Behind the Knife, the surgery podcast, relevant and engaging content designed to help you dominate the day. Behind the Knife would like to sincerely thank Medtronic for sponsoring the entire 2023 Abcite podcast series. Medtronic has a rich history of supporting surgical education, and we couldn't be happier they chose to partner with Behind the Knife.
Their sponsorship goes a long way in supporting us as we develop exciting new content. As surgeons, we know and love Medtronic for the trusted brands like the Signia, Tri-Staple Smart Stapling Platform, and Ligature Vessel Sealer. But Medtronic's impact extends well beyond the operating room. Medtronic's mission is to engineer the extraordinary. And with 90,000 plus people in over 150 countries, Medtronic is committed to accelerating access to healthcare technology.
advancing inclusion, diversity, and equity, and protecting our planet. Learn more at Medtronic.com. All right, welcome back. It's Absight 2023. As always, Behind the Knife is ready to help you dominate the exam. with our 30-episode AppSite Review series and our AppSite Review book. We also want to share with you what's up next for Behind the Knife. 2023 is going to be a banner year. We are investing big time in our platform, and we are currently working on a brand new website.
and accompanying iOS and Android apps. The website and apps will include tons of useful features and will make it easier to access all of the exciting new content we are making. Speaking of content, we are expanding our oral board review resources with a general surgery oral board review book and oral board audio review courses for vascular surgery, colorectal surgery, and surgical oncology.
We are also almost finished with an incredible new trauma video surgical atlas. This will include 24 beautifully shot and edited trauma video scenarios, many of which have never been captured on video before. For students, we are creating a comprehensive resource designed to help them dominate their surgery rotation. This is no small project and includes written content, original illustrations, audio and video.
We've also created our very own suture kit and knot board with high-quality instructional videos for right and left-handed learners. Finally, we are well underway with a full makeover of the Abcite Review Series and book. both of which will be ready before the 2024 test. Be sure to follow us on Twitter and Instagram, and please leave us a review wherever you listen to your podcasts. If you want to learn more, visit BehindTheKnife.org. Now, take a deep breath.
you've got this and welcome back to another behind the knife ab site review today we are doing esophagus and we are lucky enough to have with us jason bingham wudo and myself kevin canary jason take it away Okay, so behind the knife, Abcite and Board Review esophagus. So as always, starting with some high-yield anatomy. So woo, layers of the esophagus from inside to outside.
So from inside to out, you have the mucosa, the submucosa, and the muscularis propria. The key here to remember is that there is no serosa. Right. So this is one of the parts of the GI tract where there's no serosa, and that's very important. Why, Kevin? The importance of having nocerosa is that it spreads through the submucosal lymphatics, cancer.
Right. So you don't have that extra barrier and you have a very rich lymphatic system there. So it has to do with the spread of malignancy. So this is one of the parts of the body that has... multiple different blood supplies from different origins. So Kevin, walk us through what the esophageal blood supply is. Yeah, we just got finished talking about the inferior thyroid artery off the thyrocervical trunk supplies the cervical.
portion of the esophagus. The thoracic portion of the esophagus actually gets blood flow straight from the aorta. And then the abdominal portion of the esophagus gets its blood supply from the left gastric and inferior phrenic arteries. I've seen that asked several times. They'll just ask you, it's one of those straightforward questions you've got to know. What supplies the cervical portion of the esophagus, inferior thyroid artery? What makes up the upper esophageal sphincter?
Oh, this is the cricopharyngeus muscle. Yep, and innovated by? The superior laryngeal nerve? Yes. The head and neck surgeons love triangles. There's always different triangles. So what's Killian's triangle? Killian's triangle is a triangular area in the wall of the pharynx. It's located superior to the cricopharyngeus muscle and inferior to the inferior constrictor muscles. And why is this triangle important? So clinically, it's important because it's a potential...
weak spot where the pharyngoesophageal diverticulum or Zenker's diverticula are more likely to occur. Perfect. Okay, let's get into some clinical stuff because that's more fun. Okay, so first things first, esophageal perforations. Can you tell me about these, Kevin? What causes them?
The most common cause is iatrogenic from generally esophageal dilations, cause esophageal perforations. Trauma can cause it. And then also retching and Bohr-Havre syndrome. Malignancy and chemical ingestion are other causes of... esophageal perforation and what are some methods for diagnosis of an esophageal perforation so classically you'll have a pleural effusion on the side of the perforation. So likely on the left chest, you'll have a pleural effusion after someone's had a massive retching.
You'll see pneumomediastinum, so you'll see air tracking along the cardiac silhouette. You'll feel subcutaneous emphysema. This is a... pretty ominous sign. And then they can have a pneumothorax. And then you'll also sometimes see if it's an intra-abdominal esophageal perforation, you'll see sub-diaphragmatic error. Okay, so those are your chest x-ray findings. What are some other methods?
a diagnosis. So you want to get a swallow study and you can either do this with fluoroscopy or oral contrasted CT. You first use the water-soluble gastrographin. followed by dilute barium. If no perforation is seen with gastrographin, then you use barium. And then if the patient is an aspiration risk, you should only use dilute barium. Right. So you'll start with either a fluoroscopy or oral contrast in CD. You use some water-soluble contrast or the gas of graphene.
If you don't see it on that and you still have a clinical suspicion, you'll follow up with a dilute barium swallow for diagnosis. What's the most common site of an esophageal perforation? The most common site of perforation is the distal esophagus on the left posterolateral aspect about 2 to 3 centimeters above the GE junction. Right, and there's just a natural weak spot right there. And most common site for an iatrogenic injury.
It's going to be what we mentioned earlier, the cricopharyngeus. Okay. Kevin, walk us through how you would manage a patient that you have confirmed has a esophageal perforation. Right. So it's going to vary based on the location. It's very...
pertinent to where and how you manage this in the physiologic state of the patient and the damage surrounding tissue, how long the perforation has been there. And then the underlying pathology, do they have cancer? Do they have a cost of congestion, et cetera? But generally, you're going to start with resuscitation and antibiotics from peer coverage to cover.
gram-negative rods oral flora anaerobes and fungus so you might put them on something like ampicillin ceftriaxone flagyl and fluconazole to kind of shotgun cover everything that's important not to forget about the fungal coverage because They'll give you a list of options. You got to be sure you choose the one that has broad coverage and also covers a fungus. Yep. And so for the ab site, as far as management, you're generally going to take these patients to surgery.
If it's a very small contained leak and the patient is not ill from it, you can consider conservative management possible. stent, possible T-tube drainage. But most of these patients, you're going to do a thoracotomy on if it's a esophageal perforation and do a full myotomy and then closure of the mucosa. I actually disagree. I think that I think that.
esophageal like stents are, I think we're going to start seeing those worked into the answers for these, these tests. So I think if you have a stables patient and with a small, you know, leak. that I think stenting was starting to become a reasonable answer, even on the tests. And I think we're seeing more and more of that. More senators are capable of doing that. And I think they'll make it clear. Yeah, I agree. If the patient is septic in any appearance, you're not.
going to stent them correct you're going to wash out their chest if they have a big pleural effusion in their chest and so and why you know they're going to make it clear to you if it's truly they did a esophageal dilation. There's a small perforation scene. Totally stable patient. Totally stable patient. I think that's an indication for a stint, and I wouldn't get too stressed about the difference. I agree with you. I think they'll make it clear. Okay.
So let's talk about, you said it varies depending on location. So how about Wu, you have an isolated cervical esophageal injury. For this patient, you can open the neck and just drain. Correct. I think that it's reasonable to try and do a primary repair there, but definitely the key there, the most therapeutic thing you can do is drain that. So Kevin, you mentioned a little bit, but a thoracic perforation.
So generally, these are on the left side. And so you'll do a left thoracotomy, debride the devitalized tissue, and then you always have to perform the myotomy to visualize the full extent of the mucosal injury. And then you repair in two layers, first with an inner...
absorbable suture, and then the outer layer of the muscle is closed with a permanent suture. And then you always want to cover with a well-vascularized tissue, such as the intercostal muscle, the omentum, with the Smith's dorsi flap, some people say pericardium.
Uh, and then you do leak tests and then you want to widely drain this area. So you place the NG tube past the repair, drain the chest and close. Um, and then depending on, you may want to consider interral access, such as a J tube. Right. So key steps there. Do your thoracotomy, debride the devitalized tissue. You have to, have to, have to extend your myotomy so that you see the extent of the mucosal injury. Repair in two layers. Cover with a vascularized piece of tissue.
leak test, drain with an NG tube and with chest tubes. And then before you leave the operating room, make sure that you have a way of feeding that patient. And you mentioned before, considering it depends on the cause, how does that affect what you do in the operating room? So if you have underlying pathologies such as malignancy, caustic perforation, or burned out megasophagus from achalasia,
then you might consider doing an esophagectomy as opposed to doing a simple repair of this. And one thing to say, I actually have seen questions where they ask...
the type of suture you would use to repair this. So I think that like, you know, they're not going to, you're not gonna be able to list every step of the procedure out, but knowing, you know, the myotomy, knowing that you're going to repair in two layers first with the inner absorbable and outer permanent, those are important things to know. know, um, for this procedure. Absolutely. Uh, what if the cause is from a, I interject in injury from you're doing a, um,
Dilation for achalasia, what would you need to do before you left the operating room? The classic oral board question. You perforate them for achalasia. You want to make sure you do a myotomy, so you're going to close the injury on the side that's injured.
but then you want to do a contralateral myotomies in order to relieve their achalasia. It just goes into what you're saying. You really have to consider what caused the perforation in the first place, and you have to address the underlying pathology at the time of the operation as well. How about if you get in there and you see a severely devitalized esophagus, the patient's unstable, what are your options? So this patient should receive an exclusion and diversion. So the components of that...
You first close the perforation. You drain. You do a cervical esophagostomy for proximal diversion. You place a T-tube into the defect and drain externally, essentially creating a controlled fistula. And then distally, you would place a J-tube for enteral access. Great. So that's like your damage control procedure. They're unstable. You just have to control the contamination. A lot of these will be the...
I think the question you'd see on this is the homeless guy that was found down and has been perforated for greater than 24 hours is this is the procedure you're going to do super sick, super, super sick. Okay, moving on. So let's get into. some esophageal motility disorders because these are favorites so uh kevin achalasia what is it well for achalasia um it's
Abnormal relaxation of the LES, the hypertonic lower esophageal sphincter. And so what's really important about this is the manometry findings. We unfortunately are going to see manometry findings on the exam. And so these are... important to remember. So the manometry findings is you're going to have a high or normal LES basal pressure with incomplete lower esophageal sphincter relaxation. And then you'll see...
hypotonic or absent peristalsis throughout the esophagus, especially in more severe cases. Yeah, those are very key. You have to have the abnormal LAS relaxation and you have to have the either hypotonic or absent peristalsis for the diagnosis of achalasia. What do you see on imaging? So that's where you'll see the bird's beak on a barium swallow. Yeah, and so what's the underlying pathophysiology behind this?
It's thought to be caused by degenerative loss of the nitric oxide producing inhibitory neurons in the LES. So ideology is a little mix between autoimmune genetic and infectious. Yep, so it can be idiopathic, I think, is the most common cause or secondary to Chagas disease, if everybody remembers. It's a trympanosoma cruzi from their medical school as a cause.
What's a key distinction? What is pseudo-achalasia? So that's a barium swallow finding that looks like achalasia, but is actually caused by malignancy. Or it can be, I mean, it can be the same physiology as you can have loss of those same cells, but it's secondary to a tumor and secondary to a malignancy. Oh, okay. Yeah, that makes sense. Treatment. So currently it's a minimally invasive hellermyotomy with a partial fund application. And so the importance of this and what you're...
they'll be tested on is you want to make sure you're extending that myotomy. I think it's six and two, six centimeters up on the esophagus to get a good myotomy and then two centimeters onto the stomach. So they're going to give you an option of either surgery for a helleromyotomy. or a pneumatic dilation. Or let's say they give you, you know, helleromyotomy, pneumatic dilation, rigid dilation. What are you going to choose?
And a young patient that's a good surgical candidate, I'm going to do the heller myotomy. Okay. What about somebody who's not a good surgical candidate? You can get some benefit out of Botox injections and pneumatic dilatation. Right. Right. So pneumatic dilation is effective, but it has a very, very high recurrence rate, and it makes the subsequent surgery more complicated. So for young patients who are good surgical candidates, you...
It's okay to go ahead and take these patients for a helleromyotomy as a preferred treatment. My personal opinion is that the POEM procedure is not abcite relevant yet. Yeah, I would agree with that. Maybe five to ten years. We'll see where it goes. But for right now, I would avoid any endoscopic myotomies. On the boards. And so what's the LES finding again on achalasia? So incomplete LES relaxation and either hypotonic or aperistalsis. Okay. Next one. So that's achalasia.
Next one, Wu, is an isolated hypertensive lower esophageal sphincter. It kind of says everything it is right there in the name, but what are the manometry findings on that one? So on manometry, these patients have a high basal LES pressure. They have complete LES relaxation, which is in stark contrast to the patients with achalasia, and they have normal peristalsis.
Okay. And how can you, how do you treat these patients? So these patients are managed medically at first with calcium channel blockers and nitrates. And if they fail to respond to those therapies, you can move on to a heller myotomy. Great. Okay. So achalasia covered. Isolated hypertensive LES we covered. Kevin, diffuse esophageal spasm. What are the manometry findings on that one?
So once again, in contrast to achalasia, you're going to have a normal LES pressure and relaxation. But what you will have is high amplitude, uncoordinated esophageal contractions. So it won't be a rhythmic contraction. It'll be sporadic.
greater than 30 millimeters of mercury simultaneous contractions in greater than 10 percent of swallows okay and treatment so the vast majority of these are able to be treated with calcium channel blockers and nitrates as we discussed and then surgery is less effective but For refractory cases, long segment myotomy.
Yeah. So these can be very challenging. So again, it's a diffuse esophageal spasm. So high amplitude, uncoordinated esophageal contractions on your, on your manometry. You really want to try and treat these medically because it's. Surgery is not, you know. uh is less effective than it is for achalasia and you have to do a long segment of myodomy along the entire course of the esophagus um so contrast that then to nutcracker esophagus what are the menometry findings on that one
So here you have generally normal LAS pressure and relaxation and high amplitude coordinated esophageal contractions. So coordinated as opposed to the uncoordinated that you found on DES. For these patients, you also treat medically with calcium channel blockers and nitrates. And again, just like DES, surgery is less effective. And if you were to do surgery, you would need a long segment myotomy. Great.
And I remember the difference between those two is a diffuse esophageal spasm. A spasm isn't a coordination. It's a reaction, essentially. So whereas a nutcracker esophagus, think of the little guy standing on your... You know, your furnace, they're very coordinated. And so, yeah, that's all I remember. Great. Wu, you mentioned something earlier about Zinker's diverticulum. What is that exactly?
So a Zanker's diverticulum is a false pulsion-type diverticulum. It's due to dysfunction of the superior esophageal sphincter muscles that then cause increased intraesophageal pressure. These can generally be addressed by division of the... esophageal sphincter to prevent continued symptoms, recurrence, and post-op fistula development. Yep. So treatment is division of the upper esophageal sphincter, which is what again?
The cricopharyngeus. Okay. So this a lot of times will be broken down into different sizes as to how you approach these surgically. So what are your surgical options and how do you make a decision on what approach to go with? So I would think of the number three.
3 centimeters is a good cutoff. If you have a diverticulum that's greater than 3 centimeters, you'll need endoscopic division of the upper esophageal sphincter, creating a common lumen between the diverticulum and the esophagus, and that's generally effective. However, if your diverticulum is less than 3 centimeters, you would consider an open myotomy. You could do this through a left neck incision with or without the diverticulectomy.
Yeah, so the key step of the procedure is that division of the sphincter. I think the preferred approach is the more minimally evasive approach through endoscopy, but you need to have a large enough diverticulum in order for...
that approach to be a viable option. Before I saw one of these, I had a lot of trouble visualizing how you do an endoscopic division of the upper esophageal sphincture. So if anybody's curious out there, there's good videos on YouTube, but you do need a diver taken with about three centimeters in order for that. to be in order to use that approach. I don't know what it is about Zankers. It's kind of like MEN syndrome, but they love testing this topic. Yeah, absolutely.
Again, just one of those commonly tested things that every general surgeon needs to do. So moving down a little bit, so that's your cervical diverticula. There's also epiphrenic esophageal diverticula. Kevin, tell me a little bit about that and what it is and what you do about it. So maybe in your patient with...
nutcracker esophagus or some other motility disorder, it can create a diverticulum. Once again, these are a pulsion diverticulum and these are treated by diverticulectomy and treatment of the motility disorder. Yeah. So again, it's kind of like what we were talking about with the perforation is when you're in there in the operating room, you got to, you got to address the underlying pathology. So this is a pulsion diverticulum from a motility disorder.
You got to address that. So typically, you'll do a helleromyotomy at the time of the diverticulectomy. And then there's one other kind of esophageal diverticula. These are the mid-esophageal or the thoracic diverticula. They're a little bit different. So walk us through how these are different, what causes them, and what you do about them.
So the big difference here is that unlike the former pulsion diverticula, this is a traction diverticulum. In essence, it's a true diverticulum. You could think of all three layers of the wall being pulled. and thus this being a traction diverticulum. The pulling, you can think of that happening because it's associated with some adjacent inflammatory condition. The hallmark is TB or malignancy.
If symptomatic for these patients, a VATS diverticulectomy and myotomy is typically the best course of treatment. Yes, certainly. You know, you need to, again, address what the cause is. So you need to work them up for what's causing this traction diverticula in the middle of the esophagus. That's not normal. There's either some inflammation or a malignancy there, so you address that. And then, again, if you're going to treat these, you need typically a VATS approach for that.
Okay, so moving out of our diverticula, we'll move on to a different area, and that's another commonly tested area, which is the Barrett's esophagus, which we all know is intestinal metaplasia at the lower esophagus. So that's a change from your squamous. to your columnar type cell. So what causes this metaplasia, Kevin? So it's from prolonged exposure of the esophageal mucosa to gastric acid.
And so what's a big concern with this, Wu? Why are we so worried about Barrett's esophagus? What's the problem there? It markedly increases your risk of developing esophageal cancer, and it's on the order of 30 to 60 times. Yeah, 30 to 60 times. So that's significant. So these patients, a lot is focused on how to treat these, what to do about these, how do we... monitor them so what's a good kind of general rule safe answer for surveillance of Barrett's esophagus Kevin so you want to do an EGD
with biopsies and so um and at least annually and then if two consecutive years are negative for dysplasia you can space that out to every three but you want to do a four quadrant biopsies every one to two centimeters of involved segment Yeah, I think that's a good safe. You'll see different recommendations out there, but I think that's a good safe surveillance schedule for these patients. So let's say you're doing, you're surveilling your patients at WU and you see.
Low-grade dysplasia on the biopsy. What do you do? So at this point, instead of waiting a year to do the repeat biopsy, I would... decrease the surveillance interval so you're repeating the endoscopy in six months. Okay, so low-grade dysplasia on your surveillance biopsy, repeat endoscopy with biopsy in six months. How about high-grade dysplasia?
So this, you want to repeat the biopsy and confirm with an expert GI pathologist. And then you would, if it is confirmed, you'd proceed with an endoscopic mucosal resection.
Yep. Okay. Perfect. So, uh, and that's the answer. What the answer used to be, the answer used to be esophagectomy, right? For I grade dysplasia. Yeah. Like even, even maybe like last year I would have answered esophagectomy, but I think, uh, nowadays, I think you probably would have got it wrong last year, but maybe a couple of years ago.
you would have got it right. But yeah, endoscopic mucosal resection for high gator dysplasia. And why? Why not? Because the rate of progression to invasive cancer is lower than originally thought. And these procedures are... therapeutic you know you're removing the disease tissue yep so i think i think i think it's official now i think if i saw this on the boards i would absolutely answer endoscopic mucosal resection for high-grade dysplasia
Moving on, so let's say we progress and now we're dealing with esophageal or esophagogastric junction cancer. Wu, can you tell me a little bit about these, just general broad strokes? Yeah, so you can classify them histiologically into two categories, the squamous cell and adeno. Both are more common in men.
The squamous type is more common in Asia and Eastern Europe. Adeno, though, is most common in North America and Western Europe. Tobacco and alcohol are strong risk factors for the squamous type. whereas obesity, GERD, and Barrett's are major risk factors for adeno. It makes a little sense as to why adeno would be more common in North America with the obesity, you know, GERD being risk factors for that. And so how do you work these patients up, Kevin?
So, of course, H&P labs, but importantly, you're going to be doing an endoscopy. with biopsy. And then you're going to stage the patient with a CT chest and abdomen, a lot of times with a PET. And then you're also going to need to be able to determine the T stage of these tumors. And that is done with an endoscopic ultrasound. of the esophagus. And then you can also get FNA of suspicious nodes with that.
Yeah. So, you know, if you have your diagnosis, the question is really, how do you stage these patients? And you're going to do that with the CT chest abdomen. You're going to do an endoscopic ultrasound. You're going to FNA any suspicious nodes. And this is one of those cancers where PET-CT. is a part of the staging. So PET CT, CT chest abdomen, US, FNA suspicion lesions.
This is unfortunately one of those ones where staging is important. So we'll try and break it down into kind of the important distinctions along the staging. But Wu, what are some important... pearls for staging esophageal and esophagogastric junction cancers. So let's start with the T stage. So T1 through 4. T1a invades lamina propria or the muscularis mucosa. T1b invades the submucosa. And this is an important distinction because
We noted before the rich submucosal lymphatic system. So once it reaches into T1b, there's a greater likelihood of lymphatic spread. Moving on to T2, this invades the muscularis propria. T3 invades the adventitia. Remember, there was no serosa in the esophagus. And T4, it invades the surrounding structures.
T4A is considered to be resectable, so meaning it invades the pleura, the pericardium, or the diaphragm, whereas T4B is considered unresectable, meaning it invades the aorta, the vertebra, or the trachea. Yeah, so it's one of those tricky ones. Like, you really got to know the difference between...
T1A and T1B because that's going to, we'll see in a little bit as we go through what some of the different NCCN guidelines are, that's going to affect your treatment algorithm. You have to know the difference between 4A and 4B. 4A is all those invasional, those resectable structures. chest the pleura the pericardium the diaphragm t4b is unresectable so the things that you can't resect like your aorta obviously um so yeah great those are just some very
key things that, unfortunately, I hate memorizing staging as much as the next guy, but that's something you've got to know. Okay, how about your nodes, Wu? So moving on to the end stages, N1 is considered one to two nodes being involved, N2 is three to six nodes, and N3 is seven or more nodes. Okay. And then metastasis is easy. Metastasis is always the easiest part of the staging system. M0 is no metastasis. M1 is metastasis. But in addition, this is...
makes it even more difficult to the TNM staging for esophageal cancer. What else is important? Grade is also important for management decisions.
EMR, endoscopic mucosal resection versus esophagectomy for small superficial lesions, and then like neoadjuvant versus surgery first. Right, right. So if you have a low-grade small lesion, that may be amenable to EMR. But if you have a high-grade, you know, small lesion you're going to be less likely to do that and you're going to need an esophagectomy so yeah grade is also important um so let's staging woo how do you kind of break these up into the stage based on what we know about tnm
Yeah, so stage 1 and 4 are the easiest. So stage 1 is strictly limited to T1, N0, M0, and stage 4 is any involvement of distant metastases. To remember stage 2 and 3... So for stage 2, you can have up to T3 and N0, M0, or if you have a single node being involved, you can have T2, N1, M0. So again, that's...
T3N0M0 or T2N1M0? Yeah, and for this one, this is one of the ones where I don't really memorize the exact stage. I mean, you know that, okay, you can have positive nodes with stage 2. That's important to know. know that stage four is distant know that stage one is you know a small tumor without nodes without metastasis but as far as recognizing you know memorizing exactly up to t3 n0 m0 for i don't necessarily do that i think what's most important with this cancer
is your T-staging. So knowing that distinction between invading into the lamina propria or the muscularis mucosa or invading into the submucosa, submucosal invasion is a big deal. I think that's more important. So knowing those important facts about your T staging is important for your management. But according to this, they don't differentiate between T1A and T1B.
is from not according to your staging. Correct. That's why I think the T stage is more important than knowing stage one versus stage two. But your T stage is going to affect your management decisions. So that's why I think it's more important to memorize your T staging for this particular cancer than it is to memorize each stage. If I were choosing what I was going to memorize.
So that being said, let's get into some management of esophageal cancer. So, you know, there's the cross-study, the MAGIC trial. These are all important things that have guided our management. What can you tell me about those, Kevin? Yeah. So the takeaway message, anything greater than T1 esophageal cancer, they're going to get neoadjuvant chemo rad. So the cross trial showed that preoperative chemo rads in the.
Perioperative chemotherapy in the MAGIC trial both improved survival in patients with resectable esophageal and esophagogastric cancers. So also important is the location along the esophagus. So let's talk about first thoracic esophageal cancers. that are greater than five centimeters from your cricopharyngeus. Um, and so that would include, uh, anything below that abdominal esophageal cancers, uh, gastro, GE junction cancers. Uh, what should.
be your primary modality for treatment for those patients. So the primary surgery for these patients is esophagectomy? Again, assuming it's resectable, yes. But yeah, esophagectomy. So how about above that? So less than five centimeters from the cricopharyngea. So your cervical and your cervical thoracic esophageal cancers. Right.
What is the treatment for those? Right. The distinction here is that these patients' esophagectomy is not ideal for. So you're going to think about definitive chemoradiation.
Correct. And that again goes for, that has to do with your morbidity associated with that resection, your reconstruction, all that. So think about your cricopharyngeas, but greater than five centimeters, you know, you're thinking about resection, reconstruction, less than five centimeters, you're going with definitive chemorads.
So let's get into some of the official NCCN recommendations for the treatment of this. So for high-grade dysplasia, you know, carcinoma in situ, or, you know, select T1A tumor. Again, that's T1A, so there's no invasion of the submucosa. How do you want to treat those? This is where you can do one of the endoscopic mucosal resection versus ablation to treat. definitively treat the cancer.
But again, another distinction is the grade. So you think about, we said select T1A tumors. So, you know, ones that are well to moderately differentiated, there's no evidence of lymph node metastasis. Those may be canon. This is official. CCN guidelines. So I think this is safe to answer on the boards. Endoscopic resection with plus or minus ablation. Now, how about we move into that T1B. So there's submucosal invasion, but no nodes.
What do you do with those? So these patients, you could do a esophagectomy. Right. And the important part about that is, is it's upfront esophagectomy, whereas all the other esophagectomies we're going to do are after chemo RADs. The vast majority of your esophagectomy patients, as we said, the vast majority come with distant.
disease. There's no serosa to contain the cancer. So the vast majority of patients that have esophageal cancer are getting chemo RADs before you do your esophagectomy. So I agree. So if I were given this on a test and they had submucosal invasion T1B, I would be thinking esophagectomy. However, NCSCN guidelines, young patients, and you got to think about grade again. So if you have a high grade T1B.
Those may be patients you want to think about neoadjuvant therapy. So we're using neoadjuvant therapy, neoadjuvant chemorads more and more for esophageal cancers. So high grade, again, T1B high grade, I would think neoadjuvant. Low grade. esophagectomy first is likely what I would answer. So then T2 or greater, Kevin? So like we discussed, all these patients will get neoadjuvant chemo radiation followed by esophagectomy as long as it is resectable.
And I should also say T2 or greater or any positive nodes. So T2 or greater or any positive nodes definitely get a neoadjuvant chemorads followed by a esophagectomy if resectable. How about unresectable disease? These patients will undergo definitive chemo radiation. And again, unresectable disease is that T4B, so it invades those structures. You can't resect your aorta, for instance, or distant metastasis. Okay.
Now, we're saying definitive chemoraz, but what does that mean? What are we talking about for our chemotherapy regimens? So, whether it is neoadjuvant or definitive, the chemotherapy regimen is both based on... 5-FU, so fluorouracil and taxane. Yeah, so the fluorouracil or taxane-based therapy for our chemotherapy. We hear a lot about different approaches to your esophagectomies. So what are your different approaches and what are some key points and pluses to minuses to the different?
Yeah, so there's two primary ones, the transthoracic or Ivor Lewis esophagectomy and then the transhiatal esophagectomy. With the Ivor Lewis esophagectomy, you're going to make a laparotomy and a right thoracotomy. And you're going to make your anastomosis in the chest. So this is good for distal tumors. So you mobilize the stomach and the abdomen. You can do it laparoscopically too.
But you mobilize the stomach and make it into your conduit, which is based on the right gastroepipoic artery, which like in my intern year was a question on the test. And then you mobilize it. And then in the chest is where you do the esophageal resection and bring it up and make a thoracic anastomosis. The downside of an Ivor Lewis esophageal, or I guess a positive side first, is that some people feel you get a better lymph node harvest.
this procedure. A downside is, is that if you have a leak, it's a thoracic and leaks in these surgeries are relatively common compared to other anastomosis. It can be devastating as it's in the chest and the mediastinum. So that is a positive and a negative of the Ivor Lewis esophagectomy. Perfect.
And then so a McCown esophagectomy is similar, except that you're making a higher anastomosis, a cervical anastomosis, and that's good for your more proximal lesions. One of the other major options for resection. Wu is a transhiatal isobjectomy. Tell me, what does that mean? So here you're avoiding the thoracotomy, and you're doing a laparotomy and a left cervical incision, and the anastomosis is going to be in the neck, so a cervical anastomosis.
The advantage here is that we avoid the morbidity of the thoracotomy, particularly if the leak occurs in the chest, there won't be any mediastinitis. The disadvantage, though, is that unlike a Ivor Lewis esophagectomy, you're not directly visualizing the chest. And so the lymph node harvest tends to be smaller. And again...
done a little bit more blindly. Additionally, large mid-thoracic level tumors could be very difficult to mobilize through this method. That said, the long-term survival is equal to the transthoracic approach.
Yeah. So I, you know, I think a lot of this is depending on, you know, surgeon experience and surgeon preference and the location of the tumor and the size of the tumor and what's involved. So I don't really see them getting into the weeds and asking you specifically what approach you're going to use for your esophagectomy. I think if I had to.
choose all things being equal i would as i would answer a transhiatal esophagectomy but again i don't really see him getting too much into that on the boards um it's also important to note there's you know these there's minimally invasive techniques um you know robotic, laparoscopic. But again, that's going to vary depending on the institution and the surgeon experience.
But let's say we had a patient who had had a previous gastric resection for whatever reason, and now they got a distal esophageal tumor, esophageal cancer, and you need to do an esophagectomy. How are you going to, what's another option for your reconstruction? So here the conduit of choice would be the colon. So it'd be colon interposition. So, yep, the colon interposition graph would be the answer for that one.
So we've, let's say, let's talk about adjuvant therapy. Just in general, broad strokes for adjuvant therapy for esophageal cancer. What do we need to know, Kevin? For squamous cell cancer. If you have an R0 resection, which means negative microscopic margins, you do not need adjuvant therapy. But for adenocarcinoma, they generally get adjuvant chemo, except...
when T1 and 0 and R0 section, and that did not receive neoadjuvant therapy. But remember, the majority of these patients are going to get neoadjuvant chemorads, so they would not get adjuvant therapy if they had neoadjuvant.
Right. So squamous cell cancer, if you have an R0 resection, you're done. They don't need adjuvant therapy. For adenocarcinoma, generally most people will get it. But if you have a very small, low-grade tumor that didn't get neoadjuvant therapy... um and you do your resection and they didn't get upstaged so there's still a low grade t1 n0 and you have an r0 resection those patients don't need adjuvant now you know
The reason for that is if they've got neoadjuvant, you don't know if you downstage this tumor, so you have to continue to treat them as if they're a higher stage and they get adjuvant therapy. Okay. That was a lot. Esophageal cancer. Um, esophagus is a complex topic, very important, very highly tested. Um, but, uh, but that was a good review, I think. So let's do our close out with our quick hits. Um, woo.
So what are the different anatomic areas of esophageal narrowing? So there are four to think of. The cricopharyngeus muscle, the aortic arch. the left mainstem bronchus, and the LES. And why are those locations important? So clinically, they're relevant because they're the most vulnerable sites to injury. Okay. Common question, Kevin. You said you got it yourself several years ago. The primary blood supply to the gastric contuit after an esophagectomy.
is the right gastroepiploic artery. So you have to be very careful when making that gastric conduit to not bag the gastroepiploic. Okay, this one is a zebra for sure, but it shows up in the review books, review questions. So a patient has dysphagia, and you note skin thickening on the palms and soles of their hands and feet. What's the diagnosis? So you want to think tylosis. It's an autodidomal dominant condition linked to chromosome 17q25. It's associated with palmoplanter keratoma.
There's a 40% to 90% risk of squamous cell cancer of the esophagus by age 70. So these patients require annual upper GI screening starting at age 20. Yeah, so I don't know how they may show you a picture. I've seen pictures of this, of these palmoplantar keratomas, and they may ask you what they need, and the answer would be an upper endoscopy.
Okay, so squamous cell cancer of the head and neck, esophagus, and pancytopenia. What's the syndrome? So this is Fanconi's anemia, which is different than Fanconi's syndrome. Oh, yeah. I'm sorry. Not a syndrome. So, what is this? Fanconi anemia. Fanconi anemia. Okay. So, woo. A patient with a locally advanced esophageal cancer is undergoing neoangivate chemoradiation, has severe dysphagia, and is malnourished. What type of feeding tube are you going to place?
So here you would choose a jejunal feeding tube, so J-tube. The reason you would avoid a G-tube or a peg tube is because you want to preserve the gastric conduit. Right. So no G-tubes, no pegs in people with esophageal cancer. You need that gastric conduit, so a jejunal fetal tube. So you have dysphagia with a well-circumscribed 6-centimeter mass on barium swallow in the wall of the mid-esophagus. What are you thinking, Kevin? Also seeing this on the test. This is the esophageal leiomyoma.
And you want to be careful to not biopsy these. These are very characteristic on the swallow studies and CT scans that you do not need. biopsy because if you biopsy, it complicates the excision of it. And the way you do this is by a VATS or a thoracotomy on the right side for mid-esophageal lesions and you enucleate it.
Yep. So for symptomatic tumors or tumors, like I said, they're very characteristic. So symptomatic tumors or tumors greater than five centimeters, the treatment is enucleation. And so since the treatment's enucleation, if you do...
perform an FNA, it's going to scar it to the mucosa, and it's going to make your enucleation even more difficult. Your approach is going to depend on the location. So for mid-esophagus, you're going to go with a right-sided approach. For your distal esophagus, what side are you going to go into, Wu? Left-sided. Left-sided. Perfect. Okay. So last one. So a patient with longstanding esophageal reflux, GERD.
Now has dysphagia. EGD demonstrates a narrowed ring of mucosal just above the GE junction. What's the diagnosis? So this is a Schatzky's ring, and the key here is that you dilate and treat with PPIs, but you do not resect these. Yep, do not resect Schatzky's rings. It's benign. Treatment is PPI and dilation.
And I think one thing that we've kind of covered throughout, but we did not directly mention is the approaches to the esophagus at each level. So if they have a perforation at each level, you're going to go the left neck for a cervical perforation.
the right chest for a mid-thoracic perforation because the heart's not in the way, and then a distal perforation, you're going to go through the left chest. Perfect. And we'll end it there. So that is your esophageal review for Abcide and the Bores from Behind the Knife. We'll see you next time.
Thanks for listening and thank you to Medtronic for supporting surgical residents preparing for the 2023 app site. Since 1949, Medtronic has relentlessly pursued therapies that change lives. Today, we thank Medtronic for supporting surgical residents as they relentlessly pursue their dreams. From all of us at Behind the Knife and Medtronic, dominate the app site.
Be sure to check out our website at www.behindthenife.org for more great content. You can also follow us on Twitter at Behind the Knife and Instagram at Behind the Knife Podcast. If you like what you hear, please take a minute to leave us a review. Content produced by Behind the Knife is intended for health professionals and is for educational purposes only. We do not diagnose, treat, or offer patient-specific advice. Thank you for listening. Until next time, dominate the day.