Esophagus

Name the layers of the esophagus:

• Mucosa and muscularis propria (esophagus has no serosa)

What is the arterial blood supply to the cervical esophagus?

• Inferior thyroid arteries (branch of thyrocervical trunk on left and subclavian artery on right)

What is the arterial supply to the thoracic esophagus?

• Direct blood supply from 4 to 6 esophageal arteries off of the aorta; esophageal branches off of right (R) and left (L) bronchial arteries; supplemented by descending branches off the inferior thyroid arteries, intercostal arteries, and ascending branches of the paired inferior phrenic arteries

What is the arterial blood supply to the abdominal esophagus?

• Left gastric artery and the paired inferior phrenic arteries

Describe the venous drainage for the cervical esophagus:

• The submucosal venous plexus drains into the inferior thyroid veins (tributaries of L subclavian vein and R brachiocephalic vein)

Describe the venous drainage for the thoracic esophagus:

• The submucosal venous plexus of the thoracic esophagus joins with the more superficial esophageal venous plexus and the venae comitantes that surround the esophagus at this level. This plexus then drains into the azygos veins on the right and the hemiazygous veins on the left.

Describe the venous drainage of the abdominal esophagus?

• Drains into both the systemic and portal venous systems through the L and R phrenic veins, and the L gastric (coronary) vein and short gastrics

In what direction is the lymphatic flow in the upper two-thirds of the esophagus?

• Cephalad

In what direction is the lymphatic flow in the distal third of the esophagus?

• Caudad

Describe the sympathetic innervation of the esophagus:

• Cervical esophagus receives branches from the cervical sympathetic trunk (from superior ganglion in neck); the thoracic esophagus receives branches from the thoracic sympathetic trunk (from stellate ganglion), which form an esophageal plexus that envelops the thoracic esophagus anteriorly and posteriorly; the distal thoracic esophagus receives innervation from the greater and lesser splanchnic nerves.

The parasympathetic fibers to the esophagus arise from which cranial nerve?

• Vagus nerve

The esophagus is composed of which 2 concentric muscle bundles?

• Inner circular and outer longitudinal

What kind of muscle composes the upper one-third of the esophagus?

• Striated muscle

What kind of muscle composes the lower two-thirds of the esophagus?

• Smooth muscle

At what vertebral level does the esophagus enter the diaphragm through the esophageal hiatus?

• T11

What are the areas of anatomical narrowing of the esophagus?

• Cricopharyngeus muscle; compression by the left mainstem bronchus and aortic arch; diaphragm

What is the Z line?

• The transition of the distal 1 to 2 cm of esophageal mucosa to cardiac mucosa/junctional columnar epithelium

Identification of gastroesophageal junction (external):

• The collar of Helvetius (loop of Willis) and the gastroesophageal fat pad

Identification of gastroesophageal junction (internal):

• The squamocolumnar epithelial junction (Z-line), provided the patient does not have Barrett.

• The transition from the smooth esophageal lining to the rugal folds of the stomach.

What are the 6 events that occur during the oropharyngeal phase of swallowing?

• Elevation of the tongue, posterior movement of the tongue, elevation of the soft palate, elevation of the hyoid, elevation of the larynx, tilting of the epiglottis

What are primary peristaltic contractions of the esophagus?

• Progressive contractions (2 to 4 cm/s) that move down the esophagus and reach the LES after the initiation of swallowing (~9 seconds)

What are secondary peristaltic contractions of the esophagus?

• Progressive contractions generated from distention/irritation of the esophagus or from an independent local reflex to clear the esophagus of material that was left behind after a primary peristaltic wave rather than voluntary swallowing

What are tertiary contractions of the esophagus?

• Uncoordinated contractions of smooth muscle that are nonprogressive, nonperistaltic, monophasic, or multiphasic simultaneous waves that can occur either after voluntary swallowing or spontaneously between swallows

Normal upper esophageal sphincter pressure at rest:

• 50 to 70 mm Hg

Normal upper esophageal sphincter pressure with food bolus:

• 12 to 14 mm Hg

Give examples of pulsion (false; mucosa and submucosa herniate through esophageal musculature) diverticula in the esophagus:

• Zenker diverticulum and epiphrenic diverticulum

What esophageal diverticulum is a traction (true) diverticulum that results from external inflammatory mediastinal lymph nodes adhering to the esophagus that heal and contract and pull the esophagus resulting in the diverticulum?

• Parabronchial (midesophageal) diverticulum

What side are midesophageal diverticula usually found?

• Typically present on the right secondary to the overabundance of structures in the midthoracic region of the left chest.

Treatment for a midesophageal diverticula:

• If asymptomatic patient with inflamed mediastinal lymph nodes from tuberculosis or histoplasmosis, treat medically with antituberculin or antifungal agents; if diverticulum <2 cm, observe; if patient symptomatic or diverticulum >2 cm, perform diverticulopexy (suspend from thoracic vertebral fascia) and a long esophagomyotomy is indicated in patients with severe chest pain or dysphagia and a documented motor abnormality.

Treatment for epiphrenic diverticulum:

• If diverticula <2 cm, perform diverticulopexy; in patients with severe chest pain, dysphagia, or a documented motor abnormality, perform long esophagomyotomy: if diverticulopexy, begin long esophagomyotomy at the neck of diverticulum and extend onto LES), and if diverticulectomy, perform esophagomyotomy on opposite esophageal wall, extending from the level of the diverticulum onto the LES; if large associated hiatal hernia, perform diverticulectomy, long esophagomyotomy, and repair of hiatal hernia

Killian triangle (site of a Zenker diverticulum):

• Point of potential weakness at the transition between the oblique fibers of the thyropharyngeus muscle and the horizontal fibers of the cricopharyngeus muscle

The surgical treatment of a Zenker diverticulum:

• If diverticulum >3 cm—cricopharyngeal myotomy with diverticulectomy with TA stapler versus invert and perform diverticulopexy to precervical fascia

• If <2 cm—leave alone

Most common site of esophageal perforation:

• Cricopharyngeus muscle

Recommended first test in any patient presenting with dysphagia:

• Video-esophagram

Indications for a video-esophagram:

• Regurgitation, globus sensation, dysphagia, GERD, noncardiac chest pain, esophageal neoplasm

What characteristics of the esophagus help determine if a lower esophageal sphincter is mechanically defective?

• Pressure <6 mm Hg, total length <2 cm, abdominal length <1 cm

What is the definition of a hypertensive lower esophageal sphincter?

• LES with a sphincter pressure above the 95th percentile of normal

What are the manometric characteristics of achalasia?

• Hypertensive LES resting pressure, incomplete or nonrelaxing LES, aperistalsis of the esophageal body, esophageal pressurization, and elevated lower esophageal baseline pressure

What is the gold standard for the diagnosis of achalasia?

• Esophageal manometry

Term for a patient with achalasia with preserved muscle function as demonstrated by simultaneous contraction waves of the esophagus with various amplitudes:

• Vigorous achalasia

What is presumed pathogenesis of achalasia?

• Primary destruction of nerves to the LES with secondary degeneration of the neuromuscular function of the body of the esophagus from idiopathic or infectious neurogenic degeneration

What is the classic triad of presenting symptoms for achalasia?

• Dysphagia, regurgitation, weight loss

What is the most common esophageal carcinoma identified with achalasia?

• Squamous cell carcinoma

Standard surgical treatment for achalasia:

• Heller myotomy

What are the classic manometry findings with diffuse esophageal spasm?

• Simultaneous, multipeaked contractions of high amplitude (>120 mm Hg) or long duration (>2.5 seconds)

What is the mainstay of treatment for diffuse esophageal spasm?

• Medical treatment or endoscopic intervention (nonsurgical)

Indications for surgery in a patient with diffuse esophageal spasm:

• Incapacitating chest pain or dysphagia after failure of medical and endoscopic therapy or presence of a pulsion diverticulum of the thoracic esophagus

If indicated, what surgical procedure should be performed in patients with diffuse esophageal spasm?

• Long esophagomyotomy with the proximal extent high enough to include the entire length of the abnormal motility as determined by manometric measurements and the distal extent of the myotomy down onto the LES with or without extension onto the stomach through a left thoracotomy or a left video-assisted technique; Dor fundoplication can be performed to provide protection from reflux and prevent healing of the myotomy site.

What is the gold standard for the diagnosis of nutcracker esophagus?

• Subjective complaint of chest pain with simultaneous objective evidence of peristaltic esophageal contractions 2 standard deviations above the normal values on manometric tracings (amplitudes >400 mm Hg)

Treatment of nutcracker esophagus:

• Medical (calcium channel blockers, nitrates, and antispasmodics) for temporary relief during acute spasms; avoidance of caffeine, cold, and hot foods

Manometric findings with hypertensive LES:

• Elevated LES pressure (>26 mm Hg) and normal relaxation of the LES

Treatment of hypertensive LES:

• Initially endoscopically with Botox injections and hydrostatic balloon dilation; surgery indicated in symptomatic patients who fail interventional treatments

If indicated, what is the operation of choice for hypertensive LES?

• Laparoscopic modified Heller esophagomyotomy with a partial antireflux procedure (Dor, Toupet) in patients with normal esophageal motility

What is the manometric definition of ineffective esophageal motility?

• The sum total of the number of low-amplitude contractions (<30 mm Hg) and nontransmitted contractions exceeds 30% of wet swallows

Best treatment for ineffective esophageal motility:

• Prevention with effective treatment of GERD; altered motility is irreversible.

Treatment for a patient with Barrett esophagus with no dysplasia?

• Acid suppression medication and yearly surveillance endoscopy with surveillance extended to every 2 to 3 years if there is no evidence of dysplasia on 3 consecutive yearly endoscopic exams

Treatment for a patient with Barrett esophagus with low-grade dysplasia:

• Acid suppression medication and surveillance endoscopy performed at 6-month intervals for the first year and then yearly thereafter if there has been no change

Recommended treatment for a patient with Barrett esophagus with high-grade dysplasia:

• Esophageal resection (near-total esophagectomy through a transhiatal approach); additional treatment options include ablative therapy or endoscopic mucosal resection in patients who are not acceptable surgical candidates

What is the most common aortic arch anomaly that creates an incomplete vascular ring around the esophagus?

• Right subclavian artery arising from the descending aorta and traveling behind esophagus in its course to the right upper extremity

What is a pulmonary artery sling?

• An anomaly of the pulmonary arterial trunk where the left pulmonary artery arises from the right pulmonary artery (instead of main pulmonary artery trunk) and courses between the trachea and the esophagus with resultant significant anterior compression of the esophagus

What can develop with a long-standing untreated pulmonary artery sling?

• Tracheal stenosis and left pulmonary artery narrowing

Treatment of a pulmonary artery sling:

• Open sternotomy with cardiopulmonary bypass and anatomic repositioning of the great vessels

What are the theories regarding the etiology of a Schatzki ring?

• A result of reflux esophagitis versus overcontractility of the circular esophageal musculature of the inferior esophageal sphincter combined with the sliding gastric mucosa of a hiatal hernia results in persistent apposition of the 2 mucosal layers and fibrosis of the submucosal layer below

How is the diagnosis of a Schatzki ring made?

• Barium esophagram

Treatment for an asymptomatic patient incidentally found to have a Schatzki ring:

• No treatment

Treatment for a patient with a Schatzki ring who presents with acute obstruction:

• Administration of oral papain (2.5% solution) in 5-mL aliquots every 30 minutes for a total of 4 doses for proteolytic digestion of impacted protein food; intravenous (IV) meperidine (25–50 mg) to encourage spontaneous dislodgment of the impacted food bolus; esophagoscopy with the use of an overtube (rigid or flexible) for extraction

Treatment for a patient with a Schatzki ring who presents with dysphagia:

• Disruption of the ring by oral dilation (50-French tapered Maloney bougie) with sequential bougienage dilation as symptoms recur

Indications for surgery in a patient with a Schatzki ring:

• Patients who fail bougienage or have intractable reflux intraoperative bougienage followed by a Nissen fundoplication is recommended, but excision of the ring is not indicated.

If indicated, what surgical procedure is performed in a patient with a Schatzki ring?

• Intraoperative bougienage followed by Nissen fundoplication without excision of the ring

How is an esophageal web distinguished from a Schatzki ring based on epithelium?

• Esophageal web has squamous cell epithelium above and below the web. Schatzki ring is composed of esophageal epithelium above and gastric epithelium below the ring.

What is the treatment for a thin esophageal web?

• Membranous disruption through an endoscope or bougie versus piecemeal excision with biopsy forceps versus laser lysis versus balloon dilation

What is the treatment for a thick esophageal web refractory to bougienage?

• Surgical mucosal resection via a transcervical or transthoracic approach, longitudinal myotomy created and circumferential excision of the web performed, mucosa is circumferentially reapproximated with interrupted absorbable sutures, and muscle is closed longitudinally

What is the characteristic appearance that a leiomyoma has on barium esophagram?

• A smooth, well-defined, noncircumferential mass with distinct borders

What is the treatment for a leiomyoma?

• Surgical enucleation; observation acceptable in patients with significant comorbidities or with small (<2 cm) asymptomatic tumors

What is a type I hiatal hernia?

• Sliding hiatal hernia; simple herniation of GE junction into chest

What is a type II hiatal hernia?

• GE junction remains at esophageal hiatus and gastric fundus herniates alongside the esophagus into the chest

What is a type III hiatal hernia?

• Combination of type I and type II hiatal hernia; GE junction and gastric fundus/body in chest

What is a type IV hiatal hernia?

• Advanced stage of hiatal hernia with entire stomach and other intraabdominal content is herniated into the chest

What kind of necrosis occurs with a caustic esophageal injury from alkali?

• Liquefaction necrosis

What kind of necrosis occurs with a caustic esophageal injury from acid?

• Coagulation necrosis

What are the 3 phases of tissue injury from alkali ingestion?

• Acute necrosis, ulceration and granulation, cicatrization and scarring

What is a grade I caustic injury to the esophagus and the associated endoscopic findings?

• Superficial mucosal burn, mucosal edema, and hyperemia

What is a grade IIA caustic injury to the esophagus and the associated endoscopic findings?

• Transmucosal injury, patchy ulcerations, exudates, sloughing mucosa

What is a grade IIB caustic injury to the esophagus and the associated endoscopic findings?

• Transmucosal injury, circumferential injury

What is a grade III caustic injury to the esophagus and the associated endoscopic findings?

• Transmural injury with periesophageal/perigastric extension; deep ulcerations; black/gray discoloration; full-thickness necrosis

Which grade or grades of caustic injury will progress to stricture?

• Grade IIB and III

Treatment for a patient who presents within the first hour following alkali ingestion:

• Neutralization with half-strength vinegar or citrus juice

Treatment for a patient who presents within the first hour following acid ingestion:

• Neutralization with milk, egg whites, or antacids

Management for a patient with no evidence of burn on endoscopy or physical exam following corrosive ingestion in the acute phase:

• Observation and oral nutrition when the patient can painlessly swallow saliva

Management for a patient with an endoscopically identified first-degree burn following corrosive ingestion in the acute phase:

• 48 hours of observation and oral nutrition when the patient can painlessly swallow saliva; repeat endoscopy and barium esophagram are performed in follow-up at intervals of 1, 2, and 8 months

Management for a patient with an endoscopically identified second- or third-degree burn following corrosive ingestion in the acute phase:

• Monitor in the ICU and keep NPO with IV fluids; start IV antibiotics and a proton pump inhibitor; If evidence of acute airway involvement, airway obstruction can be relieved with aerosolized steroids with the possible need for fiberoptic intubation

How can the diagnosis of corrosive injury to the esophagus/stomach be made if not originally secured with endoscopy?

• Exploratory laparoscopy in stable patients or laparotomy in unstable patients

After performing an exploratory laparotomy/laparoscopy after corrosive injury, a viable stomach and esophagus are encountered; what should be performed?

• The viable stomach and esophagus are left in situ and a feeding jejunostomy tube is placed with endoscopic placement of an esophageal stent

After performing an exploratory laparotomy/laparoscopy after corrosive injury, a questionable esophagus and stomach are encountered; what should be performed?

• The questionable esophagus and stomach are left in situ with a second-look operation performed in 36 hours with further management based on the findings.

After performing an exploratory laparotomy/laparoscopy after corrosive injury, full-thickness necrosis, or perforation of the esophagus/stomach is found; what should be performed?

• Resection of the esophagus, stomach, and all affected surrounding organs and tissues; creation of an end-cervical esophagostomy; and placement of a feeding jejunostomy

How is a patient who develops an esophageal stricture secondary to corrosive injury managed?

• After re-epithelialization, aggressive treatment with bougie dilation regardless of symptoms; dilations performed daily for 2 to 3 weeks, then every other day for 2 to 3 weeks, then weekly for months and lengthening the interval as time passes

Name some types of conduits that can be used for esophageal reconstruction:

• Gastric pull-up, jejunal interposition, colon interposition

How much does the presence of Barrett esophagus increase the risk of developing adenocarcinoma?

• 50×

What is the most common esophageal cancer?

• Adenocarcinoma

Where does adenocarcinoma of the esophagus usually occur?

• Lower one-third of the esophagus

Where does squamous cell carcinoma of the esophagus usually occur?

• Upper two-thirds of the esophagus

Most common presentation of esophageal cancer:

• Dysphagia

Complications of esophagectomy:

• Bleeding, airway injury, insufficient conduit length, thoracic duct injury, respiratory (pneumonia), esophageal conduit necrosis, anastomotic leak, anastomotic stricture, hoarseness, chylothorax, transhiatal herniation of abdominal contents

What are the characteristic findings of a chylous effusion?

• Turbid, milky white fluid, specific gravity 1.020 to 1.030, protein content 3 to 4 g/100 mL, fat content 1 to 4 g/100 mL, triglyceride content >110 mg/dL

What is the reported incidence of chylothorax as a complication of esophageal surgery?

• ~4%

Management for a chylous effusion with <500 cc/24 h chest tube output:

• Nonoperative management (should stop spontaneously)

Management for a chylous effusion with (>500 cc but <1000 cc)/24 h chest tube output:

• Initially, nonoperative management; if not resolved or significantly improved in 5 to 7 days, perform operative duct ligation

Management for a chylous effusion with >1000 cc/24 h chest tube output:

• Early duct ligation