absite esophagus

7/25/2019 ABSITE Esophagus

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EsophagealEsophageal

DiseasesDiseases ABSITE Lecture Series ABSITE Lecture SeriesFaiz Bhora, MDFaiz Bhora, MD

Attending Thoracic Surgeon Attending Thoracic SurgeonSt. Lukes Roosevelt MedicalSt. Lukes Roosevelt Medical

Center, !,Center, !,


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"so#hagus Lecture $art %"so#hagus Lecture $art %


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Essential EsophagealEssential Esophageal Anatomy Anatomy

The eso#hagus is &' c( in length. The lo)er '*+The eso#hagus is &' c( in length. The lo)er '*+c( are elo) the dia#hrag(c( are elo) the dia#hrag(

Average distance -ro( incisors to " /unction is Average distance -ro( incisors to " /unction is

01*23 c( in (en. The distance -ro( the incisors01*23 c( in (en. The distance -ro( the incisorsto the crico#har4ngeus is %' c(to the crico#har4ngeus is %' c(To#ogra#hicall4, the eso#hagus egins at theTo#ogra#hicall4, the eso#hagus egins at thelo)er order o- C5. The dia#hrag(atic hiatus islo)er order o- C5. The dia#hrag(atic hiatus isat T%3at T%3The u##er %60 eso#hagus is slightl4 to the le-t o-The u##er %60 eso#hagus is slightl4 to the le-t o-(idline, the (iddle %60 slightl4 to the right, and(idline, the (iddle %60 slightl4 to the right, andthe lo)er %60 slightl4 to the le-tthe lo)er %60 slightl4 to the le-t


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Essential EsophagealEssential Esophageal Anatomy Anatomy The u##er %60 is co(#osed o- striated (uscle and isThe u##er %60 is co(#osed o- striated (uscle and is

innervated 4 the vagus and its recurrent ranch. The lo)erinnervated 4 the vagus and its recurrent ranch. The lo)er&60 is co(#osed o- s(ooth (uscle and is su##lied 4 the&60 is co(#osed o- s(ooth (uscle and is su##lied 4 the

vagus and the intrinsic autono(ic nerve #le7us vagus and the intrinsic autono(ic nerve #le7usThe arterial lood su##l4 is seg(ental. These include theThe arterial lood su##l4 is seg(ental. These include thein-erior th4roid arter4, ronchial arteries and aortic ranches,in-erior th4roid arter4, ronchial arteries and aortic ranches,

and ranches o- the le-t gastric and in-erior #hrenicand ranches o- the le-t gastric and in-erior #hrenicThe venous drainage like)ise is via the az4gous,The venous drainage like)ise is via the az4gous,he(iaz4gous, intercostals, and le-t gastric veinshe(iaz4gous, intercostals, and le-t gastric veinsThe l4(#hatic drainage o- the u##er %60 is to the internalThe l4(#hatic drainage o- the u##er %60 is to the internal

/ugular, dee# cervical and #ara tracheal nodes. The (iddle /ugular, dee# cervical and #ara tracheal nodes. The (iddle

%60 drains into the su carinal and in- #ul(onar4 liga(ent%60 drains into the su carinal and in- #ul(onar4 liga(entnodes. The lo)er %60 drains into the #araeso#hageal andnodes. The lo)er %60 drains into the #araeso#hageal andceliac nodes.celiac nodes.


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Esophageal SpasmEsophageal SpasmSyndromesSyndromes

8nade9uate L"S rela7ation8nade

9uate L"S rela7ation Achalasia, e#i#hrenic diverticulu( Achalasia, e#i#hrenic diverticulu(:ncoordinated eso#hageal contraction:ncoordinated eso

#hageal contraction

Di;use eso#hageal s#as( 4#ercontraction>

4#ercontraction>igh*a(#litude #eristaltic contraction A$C,>igh*a(#litude #eristaltic contraction A$C,?nutcracker eso#hagus@=, >4#ertensive lo)er?nutcracker eso#hagus@=, >4#ertensive lo)er

eso#hageal s#hincter L"S=eso#hageal s#hincter L"S=>4#ocontarction>

4#ocontarction8ne;ective eso#hageal (otilit4


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$ain is the $redo(inant S4(#to($ain is the $redo(inant S

4(#to(%.%. D"SD"S

$atients #resent )ith cardiac like chest #ain$atients #resent )ith cardiac like chest #ainD4s#hagia to oth solids and li9uidsD4s#hagia to oth solids and li9uidsCorkscre) eso#hagus on contrast eso#hagogra(Corkscre) eso#hagus on contrast eso#hagogra(Mano(etr4 sho)s %3 o- a series o- )et s)allo)sMano(etr4 sho)s %3 o- a series o- )et s)allo)sassociated )ith si(ultaneous contractions and )ithassociated )ith si(ultaneous contractions and )ith(ean a(#litudes o- 03 ((>g. L"S is nor(al(ean a(#litudes o- 03 ((>g. L"S is nor(al

Treat(ent includes (edications, #neu(atic dilatation,Treat(ent includes (edications, #neu(atic dilatation,otulinu( to7in in/ections. #erative intervention )henotulinu( to7in in/ections. #erative intervention )hen

conservative (easures have -ailedconservative (easures have -ailed


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$ain is the $redo(inant S4(#to($ain is the $redo(inant S 4(#to(&.&. >A$C < utcracker eso#hagus=>A$C < utcracker eso#hagus=

$atients #resent )ith shar#, e#isodic chest #ain$atients #resent )ith shar#, e#isodic chest #ainD4s#hagia unco((onD4s#hagia unco((onContrast eso#hagogra( o- lo) 4ieldContrast eso#hagogra( o- lo) 4ieldMano(etr4 sho)s high a(#litude, coordinated,Mano(etr4 sho)s high a(#litude, coordinated,#eristaltic contractions#eristaltic contractionsTreat(ent )ith diltiaze( has een sho)n to e hel#-ul.Treat(ent )ith diltiaze( has een sho)n to e hel#-ul.

Long eso#hageal (4oto(4 and #artial -undo#lication i-Long eso#hageal (4oto(4 and #artial -undo#lication i-(edical thera#4 -ails(edical thera#4 -ails


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$ain is the ot the $redo(inant S4(#to($ain is the ot the $redo(inant S 4(#to(%.%. Achalasia Achalasia


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Achalasia Achalasia

Achalasia is est con r(ed 4E Achalasia is est con r(ed 4E%.%. A irds eak a##earance on ariu( A irds eak a##earance on ariu(

eso#hagogra(eso#hagogra(

&.&. A#eristalsis o- the cervical eso#hagus A#eristalsis o- the cervical eso#hagus0.0. Failure o- the L"S to rela7 on s)allo)ingFailure o- the L"S to rela7 on s)allo)ing2.2. L"S #ressure ' ((>gL"S #ressure ' ((>g'.'. Bio#s4 #roven eso#hagitis on Ge7i leBio#s4 #roven eso#hagitis on Ge7i le

endososco#4endososco#4


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Achalasia Achalasia Achalasia is a #ri(ar4 (otor disorder o- the Achalasia is a #ri(ar4 (otor disorder o- theeso#hagus characterized 4 -ailure o- rela7ation o-eso#hagus characterized 4 -ailure o- rela7ation o-the L"S and loss o- #eristaltic )ave-or( in thethe L"S and loss o- #eristaltic )ave-or( in the

od4od4The cause is elieved to e neuronal degenerationThe cause is elieved to e neuronal degenerationin the (4enteric #le7us


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Characteristics ofCharacteristics of Achalasia Achalasia

Mano(etr4Mano(et r4%.%. 8nco(#lete L"S rela7ation on s)allo)ing8nco(#lete L"S rela7ation on s)allo)ing&.&. A#eristalsis o- the od4 A#eristalsis o- the od40.0. "levated L"S #ressure < 0' ((>g="levated L"S #ressure < 0' ((>g=2.2. 8ncreased resting eso#hageal #ressure8ncreased resting eso#hageal #ressure

"so#hagogra("so #hagogra(%.%. "so#hageal dilation"so#hageal dilation&.&. Air6Fluid level Air6Fluid level0.0. Birds eak or Sig(oid eso#hagusBirds eak or Sig(oid eso#hagus"ndosco#4"ndosco #4%.%. "so#hageal dilation"so#hageal dilation&.&. Retained -oodRetained -ood0.0. Fre9uentl4 nor(alFre9uentl4 nor(al


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Treatment of AchalasiaTreatment of AchalasiaTraditionall4, the #ri(ar4 thera#eutic a##roach -orTraditionall4, the #ri(ar4 thera#eutic a##roach -orachalasia involves #har(acological agents,achalasia involves #har(acological agents,endosco#ic otulinu( to7in into the L"S andendosco#ic otulinu( to7in into the L"S and#neu(atic dilatation o- the L"S#neu(atic dilatation o- the L"S

$har(acologic Agents$har(acolo gic Agents%.%. Calciu( channel lockers and long acting itratesCalciu( channel lockers and long acting itrates

oth decrease L"S resting #ressure. :suall4 #oor,oth decrease L"S resting #ressure. :suall4 #oor,short*lived res#onse, side e;ects li(it theirshort*lived res#onse, side e;ects li(it theire;ectivenesse;ectiveness

&.&. "ndosco#ic otulinu( to7in is success-ul in 13 o-"ndosco#ic otulinu( to7in is success-ul in 13 o-#atients in relieving d4s#hagia. >o)ever, s4(#to(s#atients in relieving d4s#hagia. >o)ever, s4(#to(sreturn in '3 in 5 (onths. Retreat(ent is success-ulreturn in '3 in 5 (onths. Retreat(ent is success-ulin '3 o- original res#ondersin '3 o- original res#onders


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Treatment of AchalasiaTreatment of Achalasia

$neu(atic Dilatation$neu(atic DilatationDisru#ts L"S (uscle ers and #roduces relie-Disru#ts L"S (uscle ers and #roduces relie-o- s4(#to(s in '3*1' o- #atients. >o)ever,o- s4(#to(s in '3*1' o- #atients. >o)ever,(ost #atients re9uire (ulti#le dilatations,(ost #atients re9uire (ulti#le dilatations,increasing the risk o- #er-oration


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Treatment of AchalasiaTreatment of Achalasia

Surgical M4oto(4Su rgical M4oto(4Transa do(inal vs TransthoracicTransa do(inal vs TransthoracicD4s#hagia relie- a out H3 at & 4earsD4s#hagia relie- a out H3 at & 4ears

Recurrent d4s#hagia )ithin & (onths likel4 dueRecurrent d4s#hagia )ithin & (onths likel4 dueto inco(#lete (4oto(4, torsion o- the re#air orto inco(#lete (4oto(4, torsion o- the re#air orscarring o- the (ucosa -ro( cauter4scarring o- the (ucosa -ro( cauter4Late*onset d4s#hagia due to (ucosal strictureLate*onset d4s#hagia due to (ucosal stricture

-ro( reGu7, or the latent e;ects o- dela4ed-ro( reGu7, or the latent e;ects o- dela4edgastric e(#t4ing. These #atients ulti(atel4 needgastric e(#t4ing. These #atients ulti(atel4 needgastric or eso#hageal resectiongastric or eso#hageal resection


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Treatment of AchalasiaTreatment of AchalasiaSurgical M4oto(4Su rgical M4oto(4

A resting L"S 05 (( >g is associated )ith a A resting L"S 05 (( >g is associated )ith agood surgical outco(egood surgical outco(e$atients )ith eso#hageal dilation 5 c( or )ith$atients )ith eso#hageal dilation 5 c( or )ithloss o- the eso#hageal a7is


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$ain is the ot the $redo(inant S4(#to($ain is the ot the $redo(inant S 4(#to(&.&. >4#ertensive Lo)er "so#hageal S#hincter>4#ertensive Lo)er "so#hageal S#hincter

L"S=L"S=

Most #atients #resent )ith d4s#hagiaMost #atients #resent )ith d4s#hagiaMano(etr4 sho)s elevated asal L"S #ressure,Mano(etr4 sho)s elevated asal L"S #ressure,nor(al #eristalsis and nor(al L"S rela7ationnor(al #eristalsis and nor(al L"S rela7ationTreat(ent o#tions include (edication,Treat(ent o#tions include (edication,

#neu(atic dilatation or (4oto(4#neu(atic dilatation or (4oto(4


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$ain is the ot the $redo(inant S4(#to($ain is the ot the $redo(inant S 4(#to(0.0. 8ne;ective "so#hageal Motilit4


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A '' 4r old )o(an has a 5 (onth histor4 o- A '' 4r old )o(an has a 5 (onth histor4 o-inter(ittent heart urn and d4s#hagia. "ndosco#4inter(ittent heart urn and d4s#hagia. "ndosco#4sho)s severe eso#hagitis. The ariu( s)allo)sho)s severe eso#hagitis. The ariu( s)allo)sho)s a lead*#i#e eso#hagus. The L"S restingsho)s a lead*#i#e eso#hagus. The L"S resting

#ressure is ' ((>g )ith (arkedl4 di(inished#ressure is ' ((>g )ith (arkedl4 di(inished#eristaltic activit4. The (ost likel4 diagnosis isE#eristaltic activit4. The (ost likel4 diagnosis isE

%.%. Achalasia Achalasia&.&. "RD"RD

0.0. CohnJs diseaseCohnJs disease2.2. Scleroder(aScleroder(a'.'. S/ogrens s4ndro(eS/ogrens s4ndro(e


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Esophageal DiverticulumEsophageal Diverticulum

A 65 yr old man has orsening dysphagia A 65 yr old man has orsening dysphagiaand regurgitation! Barium s allo sho sand regurgitation! Barium s allo sho sa 5 cm epiphrenic diverticulum!a 5 cm epiphrenic diverticulum!Treatment should "e#Treatment should "e#

%.%. Distal eso#hageal resectionDistal eso#hageal resection&.&. "so#hageal dilation and -undo#lication"so#hageal dilation and -undo#lication0.0. Resection o- the diverticulu( and longResection o- the diverticulu( and long

(4oto(4(4oto(4

2.2. Resection o- the diverticulu( onl4Resection o- the diverticulu( onl4'.'. Diverticulo#e74Diverticulo#e74


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Esophageal DiverticulumEsophageal Diverticulum"#i#hrenic Diverticulu(" #i#hrenic Diverticulu(

:suall4 #ulsion diverticulu( located )ithin the distal %3:suall4 #ulsion diverticulu( located )ithin the distal %3c( o- the thoracic eso#hagusc( o- the thoracic eso#hagus:suall4 right sided:suall4 right sided

Most are -ound incidentall4, ho)ever, the (ost co((onMost are -ound incidentall4, ho)ever, the (ost co((ons4(#to(s are d4s#hagia, regurgitations4(#to(s are d4s#hagia, regurgitationBariu( eso#hagogra( re(ains the est test -or diagnosisBariu( eso#hagogra( re(ains the est test -or diagnosis"ndosco#4, &2 >r $> and (ano(etr4 should e #er-or(ed"ndosco#4, &2 >r $> and (ano(etr4 should e #er-or(edS4(#to(atic, anato(icall4 de#endent and enlargingS4(#to(atic, anato(icall4 de#endent and enlargingdiverticulu( should e surgicall4 re#aireddiverticulu( should e surgicall4 re#airedSurgical thera#4 includes diverticulecto(4, (4oto(4 and aSurgical thera#4 includes diverticulecto(4, (4oto(4 and a#artial -undo#lication as indicated


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Esophageal DiverticulumEsophageal DiverticulumKenkers Diverticulu(Kenkers Diverticulu(

Most co((on eso#hageal diverticulu(Most co((on eso#hageal diverticulu(illians triangle is usuall4 the site o- )eaknessillians triangle is usuall4 the site o- )eakness

S4(#to(s include regurgitation, halitosis,S4(#to(s include regurgitation, halitosis,chocking, as#iration, nocturnal coughing,chocking, as#iration, nocturnal coughing,lar4ngitis. Motilit4 deter(ines s4(#to(s and notlar4ngitis. Motilit4 deter(ines s4(#to(s and notthe #ouch sizethe #ouch sizeDiagnosis (ade on ariu( s)allo)Diagnosis (ade on ariu( s)allo)

"ndosco#4 to rule out (alignanc4"ndosco#4 to rule out (alignanc4Surgical treat(ent reco((ended i- s4(#to(aticSurgical treat(ent reco((ended i- s4(#to(aticTreat(ent consists o- cervical eso#hago(4oto(4Treat(ent consists o- cervical eso#hago(4oto(4and #ouch resectionand #ouch resection


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Esophageal DiverticulumEsophageal DiverticulumMideso#hageal Diverticulu(Mides o#hageal Diverticulu(

:suall4 traction diverticulu(:suall4 traction diverticulu(These are due to TB and histo#las(osis. MostThese are due to TB and histo#las(osis. Mostas4(#to(atic and need no interventionas4(#to(atic and need no interventionMideso#hageal #ulsion diverticulu( are due to anMideso#hageal #ulsion diverticulu( are due to anunderl4ing (otilit4 disorder and are due to #ulsion.underl4ing (otilit4 disorder and are due to #ulsion.Mano(etr4 is hel#-ul to de ne the e7tent o- (4oto(4Mano(etr4 is hel#-ul to de ne the e7tent o- (4oto(4Surgical intervention -or large < ' c(= andSurgical intervention -or large < ' c(= ands4(#to(atic diverticulu(s4(#to(atic diverticulu(Buttress re#air )ith #leura, #ericardial -at orButtress re#air )ith #leura, #ericardial -at oro(entu(o(entu(


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"so#hagus Lecture $art &"so#hagus Lecture $art &


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Esophageal $erforationEsophageal $erforation65 yr old female ith achalasia complains of "ac%65 yr old female ith achalasia complains of "ac%

pain after pneumatic dilation! The C&' is normalpain after pneumatic dilation! The C&' is normalpost procedure! The ne(t "est course of action is#post procedure! The ne(t "est course of action is#

%.%. Re#eat endosco#4 to identi-4 an4 (ucosal in/ur4Re#eat endosco#4 to identi-4 an4 (ucosal in/ur4

&.&. ATS6or thoracoto(4 and o#erative re#air as 4ou ATS6or thoracoto(4 and o#erative re#air as 4ousus#ect an eso#hageal #er-orationsus#ect an eso#hageal #er-oration

0.0. 8n-ectious disease consult -or the #ro(#t8n-ectious disease consult -or the #ro(#tad(inistration o- anti iotic thera#4ad(inistration o- anti iotic thera#4

2.2. Contrast stud4 o- the eso#hagusContrast stud4 o- the eso#hagus'.'. Ad(it to 8C:, 8 h4dration. 8- sta le and CNR nor(al, Ad(it to 8C:, 8 h4dration. 8- sta le and CNR nor(al,

u##er 8 endosco#4 or gastrogra n s)allo) the ne7tu##er 8 endosco#4 or gastrogra n s)allo) the ne7t(orning(orning


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Esophageal $erforationEsophageal $erforation

Co((on Causes o- "so#hageal $er-orationCo((on Causes o- "so #hageal $er-oration"ndosco#4, eso#hageal dilation, tu e"ndosco#4, eso#hageal dilation, tu einsertion, trau(ainsertion, trau(a

#erative #rocedures associated )ith#erative #rocedures associated )ith#er-orationE anterior s#ine surger4


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Esophageal $erforationEsophageal $erforation$resentation and Diagnosis$resentation and Dia gnosis

Diferential diagnosis includes myocardial in arction, pancreatitis, Diferential diagnosis includes myocardial in arction, pancreatitis,per orated peptic ulcer disease, aortic dissection, acute gastricper orated peptic ulcer disease, aortic dissection, acute gastricvolvulusvolvulusS4(#to(s var4 de#ending on site, (echanis( and interval toS4(#to(s var4 de#ending on site, (echanis( and interval to

#resentation. >o)ever, #ain is the (ost co((on co(#laint#resentation. >o)ever, #ain is the (ost co((on co(#laintFever, tach4cardia, leucoc4tosis, su cutaneous e(#h4se(a andFever, tach4cardia, leucoc4tosis, su cutaneous e(#h4se(a andcre#itus, d4s#hagia, #leural e;usion, #eritonitis, se#siscre#itus, d4s#hagia, #leural e;usion, #eritonitis, se#sisRa#id diagnosis is the ke4E (ortalit4 o- untreated eso#hagealRa#id diagnosis is the ke4E (ortalit4 o- untreated eso#hageal#er-oration increases -ro( %3*&3 to 23*53 a-ter the rst &2 hours#er-oration increases -ro( %3*&3 to 23*53 a-ter the rst &2 hoursCNRE (ediastinal e(#h4se(a, #leural e;usion, h4dro#neu(othora7CNRE (ediastinal e(#h4se(a, #leural e;usion, h4dro#neu(othora7

astrogra n s)allo)


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Esophageal $erforationEsophageal $erforation

Ohen to Manage an "so#hageal $er-oration on*Ohen to Man age an "so#hageal $er-oration on*#erativel4I#erativel4I

Mini(al S4(#to(sMini(al S4(#to(sContrast stud4 sho)s s(all, contained leak Contrast stud4 sho)s s(all, contained leak

%.%. A out &' o- eso#hageal #er-orations (eet A out &' o- eso#hageal #er-orations (eetthis criterionthis criterion&.&. Lo)er tolerance o- conservative (anage(entLo)er tolerance o- conservative (anage(ent

)ith thoracic and a do(inal vs cervical)ith thoracic and a do(inal vs cervical#er-orations#er-orations

0.0. All #atients (ust e ad(itted to a (onitored All #atients (ust e ad(itted to a (onitoredsetting )ith initiation o- h4dration, anti ioticssetting )ith initiation o- h4dration, anti ioticsand (onitoring o- urine out#utand (onitoring o- urine out#ut


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Esophageal $erforationEsophageal $erforation#erative Manage(ent o- Cervical $er-oration#erative Manage(ent o- Cervical $er-oration

Drainage usuall4 is su;icientDrainage usuall4 is su;icient8ncision (ade anterior to the sternocleido(astoid8ncision (ade anterior to the sternocleido(astoid(uscle(uscleMediastinosco#4 can e used to drain the (iddleMediastinosco#4 can e used to drain the (iddle(ediastinu((ediastinu(

eck drained )ith closed suction or #enrose drainseck drained )ith closed suction or #enrose drainsDirect o#erative re#air i- #er-oration easil4Direct o#erative re#air i- #er-oration easil4localizedlocalizedMa4 e co( ined )ith thoracic drainage i-Ma4 e co( ined )ith thoracic drainage i-e7tensive (ediastinal and #leural soilage #resente7tensive (ediastinal and #leural soilage #resent


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Esophageal $erforationEsophageal $erforation#erative Manage(ent o- Thoracic $er-oration#erative Manage(ent o- Thoracic $er-oration

Most cases can e #ri(aril4 re#aired. :##er &60 a##roachedMost cases can e #ri(aril4 re#aired. :##er &60 a##roached via right ' via right ' thth intercostal s#ace and lo)er %60 via le-t +intercostal s#ace and lo)er %60 via le-t + thth intercostal s#aceintercostal s#aceMust de ride all necrotic (uscle and identi-4 the (ucosa.Must de ride all necrotic (uscle and identi-4 the (ucosa.Mucosa closed as a se#arate la4er


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$araesophageal )ernias$araesophageal )ernias*rganoa(ial*rganoa(ial sto(ach rotates a out its longitudinalsto(ach rotates a out its longitudinal+esoa(ial+esoa(ial sto(ach rotates a out a line #er#endicular to thesto(ach rotates a out a line #er#endicular to thecardio#4loric linecardio#4loric line

Classi cationClassi cationT4#e 8E Sliding, -undus onl4, %*' c(, no rotationT4#e 8E Sliding, -undus onl4, %*' c(, no rotationT4#e 88E True $araeso#hageal, -undus6 od4, %*' c(, organoa7ialT4#e 88E True $araeso#hageal, -undus6 od4, %*' c(, organoa7ial

rotationrotationT4#e 888E Mi7ed, -undus and od4, P or (ore o- sto(ach,T4#e 888E Mi7ed, -undus and od4, P or (ore o- sto(ach,

organoa7ial and (esoa7ial rotationorganoa7ial and (esoa7ial rotation

T4#e 8 E Mi7ed )ith other organs, -undus and od4 #lus otherT4#e 8 E Mi7ed )ith other organs, -undus and od4 #lus otherorgans, P or (ore o- sto(ach and colon, organoa7ial andorgans, P or (ore o- sto(ach and colon, organoa7ial and(esoa7ial rotation(esoa7ial rotation


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$araesophageal )ernias$araesophageal )ernias

S4(#to(s and SignsS 4(#to(s and Signs'3 are as4(#to(atic, although (inor'3 are as4(#to(atic, although (inors4(#to(s are usuall4 overlookeds4(#to(s are usuall4 overlookedT4#ical s4(#to(s include e#igastric #ain, #ost*T4#ical s4(#to(s include e#igastric #ain, #ost*#randial disco(-ort in the chest, heart urn,#randial disco(-ort in the chest, heart urn,regurgitation, vo(iting, )eight loss, d4s#nearegurgitation, vo(iting, )eight loss, d4s#nea8(#ortant signs include ane(ia, #neu(onia8(#ortant signs include ane(ia, #neu(onia

An incarcerated intrathoracic sto(ach is a An incarcerated intrathoracic sto(ach is a

surgical e(ergenc4. These #atients #resent )ithsurgical e(ergenc4. These #atients #resent )ithacute chest or e#igastric #ain and retching, utacute chest or e#igastric #ain and retching, utthe ina ilit4 to vo(itthe ina ilit4 to vo(it


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DiagnosisDia gnosisCNR sho)s a retro cardiac air u le, )ith orCNR sho)s a retro cardiac air u le, )ith or)ithout an air Guid level)ithout an air Guid level

Bariu( s)allo) con r(s the diagnosis andBariu( s)allo) con r(s the diagnosis andusuall4 sho)s a large, intrathoracic u#side do)nusuall4 sho)s a large, intrathoracic u#side do)nsto(achsto(ach"ndosco#4 hel#-ul to evaluate -or ulcers,"ndosco#4 hel#-ul to evaluate -or ulcers,Barretts and neo#las(sBarretts and neo#las(s"so#hageal (otilit4 studies hel#-ul in an elective"so#hageal (otilit4 studies hel#-ul in an electivesetting to hel# guide decisions regarding a )ra#setting to hel# guide decisions regarding a )ra#


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$araesophageal )ernias$araesophageal )erniasTreat(entTreat(ent

All patients ith symptoms or signs should undergo All patients ith symptoms or signs should undergoelective repair in the a"sence of prohi"itiveelective repair in the a"sence of prohi"itivesurgical ris% surgical ris%

A##roaches include transthoracic, a do(inal or la#arosco#ic A##roaches include transthoracic, a do(inal or la#arosco#icTransthoracic a##roach #rovides the a ilit4 to (o ilize theTransthoracic a##roach #rovides the a ilit4 to (o ilize theeso#hagus, relative ease o- dissection o- the hernia sac, and o#ti(aleso#hagus, relative ease o- dissection o- the hernia sac, and o#ti(ale7#osure -or secure crural closure. A Collis gastro#last4 can alsoe7#osure -or secure crural closure. A Collis gastro#last4 can alsoeasil4 e #er-or(edeasil4 e #er-or(edThe (ain advantage o- the a do(inal a##roach is the a ilit4 toThe (ain advantage o- the a do(inal a##roach is the a ilit4 to#lace the sto(ach in the a##ro#riate anato(ic orientation#lace the sto(ach in the a##ro#riate anato(ic orientationLa#arosco#4 is associated )ith '*1 incidence o- eso#hagealLa#arosco#4 is associated )ith '*1 incidence o- eso#hageal#er-oration, and higher recurrence rate than the o#en #rocedure#er-oration, and higher recurrence rate than the o#en #rocedure


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Treat(entTreat(ent All patients ith symptoms or signs should All patients ith symptoms or signs should

undergo elective repair in the a"sence ofundergo elective repair in the a"sence ofprohi"itive surgical ris% prohi"itive surgical ris%

eed -or eso#hageal (o ilization andeed -or eso#hageal (o ilization andlengtheninglengtheningThe i(#ortance o- sac e7cisionThe i(#ortance o- sac e7cision

The role o- gastrosto(4 and gastro#e74The role o- gastrosto(4 and gastro#e74The need -or (esh in crural re#airThe need -or (esh in crural re#air


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Caustic IngestionCaustic Ingestion A , year old "oy s allo ed some ammonia -glass A , year old "oy s allo ed some ammonia -glass

cleaner.! )e is crying/ complaining of pain andcleaner.! )e is crying/ complaining of pain andis drooling! 0hich of the follo ing is true#is drooling! 0hich of the follo ing is true#

%.%. The #atient should i((ediatel4 e intu ated toThe #atient should i((ediatel4 e intu ated to

secure his air)a4secure his air)a4&.&. "ndosco#4 is contraindicated, as it could e7acer ate"ndosco#4 is contraindicated, as it could e7acer ate

the in/ur4the in/ur40.0. Sodiu( h4#ochlorite < leach= ingestion has theSodiu( h4#ochlorite < leach= ingestion has the

highest likelihood o- #er-orationhighest likelihood o- #er-oration2.2. astrogra n s)allo) is #er-or(ed at 0 )eeks andastrogra n s)allo) is #er-or(ed at 0 )eeks and

hel#s guide dilation o- strictureshel#s guide dilation o- strictures'.'. Steroids hel# decrease the incidence o- stricturesSteroids hel# decrease the incidence o- strictures


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1astroesophageal 'e2u(1astroesophageal 'e2u(DiseaseDisease

True statements regarding an a"dominal approachTrue statements regarding an a"dominal approach versus a thoracic approach to anti3re2u( versus a thoracic approach to anti3re2u(surgery include#surgery include#

%.%. A Collis gastro#last4 -or a shortened eso#hagus is A Collis gastro#last4 -or a shortened eso#hagus is

easier #er-or(ed through the a do(eneasier #er-or(ed through the a do(en&.&. Large hernias are easier re#aired la#arosco#icall4Large hernias are easier re#aired la#arosco#icall4

)ith etter results)ith etter results0.0. Redo o#erations are etter #er-or(ed through theRedo o#erations are etter #er-or(ed through the

a do(ena do(en2.2. There is a lo)er incidence o- eso#hageal #er-orationThere is a lo)er incidence o- eso#hageal #er-oration'.'. The issen re#air is easier #er-or(edThe issen re#air is easier #er-or(ed

transa do(inall4transa do(inall4


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$reoperative 0or%3up$reoperative 0or%3up

%= eso#hagogastroduodenosco#4%= eso#hagogastroduodenosco#4&= eso#hageal (ano(etric evaluation.&= eso#hageal (ano(etric evaluation.0= &2*hour intraeso#hageal #> (onitoring0= &2*hour intraeso#hageal #> (onitoring2= ariu( cineradiogra#h42= ariu( cineradiogra#h4


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Indications for Surgery Indications for Surgery Surgical thera#4 should e considered in those individuals )ithSurgical thera#4 should e considered in those individuals )ithdocu(ented "RD )hoEdocu(ented "RD )hoE

%= have -ailed (edical (anage(ent%= have -ailed (edical (anage(ent

&= o#t -or surger4 des#ite success-ul (edical (anage(ent&= o#t -or surger4 des#ite success-ul (edical (anage(ent


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T4#es o- Re#airsET4#es o- Re#airsEissenissen

>ill>ill

Tou#etTou#etDorDorBelse4 Mark 8 Belse4 Mark 8 Collis astro#last4Collis astro#last4


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Barrett4s EsophagusBarrett4s Esophagusalse statements regarding Barrett4s esophagusalse statements regarding Barrett4s esophagus

include#include#%.%. &3*23 o- #atients )ith severe d4s#lasia )ill have&3*23 o- #atients )ith severe d4s#lasia )ill have

invasive carcino(a in the resected s#eci(eninvasive carcino(a in the resected s#eci(en&.&. The likelihood o- develo#ing cancer in the rst 0*'The likelihood o- develo#ing cancer in the rst 0*'

4ears a-ter severe d4s#lasia has een identi ed is &'* 4ears a-ter severe d4s#lasia has een identi ed is &'*'3'3

0.0. The ideal thera#4 -or BarrettJs )ith severe d4s#lasiaThe ideal thera#4 -or BarrettJs )ith severe d4s#lasiais endosco#ic laser a lation o- the (ucosa and anis endosco#ic laser a lation o- the (ucosa and ananti*reGu7 #rocedureanti*reGu7 #rocedure

2.2. The ideal thera#4 -or unco(#licated BarrettJsThe ideal thera#4 -or unco(#licated BarrettJseso#hagus is controversialeso#hagus is controversial

'.'. 8t is a #re(alignant condition and occurs in %3 o- all8t is a #re(alignant condition and occurs in %3 o- all#atients )ith reGu7#atients )ith reGu7


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Esophageal Cancer Esophageal Cancer

%2,333 ne) cases each 4ear, (ore co((on in%2,333 ne) cases each 4ear, (ore co((on in(en(en

Adenocarcino(a no) re#resents a out 53*+3 Adenocarcino(a no) re#resents a out 53*+3o- these tu(orso- these tu(ors

$resentation$resentation%.%. H3 #resent )ith d4s#hagiaH3 #resent )ith d4s#hagia

&.&. +3 #resent )ith )eight loss+3 #resent )ith )eight loss0.0. '3 #resent )ith su sternal or e#igastric #ain'3 #resent )ith su sternal or e#igastric #ain2.2. >oarseness is rare>oarseness is rare


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Role o- ":S in T Stage Assess(entRole o- ":S in T St age Assess(ent"so#hageal carcino(a #resents as a h4#o echoic (ass"so#hageal carcino(a #resents as a h4#o echoic (assthat disru#ts the nor(al anato(4 o- the eso#hagusthat disru#ts the nor(al anato(4 o- the eso#hagus

Accurac4 -or assessing de#th o- tu(or #enetration is Accurac4 -or assessing de#th o- tu(or #enetration is1'*H31'*H3

Role o- ":S in Stage Assess(entRole o- ":S in Sta ge Assess(ent>4#o echoic nodes, shar#l4 de(arcated and larger>4#o echoic nodes, shar#l4 de(arcated and largerthan ' (( are likel4 to e (alignantthan ' (( are likel4 to e (alignant

Accurac4 -or overall stage accurac4 is ++ . F A Accurac4 -or overall stage accurac4 is ++ . F Aadded to ":S increases the accurac4 to H%added to ":S increases the accurac4 to H%


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$"T6CT no) )idel4 used -or #re o#erative$"T6CT no) )idel4 used -or #re o#erativeassess(entassess(ent

Bronchosco#4 is done i- tracheal orBronchosco#4 is done i- tracheal orronchial involve(ent is suggestedronchial involve(ent is suggested


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Esophageal Cancer Esophageal Cancer StagingSta gingT%E invades la(ina #ro#ria or su (ucosaT%E invades la(ina #ro#ria or su (ucosaT&E invades (uscularis #ro#riaT&E invades (uscularis #ro#riaT0E invades adventitiaT0E invades adventitia

T2E invades ad/acent structuresT2E invades ad/acent structures

3E no l4(#h nodes3E no l4(#h nodes%E regional l4(#h nodes%E regional l4(#h nodes

M%E distant (etastasis, including celiac or cervical nodesM%E distant (etastasis, including celiac or cervical nodes


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Esophageal Cancer Esophageal Cancer StagingSta gingT%E invades la(ina #ro#ria or su (ucosaT%E invades la(ina #ro#ria or su (ucosaT&E invades (uscularis #ro#riaT&E invades (uscularis #ro#riaT0E invades adventitiaT0E invades adventitiaT2E invades ad/acent structuresT2E invades ad/acent structures

3E no l4(#h nodes3E no l4(#h nodes%E regional l4(#h nodes%E regional l4(#h nodes

M%E distant (etastasis, including celiac or cervical nodesM%E distant (etastasis, including celiac or cervical nodes

Stage 8Stage 8 E T% 3E T% 3Stage &A Stage &A E T& 3 and T0 3E T& 3 and T0 3Stage &BStage &B E T% % and T& %E T% % and T& %Stage 0Stage 0 E T0 % and T2 an4 E T0 % and T2 an4 Stage 2Stage 2 E M%E M%


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eoad/uvant Thera#4eoad /uvant Thera#4' 4r survival )ith surger4 alone is &'' 4r survival )ith surger4 alone is &'

Although + rando(ized trials have een done, Although + rando(ized trials have een done,onl4 one %HH5 stud4


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Surgical A##roachesSur gical A##roachesTranshiatal eso#hagecto(4Transhiatal eso#hagecto(4

8vor*Le)is eso#hagecto(48vor*Le)is eso#hagecto(4"so#hagecto(4 )ith cervical"so#hagecto(4 )ith cervicalanasto(osisanasto(osis

Thoracoa do(inal )ith le-t chestThoracoa do(inal )ith le-t chestanasto(osisanasto(osis


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Esophageal Cancer Esophageal Cancer Regarding eso#hageal cancer and itsRegarding eso#hageal cancer and its(anage(ent, )hich state(ent is -alseE(anage(ent, )hich state(ent is -alseE

%.%. 8ts incidence is rising in the :S8ts incidence is rising in the :S&.&. $reo#erative )orku# should include ":S, $"T6CT$reo#erative )orku# should include ":S, $"T6CT

and $FTsand $FTs0.0. eoad/uvant treat(ent is the standard o- care -oreoad/uvant treat(ent is the standard o- care -or

T&, 3 eso#hageal cancerT&, 3 eso#hageal cancer2.2. There is no signi cant di;erence in survivalThere is no signi cant di;erence in survival

et)een the transhiatal or transthoracic a##roachet)een the transhiatal or transthoracic a##roach'.'. The leak rate is higher )ith the transhiatalThe leak rate is higher )ith the transhiatal

a##roacha##roach

absite esophagus

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