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Flashcards in ESOPHAGUS Deck (25):
1

Management of softgel attraction diverticulum

If asymptomatic just observe

They will in empty themselves into the esophageal lumen

2


Work up of esophageal leiomyoma

No biopsy!

Characteristic CT scanned findings

SUB mucosal on endoscopy

3

Treatment of esophageal leiomyoma

Right thoracotomy
Single long ventilation
Lung interior
enter mediastinal pleura
Blunt exposure of esophagus
Longitudinal myotomy
ennucleate

Guide placement of NG tube
Introduce air to ensure no leak

4

Zenker's diverticulum procedure

Modified Fowler
Aspirate contents of diverticulum with soft red rubber catheter

Semi upright integration

Left ant SCM

Platysma
Strap muscles
Ligate and divide middle thyroid vein
Mobilize and retract sternocleidomastoid and carotid sheath posteriorly

manual Anterior retraction of trachea and thereby protecting recurrent laryngeal nerve in the tracheoesophageal groove

Place 56 French bougie into true lumen
Staple diverticulum at the base
(Diverticulum is cephalad to cricopharyngeal muscle)

My army of the entire length of cricopharyngeal muscle usually 8 cm and is continues down upon the muscle fibers of the esophagus

leave drain

Clears that night

Swallow study then advanced diet and pull drain.

5

Staging for gastric cancer

EUS

T2 equals neoadjuvant chemo

6

Palliotive gastrectomy for cancer?

Possibly if it obstructed

7

D1 nodal resection

periAortic

8

D2 nodal resection

Goes all the way to hilum

9

neoadjuvant in esophageal cancer when

chemotherapy and RT

o For any T3, T4, or N1 patient

o 4 weeks of concomitant chemotherapy and RT

(5fu and cisplatinum)
{though new reg is also considered)

followed by a 4 week break

and

then surgery

10

Special work of studies for esophageal cancer

Pulmonary function test

Cardiac

11

risk factors for esophageal cancer including:

smoking,

alcohol,
Plummer
Vinson syndrome,
achalasia,
Barrett’s,
tylosis,
lye injury

12

Tylosis


A genetic disorder

thickening (hyperkeratosis) of the palms and soles,

white patches in the mouth (oral leukoplakia),

very high risk of esophageal cancer.

This is the only genetic syndrome known to predispose to squamous cell carcinoma of the esophagus.

13

What is the management of a pneumomediastinum found without leak identified

Just watch them

Restudy in a couple days with thin barium again

14

epiphrenic diverticulum

The operative approach to the is identical to the approach for laparoscopic Heller myotomy. Five ports are placed as described previously. The short gastric vessels are divided, the left and right crus are dissected free from the esophagus, and the esophageal attachments to the mediastinum are dissected as superiorly as possible. Any adhesions between the diverticulum and esophagus are also freed to show the neck of the diverticulum. The vagus nerve, which often is overlying the diverticulum, is protected and retracted. The diverticulum is then resected with an endoscopic linear stapler (3.5-mm staple width) over a 50F lighted bougie to prevent esophageal narrowing. The Heller myotomy and fundoplication are then performed with the technique described previously. The fundoplication may be a Dor or a Toupet. It usually does not reach the area of the diverticulum, and thus, the choice has to do with the myotomy, not with the diverticulectomy. With that in mind, the principles and rationale described previously for patients with achalasia are applied. An esophagram is obtained 2 days after the operation to evaluate for esophageal leak and narrowing. If the esophagram does not show any residual diverticulum or leak, the patient is started on a liquid diet and is discharged the following day on the modified diet described previously

15

midesophageal diverticula

If the diverticulum is smaller than 2 cm, it can be observed. If patients progress to become symptomatic or if the diverticulum is 2 cm or larger, surgical intervention is indicated. Usually, midesophageal diverticula have a wide mouth and rest close to the spine. Therefore, a diverticulopexy can be performed where the diverticulum is suspended from the thoracic vertebral fascia. In patients with severe chest pain or dysphagia and a documented motor abnormality, a long esophagomyotomy is also indicated.

16

The treatment of an epiphrenic diverticulum

is similar to that of a midesophageal diverticulum. These types of diverticula also have a wide mouth and rest close to the spine. Small (

17

Massive G.I. bleed and esophageal varices is found–G.I. is not available to do sclerotherapy

What is your management

Two large bore IV

Typing cross

NG tube and lavage

Octreotide 15 mg bolus over 20 minutes

Repeat lavage to see bleeding has stopped

Minnesota tube
May keep the esophageal balloon inflated at 30 – 40 mmHg for 24 hours and deflated

Still no endoscopist

Tips

If note tips:

Surgery options:
EEA limited esophagectomy with ligation of the left gastric pain

Gastrotomy and perform Intrumentals six relation of varices in the esophagus

Measle cable shunt

Sugiura procedure:

18

Dysphasia persisting past six – eight weeks

Persistent hiatal hernia

Slipped wrap
fundus slipped behind the wrap

If neither of these are present try dilation and the scopic link

Symptomatic retreat with avoiding carbonated beverages and eating small meals five to 6 times per day

19

What needs to be included for preop preparation for the patient undergoing a surgical esophagectomy

PFTs
EKG/stress
Bowel prep!

20

At what level does the thoracic duct cross

Thoracic level IV – five

21

What artery feeds the transverse colon conduit for surgical esophagectomy

A sending branch of the left colic

22

When you giving you ad event therapy and what is it for esophageal cancer

Greater than T1 b - this goes into the submucosa - probably neoadjuvant

~T2 - this goes into the muscularis propria - new acumen for sure

Includes XRT!!
5FU Platnum (same as gastric)

23

Maximum esophageal stage and still go for care

T4 a! N0

T1-3 N


This includes invasion of:
The pleura
Pericardium
Diaphragm

(not D heart, aortic, vertebrae, trachea

24

36-year-old male with hematemesis EGD shows mucosal tear gastroesophageal junction

This is a Mallory-Weiss tear

Management is nonoperative

25

Patient is found to have an 8 cm the paracellular carcinoma

If Child a.m. possibly a very good child B
With psoriasis need 40 – 50% functional liver reminnent

Consider preoperative portal embolization

Consider preoperative chemoembolization

Restage

Hepatectomy

* this is too big for transplant