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Esophageal Anatomy
Treatment
Workup / Post-op care
Tracheal Injury
Potpourri
100
These are the four microscopic / concentric layers of the esophagus
What are the mucosa, submucosa, muscularis, adventitia
100
Cervical perforations can often be treated with this modality
What is conservative management with debridement and drainage via an oblique left neck incision -especially if the defect is difficult to visualize (i.e. posteriorly located @ Killian's triangle) -alternatively, can attempt a primary repair if there is limited contamination
100
This is type of contrasted esophagram recommended to evaluate for esophageal perforation but not for evaluation of TE fistulae
What is barium esophagram --less hypertonic and less likely to cause aspiration pneumonitis compared to gastrograffin (water soluble contrast)
100
This is the most common sign of proximal airway injury
What is subcutaneous emphysema followed by pneumothorax, hemoptysis
100
This type of corrosive injury causes liquefactive necrosis and deep tissue (usually transmural) penetration
What is Alkali exposure / ingestion (Contrast to acids -- superficial, coagulative necrosis)
200
This is the location of the esophageal hiatus relative to the spine.
What is T10
200
This is an alternative technique used to close the mucosal layer during primary esophageal repair (aside from suture repair).
What is 3.5 mm loaded GIA stapler with Allis clamps approximating the mucosa.
200
The top three most common causes of esophageal trauma
What are iatrogenic perforation, Boerhaave's, external trauma (blunt, penetrating)
200
In the acute setting, when suspecting a proximal airway injury, this is recommended to establish airway control. (treatment modality)
What is fiberoptic intubation (using a flex bronch as a obturator for the ET tube to position the apparatus distal to the injury).
200
Chronic esophagitis and stricture from GERD may often result in overall shortening of the esophageal length. This procedure is often indicated if a anti-reflux operation is performed.
What is Collis gastroplasty
300
These are the borders of Killian's triangle (two)
What are the oblique inferior constrictor muscle and the cricopharyngeus muscle. (no posterior muscular layer -- most common spot for cervical esophageal perforation)
300
These are a few of the options available to buttress or patch a primary esophageal repair (name 3).
What are intercostal muscle, pericardial patch, pleural (Grillo patch), omentum.
300
These are a few (mention three) methods to ventilate a patient during operative repair of an airway injury (including main stem bronchial injuries).
What are -- contralateral double lumen tube, high frequency jet ventilation, intermittent apnea, cross table ventilation.
300
Patients suffering from thermal injuries to their airway may benefit from inhalation of these two compounds in the acute setting.
What are racemic epinephrine and / or hemiox
400
What are the three naturally occurring anatomic points of narrowing along the length of the esophagus and the distance they are from the incisors.
What are the cricopharyngeus (14-16 cm), the bronchoaortic constriction (22-24 cm), EGJ (40-45 cm)
400
These are the respective lateralities used to approach a cervical, mid chest, and distal esophageal tear.
What is left neck, right chest (mid-esophagus), left chest (distal esophagus) Also think about the intra-abdominal esophagus (may need an upper midline laparotomy)
400
The distal half of the trachea, right bronchus, proximal left bronchus, and carina may best be exposed via this incision
What is right posterolateral thoracotomy
400
This man who lived in the 1700s frequently experienced post-prandial discomfort by self-induced vomiting. He reportedly feasted on duck and beer one morning and made himself vomit. This was followed by an intense tearing pain in his upper abdomen and he soon died.
Who is Baron Jan van Wassenaer -- presented to Dr. Boerhaave before passing away --i.e. Boerhaave's syndrome
500
Name all of the main arteries that supply blood to the esophagus
What are the inferior thyroid artery (top), direct branches of the aorta (mid), left gastric artery (bottom)
500
These suture types are used to reapproximate the mucosal layer and the muscularis layer during primary esophageal perforation repair.
What is absorbable suture? (4-0 or 3-0 vicryl in an interrupted configuration as described in the reading)
500
“What should be done if there is an obstruction distal to the site of the perforation during a primary repair?”
Studies have shown that if primary repair was performed without treatment of a distal obstruction to the site of the perforation, mortality approaches 100%. However, with treatment of the distal obstruction and the perforation, survival increases significantly. Attempts should be made to do an intraoperative dilatation for a distal stricture prior to repair. An esophagomyotomy opposite the site of perforation should be performed in cases of achalasia prior to attempting repair. In cases of a malignant obstructing lesion with a more proximal perforation, the patient should undergo esophagectomy and bipolar exclusion as described above. A substernal gastric pull-up may then be performed at a later date if appropriate (depending on stage on cancer, if they need adjuvant therapy, etc). Patients that have undergone multiple prior dilations for tight peptic strictures, achalasia, or other anatomical obstruction, consideration should be given to performing a formal esophagectomy at the time of perforation. Since these perforations are identified at the time of dilatation or shortly after and patients are usually in a fasting state prior to dilatation, there is minimal contamination. Performing a formal esophagectomy with immediate reconstruction can be considered in these cases. If there is extensive contamination due to a delay in diagnosis of the perforation, then esophageal exclusion may be the safest treatment plan.
500
Describe how you would establish transpericardial exposure of the carina.
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500
Another term used to describe peptic esophageal strictures
What is Schatzki's ring