Term
|
Definition
-cervical = inf thyroid a
-thoracic = aorta br
-abd = left gastric, inf phrenic |
|
|
Term
| L vs R vagus orientation? |
|
Definition
R = on posterior side, becomes celiac
L = anterior, goes to liver |
|
|
Term
|
Definition
-crosses R-->L @ T4-T5
-enters left SC/IJV junction |
|
|
Term
|
Definition
Upper = striated
Lower = smooth
---------
inner = circular
outer = longitudinal |
|
|
Term
|
Definition
right vagus
*high acid levels post-op if left undivided* |
|
|
Term
Normal Esoph Pressure(mmHg)
-rest-->w/food bolus |
|
Definition
-Pharyngeal w/food= 70-120
-UES 60-->15
-LES 15-->0 |
|
|
Term
| Resting LES pressure in Pts w/GERD? |
|
Definition
|
|
Term
| normal esoph contraction pressure with swallowing? |
|
Definition
30-120 mmHg
-ineffective if < 10 (burned out esoph) |
|
|
Term
| Normal distances of esoph structures from incisors |
|
Definition
-Cricopharyngeous = 15 cm
-Aortic arch indent = 25 cm
-LES = 40 cm
-hiatus = 45 cm |
|
|
Term
muscle of UES?
muscle type? |
|
Definition
cricopharyngeus
circular m |
|
|
Term
|
Definition
MC site esoph perf (MC EGD)
MC forgeign body site: Killians triangle (just above cricophyr). |
|
|
Term
| cause of aspiration with brain stem stroke? |
|
Definition
|
|
Term
|
Definition
-primary = w/food bolus/swallowing
-secondary = wave propagation after esoph is distended
-tert = dysfunctional, non-propogating |
|
|
Term
| What induces LES changes during swallowing? |
|
Definition
vagus causes relaxation
-occurs after swallow initiation |
|
|
Term
|
Definition
| Vagus-->phrenic-->symp chain T6-T12 |
|
|
Term
| MCC pharyngoesoph. disorders? |
|
Definition
Neuromuscular dz
-myshtenia, parkinsons, polymyositis, MD, stroke, Zenkers |
|
|
Term
plummer vinson
-description
-tx |
|
Definition
= esoph webs, Fe def anemia,
tx: Dilation, Fe,
*screen for oral Ca* |
|
|
Term
pharyngoesoph disorders
-what causes most difficulty? |
|
Definition
|
|
Term
| best test for dys/odynophagia? |
|
Definition
-Barium swallow = first test(then EGD w/bx after)
-manometry
-pH study |
|
|
Term
| likely cause of dysphagia based on trouble with liq vs solid? |
|
Definition
-Liq only = pharyngoesoph d/o
-both = motor d/p
-solids only = CA or stricture |
|
|
Term
|
Definition
| Autoimm destruction of myenteric plexus = loss of ganglion cells (Auerbach myenteric plexus) |
|
|
Term
|
Definition
T cruzi
sxs similar to achalasia |
|
|
Term
| 2 major characteristics of achalasia |
|
Definition
1. inability of LES to relax
2. loss of peristalsis |
|
|
Term
|
Definition
-dysphagia to BOTH liq/solids
-regurg |
|
|
Term
|
Definition
1. esophagogram (dilated->bird beak)
2. EGD: R/o CA
3. mano (best test for definitive dx) |
|
|
Term
| Typical achalasia mano findings? |
|
Definition
1. LES > 25 mmHg (no relaxation
2. low amplitude, failed peristalsis |
|
|
Term
pseudoachalasia
-typical dx scenario? |
|
Definition
doing EGD for achalasia, but can't pass scope easily into stomach
-->GE junction malig |
|
|
Term
| definition of burned out esoph? |
|
Definition
>50 % non pulsatile contractions
< 30 mmHg w/each contraction
*likely to fail medical management* |
|
|
Term
| Cancer risk with achalasia? |
|
Definition
15x normal risk for SCCA
*all need CA r/o* |
|
|
Term
| medical tx of achalasia ? |
|
Definition
1. balloon dilation x 2
2. CCbx, nitrates, |
|
|
Term
|
Definition
Heller myotomy (left thora) + partial wrap
-extend form 7 cm above, to 1-2 cm below EG junction (level of inf pulm v)
-separate muscles around half of esoph to prevent re-healing
-get POD1 ggraffin swallow-->thin barium |
|
|
Term
| esophagectomy vs achalasia? |
|
Definition
if..
1. burned out esoph
2. repeated myotomies, now w/stricture |
|
|
Term
DES
-barium swallow?
-Mano findings? |
|
Definition
-corkscrew esoph
-High amp, repetitive, non-peristaltic, long duration contractions
-->30% non-peristaltic
-->normal LES function |
|
|
Term
|
Definition
medical: CCBx, trazodone, psych meds+/-
Surg: long esoph myotomy (right thora)
-180 deg along entire length of esoph including 1-2 cm onto stomach
-wrap |
|
|
Term
DES
-what sxs most improved by surg? |
|
Definition
better for dysphagia over pain.
-less effective overall than surg for achalasia |
|
|
Term
|
Definition
|
|
Term
|
Definition
| Mano: very high-amplitude, PERISTALTIC waves (>180 mmHg |
|
|
Term
|
Definition
1.CCBlk, trazodone
2. long esoph myotomy, wrap (treats dysphagia better than pain) |
|
|
Term
|
Definition
-severe heartburn
-dysphagia
-complete loss of lES tone
-fibrous replacement of smooth m |
|
|
Term
|
Definition
Calcinosis
Raynauds
Esoph dysmotility
Sclerodactyly
Teleangiectasia |
|
|
Term
|
Definition
|
|
Term
Scleroderma
-Mano findings |
|
Definition
best test for dx
-Aperistalsis, weak contractions
-Low/absent LES pressure |
|
|
Term
| histopath of scleroderma/ |
|
Definition
-atrophy, fibrosis @ distal 2/3 esoph
-small artery sclerosis
*affects many organs, but MC is esoph* |
|
|
Term
| tx options vs scleroderma? |
|
Definition
1. omep, reglan, nystatin vs thrush,
2. elevate HOB, small meals
3. balloon dilation vs strictures
4. Surg: partial wrap + collis g-plasty vs possible esophagectomy |
|
|
Term
|
Definition
partial wrap + collis
vs
esophagectomy |
|
|
Term
| location of esoph diverticula? |
|
Definition
Zenkers = false = upper
Traction = true = middle
Epiphrenic = false = distal |
|
|
Term
| MCC epiphrenic vs traction divertic? |
|
Definition
epiphrenic = achalasia (primary motility d/o)
Traction = infection (chronic granulomatous dz) (inflammation, tumor) |
|
|
Term
| PPhys of epiphrenic divertic? |
|
Definition
= pulsion diverticula
-distal narrowing->inc pressure->divertic |
|
|
Term
|
Definition
|
|
Term
|
Definition
1.fix underlying motility issue
2. if needed..
-longitudinal myotomy opposite side of tic
-resection if trapping food, vs suspend |
|
|
Term
|
Definition
|
|
Term
|
Definition
if asympt..nothing
-otherwise excise and primary closure
-palliative tx if 2/2 ca (XRT, stent) |
|
|
Term
|
Definition
-ineffective relax of cricoph m.
-between cricoph m. and pharyngeal constrictors..MC posteriorly. |
|
|
Term
|
Definition
dysphagia
regurg non-digested food (almost all pts) |
|
|
Term
|
Definition
NO EGD (risk of perf)
-barium swallow |
|
|
Term
|
Definition
1)Cricopharyngeal myotomy,
-left neck @ ant SCM border
-ligate inf thy a and mid thy v
-extend 3 cm each direction
2)staple off divertic over bougie (but don't NEEEED to resect. can suspend)
3)leave drains..POD1 swallow |
|
|
Term
post-op Zenker's
stricture mgmt |
|
Definition
dilate early
-problematic if not treated early |
|
|
Term
Zenker's
mgmt. post op wound infection? |
|
Definition
open wound
gsatsrograffin swallow to r/o leak |
|
|
Term
|
Definition
g-griffin then barium if needed
*get even if you know pt has perf* |
|
|
Term
cervical esoph perf:
-incision
-next step if cant find hole |
|
Definition
-left neck
-leave drains (if cant repair, if cant find it)(leave even if repaired) |
|
|
Term
| Criteria for primary repair of esoph perf? |
|
Definition
< 24 hrs, minimal contam, no mediastinitis/no sepsis
-longitud myotomy, 2 layer closure, coverage with viable tissue
-relieve any distal obstruction |
|
|
Term
esoph perf
-post op imaging timing? |
|
Definition
| 1 week swallow for thoracic perfs |
|
|
Term
Pt with esoph perf who is sick..
mgmt.? |
|
Definition
-cervical esophagostomy for spit diversion
-staple above GE-->esophagectomy
-washout, chest tube, j tube
-@6-8wk..gastric pull up
*can leave esoph if SUPER sick* |
|
|
Term
|
Definition
MC left lower esoph
-(4 cm from EGJ @ 80%)
-Caused by forceful vomiting |
|
|
Term
|
Definition
Food + EtOH = Vomit = chest pain
*almost never contained perf* |
|
|
Term
| Highest mortality rate w/esoph perf? |
|
Definition
|
|
Term
| esoph caustic injury grading? |
|
Definition
0: normal
1: hyperemia, edema
2a: SF ulceration, sloghing, exudate
2b: + circumferential ulceration
3a: lumen obliterated, deep ulcers, perf,
3b: + necrosis |
|
|
Term
| injury / risks of alkali vs acid esoph injury? |
|
Definition
-alkali = worse. Liquefaction necrosis. Inc CA risk
-Acid = coagulation necrosis (causes more gastric injury) |
|
|
Term
caustic injury mgmt..
-do NOT.. |
|
Definition
..place NGT
..go past point of severe injury on EGD
..perform primary repair if perf |
|
|
Term
| time frame for stricture after caustic injury? |
|
Definition
MC 3 weeks.
-MC cervical or @ aortic indentation |
|
|
Term
| MC age groups esoph foreign bodies? |
|
Definition
|
|
Term
| MC foreign object in esoph vs age? |
|
Definition
kids-> non edible (coins).
adults-> meat f/b bones |
|
|
Term
| MC site for foreign body esoph? |
|
Definition
|
|
Term
| highest rate of injury with esoph foreign body? |
|
Definition
bones and fish bones
-10% perf, 75% injury |
|
|
Term
| stomach vs esoph fb mgmt.? |
|
Definition
NEVER leave esoph foreign body
-but..most pass once in stomach
-disk batteries/coins: extract if not moved in 48 hrs
-sharps: watch them pass (10% get lap) |
|
|
Term
| MC problem that increases changes of esoph FB? |
|
Definition
| GERD and resulting strictures |
|
|
Term
|
Definition
1.pH (best test)
2.Mano
3.EGD w/bx
4.Swallow |
|
|
Term
best test for GERD
-how it is performed/interp |
|
Definition
pH test
-probe 5 cm above LES- >4.5% of time with pH<4 = dx
*must be off PPI/H2 blk for 1 week* |
|
|
Term
|
Definition
LES pressure < 6 w/GERD
-need 3 readings |
|
|
Term
| MC 2ndary esoph motility problem? |
|
Definition
| esoph deterioration from GERD |
|
|
Term
| best test for suspected para-esoph hernia? |
|
Definition
Barium swallow
(most people w/GERD have hiatal hernia) |
|
|
Term
|
Definition
|
|
Term
| surgical consideration for GERD induced stricture? |
|
Definition
these pts have shortened esoph..
need Collis gastroplasty if performing a wrap |
|
|
Term
| MCC benign esoph stricture? |
|
Definition
GERD
**MUST GET Bx TO RO CA** |
|
|
Term
| requirements for adequate LES function? |
|
Definition
adequate pressure (GERD pts usually<6)
adequate length (5 cm)
adequate abd length (2 cm) |
|
|
Term
| measurements found in esoph shortening? |
|
Definition
EGJ 4-5 cm above diaphragm hiatus
-need 2 cm of room below hiatus- |
|
|
Term
|
Definition
-squam-->columnar metaplasia
*intestinal type metaplasia = highest CA risk*
-10% of GERD pts |
|
|
Term
Barretts
-surveillance regimen |
|
Definition
-yearly EGD bx @ 1 cm intervals, 4 quad
*3-6 months initially*
*does not change even if s/p wrap* |
|
|
Term
|
Definition
0.5% per year
-50x risk vs gen population |
|
|
Term
| Indications for esophagectomy vs barrett? |
|
Definition
-High grade dysplasia (20-25% harbor CA)
-perf (don't repair barrett area)
-refractory bleed, stricture,
-CA
**anastomosis should be in the neck** |
|
|
Term
Lower esoph ring
-associated condition
-sx/dx |
|
Definition
|
|
Term
|
Definition
Axs: ntd
Sxs: dilation + PPI
fail-->dilate and perform wrap
(NEVER RESECT THE RING) |
|
|
Term
|
Definition
-Acquired = MC type = higher up, a/w zenkers
-Congen = mid to lower esoph |
|
|
Term
|
Definition
-Dysphagia
-Esophagogram
-Dilation first. +/- circumferential web excision via longitudinal esophagotomy
**ESOPHAGECTOMY NEVER INDICATED** |
|
|
Term
|
Definition
|
|
Term
Nissen
anatomic key to dissection vs wrap? |
|
Definition
-dissection = find right crura
-wrap = find left crura |
|
|
Term
Nissen
-esoph length requirements? |
|
Definition
-mobilize at least 5 cm of intra-thoracic esoph
-need at least 2 cm free esoph in the abdomen |
|
|
Term
|
Definition
54 fr
-wrap around it to prevent stenosis |
|
|
Term
| what is the phrenoesophageal membrane an extension of? |
|
Definition
|
|
Term
nissen
-length of fundus wrap? |
|
Definition
|
|
Term
| potential artery found in gastro-hepatic ligament? |
|
Definition
| replaced left hepatic artery |
|
|
Term
|
Definition
posterior 180 partial wrap
-used it pt has esoph motility problems |
|
|
Term
| wrap used for pt with esoph motility problem? |
|
Definition
Toupet
-posterior 180 partial wrap |
|
|
Term
|
Definition
intra-thoracic wrap
-approach through chest |
|
|
Term
| procedure to extend esoph length? |
|
Definition
Collis gastroplasty
-staple along the cardia
-->perform wrap around neo-esoph |
|
|
Term
Nissen
-MC Cx
intra-op vs post-op |
|
Definition
intra-op = esoph perf (repair it)
post-op = dysphagia |
|
|
Term
Nissen
-causes of post op dysphagia |
|
Definition
1. too tight
2. twisted fundop
3. wrap herniation
4. Slipped fundop
5. two compartment fundop |
|
|
Term
|
Definition
| Too tight (presents EARLY) |
|
|
Term
|
Definition
Clears x 1 week, then dilate
-OR if can't tolerate liquids
*95% resolve w/conserv. mgmt*
*often from edema* |
|
|
Term
Post op dysphagia NIssen
-first test? |
|
Definition
|
|
Term
Nissen
-causes of dysphagia more common w/laparoscopy? |
|
Definition
-Twisted fundop
-Wrap herniation
-Two compartment fundop |
|
|
Term
|
Definition
when body of stomach, not fundus, is used for wrap
-re-op
-p/w dysphagia, inability to belch/vomit |
|
|
Term
| MCC dysphagia after re-do nissen |
|
Definition
wrap herniation
-likely from too short esoph
-re-do with Collis gastroplasty |
|
|
Term
|
Definition
|
|
Term
|
Definition
1 = GE above D
2 = para-esoph (nrml GE location)
3 = 1+2
4= type 2 or 3 but includes non-stomach organ |
|
|
Term
|
Definition
weakness or defect in phrenoesophageal membrane
(continuation of transversalis fascia) |
|
|
Term
| relative % w/type 1 hernia that have sxs |
|
Definition
most do NOT have reflux
-and most pts w/reflux do not have hiatal hernia. |
|
|
Term
|
Definition
|
|
Term
| Sxs of incarcerated para-esoph hernia |
|
Definition
1. chest pain, can't vomit, can't pass NGT (borchardt triad)
2. +/- inability to swallow saliva
3. Retching without vomiting (classic) |
|
|
Term
| condition a/w type 2-4 hiatal hernia? |
|
Definition
gastric volvulus
MC organo-axial |
|
|
Term
MC benign esoph tumor = ?
-location
-histo |
|
Definition
= Leiomyoma
-distal 2/3 esoph
-smooth muscle @ muscularis propria |
|
|
Term
| Swallow findings leiomyoma? |
|
Definition
smooth, convex semu-lunar filling
-distal 2/3 esoph |
|
|
Term
|
Definition
-Swallow: smooth, convex, semi-lunar
-EGD w/EUS: homogenous, hypo-echoic
***NO BX-->scar***
-CT (hypodense tumor) |
|
|
Term
esoph leiomyoma
-surg indications |
|
Definition
1. > 5 cm
2. Sx (dys/odynophagia)
3. unclear dx
4. Intraluminal, pedunc, mobile |
|
|
Term
| surgical tx vs esoph leiomyoma? |
|
Definition
Enucleation (no resection)
-leave mucosa intact
**esophagectomy if leiomyosarcoma** |
|
|
Term
2nd MC benign tumor esoph?
-location? |
|
Definition
Fibrovascular polyp
-cervical esoph |
|
|
Term
|
Definition
Swallow: intra-luminal filling defect
**NO EGD (unless @ surgery) as these are mobile and can acutely block airway** |
|
|
Term
Fibrovascular polyp
-histopath |
|
Definition
-fibrovscular/adipose tissue w/normal mucosal covering
*Nomral mucosa-->easy to miss on EGD*
-long, pedunculated intra-luminal mass |
|
|
Term
Fibrovascular polyp
-surg indications |
|
Definition
all need removal due to airway risk
> 8 cm = surg (myotomy, take stalk, fix hole)
< 8 cm = EGD |
|
|
Term
|
Definition
-Achalasia, GERD, Barretts, tylosis
-EtOH, Tobacc, -
-Caustic inj (alkali>acid)
-Male |
|
|
Term
Esoph CA
Best test for tumor depth
best for resectability? |
|
Definition
EUS for depth
CT vs resectability |
|
|
Term
esoph CA
-Best initial test and findings? |
|
Definition
Swallow
-Apple core lesion |
|
|
Term
| Common met sites for esoph CA? |
|
Definition
|
|
Term
|
Definition
-swallow
-EGD w/EUS
-Bronch (if upper 2/3 esoph)
-CT, PET
-Labs |
|
|
Term
| when need bronch for esoph CA? |
|
Definition
if tumor in upper 2/3
-rule out bronchial invasion |
|
|
Term
Esoph CA
-suspicious LN and w/u |
|
Definition
-Supraclav or retrocural, >0.5 mm-->FNA
-Intra-abd > 1 cm-->EUS, CT-guided, lap bx
-intra-thor > 1cm -->bronch/wang needle vs mediastinoscopy |
|
|
Term
Esoph CA
-unresectable nodes? |
|
Definition
| supraclav, celiac, SMA = M1 = unresectable |
|
|
Term
|
Definition
-Mets, +distant node
-hoarseness (RLN), Horners
-Phrenic involved
-Malig pleural effusion, malig fistula
-airway, vert invasion |
|
|
Term
Esoph CA
-biggest prog factor?
-marker for poor prog? |
|
Definition
|
|
Term
Esoph CA
Type of LN spread |
|
Definition
Spreads along submucosal lymphatics
-longitudinally |
|
|
Term
Adeno vs SCC of esoph
-location
-MC met |
|
Definition
Adeno = lower 1/3-->met to liver
SCC = mid 1/3--> met to lung (get a bronch) |
|
|
Term
| Ethnicity and type of esoph CA? |
|
Definition
Adeno = caucasian, 50-60 y/o (BARRETTS)
SCC = AA, 60-70 y/o |
|
|
Term
|
Definition
-SCJ found 3 cm above EGJ
-pink mucosa stains blue (normal stains grey)
- |
|
|
Term
|
Definition
|
|
Term
Esoph CA
-neoadj indications? |
|
Definition
for anything grearter than T1
*T1 = submucosal invasion*
-Cisplatin, 5FU, + XRT (x 6 wk)
(can result in down-staging) |
|
|
Term
Esoph CA
-indication for J tube |
|
Definition
> 20 lb weight loss
-place lap j tube if getting neo-adj chemo/xrt |
|
|
Term
Esoph CA
-esophagectomy Mortality rate vs cure rate |
|
Definition
| 25% mortality from surgery vs 5% cure |
|
|
Term
| Influence of XRT on surgery vs Esoph CA? |
|
Definition
= inc leak risk
-perform anastomosis outside of XRT field |
|
|
Term
| when to consider transhiatal approach? |
|
Definition
-poor PFTs (FEV 1 < 1L)
-pre-op reflux disease (anast in neck) |
|
|
Term
|
Definition
|
|
Term
| MC cx with lymphadenectomy during Esoph CA surgery? |
|
Definition
|
|
Term
| blood supply to stomach after Esoph CA surg? |
|
Definition
Right gastro-epiploic (from GDA)
*short gastrics, LGA are ligated when using stomach as conduit* |
|
|
Term
| list the surgical options for esophagectmoy vs Esoph CA? |
|
Definition
-transhiatal
-3 hole
-Ivor Lewis
-Colonic interposition |
|
|
Term
surg option vs Esoph CA
-location of incisions + (anastomosis) |
|
Definition
1. transhiatal = abd and neck (neck)
2. 3 hole = abd, neck, right thora (neck)
3. abd, right thoracotomy (chest) |
|
|
Term
thoracic vs cervical anastomosis vs esoph CA
-leak rate/complication rate? |
|
Definition
-cervical: less mortality from leak
-Thoracic: decreased leak rate overall |
|
|
Term
when to do colonic interposition?
-blood supply used? |
|
Definition
-@ young pts w/ benign disease. Allows preservation of gastric function.
-BS depends on marginal vessels |
|
|
Term
Esoph CA
When to abort esophagectomy? |
|
Definition
1.Incidental liver/peritoneal/lung mets
2.Incidental M1a (celiac/supraclav node)
-->continue w/rsxn and resect nodal area |
|
|
Term
Esoph CA Cx
-intra op bleeding mgmt with trans-hiatal |
|
Definition
-high/dark: azygous bleed-> do right thora
-low/bright: aortic br->left thora |
|
|
Term
Esoph CA Cx
-intra-op air leak dx/mgmt |
|
Definition
likely tear in distal trachea/left mainstem
-bronch |
|
|
Term
Positive or close margins with Ivor Lewis..
-mgmt? |
|
Definition
Drape for 3 hole with neck anast
-resect for additional margins |
|
|
Term
|
Definition
NPO, TPN x 3 weeks. feed with short to medium chain FAs
-Still high output / >2L per day?
-->surg to ligate thoracic duct |
|
|
Term
Esoph CA
-post op wound infection? |
|
Definition
1. open the wound in OR
2.If necrotic stomach, resect it, return rest of stomach to abd, + g tube & feeding J.
-cervical esophagostomy
-fix with colonic interpos 3 mo later |
|
|
Term
Esoph CA
-post op stenosis mgmt |
|
Definition
|
|
Term
post op Esoph CA surg
-regurgitation mgmt |
|
Definition
|
|
Term
| Complications MC with trans-hiatal esoph? |
|
Definition
Chylothorax
Posterior membranous trachea tears
Blood loss
Right RLN injury |
|
|
Term
| Cx MC with trans-thoracic esoph? |
|
Definition
|
|
Term
Perf of unresectable esoph CA
-mgmt |
|
Definition
|
|
Term
| Chemo indications @ esoph CA? |
|
Definition
5-FU + cisplatin
vs node +ve, full thickness, or to attempt down-staging |
|
|
Term
|
Definition
pre or post op
-dec local recurrence |
|
|
Term
Esoph CA
-5YSR with resection for cure |
|
Definition
|
|
Term
| Median survival for pts with esoph CA mets? |
|
Definition
|
|
Term
Esoph CA
-which side of colon is MC used to interpose and what artery supplies it? |
|
Definition
Left = left colic (MC)
Right = middle colic |
|
|
