Esophagus

Association of Carcinoma Esophagus

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Q) Adenocarcinoma of esophagus is associated with which of the following? ( #All Esophagus MCQS) 

a) Achalasia cardia

b) Barrett's disease

c) Human Papilloma virus (HPV)

d) Alcohol use

Answer - b

Association of carcinoma esophagus is with a number of risk factors. Both squamous cell carcinoma and adenocarcinoma of esophagus have different etiologies

Risk factors for Adenocarcinoma are                                                Risk factor for SCC 

  1. Tobacco                                                                                                   1. Alcohol
  2. GERD                                                                                                       2. tobacco 
  3. Obesity                                                                                                     3. Achalasia
  4. Barrett                                                                                                      4. Caustic injury of esophagus
  5. H/o previous radiation for breast cancer                                         5. Previous radiation of CA breast                

                                                                                                                             6. H/o head and neck cancer

                                                                                                                             7. Plummer vinson and tylosis

 

Achalasia is associated with both Adenocarcinoma and SCC ( Table 35.2 - Shackelford) 

Esophagus Length

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Q) Length of Esophagus is 

 A. 20 cm
B. 25 cm
C. 30-35cm
D. 40cm

Length of esophagus is important in various resection surgeries as well as endoscopy

Answer

 b 25 cm

The length of esophagus  is anatomically defined as the distance between the cricoid cartilage and the gastric orifice. It ranges in adults from 22 to 28 cm (24 ± 5 SD),  last 3 to 6 cm of which are located in the abdomen.

The shortest distance between the cricoid cartilage and the celiac axis is the orthotopic route in the posterior mediastinum, being 30 cm. The retrosternal (32 cm) and the subcutaneous route (34 cm) proved to be longer

Deviations to the left 

Esophagus through out its length deviates to the left in superior mediastinum and lower posterior mediastinum.

Constrictions of esophagus

Cervical narrowest at c5/6

Thoracic T4-5

Abdominal

 

Ref Shackelford page 10

anatomy of esophagus

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Q Which of the following is true about anatomy of esophagus?
A. Oesophageal hiatus is superior to aortic hiatus
B. Thoracic duct crosses esophagus at T3-T4level at the level of azygos vein arch
C. Laimer triangle is superior to the Killians triangle
D. In the mediastinum right vagus runs anteriorly and left vagus runs posteriorly

Answer

Post op chyle leak

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Q. Which of the following statements about postoperative chyle leak following esophagectomy is true?

A. Prophylactic intraoperative thoracic duct ligation reduces the risk of chyle leak
B. Conservative management results in spontaneous resolution in nearly all cases within 3 weeks
C. Surgical management requires transthoracic thoracic duct ligation exclusively
D. Conservative treatment includes antibiotics and enteral nutrition only

Answer 

 

Oropharyngeal dysphagia

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 Q) Oropharyngeal dysphagia false is
A. Nasal twang in voice, ptosis
B. Treatment is most often not satisfactory if conservative
C. Associated with myesthenia gravis and Parkinsonism
D. Water brasch and regurgitation presentation

Answer 

Chyle leak after esophagectomy

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Q 66 year old male undergoes TTE. After  esophagectomy,  ICD output is  1000ml chyle on 5th  days post operatively. What should be the next step in management?

a) NPO, TPN

b) Enteral feeding with medium chain fatty acid

c) Re explore and suture the defect

d) Radiographic embolization

Answer c

Once the diagnosis is made, one should ensure the pleural space is completely evacuated; if needed, drainage is done by a chest tube or a radiologically directed catheter placement.

Feedings are stopped and total parenteral nutrition (TPN) is started.

The amount of chest tube output is then monitored for several days in order to make a decision about the possible need for reoperation. Small leaks can seal with nonoperative therapy. Large initial daily outputs (typically greater than 1 L/day) often fail nonoperative therapy and require reoperation. An absolute amount of drainage for prediction of failure is unknown and one should consider also if there is a gradual reduction in daily output to continue with conservative therapy.

If the drainage is less than 500 mL per day and slowly decreasing, continued conservative therapy is frequently successful.

Continued volumes more than 1 L after 2 days of TPN is a good indication of the need for reoperation.

In general, it is better to be more rather than less aggressive in returning to the operation theater with a chylothorax. It was more common after THE and was associated with longer intensive care unit (ICU) and hospital stays. There was no difference in mortality between those with and without a chylothorax.

Patients with initial drainage exceeding 2 L within 2 days of starting conservative treatment all required reoperation.

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