1
Q
What are the layers of the esophagus?
A
- mucosa
- submucosa
- muscularis propia
- no serosa!
2
Q
What is the bloody supply to the esophagus?
A
- cervical: the inferior thyroid artery
- thoracic: vessels off the aorta
- abdominal: left gastric and inferior phrenic arteries
3
Q
What forms and what innervates the upper esophageal sphincter?
A
the cricopharnygeus, innervated by the superior laryngeal nerve
4
Q
How far from the incisors is the UES and the GEJ?
A
- 15cm to the UES
- 40cm to the GEJ
5
Q
What is Killian’s Triangle?
A
- it is a triangular area in the wall of the pharynx superior to the cricopharyngeus muscle and inferior to the inferior constrictor muscles
- it is a potential weak spot where a pharyngoesophageal diverticulum (Zenker’s diverticulum) is most likely
6
Q
Describe the diagnosis of esophageal perforation.
A
- may have an abnormal CXR; can look for pneumomediastinum, subq emphysema, pix, or pleural effusion
- study of choice is gastrografin esophagram
- if negative but index of suspicion remains high, can follow with a dilute barium study
7
Q
When should a barium esophagram be performed for suspected esophageal perforation?
A
- for those in whom a gastrografin esophagram was negative but suspicion remains high
- as first line for those who are an aspiration risk
8
Q
What is the most common site of esophageal perforation? What is the most common site of iatrogenic perforation?
A
- the distal esophagus in the left posterolateral aspect, 2-3 cm above the GEJ is most common
- the cricopharyngeus is the most common for iatrogenic injury
9
Q
How should cervical esophageal perforation be managed?
A
- resuscitate
- start antibiotics (gram - rods, anaerobes, fungus)
- open the neck and place drains
10
Q
How should thoracic esophageal perforation be managed?
A
- resuscitate
- start antibiotics (gram - rods, anaerobes, fungus)
- primary repair is preferred: left thoracotomy, debridement, myotomy to visualize full mucosal injury, two layers of repair (inner absorbable, outer permanent), cover with vascularized flap, perform a leak test, drop an NGT, place drains
- consider esophagectomy for malignancy, caustic perforation, megaesophagus from achalasia
- consider contralateral mytomy if secondary to achalasia with normal esophagus
- consider exclusion and diversion for unstable patients: closure, drainage, cervical esophagostomy, T-tube for external drainage as controlled fistula, J-tube access
11
Q
How is a thoracic esophageal perforation diagnosed and treated in stable patients?
A
- diagnose with gastrografin esophagram followed by a dilute barium esophagram if negative
- begin treatment with resuscitation and antibiotics/antifungals
- primary closure: left thoracotomy, debridement, myotome to expose mucosa, two layer repair (inner absorbable, outer permanent), cover with vascularized flap, leak test, place drains, drop NGT,
12
Q
Esophageal Perforation
A
- most commonly in the thoracic esophagus, 2-3 cm proximal to the GEJ in the left posterolateral aspect
- most commonly at the cricopharyngeus when iatrogenic
- diagnose with gastrografin esophagram unless an aspiration risk; second line is dilute barium swallow
- initiate treatment with resuscitation and antibiotics/antifungals
- for cervical injuries, treat with wide local drainage
- for thoracic, primary repair in two layers with vascularized flap, NGT, and drains is preferred
- consider esophagectomy for malignancy, caustic ingestion, megaesophagus secondary to achalasia
- consider contralateral myotomy if secondary to achalasia with normal esophagus
- consider exclusion for unstable patients with closure of injury, cervical esophagostomy, T-tube drainage, J-tube access
- also consider, clip and stents
13
Q
What is achalasia? What are the three kinds?
A
- incomplete relaxation of the LES along with peristalsis or hypotonic esophageal contractions
- type I: normal esophageal pressure
- type II: increased pan esophageal pressure
- type III: spastic distal esophageal contractions
14
Q
Describe the diagnosis of achalasia.
A
- will see a bird’s beak sign on barium swallow
- diagnosis requires normal/high LES pressure, incomplete LES relaxation, hypotonic or absent peristalsis
15
Q
What is the pathophysiology of achalasia?
A
- degenerative loss of NO-producing inhibitory neurons within the LES
- has a mixed etiology of autoimmune, genetics, and infectious (Chagas’ disease)
16
Q
How is achalasia treated?
A
- can use endoscopic therapies such as pneumatic dilation and botox injection; however, these are less effective and increase the rate of surgical complication later
- most effective is a minimally invasive Heller myotomy with partial fundoplication
- if patient’s perforate secondary to dilation, perform a contralateral myotomy after the repair
17
Q
Achalasia
A
- an esophageal dysmotility disorder characterized by normal/high LES tone, incomplete LES relaxation, and absent or hypotonic esophageal contractions
- due to the loss of NO-producing, inhibitory neurons
- diagnosed based on barium swallow showing bird’s beak appearance and manometry
- type I has a normal esophageal pressure, type II has high panesophageal pressure, type III has spastic distal contractions
- first line treatment is Heller myotomy (2cm on stomach, 6cm on esophagus) as endoscopic therapies are less effective and increase later risk of surgical complications
- if repairing a perf secondary to dilation, perform a contralateral myotomy after the repair
18
Q
What is isolated hypertensive LES and how is it treated?
A
- it is high basal LES pressure with complete relaxation and normal peristalsis
- treated with calcium channel blockers, nitrates, or Heller myotomy
19
Q
What is diffuse esophageal spasm and how is it treated?
A
- normal LES pressure and relaxation but high amplitude and uncoordinated esophageal contractions (> 30 mmHg)
- treat with calcium channel blockers and nitrates; long-segment myotomy can be an option in rare cases
20
Q
What is nutcracker esophagus and how is it treated?
A
- normal LES pressure and relaxation but high amplitude and coordinated esophageal contractions
- treat with calcium channel blockers and nitrates; long-segment motomy can be an option in rare cases
21
Q
Define each of the following:
- achalasia
- pseudoachalasia
- isolated hypertensive LES
- diffuse esophageal spasm
- nutcracker esophagus
A
- achalasia: normal/high LES with incomplete relaxation and hypotonic or absent peristalsis
- achalasia secondary to malignancy
- isolated HTN LES: high LES with normal relaxation and normal peristalsis
- diffuse spasm: high amplitude, uncoordinated contractions greater than 30 mmHg
- nutcracker: high amplitude, coordinated contractions
22
Q
What is an infectious cause of achalasia?
A
Chagas’ disease (Trypanosoma Cruzi)
23
Q
What is pseudoachalasia?
A
achalasia caused by malignancy
24
Q
What is a Zenker’s diverticulum?
A
a cervical esophageal false pulsion diverticulum due to dysfunction of the upper esophageal sphincter muscles
25
What is a pulsion diverticulum?
a false diverticulum without muscular extrusion
26
How is a Zenker's diverticulum treated?
- if greater than 3cm, endoscopic division of the UES, creating a common lumen between the diverticulum and esophagus
- if less than 3cm, perform an open myotomy via left neck incision with or without diverticulectomy
27
What is an epiphrenic diverticulum and how is it treated?
- a pulsion esophageal diverticulum associated with motility disorders
- treated with diverticulectomy and treatment of the underlying motility disorder (usually requiring Heller)
28
What is a thoracic, mid-esophageal diverticula and how is it treated?
- it is usually a true, traction diverticula associated with adjacent inflammatory or malignant conditions but can also be a pulsion diverticulum
- treated with VATS diverticulectomy and myotomy
29
What is the difference between the following esophageal diverticulum?
- Zenker
- Epiphrenic
- Thoracic
- Zenker: false, pulsion diverticulum of the cervical esophagus associated with cricopharyngeus dysfunction
- Epiphrenic: false, pulsion diverticulum of the distal esophagus associated with motility disorders
- Thoracic: more commonly true, traction diverticulum than false, pulsion diverticulum of the thoracic esophagus associated with inflammatory or malignant conditions
30
What histologic change does Barrett's esophagus involve?
columnar metaplasia
31
What is the risk associated with Barrett's?
30-60x increased risk of esophageal adenocarcinoma
32
What surveillance is indicated for those with Barrett's?
- annual EGD with 4-quadrant biopsies every 1-2cm
- after two consecutive years negative for dysplasia, can transition to every three years
- if low-grade dysplasia: repeat in 6 months
- if high-grade dysplasia: repeat immediately for endoscopic mucosal resection
33
Compare and contrast the two types of esophageal cancer.
- both more common in men
- SCC more common in Asia and Eastern Europe while ACA more common in N. America and W. Europe
- smoking and alcohol use are risk factors for SCC while obesity, GERD, and Barrett's are risk factors for ACA
34
What should be included in the workup of esophageal cancer?
- basic labs
- endoscopy with biopsy
- bronchoscopy if above the carina
- CT C/A/P and PET
- EUA with FNA of suspicious nodes
35
Describe the staging for esophageal cancer.
- T1a: invades lamina propria or muscularis mucosa
- T1b: invades the submucosa (rich in lymphatics)
- T2: invades muscularis propria
- T3: invades the adventitia
- T4a: invades surrounding structures but remains resectable
- T4b: invades aorta, vertebrae, or trachea and is therefore unresectable
- N1: involves 1-2 nodes
- N2: involves 3-6 nodes
- N3: invades 7+ nodes
- M1: distant metastasis
- stage I: T1, N0, M0
- stage II: T3, N0 or T2, N1
- stage III: T4, N3, M0
- stage IV: M1
36
Why is histologic grading important for esophageal cancer?
- helps with decision of EMR vs. esophagectomy for small superficial lesions
- helps decide whether neoadjuvant chemo or surgery first should be offered
37
What are the principles of management for esophageal cancer?
- preoperative chemo improves survival for patients with resectable lesions (CROSS)
- neoadjuvant chemo may be of benefit for young patients and those with high-grade T1 lesions
- perioperative chemo improves survival for patients with resectable lesions (MAGIC)
- consider esophagectomy for patients with lesions >5cm distal to the cricopharyngeus
- chemoradiation for those with lesions in the cervical esophagus or < 5cm distal to the cricopharnygeus
38
Which esophageal cancers are suitable for endoscopic resection and ablation?
- HGD, Tis, T1a tumors (<2cm and well-to-moderately differentiated)
- some advocate for T1b tumors without NVI
39
What is the chemotherapy of choice for esophageal cancer?
fluorouracil or taxane-based therapies
40
What is an Ivor-Lewis esophagectomy?
- involves a laparotomy and right thoracotomy with upper thoracic esophagogastric anastomosis
- must preserve the right gastric and right gastroepiploic artery for the gastric conduit
- good for distal tumors
41
What is a McKeown esophagectomy?
similar to an Ivor-Lewis except with a cervical anastomosis, therefore better for more proximal lesions
42
What is a transhiatal esophagectomy?
- involves a laparotomy and left cervical incision with cervical anastomosis
- avoids the morbidity of a thoracotomy and cervical leaks are tolerated better than thoracic
- downside is potentially fewer LNs harvested and there may be difficulty mobilizing large mid-thoracic tumors
43
Is a cervical or thoracic esophageal anastomosis better tolerated by patients?
cervical
44
What is the conduit of choice for patients undergoing esophagectomy with a history of gastric resection?
colon interposition conduit
45
What is the role of adjuvant chemotherapy for esophageal cancer?
- SCC does not require adjuvant therapy if there is an R0 resection, regardless of LN status
- ACA usually get adjuvant therapy except when they have T1, N0 disease and did not receive neoadjuvant therapy
46
Describe chemotherapy in patients with esophageal cancer.
- typically fluorouracil or taxane based
- survival benefit for neoadjuvant and peri-operative chemotherapy in patients with resectable lesions
- chemoradation is the definitive therapy for unresectable disease
- adjuvant therapy indicated for ACA (except T1, N0 disease that did not get neoadjuvant therapy) but not SCC
47
What are the anatomic areas of esophageal narrowing? Why is this important?
- important because they are most vulnerable to injury
| - cricopharyngeus, aortic arch, left mainstream bronchus, LES
48
What is the primary blood supply to a gastric conduit after esophagectomy?
right gastroepiploic
49
Why is Tylosis?
- an autosomal dominant condition linked to chromosome 17q25
- presents with dysphagia and skin thickening on the palms and soles
- carries at 40-90% risk of esophageal SCC by age 70 and therefore requires annual EGD starting at age 20
50
What diagnosis is suggested by SCC of the head, neck, and esophagus along with pancytopenia?
Fanconi Anemia
51
What kind of enteral access is indicated for locally advanced esophageal cancer?
J-tube since you want to preserve the stomach as a conduit
52
What is the most common benign tumor of the esophagus?
esophageal leiomyoma
53
What diagnosis is most likely for a patient with dysphagia and a well-circumscribed, ovoid mass on barium swallow in the wall of the mid-esophagus?
esophageal leiomyoma, the most common benign tumor of the esophagus
54
How is esophageal leiomyoma diagnosed and treated?
- typically diagnosed based on characteristic appearance on barium swallow
- should not biopsy because this creates mucosal scarring and makes enucleation more difficult/dangerous
- treat with enucleation via VATS or thoracotomy (right-side for mid-thoracic, left-side for distal) if tumors are symptomatic or greater than 5cm
55
What is the indication for surgical intervention for patients with esophageal leiomyomas?
enucleation via VATS or thoracotomy (right-side for mid-thoracic, left-side for distal lesions) for tumors >5 cm or that are symptomatic
56
What is a Schatzki's ring?
- a narrowed ring of mucosa just above the GEJ at the squamocolumnar junction secondary to long-standing GERD
- typically presents with dysphagia
- treat with dilation and PPI
57
From which side should you approach the esophagus at the following levels:
- cervical
- mid-thoracic
- dista
- cervical: left
- mid-thoracic: right
- distal: left
58
How are esophago-gastric junction tumors classified?
- type I: distal part of the esophagus located between 1-5 cm above the GEJ
- type II: in the cardia, within 1cm above and 2cm below the GEJ
- type III: in the subcardial stomach, 2-5 cm below the GEJ
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