Latest / Behind The Knife: The Surgery Podcast / Behind the Knife ABSITE 2026 - Esophagus
Transcript
- 4 Esophagus - Final Edit [00:00:00] Okay. Welcome to behind the knives, the outside review today we're talking about esophagus. So as always, let's start with some anatomy and physiology. So John let's start with the layers of the esophagus. It's a little bit different than other enteric organs. So what are the layers of the esophagus? Yeah. The most important thing to remember is that there is no serosa here. So you have mucosa, some mucosa and muscularis propio. Yeah. Great. No serosa. And that becomes important when we start talking about malignancy and lymphatic spread and those types. things. So Kevin blood supply to the esophagus. Yep. So for the cervical esophagus, it's that inferior thyroid artery. And then for the thoracic esophagus, you have the vessels coming directly off the aorta and feeding the esophagus in the abdominal portion. You have the left gastric and inferior phrenic arteries. Exactly. So what's important to remember there is there's a segmental supply to the esophagus as it courses along its length. John, the upper esophageal sphincter, what what muscle is [00:01:00] equivalent to this and what is it innervated by? Yeah. So this is the sphincter is the crico pharyngeal muscle and it's innervated by that well known recurrent laryngeal nerve. Okay. Sticking with that upper esophagus Kevin, can you describe me what is Killian's triangle and what the clinical significance of it is? Yeah, so this is one of the triangles in the pharynx. anD the wall of the pharynx located superior to the cricopharyngeus muscle and inferior to the inferior constrictor muscles. And this is a potentially weak spot where a pharyngeal esophageal diverticulum, also known as a Zinker's diverticulum, is likely to occur. Excellent. We'll talk a little bit more about Zinker's in a minute here and management of that, but that's where that happens in that Killian's triangle. So, okay, that's enough. Anatomy for now let's move on to some pathology. So, one of the more dreaded things that can occur as an esophageal perforation it can be very challenging. This can occur sometimes due to trauma, external trauma, although that's rare, most likely what you're going to see it is with an [00:02:00] iatrogenic injury. So during EGD dilations a transophageal echo anything that causes increased luminal pressure, you may see it. So bore hobs with retching, you can see it occasionally with malignancy and that's the boy. That's a bad spot to be in as well as chemical ingestion. You're most likely to see it on a test as an iatrogenic injury frequently after, you know, let's say dilation for something like akalasia and you end up with an esophageal perforation. John, how do you approach these? Where do you start? How do you, let's start with diagnosis. Yeah, like most things in acute care medicine and you're worried about a thoracic pathology you're going to start with a chest x ray. On the chest x ray, you're going to see some type of combination of pleural fusion, pneumometastatum, sub q emphysema, pneumothorax or subdiaphragmatic error, depending where the perforation's at. It's also possible that you would just have a normal chest x ray, and you need to further work this up. The next step would be a contrast esophagram, and it's probably the best study of [00:03:00] choice. But some people may also say oral contrast CT and it depends on the institution that you're working in. But you do want to use water soluble first also known as gastrographin followed by dilute barium if no perforation is seen with the gastrographin. If the patient is at aspiration risk, use only dilute barium. Great point. Yeah. So, again, a little bit institution specific. Some places will go with an oral contrast of CT, but the more sensitive study is that esophagram, the contrast of esophagram. It's also more useful for localization of the perforation. As you say, water soluble gastrografin is a good choice. Although gastrografin pneumonitis is, has a very high mortality. So be careful with that against aspiration risk. And if you're not seeing it, that dilute barium is going to make that test a little bit more sensitive in identifying it. How about Kevin where is the most common site of perforation? So the most common site is the distal esophagus in the left posterolateral aspect, two to three centimeters above the GE junction. [00:04:00] Yeah, that's right. That's the most common site. However, remember the most common iatrogenic location is at the cricopharyngitis. So most common site overall, right above the G junction, left posterior lateral, most common iatrogenic at the cricopharyngitis. John, how do you approach these as far as treatment wise? These patients can often be very sick. So just talk me through your thought processes as how to approach a patient with an esophageal perforation. Yeah. These patients would be very variable on how they present mainly because there's different potential cavities for this to decompress into it'll depend on the location of injury, the comorbidities and the physiological status of the patient what types of damage has been done to the surrounding tissues especially in trauma or in an isogenic issue. Thank you. And then also the reason why they perforated in the first place. The basic tenets of resuscitation and start antibiotic for empiric coverage, grandiva rods, oral flora, anaerobes, and fungus. Yeah, exactly. So you want to be very aggressive in [00:05:00] resuscitation and start antibiotics with these patients. They get very sick very quickly. So what are your options for management? So your options for this to include non operative management for contained leak. Drainage alone, T tube drainage, esophageal exclusion and diversion, esophageal stents or clips, primary repair with buttress, and esophagectomy with either immediate or delayed reconstruction. Okay. Yeah. Let's unpack that a little bit. Cause there's a lot to get in. You listed off a lot of things there. So let's say you, this is an EDD and you have an isolated cervical esophageal injury. So cervical esophagus is injured. What do you want to do? Yeah. The most common approach would be just open and explore the neck and in place strains. Okay, great. So open neck, place strains with pericervical esophageal injury. Now let's talk about a thoracic perforation. whAt's your approach for that? So you have a patient who in that classic position, just above the G junction is draining into their left chest. They're sick. Yeah there's a lot of different ways to approach this and a lot of [00:06:00] different kind of theories or preferences depending on surgeon. But if you're looking for an answer on the test primary repair is preferred if the patient can tolerate it. That includes a thoracotomy, you want to debride, devitalize tissue, you want to perform myotomy to visualize the full extent of mucosal injury, repair in two layers use a inner layer is an absorbable suture and outer is a permanent. Cover with a well vascularized tissue such as intercostal or mental or latissimus dorsi or latissimus flap. You want to leak test, place an NG to pass the repair, drain the chest and then close. And also you want to consider why you're in the operating room, placing enteral access. That's perfect. That's all the principles that you want to remember for the test as well as for the oral boards. And that was very well said. But so for surgical repair, again, these are sick patients now. You mentioned briefly a non operative option for, you know, potentially using an esophageal stent or just drainage alone. Are this patient that I just presented to you that's got drainage in their [00:07:00] left chest and they're sick, would they be a good candidate to that or who would you consider for that non operative management? Yeah. Those are only contained leaks and stable patients. Okay. Yeah. So you contain leaks, stable patient. Yeah. There are a lot of places that are doing esophageal stents, those type of things, and are successful. You're probably prepared with some type of IR, placed drain, or a chest tube. But for your operative repair, thoracic perforation, as John said, thoracotomy, now your side of your thoracotomy is going to depend on where the perforation is. So if you're trying to get to that middle third of the esophagus, John, where are you going to go? Great posterolateral thoracotomy. Okay, and how about that lower third of the esophagus that's most common? That'd be the left posterior lateral thoracotomy. Okay, so thoracotomy, now, the thing to remember is that you're gonna need to buttress this, which means you're gonna have to harvest intercostal, so you wanna do that, think of that ahead of time as you're entering the chest, so you preserve that. You have to often extend the myotomy in order to visualize the full extent of the mucosal injury, that's very important, and then repair two layers. As you say, [00:08:00] interabsorbable, outer permanent, cover with that pedicle that you preserved. Do your leak test, NG, place strains, close, and then as always, you have to think about nutrition. So you may need to place a mineral access. You should at least think about that before leaving the OR. How does the underlying pathology affect what we're going to do? And what are some important things to think about as you're doing this? Yeah, that it does. So if you're looking at it, such as a malignant perforation you want to consider esophagectomy. Other reasons you consider esophagectomy would be for caustic perforation or burnt out mega esophagus from achalasia and that's just be due to the underlying like health of the esophagus surrounding the injury site. Yeah. So don't get sidetracked and just go into autopilot. You have to think about why they perforated and you have to correct that underlying pathology. Otherwise you're not doing them many favors. So you mentioned achalasia. So a common board scenario is somebody who gets perforated because they're getting dilated [00:09:00] for achalasia. How does that change what you're going to do in the OR? Yeah. You want to consider performing, or actually you would want to perform a contralateral myotomy. Yeah. Don't forget about doing that myotomy if you're doing it for achalasia because otherwise they will leak. They will all leak a hundred percent of times, both in real life and on the boards. So again, don't forget that underlying pathology. Now let's say you have we'll stick with you, John, here on this. Let's say you have a severely devitalized esophagus and the patient is wildly unstable. So you have a big defect in the esophagus. It's not well vascularized. What are your options there? Yeah, you got to think of your damage control options in this situation which would basically be controlling the contamination through either exclusion. And diversion some other options, you could close the perforation wide drainage and perform a cervical esophagostomy for proximal diversion. You can also consider placing a T tube into the defect and draining externally as creating a controlled fistula. And then always you want to, like I said once again, [00:10:00] consider enteral access. So you, you consider placing a J tube in these situations. Right, so you have to know your bailout options, know your damage control, and if you're going down that route establish enteral access, because you're surely going to need it. Okay so Kevin. Let's move on to some esophageal motility disorders. So something we see not infrequently is something called achalasia. So what is achalasia? So that's when you have incomplete relaxation of the LES. So it's hypertonic with aparistalsis or hypotonic esophageal contractions. Okay. So, again that's a good definition. So you need to see incomplete relaxation of lower esophageal sphincter with a peristalsis. So what are your manometry findings then? So you can have three types. You can have high or normal LES basal pressure. You can have an incomplete. LAS relaxation or you can have a hypotonic or absent peristalsis. Okay, good. Yeah, so there's three different types referred to the image in the outside companion book for More in depth description of those [00:11:00] three different types as well as what they look like a manometry But really the keys there are the incomplete LES relaxation with a peristalsis or hypotonic esophageal contractions or hallmark findings. What might you see on imaging, Kevin? So this is where you'll see a bird's beak sign on barium swallow with esophageal dilation. Yeah. That's another one that you want to reverse Google image and cause the, you may get that on the test as an image that you have to know what's going on. And what causes what's the etiology or the pathophysiology behind Echolasia? Yeah. So it's due to a degenerative loss of nitric oxide producing inhibitory neurons within the LES. And then there's mixed ideology of autoimmune genetic and infectious causes. Okay. Let's say like the classic infectious cause. Yeah. So, if you it can be secondary to Chagas disease. Yeah. And what's the this is probably going back to your med student stool med school microbiology or I might have to refer to John to pronounce this for me. All right. Let me give it a shot. [00:12:00] Trypanosoma cruzi. Yeah. Trypanosoma cruzi, cruci. I remember that book that had like a little Tom Cruise that was in there, like messing up the nerves. So just think Tom Cruise and trypanosoma cruzi. As the organism behind the infectious form of akalasia an important distinction is pseudo akalasia. So Kevin, what's pseudo akalasia? So this is akalasia caused by malignancy. Yeah. So it's important in these in these patients to get an upper endoscopy. And some people will even get a CT of the chest to exclude external compression. So you have to make sure you're not dealing with pseudo akalasia before just chalking it off to a benign pathology. treatment. so You can do a minimally invasive heller myotomy with partial fund application. Generally it's six centimeters on the esophagus and two onto the stomach. Okay. John, sometimes, you know, your patients like is surgery really necessary? I've heard about doing balloon dilation. What's the pros and cons of that? Yeah, once again, [00:13:00] controversial. Those are available but they are, you know, in general are less effective and they have an increased rate of later surgical complications. So the theory is they should be avoided in the patients who are good surgical candidates. Yeah, so there are medications that can't help. They're generally not well tolerated. They have some side effects and usually not very effective. And then there's some endoscopic therapies, either balloon dilation, pneumatic dilation, or Botox injections that also are long standing don't have the best efficacy. So for, and they can complicate the later myotomy. So for good surgical candidates, they should progress to a myotomy, either surgical or many people are familiar with poem, which is an endoscopic myotomy, which is for in the right patients, that's a, an appropriate option. However, just be aware that those patients do have a higher rates of reflux and GERD postoperatively is because there is no fun duplication associated with that procedure. And also don't forget if you perforate them [00:14:00] during a dilation and you're in the O. R. that you have to perform that myotomy when you're dealing with this occipital perforation. Okay. Kevin, back to you. We're going to, let's go back into some different motility disorders. So what are the manometry findings for, let's say an isolated hypertensive LES? Okay. So you're going to have a high basal LES pressure. You're going to have complete LES relaxation. And you're going to have normal peristalsis. Okay, so just to remind everybody to distinguish that from achalasia. In achalasia you have that failure relaxation and hypotonic or aperistalsis of the esophagus. So in this one you have high LES pressure. You do have relaxation and normal peristalsis. So how do you treat these? So you can use calcium channel blockers, nitrates, or heller myotomy. Okay, yeah. So heller is less effective in some of these other motility disorders, and we tend to attempt some medical management before progressing to surgery. So yeah, calcium channel blockers and nitrates. [00:15:00] How about diffuse esophageal spasm? What would you see on manometry there? So in diffused esophageal spasm, you're gonna have normal LES pressure and relaxation, but you're gonna have high amplitude uncoordinated esophageal contractions. Generally, you're gonna see greater than 30 millimeters of mercury simultaneous contractions and greater than 10 percent of swallows. Okay, great. And treatment? Very similar. You're gonna do your calcium channel blockers and your nitrates. Yep, and there is a long segment myotomy is possible in refractory cases. So you will occasionally have to do surgery for those, but not as good a results. Okay. Last one for esophageal dysmotility is a nutcracker esophagus. What are your manometry findings? So you're going to have a normal LES pressure and relaxation, but you're going to have high amplitude, but. Coordinated esophageal contractions. Okay, good. Normal LES pressure relaxation. Again, distinguishing it from akalasia. High amplitude coordinated esophageal contractions, which is different from a diffuse esophageal spasm in which they're [00:16:00] uncoordinated. Think about the Nutcracker ballet. They're very coordinated. I like it. Okay, treatment. So once again, calcium channel blockers and nitrates and again, surgery, long segment myotomy for extreme refractory cases. So, familiarize ourselves with those, know what the manometry findings are. They each have key manometry findings and it would not be out of the realm of possibility to be presented with a manometry finding and having to make a diagnosis and treatment plan on the outside. Okay, moving on. We mentioned Zenker's Diverticulum, which is an esophageal diverticula, cervical diverticula earlier. How, what is the pathophysiology behind a zenker's? Yeah, Zenker's. Which is a false Sion diverticulum I've seen that come up before. It's due to the dysfunction of superior esophageal sphincter muscles causing in increased intra esophageal pressure. Okay. What do you mean by false dive Reticulate? It's a false diverticulum because it does not include all three layers of the esophagus. Okay, we'll distinguish that in [00:17:00] a little bit here from our thoracic mid esophageal diverticula, which is a traction, true diverticula. Okay what are your treatment options for a Zenker's diverticulum, John? The key to treating Zenker's diverticulum is division of the upper esophageal sphincter. To prevent continued symptoms, fistula. If the diverticulum is greater than three centimeters, you can do an endoscopic division of the upper esophageal sphincter, which then creates a common lumen between the diverticulum and the esophagus. For a diverticulum less than three centimeters, you need to do an open myotomy via a left neck incision, with or without diverticulectomy. You can also, that also means performing a resection or suspension of the diverticula. Yeah, perfect. I see that. I've seen that on the outside back in the day several times, that three centimeter distinction. So greater than three centimeters, it is pretty amenable to an endoscopic division. Less than three centimeters open with either a diverticulectomy or a pexy to suspend the diverticula and [00:18:00] prevent stuff from collecting in there. So great. Staying on the theme of diverticula let's go a little bit further down the esophagus to the epiphrenic esophageal diverticula. What kind of diverticulum is this and what is it associated with Kevin? This is a pulsion diverticulum. It's associated with esophageal dysmotility. Disorders. And the treatment for this is a diverticulectomy and treatment of the underlying motility disorder, generally requiring a heller myotomy. Yeah, boy, that's for sure. You want to know what your esophageal motility is when you're treating these and make sure that you're not dealing with akalasia. Cause that will certainly put that's a diverticulectomy site at risk postoperatively. If you don't perform that's a heller myotomy concurrently. Okay. So John thoracic mid esophageal diverticula. What are these, how are they different, and how are they treated? Yeah, this one's different as it is the only traction diverticula, also true diverticula. It's commonly associated with adjacent inflammatory conditions, such as tuberculosis or malignancy. Additionally, a mid thoracic, mid [00:19:00] esophageal diverticula can be considered a pulsion diverticula, which is caused by a motility disorder. If it's symptomatic, you want to perform a VATS diverticulectomy. And perform a myotomy. Yeah, great. And of course, if there's a malignancy, you're going to have to deal with that, and the treatment's going to be different and based upon what the reason for the diverticulectomy is, obviously. But let's get away from esophageal motility disorders and let's move on to something that's very common that we see pretty frequently, and that's Barrett's esophagus. So Kevin, what's the definition of Barrett's esophagus? Yeah, so this is intestinal metaplasia of the lower esophagus. So the squamous cells become columnar. Yeah. So this is essentially likely due to a mucosal reaction. To GERD and reflux and that distal esophagus being bathed and exposed to gastric acid. So your esophageal cells start to change and look like stomach cells in response to that acid. So we know that it increases your risk of esophageal adenocarcinoma by some studies 30 to [00:20:00] 60 times. So what is how do you survey these patients? So you need to do an EGD annually with biopsies, and if two consecutive years are negative for dysplasia, you can do an EGD every three years. How do you do those biopsies? Can you talk a little bit more about that? Yes, you do four quadrant biopsies every one to two centimeters of the involved segment. Okay, so let's say you do that so I agree with that, EGD annual biopsies. Four quadrant, one to two centimeters. If you have two consecutive negative, you can do that every three years. That's pretty standard. So let's say you do that and you get low grade dysplasia on your biopsy. What do you want to do then? So now you want to repeat your endoscopy within six months. Okay. Biopsy. Yep. So short interval, six months, repeat that, repeat your biopsy. Let's say you get a high grade dysplasia on that biopsy. So in this situation, you want to repeat the biopsy and confirm with an expert in GI pathology. And then potentially do an endoscopic mucosal resection if high grade dysplasia is confirmed. Yeah, so you want to confirm that with a repeat biopsy. Most places [00:21:00] will do that, but ultimately the treatment for high grade dysplasia, and this is the answer you're going to look for in the test, high grade dysplasia in the setting of Barrett's endoscopic mucosal resection. Which is a change from several years ago where esophagectomy was the answer for for high grade dysplasia. But what we've learned though, is the rate of progression for, to invasive cancer is lower than originally thought. So now the standard is endoscopic mucosal resection. Okay, John, moving on, esophageal leiomyomas. What are these? Yeah, I actually really like these things. I think they're cool, and especially when they, the pictures, but they're the most common benign tumors. The esophagus. Okay. Where are they found? Yeah, 60% are found in the distal third of the esophagus, 30% in the middle, and 10% in the proximal esophagus. Okay. And so these are benign tumors. So how do we, what do we do with these? Yeah we used to, I mean, it used to be surgery for these, but now we have endoscopic approaches that are preferred for tumors less than five centimeters in size. You would perform a VATS or [00:22:00] laparoscopy depending where it's located in the esophagus for tumors greater than five centimeters. Now, let's say you get it on the test and you have this four centimeter mass that is radiographically very consistent with a leiomyoma and they give you the option of an EOS with a biopsy. What are you going to do in that setting? Yeah, you want to avoid biopsies and leiomyomas and just remove them because if you biopsy them, they can cause inflammation and make them more difficult to remove later on. Yeah. Generally you're enucleating these, so that can make that more challenging. If you were to perform a biopsy, preoperatively great. Okay. So let's move on to a very complex topic, which is esophageal and esophagogastric junction cancer. Histologically. These are classified as either squamous cell or adenocarcinoma. Both of these are most common in men. Squamous cell cancer is more common in Asia and Eastern Europe, and whereas adenocarcinoma is more common in North America and Europe, and that really makes sense when you think about. Risk of the risk of [00:23:00] smoking is more associated with squamous cell and obesity and reflux and all those things. All those North American problems are associated with adenocarcinoma. So again, your biggest risk factors for squamous cell are tobacco and ethanol or tobacco and alcohol. And those are synergistic, whereas obesity, GERD, Barrett's are major risk factors for adenocarcinoma. Unfortunately, a lot of these are very advanced at the time of diagnosis and they can present very late. So John, how where do you start? How do you start your workup in patients that you suspect of EEG or esophageal cancer? Yeah. The workup for suspected esophageal cancer is not any different than, you know, most types of cancers. So you only perform a full HMPE. Labs. The next step would be endoscopy with biopsy and then you want to add a bronch if the tumor is above the carina to ensure no invasion. And then perform a CT chest and abdomen. Endoscopic ultrasound with fine anal aspiration, a suspicious nose is recommended as well as a pet CT. Which is also recommended for staging. [00:24:00] Yeah, this is one of those cancers where the the nodal status as well as metastasis is going to drastically change your treatment. So you, up front, you want to get FNA biopsies of any suspicious nodes, and you want that PET CT because it can really change your management. So we don't focus a lot on staging, but it is important to know those distinctions that are gonna change your management. And esophageal cancer is one of those where there's some important distinctions. So here's some staging pearls. So T one, T. You need to know the difference between T one A and T one B. So T one A invades the lamina propria or the muscularis mucosa. Whereas T1B invades the submucosa, and this is an important distinction because the, of the rich submucosal lymphatic system. And we'll see in a little bit when we talk about treatment that distinction may change what you do preoperatively. T2 invades the muscularis propria. T3 invades the adventitia. Again, remember, there's no serosa with the esophagus. Whereas T4 invades the surrounding structures. [00:25:00] T4 is broken down into T4a or 4b based on whether or not those structures that are invading are resectable. So T4a, resectable structures include the pleura, pericardium, and the diaphragm, whereas unresectable structures, or T4b, invades the aorta, the vertebra, or the trachea. With regard to nodal stage, so N1 involves one to two nodes, N2 involves three to six nodes, and N3 is seven or more nodes. And of course, metastasis is either M0, M1 based on distant metastasis. Grade is also very important when it comes to management decisions when considering endoscopic mucosal resection or esophagectomy for small superficial lesions, as well as when deciding whether or not to do neoadjuvant versus surgery first. The thing to remember is that the nodal involvement is the best predictor of long term survival. And it's an important guide for therapeutic approaches. Okay. So with that in [00:26:00] mind, let's dive a little bit into management. So management can be very confusing. It can vary a lot depending on the anatomic location of the tumor, the invasion, the stage. So in general, Kevin, what are some trials and what are some principles when it comes to the treatment of esophageal cancer? So randomized trials have shown that preoperative chemoradiation therapy as seen in the CROSS study. And perioperative chemotherapy I've seen in the magic trial improve survival in patients with resectable, esophageal, and esophagal gastric cancer. Okay. With all that in mind, let's dive into some NCCN recommendations for some various tumors. So let Kevin, let's say you have either high grade dysplasia or AT one A tumor that's less than two centimeters and well to moderately differentiated with no evidence of lymph node metastasis. What's the recommendation? So in this situation you do endoscopic resection plus or minus an ablation. Okay. So yeah, those are the early stage ones that may be amenable to [00:27:00] endoscopic resection. How about a T1B tumor with again, negative lymph nodes. So for T1B you generally do a esophagectomy. There are some T1B that are superficial and don't have neurovascular invasion that you can treat with EMR and ablation, but it's controversial. Yeah, but to be safe, I would say T1, T1A, T1B. That's the distinction between being able to treat with endoscopic mucosal resection and needed esophagectomy. So, for me, if I were on the outside and I got a T1B I would answer esophagectomy. Now, how about the role of neoadjunct chemoradiation Kevin? So, in young patients and those with high grade T1 lesions, they may be candidates. Yeah, certainly. And as well as T2 or greater or any lymph node involvement, neoadjuvant chemoradiation followed by esophagectomy, if they're deemed to be resectable after restaging, it has become the standard. There's actually, there's definitely a trend to go for more and more neoadjuvant therapy. As you say, even in select T1 [00:28:00] lesions. What are we doing unresectable cancer, Jason? So, unresectable, which would be your T4B. Remember T4B is that unresectable invasion into unresectable structures or M one required definitive chemo radiation. Now, Kevin, when we talk about perioperative or definitive chemo, what type of chemotherapy agents are we using? So they generally use the fluoro uracils or taxing based therapy. Great. Okay, so let's say we, you know, treat our patient neoadjuvantly, we restage them, they're found to be resectable. What are our different surgical approaches, John? Yeah, so we have our trans thoracic esophagectomies trans hiatal esophagectomies, and some other minimally invasive approaches. Regarding our transthoracic esophagectomy. The two well-known ones are the Ivory Lewis Esophagectomy which is a laparotomy, a right thoracotomy with upper thoracic esophagal gastric [00:29:00] anastomosis. And it's good for distal tumors. But the basics of it is the stomach is mobilized as used as a conduit, and you have to preserve the right gastric and the right gastro lytic artery. The other transthoracic esophagectomy is a une esophagectomy. It's very similar to the Iver Lewis, except for the anastomosis is made higher. It's a cervical anastomosis, and this is better for more proximal lesions than the esophagus. The trans Ial esophagectomy includes a laparotomy and a left cervical incision with a cervical anastomosis. The major advantages of the Tri trans Hial Esophagectomy is that you avoid the morbidity of a thoracotomy. And the leak of a cervical anastomosis is better tolerated than a thoracic lead. The disadvantage is that you potentially will have a smaller lymph node harvest and large mid thoracic level tumors may be difficult to mobilize. There's equal long term survival as the trans thoracic approach. Amidly evasive techniques are also options in experienced [00:30:00] hands and that includes the use of thoroscopy, laparoscopy, and robotic mobilization. Yeah, that's great. So I think those are your main ones, your trans thoracic or your trans hiatal pearls in there. I think that you have to remember. Is one that's the blood supply to the conduit. This one is frequently asked, is the right gastroepiploic, is your main blood supply there? So that's a very frequently tested question. And as you say any of these approaches can be done minimally invasive. It's gonna be a lot of institution specific and surgeon specific, but just being familiar with the different approaches will serve you well. Let's say Kevin, that the patient has had a prior gastric resection either for a benign tumor or maybe they had a sleep gastrectomy what are your options then? So, you do have the option of a colon interposition conduit. Great. John, how about some adjuvant therapy after after surgery? Yeah, for this in general squamous cell cancer does not [00:31:00] need adjuvant therapy if there's an R0 resection, regardless of the nodal status. In contrast to adenocarcinoma, which generally does get adjuvant chemotherapy, except when there's a T1, N0, and R0 resection and did not receive neoadjuvant therapy. Yeah, that can be a little, that one always confused me, that if you had adenocarcinoma that was T1, N0, and did not receive neoadjuvant, why they wouldn't get adjuvant. The reason for that is if they got neoadjuvant, that tumor might've been downstaged and it's really not reliable. So if they did not receive neoadjuvant and they're low grade T1, then those sometimes would not require adjuvant therapy. So a little bit counterintuitive there, but that's the key thing to remember. Okay. Well, that was a lot of information. Let's let's do some quick hits. So Kevin, what are your anatomic areas of esophageal narrowing? So, at the cricopharyngeus muscle, the aortic arch, and the left main stem bronchus, and the lower esophageal sphincter and this is the sites that are most more vulnerable to injury. [00:32:00] Perfect. John, primary blood supply to the gastric conduit after esophagectomy. That would be the right gastroepiploic. Absolutely. Right gastroepiploic. So what would you do if you're using a gastric conduit during a esophagectomy prior gastrectomy or poor blood supply? This is when you can use your left colonic interposition or a jejunal freegraft. Yep, colonic interposition or jejunal freegraft are both options in that scenario. You want to make sure that you talk about that with the patient beforehand in case you have to do that. John, the patient has a dysphagia and he notes skin thickening on his palms and soles. What is the diagnosis? I can honestly say I've never seen this before it's Tylosis. It's an autosomal dominant condition linked to chromosome 17, Q25. And it's associated with palmar plantar keratomas. Yeah. What's important about that is it carries a 40 to 90 percent risk of squamous cell cancer of esophagus by the age of 70. So they need annual upper GI starting at the age of 20. Also I've only ever seen it on a test and practice tests. So tylosis, [00:33:00] 49 percent risk cancer, annual upper GI starting at the age of 20. So Kevin squamous cell cancer of the head and neck esophagus and pancytopenia. Diagnosis. So this is Fanconi anemia. Okay, great. John's a 75 year old male with a history of stroke who was referred to you for evaluation of esophageal dysmotility and GERD. They're in your clinic once a Nissen. He says that food gets stuck in his throat and he chokes and he has multiple hospitalizations for pneumonia. What's your next step? Yeah, this would be my first step would be a modified barium swallow. Why? Well, these symptoms are more consistent with an oropharyngeal dysphagia or Zinker diverticulum to the multiple aspiration events and not specifically esophageal dysmotility. You're right. You're just going to make that patient worse with an anti reflex procedure. So your modified barium swallow is your best form of diagnosis. So Kevin, a patient with a locally advanced esophageal cancer is undergoing neoadjuvant [00:34:00] chemoradiation. He has severe dysphagia and is malnourished. So what type of feeding tube are you going to place? Yeah, this is really important. You do a jejunal feeding tube. You don't do any G tubes or peg tubes because you need to preserve that gastric conduit. Yeah, so in general you want to avoid G tubes when you are trying to preserve that gastric conduit. So, John, you have a patient with dysphagia with a well circumscribed ovoid 6 cm mass on barium swallow. In the wall, the mid esophagus. What are you thinking? Yeah, that's my most that's my favorite most common beyond tumor esophagus. The esophageal le Okay. And treatment leiomyoma esophageal oma. Yep. Correct. Treatment for symptomatic tumors or tumors greater in five centimeters. Innuation via vast thoracotomy. Or you, the thoracotomy would be a right-sided approach for mid esophageal lesions and a left-sided approach for distal lesions. And again, we don't biopsy these. Why? Because it creates mucosal scarring that makes inoculation more difficult and dangerous. Great. And great review of the left versus [00:35:00] right. Just know the course of your esophagus because sometimes you'll have to know which side to best approach that lesion. So Kevin, you have a patient with longstanding GERD who now has dysphagia and EGD demonstrates a narrowed ring of mucosa just above the G ejection. What is the diagnosis and the treatment? Yes, this is a Schatzky's ring found at the squamo columnar junction. You can treat these with dilation and a PPI, never resect. Yeah, you don't need to resect these, just they're benign. So, PPI and a dilation. sO, we just covered it, but let's, it's never you can't repeat things too often. So, John, what are your approaches to the esophagus by level? Yep, I remember left, right, left cervical esophagus is approached to the left neck, the mid thoracic esophagus to the right chest, and the distal esophagus is through the left chest. Okay, great. I feel like that was a very good comprehensive review of esophagus and esophageal cancer. It can be very confusing. Thanks for listening.