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2011-12-16 18:35:08

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  1. layers of esophagus
    mucosa, submucosa, muscularis propria
  2. blood supply to the esophagus
    inf thyroid, branches from aorta, left gastric/inf phrenic
  3. becomes celiac plexus and has criminal nerve of grassi
    right vagus (posterior)
  4. the thoracic duct crosses the midline where
    t4 t5
  5. normal pressures of upper esophageal sphincter
  6. normal pressures of lower esophageal sphincter
  7. lower esophageal sphincter pressure with gerd
  8. length of esophageal sphincter
    30 cm
  9. aspiration with brainstem stroke is 2/2
    failure of cricopharyngeus muscle to relax
  10. best initial test for dysphagia/odynophagia
    barium swallow
  11. best initial test for suspected perf
    gastrograffin followed by thin barium
  12. dysphunction of esophagus in achalasia
    inability for les to relax and loss of peristalsis
  13. pathophys of achalasia
    loss of neuronal ganglion cells in auerbachs
  14. sxs of achalasia
    dysphagia to liquids and solids with regurgitation of food
  15. suspected achalasia but difficulty passing scope past GE junction
    pseudoachalasia from GE junction malignancy
  16. burned out esophagus defined as
    • >50% non-pulsatile contractions
    • <30 mmhg with each contraction
  17. significance of finding burned out esophagus in achalasia
    Heller wont work need esophagectomy
  18. achalasia at risk of
    squamous cell ca of esophagus
  19. medical tx for achalasia
    relax sphincter with balloon dilation, Ca blocker, nitrates
  20. length of incision of for a heller
    7cm proximally or up to inf pulm vein and 1-2cm below egj
  21. 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
  22. best test for DES
  23. tx of des
    ca blocker, trazadone(psych)
  24. surgey for des
    right vats/thorocatomy with long esophageal myotomy plus belsy
  25. how does the manometry findings differ in nutcracker vs des
    waves are high amplitude just like des but are peristaltic
  26. CREST
    • seen in scleroderma
    • Calcinosis
    • Rayndauds
    • Esophageal dysmotility
    • Sclerodactyly
    • Teleangiectasis
  27. most common affected organ in scleroderma
  28. most important clinical finding with associated with esophageal dysphunction
  29. operation for scleroderma of affecting the esophagus
    partial wrap + collis gastroplasty or for very dilated esophagus- esophagectomy
  30. epiphrenic diverticula most commonly seen with
  31. tx for epiphrenic diverticula
    fix the underlying problem- tight les sphincter with baloon dilation or peptic stricture with GERD
  32. indications to resect epiphrenic diverticulum
    narrow neck, inflammation, large size
  33. tx of traction diverticula
    • nothing if asx otherwise:
    • excision and primarily closure
    • stent for palliation if advance lung ca
  34. initial w/u for zenker's should not consist of what
    EGD due to risk of perforation
  35. 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
  36. chest pain, dysphagia with subcu emphysema
    esophageal perf
  37. sites of esophageal perf
    UES, indentation of aortic arch, LES
  38. infxn from perforated esophagus allows access to mediastinum through what avenues
    • post mediastinum: retropharyngeal/retroviscer through alar fascia
    • ant mediastinum: pre tracheal fascia
  39. tx of cervical esphageal perf
    explore primary repair and leave drains
  40. while operating for an a cervical esophageal perf you cannot find the site of perforation, what do you do
    just leave drains
  41. important aspect of repair/management of esophageal perforations at all locations
    look for and treat any site of distal obstruction
  42. 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
  43. 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
  44. 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
  45. Tx for esophageal dissection/intramural hematoma from TEE
    NPO x 7days, abx
  46. mediastinal abscess following foreign body removal without sepsis
    ct guided drainage
  47. difference between grade IIa adn IIb esophageal caustic injury
    circumferential ulcerations
  48. difference between IIIa and IIIb esophageal caustic injury
    extensive necrosis
  49. 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
  50. tx for grade IIb or higher caustic injuries
    gastrostomy and feeding J tube
  51. when and where do strictures usually take place in caustic injuries
    3 weeks and at aortic indentation
  52. perforation after trying to repair stricture secondary to remote caustic injury
    likely will need esophagectomy
  53. tx of disk batteries or coins in stomach
    remove if they do not move in 48 hours
  54. size criteria of removal of foreign body found in stomach
    > 2 x 5cm
  55. 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)
  56. most common cause of an edible or non edible object stuck in the esophagus below the UES
    peptic stricture
  57. what needs to be r/o child presents with food lodging in the UES
    retrobulbar palsies
  58. criteria for GERD with pH probe
    >4.5% of total time with pH < 4
  59. 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
  60. diagnostic study used in w/u of GERD with with worried about a paraesophageal hernia
    barium swallow
  61. what is the adequate length of the LES
  62. what is the adequate length of intraabdominal LES
  63. most common cause of esophageal bleeding
    esophagitis from gerd
  64. why do pts with GERD and stricture need a collis gastroplasty instead of a Nissen
    shortened esophagus
  65. esophageal shortening is suggested when
    EGJ lies 4 to 5cm above diaphragm
  66. surveillance of barrets requires
    4 quadrant biopsies at 1cm intervals 3-6 months initially
  67. where should you avoid the anastomosis when doing an esophagectomy in a patient with Barrets
  68. schatzki's ring found where and associated with what
    squamocolumnar junction and associated with GERD and hiatal hernia
  69. webs are not associated with
    motility disorders
  70. when does a pt with GERD need an EGD
    if recurrent, persistent, or suspicion of complications
  71. what is the key to hiatal dissection
    finding right crura
  72. what is the key to performing the wrap
    finding left crura
  73. length of wrap
  74. phrenoesophageal membrane is an extension of
    transversalis fascia
  75. most common complication following redo nissen
    wrap herniation
  76. dysphagia and heartburn following nissen
    slipped fundoplication
  77. study of choice with early dysphagia following nissen
    barium esophagram
  78. type II hiatal hernia is caused by
    weakness in phrenoeophageal membrane
  79. triad of chest pain, inability to vomit, inability to pass ngt
    borchardt's triad
  80. retching without vomiting in a pt who has no hx of a fundoplication
    incarcerated paraesophageal hernia
  81. indications for surgery of leiomyoma
    • >5cm
    • symptomatic
    • unsure of diagnosis
    • intraluminal, pedunculated or mobile
  82. indications for surgery for fibrovascular polyp
    all need surgery secondary to risk of airway obstruction but can resect with EGD if <8cm
  83. single best test for resectability of esophageal ca
    chest ct
  84. in esophageal cancer r/o mets to where
    • lungs- bronchoscopy/ct
    • liver- lfts/ct
    • adrenals
    • celiac, sma and supraclavicular nodes
  85. best test for mets
  86. single worst tumor marker for prognosis
  87. most common site of mets in squamous esophageal cancer
  88. how is barret's confirmed
    if squamocolumnar junction is 3cm above GE junction (confirmed by manometry
  89. mucosa stains blue with what
    Toludine blue
  90. what agents are used in pre op chemo/xrt
    cisplatin and 5-FU
  91. who gets preop chemo/xrt
    anything greater than a T1 lesion
  92. whats the importance of a pt undergoing preop xrt when undergoing esophagectomy
    increase risk of leak so must perform anastomosis outside chest
  93. margins needed in esophageal cancer
  94. most common complication with lymphadenectomy in esophageal cancer
    recurrent nerve injury
  95. blood supply in colonic interposition is dependent on
    marginal vessles
  96. incidental m1a disease found during resection
    continue with resection and resect involved LNs
  97. lymph node involvement is at least what stage in esophageal ca
  98. greater than three nodes involved is atleast what stage
  99. air leak discovered during esophageal resection
    likely tear in distal trachea or left mainstem, need to intubate uninjured side
  100. bleeding during esophageal resection
    • high and dark- azygoes, needs right thoracotomy
    • low and bright red- branch of aorta need left thoracotomy
  101. positive margins found when doing ivor lewis
    resect additional esophagus and perform anastomosis in neck
  102. when do you need to operate for chylothorax
    if no improvement after 3 weeks or > 2L per day
  103. 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
  104. tx of perforated unresectable esophageal cancer
  105. adjuvant chemo used for
    tull thickness or node positive