease outside the area of resection (i.e. SMA or celiac nodes)- contraindication to esophagectomy

    11) preoperative XRT and chemotherapy may downstage tumors and make them resectable

    12) Esophagectomy- 5% mortality from surgery; curative in 20%

    13) Right gastroepiploic artery- primary blood supply to stomach after replacing esophagus (have to divide left gastric and short gastrics)
  34. Unresectability of esophageal cancer:
    • Unresectability-
    • 1- hoarseness (RLN)
    • 2- horner's syndrome
    • 3- phrenic nerve involvement
    • 4- malignant pleural effusion
    • 5- malignant fistula
    • 6- airway invasion
    • 7- vertebral invasion
  35. What is the best test for unresectability of esophageal ca:
    chest/abdominal CT best test for unresectability
  36. What is the #1 esophageal cancer
    adenocarcinoma, not squamous

    • adenocarcinoma- most often occurs in lower 1/3 of esophagus
    • squamous cell carcinoma- most often occurs in upper 2/3 fo esophagus
  37. Esophageal Cancer:

    Supraclavicular nodes:
    Distant metastases:
    supraclavicular nodes- M1 disease; unresectable

    • distant metastases- most go to lung or liver; contraindication to esophagectomy
    • -survival <12 months
  38. Esophageal cancer:
    Nodal disease outside the area of resection (i.e. SMA or celiac nodes)-
    contraindication to esophagectomy

    preoperative XRT and chemotherapy may downstage tumors and make them resectable (but if it metastasized you cant resect)
  39. Esophagectomy:
    1) 5% mortality from surgery; curative in 20%

    Right gastroepiploic artery- primary blood supply to stomach after replacing esophagus (have to divide lefet gastric an short gastrics)

    Transhiatal approach- abdominal and neck incisions; bluntly dissect intrathoracic esophagus; may have decreased mortality from esophageal leaks with cervical anastomosis

    Ivor lewis- abdominal incision and right thoractomy--> exposes all of the esophagus; intrathoracic anastomosis

    3 hole esophagectomy- abdominal, thoracic, and cervical incisions

    Need pyloromyotomy with these procedures

    Colonic interposition- may be choice in young patients with benign disease when you want to preserve gastric function; 3 anastomoses required; blood supply depends on marginal vessels

    After esophagectomy --> need contrast study on postop day 7 to rule out leak

    postoperative stricture- most can be dilated

    palliative esophagectomy may be indicated in some circumstances
  40. Esophageal cancer- whats the role for chemo and XRT?
    chemotherapy- 5FU and cisplatin (for node-positive disease or use preop to shrink tumors)

    XRT- has been shown to be effective as both preop and postop treatment
  41. Esophageal cancer:

    Malignant fistulas:
    most die within 3 months due to aspiration
  42. Leiomyoma:
    1) most common benign tumor of the esophagus; submucosal

    2) diagnosis: esophagram, endoscopy needed to rule out cancer

    3) Do not biopsy --> can form scar and make subsequent resection difficult

    4) treatment: >5cm or symptomatic- excision (enucleation) via thoracotomy
  43. Esophageal polyps
    1) symptoms- dysphagia, hematemesis

    2) 2nd most common benign tumor of the esophagus; usually in cervical esophagus

    3) small lesions can be resected with endoscopy; larger lesions require cervical incision
  44. Caustic esophageal injury:
    1) no NG tube. Do not induce vomiting. Nothing to drink.

    • 2) Alkali- causes deep liquefaction necrosis, especially liquid (i.e. draino)
    • - worse injury than acid, also more likely to cause cancer

    3) Acid- causes coagulation necrosis; mostly causes gastric injury

    4) CXR and AXR to look for free air

    • 5) Endoscopy to assess lesion
    • - do not use with suspected perforation and do not go past site of injury

    6) serial exams and plain films required
  45. Caustic esophageal injury:

    Degree of injury:
    • Primary burn- hyperemia
    • Treatment: observation and conservative therapy
    • Conservative treatent: IVFs, spitting, antibiotics, oral intake after 3-4 days; may need future serial dilation for strictures (usually cervical and near aortic indentation)

    • Secondary burn- ulcerations, exudates, and sloughing
    • Treatment: prolonged observation and conservative therapy as above
    • Surgery with specific indications
    • Relative indications for surgery- sepsis, peritonitis, persistent back and chest pain, metabolic acidosis, mediastinitis, free air, mediastinal air, crepitance, contrast extravasation, pneumothorax, effusion, air in stomach wall

    • Tertiary burn
    • - deep ulcers, charring, and lumen narrowing
    • Treatment as above; esophagectomy usually necessary
    • Alimentary tract not restored until after patient recovers from the caustic injury

    Need gastrografin swallow followed by thin barium on HD 2-3 for 2nd and 3rd degree injuries
  46. Perforations
    1) usually the result of an EGD

    2) cervical esophagus near cryicopharyngeus muscle most common site

    • 3) Symptoms:
    • 1- pain
    • 2- dysphagia
    • 3- respiratory distress
    • 4- fever
    • 5- tachycardia

    4) Diagnosis: gastrografin swallow followed by barium swallow

    5) Criteria for nonsurgical management- contained perforation by contrast, self-draining, no systemic effects

    • - conservative treatment: IVF, NPO, spit (some say you can place NGT), broad spectrum antibiotics
    • - no NGT with caustic injuries
  47. Non-contained perforations in the chest
    1) if free perforation has occured and quick to diagnose it (<24hrs) or if the area has minimal contamination --> try primary repair with drains (chest tubes) and intercostal muscle pedicle flap.

    • 2) for sick patients -->
    • 1- cervical esophagostomy for diversion
    • 2- washout of the mediastinum
    • 3- place chest tubes
    • 4- later placement of a feeding G or J tube
    • 5- later esophagectomy and gastric pull-up

    • Esophagectomy- may be needed in stable patients with intrinsic disease (burned out esophagus or malignancy)
    • -some will also go with esophagectomy and diversion in sick patients with intrinsic disease as the first procedure

    • If in neck:
    • 1- primary repair and leave drains (if grossly contaminated, can just leave drains and will usually heal)

    • Need longitudinal myotomy to see full extent of injury
    • - consider intercostal muscle flaps to area of perforation to help the area heal

    • Proximal 2/3 of thoracic esophagus- right thoractomy (may have right effusion)
    • Distal 1/3 of thoracic esophagus- left thoractomy (may have left effusion)

    Use gastrografin followed by barium swallow 10 days after the repair to rule out leak

    Leave drains in until patient taking good oral intake without increase in drainage from drains

    If patient has a leak without systemic effects, try to let it heal --> give patient TPN or place distal feeding tube
  48. Boerhaave's syndrome
    1) forceful vomiting followed by chest pain- perforation most likely to occur in the left lateral wall of esophagus at level of T8, 3-5m above the GE junction

    2) Hartmann's sign- mediastinal crunching on auscultation

    3) Early diagnosis and treatment improve survival

    4) Diagnosis: gastrografin swallow

    • 5) Treatment:
    • 1- left thoracotomy
    • 2- longitudinal myotomy to see extent of injury
    • 3- primary repair; leave chest tubes
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