Podcast
Questions and Answers
The lower esophageal sphincter (LES) is primarily composed of skeletal muscle fibers, contributing to the anti-reflux barrier.
The lower esophageal sphincter (LES) is primarily composed of skeletal muscle fibers, contributing to the anti-reflux barrier.
False (B)
The crura of the diaphragm contribute to the anti-reflux barrier by generating an intraluminal pressure at the gastroesophageal junction.
The crura of the diaphragm contribute to the anti-reflux barrier by generating an intraluminal pressure at the gastroesophageal junction.
False (B)
The phreno-esophageal ligament's primary role is to compress the lower esophageal sphincter, increasing its pressure.
The phreno-esophageal ligament's primary role is to compress the lower esophageal sphincter, increasing its pressure.
False (B)
The gastroesophageal flap-valve, located inside the stomach, functions as a primary mechanism to prevent reflux.
The gastroesophageal flap-valve, located inside the stomach, functions as a primary mechanism to prevent reflux.
The 'Collar of Helvetius' refers to a specific arrangement of smooth muscle fibers in the antrum that contributes to the anti-reflux mechanism.
The 'Collar of Helvetius' refers to a specific arrangement of smooth muscle fibers in the antrum that contributes to the anti-reflux mechanism.
The integrity of the anti-reflux mechanisms is solely determined by anatomical factors, and is not influenced by dietary habits.
The integrity of the anti-reflux mechanisms is solely determined by anatomical factors, and is not influenced by dietary habits.
A hiatal hernia reduces the likelihood of reflux because it reinforces the lower esophageal sphincter by increasing intra-abdominal pressure.
A hiatal hernia reduces the likelihood of reflux because it reinforces the lower esophageal sphincter by increasing intra-abdominal pressure.
Esophageal pressure can be mathematically expressed as: $P_{esophageal} = P_{intra-abdominal} + P_{LES}$, where $P_{LES}$ is the pressure generated by the lower esophageal sphincter.
Esophageal pressure can be mathematically expressed as: $P_{esophageal} = P_{intra-abdominal} + P_{LES}$, where $P_{LES}$ is the pressure generated by the lower esophageal sphincter.
High-grade dysplasia is considered in situ carcinoma and requires close monitoring and potential endoscopic treatment.
High-grade dysplasia is considered in situ carcinoma and requires close monitoring and potential endoscopic treatment.
A barium swallow study is not considered an important diagnostic test prior to endoscopy for assessing esophageal morphology.
A barium swallow study is not considered an important diagnostic test prior to endoscopy for assessing esophageal morphology.
A barium swallow study is the preferred method for evaluating reflux, offering superior detail compared to other imaging techniques.
A barium swallow study is the preferred method for evaluating reflux, offering superior detail compared to other imaging techniques.
CT scans are routinely performed for all hiatal hernia patients to assess the extent of the herniation.
CT scans are routinely performed for all hiatal hernia patients to assess the extent of the herniation.
Patients with a significant intrathoracic stomach due to a paraesophageal hernia commonly present with classic heartburn and dysphagia.
Patients with a significant intrathoracic stomach due to a paraesophageal hernia commonly present with classic heartburn and dysphagia.
In emergency situations involving a large hiatal hernia, inserting a nasogastric tube is always a straightforward method to decompress the stomach.
In emergency situations involving a large hiatal hernia, inserting a nasogastric tube is always a straightforward method to decompress the stomach.
The pH study stands as the definitive diagnostic tool for GERD, enabling the identification of distinct reflux patterns and their correlation with reported symptoms.
The pH study stands as the definitive diagnostic tool for GERD, enabling the identification of distinct reflux patterns and their correlation with reported symptoms.
The BRAVO system uses a surgically implanted device to monitor patients for up to 14 days.
The BRAVO system uses a surgically implanted device to monitor patients for up to 14 days.
Approximately 40% of patients with achalasia may require PPIs to improve their quality of life.
Approximately 40% of patients with achalasia may require PPIs to improve their quality of life.
During a laparoscopic Heller's myotomy, the incision extends 8 cm onto the esophageal side of the LES.
During a laparoscopic Heller's myotomy, the incision extends 8 cm onto the esophageal side of the LES.
A posterior fundoplication is typically performed in conjunction with a laparoscopic Heller's myotomy to prevent reflux.
A posterior fundoplication is typically performed in conjunction with a laparoscopic Heller's myotomy to prevent reflux.
Eschar formation resulting from electrocautery during myotomy invariably leads to significant post-operative complications.
Eschar formation resulting from electrocautery during myotomy invariably leads to significant post-operative complications.
Preservation of the anterior vagus nerve during myotomy is crucial to prevent future liver dysfunction.
Preservation of the anterior vagus nerve during myotomy is crucial to prevent future liver dysfunction.
The risk of perforation during the gastric portion of the myotomy is minimal due to the thinner muscle layer.
The risk of perforation during the gastric portion of the myotomy is minimal due to the thinner muscle layer.
POEM involves opening the muscular layer of the stomach, going down, doing the myotomy and an anti-reflux procedure.
POEM involves opening the muscular layer of the stomach, going down, doing the myotomy and an anti-reflux procedure.
Patients undergoing POEM are at decreased risk of developing post-operative gastroesophageal reflux.
Patients undergoing POEM are at decreased risk of developing post-operative gastroesophageal reflux.
Following a POEM procedure, the opening created in the esophagus must be sealed with sutures to prevent complications.
Following a POEM procedure, the opening created in the esophagus must be sealed with sutures to prevent complications.
Heller myotomy and Dor fundoplication are no longer considered the primary procedures for achalasia due to the proven benefits of POEM.
Heller myotomy and Dor fundoplication are no longer considered the primary procedures for achalasia due to the proven benefits of POEM.
In end-stage achalasia, esophagectomy is always the only viable solution to improve the patient's quality of life.
In end-stage achalasia, esophagectomy is always the only viable solution to improve the patient's quality of life.
Mega-esophagus in end-stage achalasia carries no risk of cancerization, thus regular check-ups are unnecessary.
Mega-esophagus in end-stage achalasia carries no risk of cancerization, thus regular check-ups are unnecessary.
Pulsion esophageal diverticula are caused by external traction from inflamed lymph nodes near the esophagus.
Pulsion esophageal diverticula are caused by external traction from inflamed lymph nodes near the esophagus.
True diverticula involve the extroversion of only the mucosa through the musclar fascia.
True diverticula involve the extroversion of only the mucosa through the musclar fascia.
Traction diverticula are commonly found in the lower third of the esophagus, near the gastroesophageal junction.
Traction diverticula are commonly found in the lower third of the esophagus, near the gastroesophageal junction.
Zenker's diverticulum is a true diverticulum that involves all layers of the esophageal wall.
Zenker's diverticulum is a true diverticulum that involves all layers of the esophageal wall.
The severity of a lesion from ingestion is solely determined by the concentration of the ingested substance.
The severity of a lesion from ingestion is solely determined by the concentration of the ingested substance.
Airway edema is a late sequela that occurs several weeks after alkaline exposure.
Airway edema is a late sequela that occurs several weeks after alkaline exposure.
Hiatal hernia is a primary complication that arises immediately after gastroesophageal injury.
Hiatal hernia is a primary complication that arises immediately after gastroesophageal injury.
Fibrosis and stricture formation typically manifest within 3-8 weeks after ingestion.
Fibrosis and stricture formation typically manifest within 3-8 weeks after ingestion.
In managing a patient with possible esophageal injury, establishing an airway is a lower priority than completing a CT scan.
In managing a patient with possible esophageal injury, establishing an airway is a lower priority than completing a CT scan.
Esophageal dilatation is rarely required in patients who have developed strictures following corrosive ingestion.
Esophageal dilatation is rarely required in patients who have developed strictures following corrosive ingestion.
Endoscopic evaluation is recommended within the first 24 hours for all patients with suspected esophageal injury, without exception.
Endoscopic evaluation is recommended within the first 24 hours for all patients with suspected esophageal injury, without exception.
The Zargar classification is a radiological scale used to assess the depth of esophageal injury upon initial presentation.
The Zargar classification is a radiological scale used to assess the depth of esophageal injury upon initial presentation.
In grade 2A esophageal damage, deep and circumferential ulcerations are typically observed.
In grade 2A esophageal damage, deep and circumferential ulcerations are typically observed.
Administering weak alkaline solutions is a recommended first-aid approach following acid caustic ingestion to neutralize the acid.
Administering weak alkaline solutions is a recommended first-aid approach following acid caustic ingestion to neutralize the acid.
The use of emetics is a useful method, because it diminishes exposure to the caustic agent for patients who had an acid caustic ingestion.
The use of emetics is a useful method, because it diminishes exposure to the caustic agent for patients who had an acid caustic ingestion.
Surgical intervention is typically the first-line treatment for esophageal strictures resulting from caustic ingestion.
Surgical intervention is typically the first-line treatment for esophageal strictures resulting from caustic ingestion.
The risk of esophageal carcinoma following caustic agent exposure is negligible, thus long-term follow-up is unnecessary.
The risk of esophageal carcinoma following caustic agent exposure is negligible, thus long-term follow-up is unnecessary.
Colon interposition for esophageal reconstruction involves using a section of the ileum to replace the damaged esophagus.
Colon interposition for esophageal reconstruction involves using a section of the ileum to replace the damaged esophagus.
Grade 4 esophageal damage due to caustic ingestion involves extensive necrosis.
Grade 4 esophageal damage due to caustic ingestion involves extensive necrosis.
Esophageal perforation resulting from caustic ingestion is generally not life-threatening if managed promptly with antibiotics.
Esophageal perforation resulting from caustic ingestion is generally not life-threatening if managed promptly with antibiotics.
Flashcards
Lower Esophageal Sphincter (LES)
Lower Esophageal Sphincter (LES)
A functional sphincter composed of smooth muscle fibers at the junction of the esophagus and stomach that maintains intraluminal pressure.
Crural Diaphragm
Crural Diaphragm
The part of the diaphragm that surrounds the distal esophagus, providing external compression to aid in preventing reflux.
GEJ Compliance
GEJ Compliance
The ability of the gastroesophageal junction to expand or contract in response to pressure changes.
Phreno-esophageal Ligament
Phreno-esophageal Ligament
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Gastroesophageal Flap-Valve
Gastroesophageal Flap-Valve
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Gastroesophageal Junction (GEJ)
Gastroesophageal Junction (GEJ)
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Angle of His
Angle of His
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Anti-Reflux Barrier
Anti-Reflux Barrier
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High-grade dysplasia
High-grade dysplasia
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Barium swallow study
Barium swallow study
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Paraesophageal hernia
Paraesophageal hernia
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Early fullness in chest (with paraesophageal hernia)
Early fullness in chest (with paraesophageal hernia)
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pH study (for GERD)
pH study (for GERD)
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24-hour pH-impedance
24-hour pH-impedance
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BRAVO system (for GERD)
BRAVO system (for GERD)
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Early-stage achalasia
Early-stage achalasia
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Heller's Myotomy
Heller's Myotomy
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Myotomy Technique
Myotomy Technique
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Myotomy Length
Myotomy Length
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Anterior Fundoplication
Anterior Fundoplication
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Mucosal Burn Risk
Mucosal Burn Risk
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POEM Procedure
POEM Procedure
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Anterior Vagus Nerve
Anterior Vagus Nerve
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Myotomy Tools
Myotomy Tools
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End-stage achalasia
End-stage achalasia
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Pulsion esophageal diverticula
Pulsion esophageal diverticula
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False/Pseudo-diverticula
False/Pseudo-diverticula
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True/Traction diverticula
True/Traction diverticula
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Traction diverticula (cause)
Traction diverticula (cause)
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Zenker's diverticulum
Zenker's diverticulum
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Killian's Triangle
Killian's Triangle
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Tissue Contact Time
Tissue Contact Time
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Primary Complications
Primary Complications
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Late Sequelae
Late Sequelae
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Initial Assessment
Initial Assessment
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Immediate Actions (Both Stable and Unstable)
Immediate Actions (Both Stable and Unstable)
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Investigations (Stable Patient)
Investigations (Stable Patient)
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Actions (Unstable Patient)
Actions (Unstable Patient)
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Endoscopic Evaluation
Endoscopic Evaluation
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Caustic Injury: Grade 1
Caustic Injury: Grade 1
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Caustic Injury: Grade 2A
Caustic Injury: Grade 2A
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Caustic Injury: Grade 2B
Caustic Injury: Grade 2B
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Caustic Injury: Grade 3A
Caustic Injury: Grade 3A
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Caustic Injury: Grade 3B
Caustic Injury: Grade 3B
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Caustic Injury: Grade 4
Caustic Injury: Grade 4
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Caustic Ingestion: Neutralization?
Caustic Ingestion: Neutralization?
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Colon Interposition
Colon Interposition
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Study Notes
- These notes cover surgery for benign esophageal diseases.
- The lecture agenda includes: GERD, esophageal motility disorder and diverticula, caustic ingestion, and esophageal perforation.
Esophageal Basics
- Layers of the esophagus are mucosa, submucosa, muscularis propria, and adventitia.
- The upper esophageal sphincter (cricopharyngeus) and lower esophageal sphincter (LES) are esophageal sphincters.
- LES incompetence leads to reflux, while LES hypertonia leads to achalasia.
GERD (Gastroesophageal Reflux Disease)
- GERD is defined as chronic reflux of gastric acid into the esophagus due to a weak LES, hiatal hernia, or increased intra-abdominal pressure.
- Symptoms include heartburn, regurgitation, and atypical symptoms like chest pain, cough, and hoarseness.
- Complications include esophagitis, stricture, and Barrett's esophagus.
- Barrett's esophagus is a red flag for malignant transformation, requiring mandatory endoscopic surveillance.
- Lifestyle modifications, pharmacological interventions with PPIs, and surgery (Fundoplication/Nissen) are ways to manage GERD.
Achalasia
- Achalasia is a motility disorder where the LES fails to relax, and there is absent peristalsis in the esophagus.
- Symptoms of achalasia include progressive dysphagia for solids and liquids from the start, regurgitation of undigested food, weight loss, and chest discomfort.
- Diagnosis of achalasia is confirmed by barium swallow ("bird's beak" narrowing) and manometry.
- Manometry confirms high LES pressure and no peristalsis.
- Endoscopic balloon dilation, Heller myotomy, and POEM are treatment options.
Hiatal Hernia
- Sliding (Type I) hiatal hernias involve the GE junction and a portion of the stomach sliding up and is most common, associated with GERD.
- Paraesophageal (Type II) hiatal hernias involve the GE junction staying in place while part of the stomach herniates alongside it.
- Others (Type III, IV combos) are possible types of hiatal hernias.
- Symptoms of hiatal hernia include reflux, chest pain, and possible strangulation if large paraesophageal.
- Surgical repair with fundoplication or mesh is management for symptomatic or large hiatal hernias.
Esophageal Diverticula
- Three diverticula matters: Zenker's (pharyngoesophageal junction), Mid-thoracic, and Epiphrenic.
- Zenker's diverticulum is actually above the upper esophageal sphincter and some consider it a pharyngoesophageal pouch.
- Older patients may have dysphagia, regurgitation, and foul breath (food stasis).
- Endoscopic or surgical diverticulectomy ± myotomy are performed for treatment.
Esophageal Cancer Primer
- Two main histologies of esophageal cancer are squamous cell carcinoma and adenocarcinoma.
- Squamous cell carcinoma occurs in the mid-esophagus and is linked to smoking and alcohol.
- Adenocarcinoma occurs in the distal esophagus, often arising from Barrett's.
- Esophageal cancer causes progressive Dysphagia, weight loss and other issues.
- Staging: Endoscopy + CT/PET + EUS for depth.
- Treatment: If resectable, esophagectomy ± neoadjuvant chemo/chemoradiation.
- "Persistent reflux → Barrett's → adenocarcinoma"
GERD (Gastroesophageal Reflux Disease) Additional Information
- The overall prevalence of GERD is markedly increasing worldwide.
- Typical (esophageal) symptoms of GERD include heartburn, usually accompanied by regurgitation, and dyspepsia.
- Atypical (extra-esophageal) symptoms include angina-like chest pain, chronic cough, hoarseness, pharyngodynia, asthma, pulmonary fibrosis, and dental erosion.
- 24-hour esophageal pH monitoring diagnoses GERD; reflux episodes cause pH to lower, and monitoring pH for at least 24h is important.
- A healthy individual has some reflux during the day, and it is normal to expose acid for up to 6% in 24h.
Anti-reflux Barrier
- The mechanisms protecting the esophagus from reflux are those that constitute the anti-reflux barrier: Lower esophageal sphincter, Crura of the diaphragm creating an extraluminal compression, Compliance of gastroesophageal junction, Integrity of phreno-esophageal ligament that maintain the LES in the right position, and Gastroesophageal flap-valve.
Additional protective factors to consider
- Esophageal emptying: Esophagus cleans itself by peristalsis; gravity is key.
- Nighttime Clearance: Elevate the head of the bed to ensure good nocturnal clearance.
- Salivary clearance: Neutralizes acid; consider rheumatologist referral for connective tissue disease patients.
- Lifestyle and obesity: Keep weight under control, because obesity can cause GERD and hiatal hernia.
Complications of GERD
- Esophagitis, Peptic stricture, Barrett, and Adenocarcinoma
- Pointed by the black arrows in image A are erosions of the esophageal wall.
Alarm symptom for adenocarcinoma
- Dysphagia
Hiatal Hernia Considerations
- In large hiatal hernias, elderly patients complain of dyspnea, asthma, chest pain, and post-prandial distress (the sensation of fullness in the chest prior).
- Large Hiatal Heria can be completely asymptomatic. Anemia is another presentation of Hiatal Hernia.
- Two presentations of large hiatal hernia: post-prandial distress and anemia.
- HH's natural history is organo-axial volvulus, leading to bleeding, perforation, and strangulation.
- Diaphragmatic repair sometimes uses bioabsorbable mesh.
Surgical Options and Considerations
Nissen fundoplication can produce dysphagia.
- Partial fundoplication: In circumstances, the patient may need to consider Nissen to produce dysphagia.
Approaches to diverticula
- Transoral approach: A common transoral approach proceeds by entering the septum.
Achalasia Distinctions
- Can distinguish Primary achalasia and Secondary achalasia. Primary achalasia: Rare disease that leads to lesion for relaxation and loss of peristalsis. The hallmark.
- Secondary achalasia: Achalasia of the district esophagus.
Hiatal Hernia Types
- Sliding (type 1): Sliding of the stomach up to the mediastinum is where the GEJ is above the diaphragm. Para-esophageal (type 2): is where the GEJ is still in the right place, where there is herniation of the fundus.
Caustic Ingestion Breakdown By PH
- Acid (pH < 3): Cleaning Agents
- Alkaline (pH > 11): Toilet Bowel Cleaners
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Description
Explore the intricate anatomy of the lower esophageal sphincter (LES) and its role in preventing reflux. Learn about the contributions of the diaphragm, phreno-esophageal ligament, and gastroesophageal flap-valve. Understand how these mechanisms work together to maintain esophageal health.
