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Chapter 18. Esophagus

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The most common cause of chylothorax is:

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A. Trauma to the spine and chest wall

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B. Lymphatic obstruction from mediastinal lymphoma

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C. Lymphatic leakage after mediastinal lymph node dissection

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D. Thoracic duct injury during esophagectomy

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The thoracic duct ascends in the mediastinum parallel to the esophagus and can easily be injured during mobilization for esophagectomy. Lymphatic leaks from lymph node dissections are often trivial and will usually seal on their own with no intervention.

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A 34-year-old male patient has been experiencing gastric reflux symptoms and recently underwent a workup, which included a upper endoscopy. The upper endoscopy revealed Barrett esophagus. The most appropriate therapy for this patient is:

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A. Esophagectomy

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B. Repeat endoscopy in 6 months

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C. Medical therapy with acid suppression

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D. Medical therapy with acid suppression and referral for fundoplication

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In a patient with reflux symptoms and Barrett epithelium, this is an indication for antireflux surgery, that is, Nissen fundoplication.

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What is the histologic subtype of Barrett tissue?

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A. Junctional epithelium

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B. Specialized columnar epithelium

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C. Gastric fundus epithelium

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D. Specialized squamous epithelium

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Barrett is an acquired condition thought to be caused by chronic reflux. It is associated with ulceration and stricture and has a higher rate of malignant degeneration than normal esophageal endothelium.

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After a 3-hole esophagectomy with a cervical anastomosis, the patient begins to develop leukocytosis, fever, and erythema of the wound. A barium swallow is performed and there is an anastomotic leak noted. What is the most appropriate management of this patient?

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A. Open the wound and redo the anastomosis

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B. Open the wound and widely drain the anastomosis

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C. Endoluminal stent

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D. IV antibiotics and NPO

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Patients with anastomotic leaks at the cervical area need to be made NPO, given antibiotics, and have the neck wound explored, debrided, and drained. Revising the anastomosis is unlikely to be successful due to inadequate length and friability of the tissues. In cases of catastrophic conduit necrosis, the esophagus can be diverted proximally and reconstruction performed in a delayed fashion with alternative conduits (jejunum, colon).

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