Esophagus Basic Science

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EsophagusBasic Science

• Scott Nguyen, MD
• Daniel Herron, MD
• September 8, 2005

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With regard to the anatomy of the esophagus,
which of the following statements are true?

• The outer muscular layer of the upper thoracic
  esophagus lies adjacent to the membranous portion
  of the trachea
• In patients with cirrhosis with portal
  hypertension, venous drainage flows through the
  azygus system.
• The cervical and lowest portion of the thoracic
  esophagus lie slightly to the left of the
  midline.
• The left and right vagal plexi are intimately
  attached to the esophagus and emerge as two main
  anterior and posterior trunks just above the
  esophageal hiatus
• The thoracic duct travels from right to left at
  the upper third of the esophagus
• All of the above

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Anatomy

• Pharyngoesophageal segment
• Cervical esophagus
• Thoracic segment
• Intraabdominal segment

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The most important aspect of an operation for a
correction of a Zenkers Diverticulum is

• Resection of the Diverticulum
• Pexy of the Diverticulum
• Cricomyotomy
• Cervical Drainage

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A 55 year old male experiences heartburn after
meals and during the night. He has esophageal
manometry. The finding that could explain his
symptoms is

• Failure of the LES to relax with swallowing
• Peristaltic contraction from 20-100 Hg following
  relaxation
• Resting LES pressures less than 6 mm Hg
• A LES measuring 4 cm

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Esophageal Physiology
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Which of the following tests is the most
sensitive for detection of GE reflux?

• Barium Swallow
• Manometry
• 24 Hour pH monitoring
• Acid perfusion (Berstein Test)
• Standard acid reflux test

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Lower Esophageal Sphincter

• Components
• Intrinsic distal esophageal muscles tonically
  contracted
• Muscular Sling fibers of the gastric cardia
• Diaphragmatic crura
• Transmitted pressure of the abdominal cavity

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pH Monitoring

• Calculate time that pH lt 4 at distal esophagus

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Manometry
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Other tests
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Recognized complications of GE reflux DO NOT
include which of the following?

• Ulcer
• Aspiration
• Columnar epithelium-lined esophagus
• Motility disturbance
• Zenkers Diverticulum
• Stricture
• Laryngeal inflammation

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Which of the following are NOT related to the
nonsurgical therapy of reflux?

• Alginic acid
• Prokinetic agents
• Living at higher altitudes
• Low fat meals
• Proton pump inhibitors

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Surgery for GERD
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With regard to Barretts esophagus, which of the
following statements are NOT true?

• It is congenital in orgin
• The columnar lining may be discontinuous with the
  gastric epithelium
• It is associated with an increased risk of cancer
  of the esophagus
• Surgical indications are those for reflux.
• Esophageal resection is indicated when severe
  dysplasia is present

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Barretts Esophagus
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Which of the following are effects of antireflux
operations on Barretts esophagus?

• Regression of esophagitis
• Prevention of further columnar metaplasia
• Regression of columnar esophageal lining
• Prevention of malignancy
• All of the above
• A and B only

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Early dysphagia following a Nissen Fundoplication
is usually due to

• Too tight a gastric wrap
• Undetected perforation
• Slipped Nissen
• Traumatic edema

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Which of the following factors are associated
with adenocarcinoma of the esophagus? (gt2
answers allowed)

• Achalasia
• Corrosive stricture
• Barretts esophagus
• Ectopic gastric mucosa
• Upper esophageal web

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Esophageal Cancer

• Squamous Cell Carcinoma
• Adenocarcinoma

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Esophageal Cancer
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Survival

• Stage 5yr
• I 50-94
• II 15-65
• III 6-23
• IV lt5
• Only lt 50 elligible for curative resection at
  presentation

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Surgical Options

• Ivor Lewis Procedure
• Left Thoracoabdominal approach
• Transhiatal
• Combined Thoracoscopic / Laparoscopic

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Ivor Lewis
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Left Thoracoabdominal Approach
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Transhiatal approach
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Other operations

• Combined thoracoscopic / laparotomy
• Combined thoracoscopic / laparoscopic
• Laparoscopic transhiatal

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Which of the following are FALSE statements
regarding esophageal cancer?

• Presents w/ dysphagia and weight loss
• Diagnosis confirmed w/ barium esophagram and
  endoscopic biopsy
• Lymph nodes usually involved
• No submucosal spread
• Exploration is most important determinant of
  resectability

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Blood supply to the stomach in a transhiatal
esophagectomy is provided by

• The Left gastric artery
• The left gastroepiploic artery
• The splenic artery
• The right gastroepiploic artery

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A 55 year old pt presents w/ dysphagia. A barium
swallow identifies a smooth filling defect with
the mucosa intact in the distal esophagus.
Appropriate treatment is

• Total esophagectomy
• Distal esophagectomy
• Enucleation of the Lesion
• Endoscopic drainage

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After diagnostic esophagoscopy, a patient
complains of odynophagia and chest pain, but
results of a water-soluble contrast swallow are
negative. Which of the following apply?

• Discharge if the EKG is negative
• Barium in the chest is devastating
• Esophageal manometry should be performed
  immediately
• Repeated swallow with barium

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Esophageal Perforation
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12 hours following esophagoscopy and biopsy of an
obstructing esophageal cancer, the pt presents w/
fever substernal chest pain. Esophagram reveals
perforation of the distal esophagus. Appropriate
treatment is

• Esophageal tube suction, IV, antibiotics
• Chest tube, esophageal suction, IVs, and
  antibiotics
• Closure of perforation, chest tube, IVs, and
  antibiotics
• Esophagectomy and esophagogastrostomy

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A 22 year male is stabbed in the neck anterior to
the sternocleidomastoid, above the cricoid
cartilage. Which of the following management
choices are INCORRECT.

• Mandatory neck exploration
• Four vessel angiography
• Barium esophagram
• Flexible esophagoscopy
• Laryngoscopy

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Penetrating Neck Trauma