1. Which of the following statements about the anatomic course of the esophagus is correct?

A. The cervical esophagus passes behind and to the right of the trachea.

B. The thoracic esophagus enters the posterior mediastinum anterior to the aortic arch.

C. The thoracic esophagus passes behind the right mainstem bronchus and the pericardium.

D. The esophagus enters the diaphragmatic hiatus at the level of T8.

E. The esophagus deviates anteriorly and to the left as it enters the abdomen.

Answer: E

DISCUSSION: Knowledge of the normal course of the esophagus is important in operative and endoscopic procedures. The cervical esophagus lies just anterior to the prevertebral fascia and courses through the neck posterior to the trachea and to the left of the midline. The cervical esophagus is therefore more readily approached surgically through a left neck incision. The thoracic esophagus enters the posterior mediastinum posterior to the aortic arch. Therefore, when operating on the upper esophagus, a right thoracotomy is preferred, since the aortic arch overlies the esophagus in the left chest. The esophagus descends in the posterior mediastinum behind the left mainstem bronchus and pericardium. It is the proximity of the esophagus and left mainstem bronchus that is responsible for the development of malignant tracheoesophageal fistulas between these two structures. The esophagus enters the diaphragmatic hiatus, which is located at the level of T11. As it enters the abdomen, the esophagus deviates anteriorly and to the left. Therefore, when performing rigid esophagoscopy as the distal esophagus is entered, the patient's head must be turned to the right and the esophagoscope elevated anteriorly to avoid perforation.

2. Which of the following statements about esophageal anatomy is correct?

A. The esophagus has a poor blood supply, which is segmental in distribution and accounts for the high incidence of anastomotic leakage.

B. The esophageal serosa consists of a thin layer of fibroareolar tissue.

C. The esophagus has two distinct muscle layers, an outer, longitudinal one and an inner, circular one, which are striated in the upper third and smooth in the distal two thirds.

D. Injury to the recurrent laryngeal nerve results in vocal cord dysfunction but does not affect swallowing.

E. The lymphatic drainage of the esophagus is relatively sparse, localized primarily to adjacent paraesophageal lymph nodes.

Answer: C

DISCUSSION: Poor technique, not poor blood supply, explains most esophageal anastomotic leaks. While the major blood supply of the esophagus is from four to six segmental aortic esophageal arteries, there are extensive submucosal collaterals from the inferior thyroid, intercostal, bronchial, inferior phrenic, and left gastric arteries. The esophagus lacks serosa and instead is surrounded by mediastinal connective tissue (adventitia). There are two muscle layers in the esophagus, an outer longitudinal and an inner circular one. Both layers of the upper third of the esophagus consist of striated muscle, while in the lower two thirds they are (nonstriated) smooth muscle. The recurrent laryngeal branches of the vagus nerves provide both parasympathetic innervation to the cervical esophagus and innervation to the upper esophageal sphincter (UES). Injury to the recurrent laryngeal nerve therefore results in improved UES function with secondary aspiration on swallowing as well as vocal cord dysfunction and hoarseness. The esophagus has extensive lymphatic drainage, with lymphatic capillaries coursing longitudinally in the esophageal wall and communicating with paraesophageal, paratracheal and subcarinal, other mediastinal, perigastric, and internal jugular lymph nodes. This accounts for the biologically aggressive nature of esophageal carcinoma, which tends to metastasize early in its course.

3. Which of the following statements about the lower esophageal sphincter (LES) mechanism, or high-pressure zone (HPZ), is true?

A. The LES is a circular smooth muscle ring that is 3 to 5 cm. long.

B. In assessing esophageal manometric data, mean HPZ pressure less than 6 mm. Hg or overall length less than 2 cm. is more likely to be associated with incompetence of the LES and gastroesophageal reflux.

C. Esophageal manometry and the acid perfusion (Bernstein) test reliably identify the patient with an incompetent LES mechanism.

D. Distal HPZ relaxation occurs within 5 to 8 seconds of initiating a swallow.

E. Twenty-four–hour distal esophageal pH monitoring is achieved with an intraesophageal pH electrode positioned at the esophagogastric junction.

Answer: B

DISCUSSION: The LES is not an anatomic muscular sphincter like the anus or pylorus, but rather, is a functional sphincter that serves as a barrier against abnormal regurgitation of gastric contents into the esophagus and is more appropriately termed the distal esophageal HPZ. While, in general, no HPZ value absolutely indicates either competence or incompetence of the LES mechanism, patients with a mean HPZ pressure less than 6 mm. Hg or a sphincter length less than 2 cm. are likely to have an incompetent LES and gastroesophageal reflux. Esophageal manometry defines the amplitude and length of the distal HPZ and the character of esophageal peristalsis. It does not determine whether or not the LES is competent. The Bernstein test identifies the patient with an acid-sensitive esophagus but does not indicate whether or not the patient has gastroesophageal reflux or esophagitis. Reflex distal HPZ relaxation occurs within 1.5 to 2.5 seconds after a swallow is initiated and lasts 4 to 6 seconds. Twenty-four–hour distal esophageal pH monitoring is achieved by means of an intraesophageal pH electrode positioned 5 cm. proximal to the HPZ, as determined by prior manometric evaluation.

4. Which of the following statements about esophageal motility is/are true?

A. The act of swallowing initiates UES relaxation, which persists until the bolus of food passes the LES.

B. The primary peristaltic wave normally propels the swallowed bolus through the esophagus in 4 to 8 seconds.

C. Normally, a progressive peristaltic contraction (primary wave) follows 50% of all swallows, the remainder being secondary or tertiary contractions.

D. Secondary peristalsis is initiated when the entire swallowed bolus of food fails to empty from the esophagus into the stomach.

E. Tertiary esophageal contractions are high-amplitude progressive peristaltic contractions that produce the “corkscrew” appearance of esophageal spasm on barium esophagography.

Answer: BD

DISCUSSION: Swallowing initiates UES relaxation, which lasts only 0.5 to 1.0 second, considerably less than the 4 to 8 seconds required for a swallowed bolus to pass through the esophagus and into the stomach. A progressive peristaltic contraction normally follows 97% of all swallows. If the swallowed bolus does not empty completely into the stomach, distention of the esophagus initiates secondary peristalsis, which is progressive and sequential and persists until the retained intraesophageal contents have passed into the stomach. Tertiary contractions are simultaneous, nonprogressive, incoordinated contractions of the esophageal smooth muscle that produce the contraction rings responsible for the corkscrew esophagus of diffuse esophageal spasm on barium esophagography.

5. Which of the following statements about UES dysfunction are correct?

A. This condition is diagnosed by the characteristic manometric findings of UES spasm.

B. Typical symptoms include cervical dysphagia, expectoration of saliva, and hoarseness.

C. The classic finding on barium esophagogram is a posterior cricopharyngeal bar.

D. Medical or surgical therapy of gastroesophageal reflux may be curative.

E. A cervical esophagomyotomy for UES dysfunction should be limited to 2 to 3 cm. in length so that normal muscle is not damaged.

Answer: BCD

DISCUSSION: The unique anatomic characteristics of the UES and the limitations of existing equipment in recording the rapid sequence of events associated with swallowing make standard manometric definition of UES motor abnormalities extremely difficult. Characteristic consistent abnormalities of UES function in patients with cricopharyngeal dysfunction have not been well documented. UES dysfunction results in cervical dysphagia, expectoration of saliva that is no longer swallowed freely, and, often, intermittent hoarseness due to alteration of the larynx and vocal cords by the pull of the abnormal cricopharyngeal sphincter. Barium esophagography in the patient with UES dysfunction frequently shows a posterior cricopharyngeal “bar,” representing the prominent impression of the sphincter on the esophageal lumen. Patients with gastroesophageal reflux may present with cervical dysphagia due to secondary UES dysfunction. Successful medical or surgical treatment of the reflux may eliminate the cervical complaints. Since the UES is normally 3 to 5 cm. long, when a cervical esophagomyotomy is required for treatment of cricopharyngeal dysfunction, a generous myotomy, 7 to 10 cm. long, is carried out to ensure complete division of all incoordinated UES muscle fibers.

6. Which of the following statements about achalasia is/are correct?

A. In most cases in North America the cause is a parasitic infestation by Trypanosoma cruzi.

B. Chest pain and regurgitation are the usual symptoms.

C. Distal-third esophageal adenocarcinomas may occur in as many as 20% of patients within 10 years of diagnosis.

D. Manometry demonstrates failure of LES relaxation on swallowing and absent or weak simultaneous contractions in the esophageal body after swallowing.

E. Endoscopic botulinum toxin injection of the LES, pneumatic dilatation, and esophagomyotomy provide highly effective curative therapy for achalasia.

Answer: D

DISCUSSION: While in South America achalasia is the result of Chagas' disease caused by parasitic infestation by the leishmanial forms of T. cruzi, in Europe and North America the cause of achalasia is unknown. The common presenting symptoms of achalasia are dysphagia, regurgitation, and weight loss. Chest pain is an infrequent symptom in achalasia and is more characteristic of esophageal spasm. Achalasia is a premalignant esophageal lesion: the retention esophagitis leads to metaplasia and squamous cell carcinoma, which occurs after 15 to 25 years in the middle third of the thoracic esophagus in 10% of patients. The classic manometric findings of achalasia are failure of relaxation of the LES on swallowing and absent or weak simultaneous contractions in the esophageal body after swallowing. Achalasia is currently incurable, and, though the recently described endoscopic botulinum toxin injection of the lower esophageal sphincter, pneumatic dilatation, and esophagomyotomy effectively relieve dysphagia in the majority of patients, all of these treatments are strictly palliative. The motility disturbance persists throughout life.

7. Which of the following statements about diffuse esophageal spasm is/are true?

A. Chest pain due to esophageal spasm is readily differentiated from angina pectoris of cardiac origin.

B. Bouts of esophageal obstruction and regurgitation of food are characteristic.

C. Associated psychiatric disorders are common.

D. During manometric assessment, unless the patient is having pain there may be no detectable multiphasic, high-amplitude, simultaneous esophageal contractions.

E. The treatment of choice is a long esophagomyotomy from the aortic arch to the esophagogastric junction.

Answer: CD

DISCUSSION: The chest pain of diffuse esophageal spasm is often indistinguishable from that of angina pectoris of cardiac origin. Many patients undergo cardiac catheterization to rule out coronary artery disease. Patients may experience slow emptying of the esophagus, but obstructive symptoms and regurgitation of food are unusual. Psychiatric disorders (depression, psychosomatic complaints, anxiety) have been documented in more than 80% of patients with esophageal contraction abnormalities. The classic manometric criteria of diffuse esophageal spasm are simultaneous, multiphasic, repetitive, high-amplitude contractions occurring after a swallow and spontaneously. These changes may not be detected if manometry is performed when the patient is having no pain. As the cause of esophageal spasm is unknown, treatment is far from ideal. Conservative management—avoidance of “trigger” foods and drinks, psychiatric counseling, treatment of reflux, esophageal dilatations, use of histamine H 2 blockers, anti-spasmodics, and smooth muscle relaxants—should always be attempted first. Esophagomyotomy provides no lasting relief of esophageal spasm for as many as 50% of patients and should be used only in a minority of these patients.

8. Which of the following statements about epiphrenic diverticula of the esophagus is/are correct?

A. They are traction diverticula that arise close to the tracheobronchial tree.

B. They characteristically arise proximal to an esophageal reflux stricture.

C. The degree of dysphagia correlates with the size of the pouch.

D. They are best approached surgically through a right thoracotomy.

E. The operation of choice is a stapled diverticulectomy, long esophagomyotomy, and partial fundoplication.

Answer: E

DISCUSSION: Epiphrenic diverticula are pulsion diverticula that arise in the distal 10 cm. of the esophagus. The cause is elevated intraesophageal pressure, which forces mucosa and submucosa to herniate through the muscle layers. Though this may occur with an esophageal reflux stricture or tumor, primary disordered esophageal motility is the most common cause. Many patients are asymptomatic when their epiphrenic diverticula are diagnosed by barium esophagography, symptoms being related more to the degree of disordered motility than to the size of the pouch. Distal esophageal diverticulum is best approached through a left thoracotomy. When surgery is indicated, the preferred approach is transthoracic diverticulectomy using a surgical stapler, a long esophagomyotomy to relieve the elevated intraesophageal pressure, and a nonobstructing partial (e.g., Belsey's) fundoplication.

9. Which of the following statements about Schatzki's ring is correct?

A. The ring represents a panmural fibrotic stricture resulting from gastroesophageal reflux.

B. Dysphagia occurs when the ring diameter is 13 mm. or less.

C. The ring occurs within 1 to 2 cm. of the squamocolumnar epithelial junction.

D. Schatzki's ring indicates reflux esophagitis.

E. Schatzki's ring signifies the need for an antireflux operation.

Answer: B

DISCUSSION: Schatzki's ring is seen radiographically as an annular weblike constriction at the esophagogastric junction in a patient with a sliding hiatalhernia. It represents prominence of the esophagogastric junction with slight submucosal fibrosis but not true panmural fibrotic reflux stricture. Intermittent dysphagia may occur when the ring size is 20 mm. or less, but dysphagia is almost invariable when the ring measures 13 mm. or less. Schatzki's ring occurs precisely at the squamocolumnar epithelial junction. It is indicative of the presence of a hiatal hernia but not of gastroesophageal reflux or esophagitis. An asymptomatic Schatzki's ring requires no therapy per se. Patients with refractory severe reflux symptoms after dilation therapy are candidates for antireflux surgery.

10. Choose the distance in centimeters from the upper incisor teeth at which the following radiographically identified esophageal lesions would be encountered endoscopically:

A. 10 cm. 1. Zenker's diverticulum

B. 15 cm. 2. Traction diverticulum

C. 25 cm. 3. Tumor 10 cm. proximal to the esophagogastric junction

D. 30 cm.

E. 40 cm.

Answer: 1-B, 2-C, 3-D

DISCUSSION: A barium esophagogram should be obtained routinely before performing elective esophagoscopy. The location of an esophageal lesion seen on the barium swallow study can be related to adjacent anatomic landmarks. This allows the endoscopist to anticipate the level (as measured from the upper incisor teeth) where he should expect to see the abnormality at esophagoscopy. For example, the upper esophageal (cricopharyngeal) sphincter is generally seen at the level of the C7–T1 vertebrae radiographically and at 15 cm. endoscopically. This is the level at which the mouth of a Zenker's diverticulum is seen. The tracheal bifurcation occurs at the level of the T4 or 25 cm. from the upper incisors endoscopically; a traction (parabronchial) diverticulum at the level of the carina on a barium esophagogram will be seen at approximately 25 cm. The esophagogastric junction occurs at approximately the level of T11, 40 cm. from the upper incisors; a tumor 10 cm. proximal to the esophagogastric junction stricture is seen endoscopically at 30 cm.

11. Which of the following statements about pathology encountered at esophagoscopy is/are correct?

A. Reflux esophagitis should be graded as mild, moderate, or severe, to promote consistency among different observers.

B. An esophageal reflux stricture with a 2-mm. lumen is not dilatable and is best treated with resection.

C. A newly diagnosed radiographic distal esophageal stricture warrants dilation and antireflux medical therapy.

D. In patients with Barrett's mucosa, the squamocolumnar epithelial junction occurs 3 cm. or more proximal to the anatomic esophagogastric junction.

E. After fasting at least 12 hours, a patient with megaesophagus of achalasia can safely undergo flexible fiberoptic esophagoscopy.

Answer: D

DISCUSSION: The traditional subjective grading of reflux esophagitis as mild, moderate, or severe has inherent wide variations in meaning among observers. Consistent use of standardized grading systems for endoscopic reflux esophagitis (e.g., that of Belsey or Savary) provides a more objective description of the changes seen and allows more meaningful evaluation of patients at different times and by different observers. The size of the lumen does not predict whether or not a reflux stricture is dilatable. Even a tight 2-mm. lumen can be traversed with a guidewire over which Savary dilators can be used to achieve an acceptable lumen size. Every newly diagnosed esophageal stricture warrants esophagoscopy with brushings and biopsies of the stricture (to exclude carcinoma) and an assessment of its “dilatability.” Antireflux medical therapy is not justified until carcinoma has been ruled out. Because the squamocolumnar epithelial junction may normally be found within 2 to 3 cm. of the anatomic esophagogastric junction, the diagnosis of Barrett's mucosa requires identification of the columnar epithelium at least 3 mm. proximal to the junction of the tubular esophagus and the stomach. In advanced achalasia with megaesophagus, the dilated esophagus may have a capacity of 1 to 2 liters, and simply fasting overnight does not ensure that the esophagus is empty of food and drink consumed the day before. Life-threatening massive regurgitation and aspiration may occur as the endoscope is being introduced unless an effort is made to evacuate the esophagus first by means of a nasogastric tube.

12. Which of the following statements about the diagnosis and treatment of esophageal leiomyomas is/are correct?

A. The majority are diagnosed after they cause dysphagia and chest pain.

B. Biopsy is indicated at the time of esophagoscopy, to rule out carcinoma.

C. Full-thickness elliptical excision of the esophageal wall is the preferred surgical approach.

D. Endoscopic ultrasonography is a reliable means of following leiomyomas conservatively.

E. Recurrence of resected leiomyomas is minimized by wide local excision.

Answer: D

DISCUSSION: Most esophageal leiomyomas are asymptomatic when discovered incidentally on a barium esophagogram or upper gastrointestinal tract series. When suspected on the basis of its radiographic appearance, biopsy of the mass should not be performed at the time of esophagoscopy, so that subsequent extramucosal resection will not be complicated by scarring at the biopsy site. The preferred surgical approach is submucosal enucleation of the mass, not full-thickness excision. Leiomyomas have a characteristic hypoechogenic homogeneous appearance on esophageal ultrasonography that allows a noninvasive diagnosis and means of surveillance. Submucosal enucleation of leiomyomas, without wide local excision, provides excellent long-term results with virtually no local recurrence rate.

13. Which of the following statements regarding the pathology of esophageal carcinoma is/are correct?

A. Worldwide, adenocarcinoma is the most common esophageal malignancy.

B. Squamous cell carcinoma is most common in the distal esophagus, whereas adenocarcinoma predominates in the middle third.

C. Patients with Barrett's metaplasia are 40 times more likely than the general population to develop adenocarcinoma.

D. Metastases from esophageal carcinoma are characteristically localized to regional mediastinal lymph nodes adjacent to the tumor.

E. Achalasia, radiation esophagitis, caustic esophageal stricture, Barrett's mucosa, and Plummer-Vinson syndrome are all premalignant esophageal lesions that predispose to the development of squamous cell carcinoma.

Answer: C

DISCUSSION: Histologically, 95% of esophageal cancers worldwide are squamous cell carcinomas, but the incidence of adenocarcinoma is increasing dramatically in the United States and Europe. Squamous cell carcinoma predominates in the upper and middle thirds of the esophagus, whereas adenocarcinoma is the most frequent distal esophageal cancer. A columnar lined lower esophagus (Barrett's metaplasia) is associated with an incidence of adenocarcinoma approximately 40 times greater than that of the general population. Esophageal cancer is a biologically aggressive tumor that characteristically metastasizes widely to regional and distant lymph nodes as well as to liver and lungs. Recognized premalignant esophageal lesions include achalasia, radiation esophagitis, caustic stricture, Plummer-Vinson syndrome, leukoplakia, esophageal diverticula, and Barrett's metaplasia. All but Barrett's metaplasia are associated with the development of squamous cell carcinoma.

14. Which of the following statements about the surgical treatment of esophageal carcinoma is/are correct?

A. The finding of severe dysphagia in association with Barrett's mucosa is an indication for an antireflux operation to prevent subsequent development of carcinoma.

B. Long-term survival is improved by radical en bloc resection of the esophagus with its contained tumor, adjacent mediastinal tissues, and regional lymph nodes.

C. The morbidity and mortality rates for cervical esophagogastric anastomotic leak are substantially less than those associated with intrathoracic esophagogastric anastomotic leak.

D. The leading complications of transthoracic esophagectomy and intrathoracic esophagogastric anastomosis are bleeding and wound infection.

E. Transhiatal esophagectomy without thoracotomy achieves better long-term survival than transthoracic esophagectomy.

Answer: C

DISCUSSION: Severe dysplasia in Barrett's mucosa is indicative of carcinoma in situ and is an indication for resectional therapy, not an antireflux operation. In the majority of patients, local tumor invasion or distant metastases preclude cure when esophageal carcinoma is diagnosed, and attempts to improve survival with a more radical local operation performed in the face of systemic disease have been disappointingly futile. A cervical esophagogastric anastomotic leak causes a relatively minor cervical salivary fistula that heals in 7 to 10 days in 95% of patients. In contrast, an intrathoracic esophagogastric anastomotic leak results in mediastinitis, which is fatal in 50%. The leading complications of transthoracic esophagectomy and an intrathoracic esophagogastric anastomosis are respiratory insufficiency (from combined thoracic and abdominal incisions) and anastomotic leak resulting in mediastinitis and sepsis. Both complications are minimized by transhiatal esophagectomy without thoracotomy plus cervical esophagogastric anastomosis. No single operative approach to the treatment of esophageal cancer has proved superior to others in terms of long-term survival. The biologic behavior of the tumor (its stage and aggressiveness)—not the number of lymph nodes resected with the tumor—determines survival.

15. The best management for a 48-hour-old distal esophageal perforation is:

A. Antibiotics and drainage.

B. Division of the esophagus and exclusion of the perforation.

C. Primary repair with buttressing.

D. Resection with cervical esophagostomy, gastrostomy, and jejunostomy.

E. T-tube fistula and drainage.

Answer: C

DISCUSSION: When the esophagus is repaired primarily and covered by well-vascularized autologous tissue, the rates of fistula and death are significantly less than those observed for patients who receive simple repair without any protection. Primary repair with buttressing is the first choice for treatment. Resection is reserved for esophageal perforations with extensive damage to the esophageal wall or with advanced mediastinal infection and sepsis. Exclusion of the perforated esophagus and T-tube drainage of a perforation are alternative approaches that cannot be considered for primary treatment. Antibiotics and drainage as the sole treatment is reserved for a very small, selected population of patients with well-contained esophageal perforation.

16. A 50-year-old patient develops sudden left lower chest pain and epigastric pain after vomiting. The patient shows diaphoresis, breath sounds are decreased on the left, and there is abdominal guarding. The most appropriate diagnostic test is:

A. Aortography.

B. Esophagoscopy.

C. Electrocardiogram.

D. Film of the chest.

E. White blood count.

Answer: D

DISCUSSION: The history of pain after vomiting efforts suggests esophageal rupture. Pain is often described as excruciating and frequently masquerades as a dissecting aneurysm, perforated ulcer, or myocardial infarction. Decreased breath sounds suggest the possibility of hydropneumothorax. The diagnostic procedure is a chest film. More than 90% of patients with an esophageal perforation show abnormalities suggestive of perforation. The findings are influenced by the interval between perforation and the examination, by the site of the perforation, and by the integrity of the mediastinal pleura. Esophagoscopy is not indicated.

17. The following statements about the influence of diet and lifestyle on lower esophageal sphincter (LES) function are true except one. Identify the incorrect statement.

A. A high-protein diet increases LES pressure.

B. A fat meal results in sustained decrease in LES pressure.

C. Chocolate ingestion causes a decrease in LES pressure.

D. Peppermint produces a transient decrease in LES values.

E. Cigarette smoking produces no significant changes in LES pressures.

Answer: E

DISCUSSION: There is a dramatic decrease in LES pressure following the ingestion of fat. Chocolate has the same effect on LES resting pressures. Peppermint was shown to produce transient decreases in LES pressures of 20 to 30 seconds, which occur approximately 10 minutes after ingestion. The ingestion of carbohydrates produces no significant change in sphincter pressures, but a high-protein meal increases LES pressure. Cigarette smoking has also been shown to produce significant decreases in LES pressure that persist throughout the duration of active smoking.

18. When a stricture is present in association with gastroesophageal reflux, each of the following is an acceptable repair for reflux control except one. Identify the poorest repair.

A. Intrathoracic total fundoplication.

B. Lengthening gastroplasty with total fundoplication.

C. Total fundoplication.

D. Lengthening gastroplasty with partial fundoplication.

E. Partial fundoplication.

Answer: E

DISCUSSION: When a stricture is present, periesophagitis and shortening limit the chances of obtaining a sufficient length of intra-abdominal esophagus. Even extensive mobilization of the esophagus to the aortic arch and freeing of the esophagogastric junction does not afford a comfortable 4 to 5 cm. of esophagus under the diaphragm. A tension-free repair is not possible in such circumstances. Partial fundoplication at this stage of the disease is followed by a 45% failure rate. Excellent results have been reported using a total fundoplication following dilatation of the stricture, and intrathoracic fundoplication provided good results. The lengthening gastroplasty with a partial fundoplication or with total fundoplication shows satisfactory control of reflux in a majority of patients.

19. When assessing gastroesophageal reflux disease by manometry each of the following statements is correct except one. Identify the incorrect one.

A. Absent or extremely low LES pressures have predictive value in identifying more severe reflux.

B. Peristaltic dysfunction increases with increasing severity of esophagitis.

C. With established reflux disease the UES is hypertensive.

D. Esophageal functional changes are worst in patients with a circumferential columnar-lined esophagus.

E. Absence of peristalsis may be associated with more severe forms of reflux disease.

Answer: C

DISCUSSION: In reflux disease when LES pressure is below 10 mm. Hg, manometry is too imprecise to identify a potential for significant reflux. If the pressure is less than 6 mm. Hg, this shows a reasonable high specificity as compared with abnormal reflux on pH testing. When LES pressure is extremely low or nonexistent, this identifies a more severe degree of reflux and a poorer prognosis for long-term medical therapy. In the esophageal body, active reflux esophagitis causes altered function. Failed peristalsis increases, and the contractions become weaker. Patients with a columnar-lined esophagus have the worst functional abnormalities. Although distention or acid perfusion in the proximal esophagus can produce a significant increase in UES resting pressure, there is at present no solid evidence relating UES resting pressures to active reflux disease.

20. The presence of a nonmalignant mid- or upper esophageal stricture always indicates the presence of:

A. Alkaline reflux esophagitis.

B. Barrett's esophagus.

C. Idiopathic reflux disease.

D. Mediastinal fibrosis.

E. Scleroderma.

Answer: B

DISCUSSION: A stricture at or above the aortic arch is almost certainly situated above an esophagus lined at its lower end with columnar epithelium. Barrett's esophagus is suggested radiographically when local esophagitis, ulcer, or stricture is at the limits of a normal-looking segment of esophagus under the stricture but above a herniated stomach. The columnar-lined esophagus is not always associated with a high stricture; however Messiaen and Halpert documented strictures in 80% of their Barrett's patients. These high strictures, when seen with alkaline reflux esophagitis, with idiopathic reflux disease, or in association with scleroderma, always suggest the presence of a columnar-lined esophagus. Mediastinal fibrosis is a rare condition that can cause multilevel strictures on the esophagus.

21. Which of the following is most reliable for confirming the occurrence of a significant esophageal caustic injury?

A. History of the event.

B. Physical examination of the patient.

C. Barium esophagraphy.

D. Endoscopy.

Answer: D

DISCUSSION: In the absence of physical or radiographic evidence of upper airway obstruction or esophagogastric perforation, the presence of a significant caustic injury can be defined reliably only by direct visualization at the time of endoscopy. Although the history may shed light on the possibility of a burn and its severity, all too often the event goes unwitnessed or the type and amount of ingested substance are not known with certainty. The identification of oropharyngeal burns clearly indicates the need for endoscopy, but as many as 70% of patients with such lesions escape associated esophageal injury. Conversely, 10% to 30% of patients with no external evidence of burns have subsequently been confirmed by esophagoscopy to have sustained damage. In the absence of an identifiable perforation, a barium esophagogram can rarely be considered unequivocally diagnostic of acute injury, though such an injury may be suggested when the esophagus appears atonic and dilated, rigid and persistently narrowed, or excessively irritable. Because of the importance of early confirmation of the presence or absence of a significant esophageal burn as a guide to formulating appropriate treatment, esophagoscopy should be performed expeditiously as soon as sufficient time has elapsed to allow gastric emptying and stabilization of the patient, preferably within the first 12 to 48 hours after ingestion.

22. Indications for surgical reconstruction of the esophagus include which of the following?

A. Continuing requirement for frequent dilation of an extensive esophageal stricture for a minimum of 2 years.

B. Failure or refusal of the patient to comply with a treatment regimen of regular dilation.

C. Development of a fistula between the esophagus and tracheobronchial tree.

D. Iatrogenic perforation of the esophagus during attempted dilation.

Answer: BCD

DISCUSSION: Development of a tracheobronchial fistula almost always necessitates some form of esophageal reconstruction because of the extensive damage usually associated with it. Failure of the patient to cooperate effectively condemns to failure any attempt at restoring esophageal patency by bougienage, because sporadic attempts at dilation do not allow progressive lumen enlargement but, rather, invite additional injury because of the necessity for repeated instrumentation of a recurrent, tight stricture. The need for repeated dilation of extensive or multiple strictures over a period exceeding 6 months should prompt surgical reconstruction of the esophagus, especially in young children, for whom the psychological and physical hazards are intensified by prolonged treatment. In such circumstances, a 2-year period of attempted bougienage is excessive. Although iatrogenic perforation often signals the need for esophageal reconstruction, this misadventure should not be considered an absolute indication but should be assessed in relation to (1) the extent and complexity of the stricture, (2) the potential for eventually achieving successful bougienage, and (3) the severity of complications caused by the secondary injury.

A. Vagotomy and antrectomy.

B. Upper endoscopy and biopsy to rule out tumor.

C. Evaluation for Helicobacter pylori.

D. Serum gastrin determination.

E. Cream or milk-based “Sippy” diet.

Answer: C

DISCUSSION: Vagotomy and antrectomy is the definitive surgical therapy for peptic ulcer disease but should be applied only for complications of the disease or after refractory disease has been documented. Biopsy of routine peptic duodenal ulcer is not indicated to rule out malignancy except in special circumstances, such as an endoscopic appearance typical of malignancy. H. pylori is found in a large percentage of peptic ulcer patients, and treatment alters the rate of recurrence if therapy is directed toward reduction of H. pylori in addition to acid. Measurement of serum gastrin is recommended for patients with resistant or persistent peptic ulcer disease for patients undergoing surgery for peptic ulcer disease. The Sippy diet has not been recommended clinically for years. Formerly it was recommended as a bland diet that would not exacerbate peptic ulcer disease. It is now known that these diets are heavily calcium-laden and probably exacerbate peptic ulcer disease.

A. Nasogastric suction.

B. Intravenous hydration.

C. Nutritional assessment; upper endoscopy to rule out malignancy.

D. Intravenous H 2 antagonist.

E. Oral antacid therapy.

Answer: E

DISCUSSION: All patients should undergo nasogastric suction, rehydration, and control of acid secretion. This control of acid secretion requires an H 2 antagonist since oral antacids are often inadequate to neutralize the large volume of acid often present in the obstructed stomach. Patients with a long history of obstruction are often nutritionally compromised and need careful nutritional assessment before operative planning.

A. Duodenal stump blowout.

B. Dumping.

C. Diarrhea.

D. Delayed gastric emptying.

E. Steatorrhea.

Answer: E

DISCUSSION: Duodenal stump blowout occurs after Billroth II operations, where back-pressure in the duodenal stump results in breakdown of this stump closure, leading to abdominal sepsis. Dumping syndrome and postvagotomy diarrhea are complications of peptic ulcer surgery. They represent two different syndromes, both of which are predominately related to the vagotomy portion of the operation. Delayed gastric emptying occurs frequently after peptic ulcer surgery, for a variety of reasons, but it is most common after elective peptic ulcer surgery for gastric outlet obstruction. Steatorrhea is not necessarily related to peptic ulcer surgery but is a complication of pancreatic insufficiency.

A. Hyperparathyroidism in patients with multiple endocrine neoplasia type 1 (MEN 1) syndrome.

B. Diarrhea.

C. Migratory rash.

D. Jejunal ulcers.

E. Duodenal ulcers.

Answer: C

DISCUSSION: Zollinger-Ellison syndrome occurs in two settings: sporadically and in association with MEN 1 syndrome. MEN 1 syndrome includes parathyroid adenomas, and the initial presentation is often related to this parathyroid disease. Diarrhea is a common presentation for Zollinger-Ellison syndrome, since hyperacidity can result in diarrhea due to the volume of acid secreted or from a steatorrhea-type diarrhea when the high levels of acids inactivate the pancreatic enzymes. Migratory rash is commonly associated with glucagonoma but not with Zollinger-Ellison syndrome. Both jejunal and duodenal ulcers can be found with Zollinger-Ellison syndrome.

A. Symptoms can be controlled with a somatostatin analog.

B. Diarrhea is always part of the dumping syndrome.

C. Flushing and tachycardia are common features of the syndrome.

D. Separating solids and liquids in the patient's oral intake alleviates some of the symptoms of the syndrome.

E. Early postoperative dumping after vagotomy often resolves spontaneously.

Answer: B

DISCUSSION: The somatostatin analog octreotide has been used to control the dumping syndrome and is currently the only known medical therapy for this disease. Other therapies include dietary measures such as six small meals a day and separation of solids and liquids. Postvagotomy diarrhea is a secondary complication of vagotomy and is not strictly associated with the dumping syndrome itself. The vast majority of patients with dumping syndrome experience spontaneous resolution of their symptoms without intervention in the postoperative period.

A. Visible vessel.

B. Cherry-red spot.

C. Clean ulcer bed.

D. Duodenitis.

E. Shallow, 3-mm. ulcer.

Answer: A

DISCUSSION: A visible vessel in an ulcer bed is associated with a 50% chance of rebleeding and, other than an actively bleeding vessel, is the worst endoscopic prognostic indicator for rebleeding. Cherry-red spot, adherent clot, and clean small ulcers all are associated with a lower incidence of rebleeding.

A. Intractable duodenal ulcer disease.

B. Peptic ulcer disease causing gastric outlet obstruction.

C. Fundic peptic ulceration.

D. Cigarette chain smoking.

E. Perforated peptic ulcer disease with more than 24 hours' soilage.

Answer: A

DISCUSSION: Intractable peptic ulcer symptoms are a classic indication for highly selective vagotomy. Patients with gastric outlet obstruction often do poorly with highly selective vagotomy and develop recurrent ulceration. Highly selective vagotomy is not indicated for gastric ulceration. Heavy chain smokers often get recurrent peptic ulceration after highly selective vagotomy; therefore, vagotomy and antrectomy is indicated for them. Patients who experience long periods of perforation before exploratory laparotomy should receive either patch plus vagotomy or pyloroplasty or patch of the ulcer alone. Extensive operations, such as highly selective vagotomy, are usually not indicated in this acute setting.

A. It is the only drug available that has the potential to achieve pharmacologically induced achlorhydria.

B. It works by blocking the hydrogen-potassium ATPase in the parietal cell.

C. It is parietal cell specific.

D. It has a short half-life (about 90 minutes) when taken orally.

E. It has been associated with gastric neoplasm in a rat model.

Answer: D

DISCUSSION: Omeprazole and drugs in this category are the only drugs that can produce achlorhydria. All other antiacid drugs reduce acid secretion without producing achlorhydria. Omeprazole inhibits acid at the final common pathway by blocking the hydrogen-potassium ATPase in parietal cells. It is gastric parietal cell specific and has a very long half-life, allowing once daily dosing when given orally. When it was given to rats in pharmacologic doses the gastric mucosa formed carcinoid-type tumors. This problem has not been identified in humans.

A. In species other than man and dog GRP is commonly referred to as bombesin.

B. GRP serves as a neurotransmitter.

C. GRP inhibits pancreatic secretion when given intravenously.

D. GRP stimulates gastric acid secretion when given intravenously.

E. GRP is released in response to cholinergic stimulation of the parietal cells to stimulate release of gastrin.

Answer: C

DISCUSSION: Gastrin-releasing peptide and bombesin are homologous peptides of different amino acid lengths. GRP functions as a neurotransmitter at the cholinergic nerve ending on the parietal cell and releases gastrin after cholinergic stimulation. It functions to increase gastric acid secretion and also pharmacologically increases pancreatic secretion.

A. It physiologically delays gastric emptying.

B. It appears to have a role in satiety regulation.

C. It contracts the gallbladder.

D. It stimulates pancreatic secretion.

E. It is important in the control of the anal sphincter.

Answer: E

DISCUSSION: CCK has a physiologic role in the regulation of gastric emptying, eating behavior, gallbladder contraction, and pancreatic secretion. There is experimental evidence that it may serve as a neurotransmitter in the function of the lower esophageal sphincter. It probably also has a role in augmenting the release of insulin after a meal. It has no known role in the function of the anal sphincter.

A. Antrectomy.

B. Highly selective vagotomy.

C. Total gastrectomy.

D. Vagotomy and pyloroplasty.

E. Medical therapy with Prilosec (omeprazole).

Answer: A

DISCUSSION: Patients with MEN 1 syndrome or sporadic-metastatic Zollinger-Ellison syndrome should be palliated with omeprazole to control their acid secretion. Patients who undergo exploration may have a variety of operations to control their ulcer diathesis, including total gastrectomy or various vagotomy-type operations. Antrectomy alone is not indicated, since the gastrin that is contributing to the production of acid is not coming from the antrum but coming from the tumor.

A. Cigarette smoking.

B. Nonsteroidal anti-inflammatory drugs.

C. Helicobacter pylori.

D. Gastrinoma.

E. Spicy foods.

Answer: E

DISCUSSION: Cigarettes and nonsteroidal anti-inflammatory drugs are common contributors to peptic ulceration. H. pylori is found in most patients with peptic ulceration, and eradication of this bacterium decreases the recurrence rate for peptic ulcer disease. Gastrinoma results in much acid secretion and commonly presents with peptic ulcer disease. Dietary factors such as spicy foods have little or no effect on postprandial acid secretion and do not contribute to peptic ulceration.

A. Like their colonic counterparts, gastric epithelial polyps are common tumors.

B. They are analogous to colorectal polyps in natural history.

C. Endoscopy can uniformly predict the histology of a polyp based on location and appearance.

D. In a given patient, multiple polyps are generally of a single histologic type.

E. Gastric adenomatous polyps greater than 2 cm. in diameter should be excised because of the risk of malignant transformation.

Answer: DE

DISCUSSION: As early as 1895 Hauser reported an association between familial adenomatous polyposis of the colon and multiple gastric polyps. This early association may have given rise not only to the confusing nomenclature of gastric polyps but also to the mistaken notion that they are analogous to colorectal polyps in microscopic appearance and natural history. Unlike colonic polyps, gastric epithelial polyps are very uncommon tumors (prevalence 0.4% to 0.8%). Their histologic appearance cannot be predicted on the basis of location in the stomach, although the endoscopic literature is beginning to define predictive algorithms based on location and ultrasound. Multiple polyps are almost always of a single histologic type. Gastric adenomatous polyps have long been associated with adenocarcinoma. This association is directly related to the size of the polyps. Up to 24% of polyps 2 cm. or greater in diameter are associated with adenocarcinoma. In contrast, only 4% of polyps with a diameter less than 2 cm. are associated with carcinoma. The risk, if any, of carcinoma in patients with hyperplastic polyps appears to be associated with the atrophic gastritis that frequently accompanies them rather than with the polyps themselves.

A. They are the most common type of gastric tumor of the stomach at autopsy.

B. The leiomyoblastoma cell type reflects malignant transformation of gastric leiomyomas.

C. A conservative surgical approach is indicated for their resection since regional lymphadenectomy has not been proved reliable even when they turn out to be malignant.

D. Severe hemorrhage may occur from deep ulcerations overlying the intramural tumor.

Answer: ACD

DISCUSSION: Approximately 40% of benign tumors of the stomach are leiomyomas derived from the smooth muscle of the stomach or its associated blood vessels. Because it is rare for gastric leiomyomas smaller than 3 cm. in diameter to be symptomatic, considerably fewer than 2% of gastric neoplasms resected surgically are of smooth muscle origin. Gastric leiomyomas may be smooth or lobulated, but in time a central ulceration occurs in the mucosal bulge of the tumor in approximately half of submucosal leiomyomas. Ulceration may be present in smaller tumors but absent in very large tumors. Overlying central mucosal ulceration, which may penetrate deeply into the tumor, results in hematemesis, melena, or anemia and draws attention to the tumor. Bleeding from the tumor may be massive and/or intermittent.

Gastric leiomyomas are not encapsulated, even though on section they appear to be well-circumscribed. Microscopically, the tumor cells at the margin may intermingle with cells of the surrounding gastric wall. Along with the presence of occasional large cells with hyperchromatic nuclei, this has led to confusion in distinguishing benign tumors from malignant ones. Stout described a reasonably distinct variety of gastric smooth muscle tumor that he called leiomyoblastoma (bizarre smooth muscle tumor). They were characterized histologically by polyhedral smooth muscle cells with central nuclei and abundant cytoplasm rather than elongated cells. A clear zone that surrounds the central nucleus may be an artifact of fixation. Leiomyoblastoma may be benign or malignant. Carney has described a syndrome characterized by the triad of multiple malignant leiomyoblastoma, pulmonary chondroma, and functioning extra-adrenal paraganglioma.

The principle of surgical treatment of smooth muscle tumors is local excision with a 2- to 3-cm. margin of surrounding gastric wall. In view of the difficulty in distinguishing between the benign and malignant variants, enucleation is not an appropriate method of treatment. Regional lymphadenectomy is not of proven value, even if malignancy is strongly suspected and is not consistent with the known property of these tumors to spread by the hematogenous route.

A. Extragastric extension of the gastric lesion.

B. Nodal involvement beyond the immediate stomach.

C. A germinal center in the gastric lesion.

D. Extension into esophagus and duodenum.

E. Unresponsive to conservative gastric resection.

Answer: C

DISCUSSION: Pseudolymphoma represents approximately 10% of all gastric lymphomas. These are benign conditions involving mostly the mucosa without evidence of nodal disease and without extragastric extension. The sine qua non for the diagnosis is a germinal center within the gastric lesion. These are premalignant lesions but can be cured completely with conservative resection.

A. Stage I gastric lymphomas (small lesions confined to the stomach wall) can be cured completely with surgical therapy alone.

B. Extensive gastric lymphomas that initially are treated with radiation and/or chemotherapy occasionally perforate during treatment and require secondary resection.

C. Patients explored with a presumptive diagnosis of gastric lymphoma should undergo an attempt at curative resection when this is safe and feasible.

D. Without a preoperative diagnosis resection for gastric mass should not be attempted unless lymphoma can be excluded.

E. Appropriate staging for primary gastric lymphoma includes bone marrow biopsy.

Answer: D

DISCUSSION: Operation alone is adequate treatment for very early-stage lymphoma, although chemotherapy is commonly added. For more advanced disease, particularly stages III and IV, preoperative radiation chemotherapy is often indicated, even though some of these patients suffer perforation during therapy and require emergent resection. Patients who undergo exploration for gastric mass without a preoperative diagnosis can safely be resected with potential for cure even if the diagnosis includes gastric lymphoma.

A. Glucocorticoid administration.

B. Respiratory failure.

C. Coagulopathy.

D. Organ transplantation.

E. Jaundice.

Answer: BC

DISCUSSION: Prophylactic measures such as H 2-receptor antagonists and antacid titration effectively reduce the incidence of gastrointestinal bleeding; however, prophylaxis against stress gastritis is expensive and may have adverse effects. Therefore, it should be used selectively in patients with high risk factors. In a prospective multicenter study in which 10 potential risk factors were evaluated for stress gastritis bleeding in ICU patients, respiratory failure and coagulopathy are two independent risk factors for clinically significant bleeding. Therefore, a strong recommendation for prophylaxis of stress gastritis can be made for ICU patients who have either respiratory failure or coagulopathy.

A. Improving systemic circulation by correcting any shocklike state resulting from blood loss or sepsis.

B. Correcting systemic acid-base abnormality.

C. Maintaining adequate nutrition.

D. Reducing intragastric acidity by either antacid titration or H 2 antagonists.

Answer: ABCD

DISCUSSION: Despite the lack of documentation, a strong impression exists among clinicians and clinical investigators that the incidence and prevalence of stress gastritis have decreased significantly during the past decade, perhaps owing to improved general care for critically ill patients. The improvement in general care of these critically ill patients includes vigorous efforts to correct any shocklike state secondary to blood loss or sepsis, better ventilatory support, and maintenance of adequate nutrition. These prophylactic measures enhance the ability of the gastric mucosa to protect itself against acid injury. In addition, several prospective, randomized studies have shown that antacid titration and/or H 2-receptor antagonists are effective in preventing gastrointestinal bleeding in these patients.

A. Subtotal gastrectomy and Roux-en-Y gastrojejunostomy.

B. Total parenteral nutrition.

C. Division of the ligament of Treitz and duodenal mobilization.

D. Percutaneous endoscopic gastrostomy.

E. Duodenojejunostomy.

Answer: BCE

DISCUSSION: Vascular compression of the duodenum is best treated initially with supportive care. Of paramount importance is supplying adequate nutrition, since most patients have significant weight loss with this syndrome. This can best be done with a nasojejunal feeding tube placed past the ligament of Treitz (and the obstructed area). Gastrostomy alone does not provide unobstructed enteral access. Parenteral nutrition may be used successfully when enteral access cannot be established. When operative therapy is needed, duodenojejunostomy has been the most common and successful operation and is the treatment of choice for adults. In the pediatric population, division of the ligament of Treitz and duodenal mobilization has also proved successful. Gastrojejunostomy has been used, but with a lower overall success rate. Distal gastrectomy usually worsens duodenal obstruction by preventing duodenogastric reflux.

A. The duodenum is obstructed in its distal third as it crosses over the lumbar vertebral column.

B. Structures crossing beneath the superior mesenteric artery include the duodenum, the uncinate process of the pancreas, and the left renal vein.

C. Hyperextension of the back allows the angle of origin of the superior mesenteric artery to widen, lessening the obstruction of the duodenum.

D. Patients are at significant risk for vascular compression of the duodenum if the angle between the takeoff of the superior mesenteric artery and the aorta is less than 45 degrees.

E. Arteriographic studies show a typical area of extrinsic compression and narrowing of the arterial lumen due to duodenal pressure.

Answer: AB

DISCUSSION: The superior mesenteric artery originates behind the neck of the pancreas at the level of the first lumbar vertebra. It arises from the aorta at an acute angle, usually about 37 degrees in normal patients, through which passes the left renal vein, the uncinate process of the pancreas, and the distal third of the duodenum. The duodenum crosses the lumbar spine from right to left and passes upward. It is at this point of passage of the duodenum upward and over the spine that the obstruction occurs. Arteriographic studies show that the aortomesenteric angle in patients with the syndrome is only about 8 degrees. There is no narrowing of the superior mesenteric artery or disturbance of arterial flow, but the area of duodenal obstruction corresponds to the compression of the bowel by the artery. The duodenal compression may often be relieved by assuming the knee-chest, the left lateral, or even the prone position. Increasing lumbar lordosis, as with hyperextension of the back, exacerbates the problem.

A. Dietary nitrites.

B. Dietary salt.

C. Helicobacter pylori infection.

D. Dietary ascorbic acid.

Answer: D

DISCUSSION: Numerous epidemiologic studies support the role of certain foods in the development of gastric cancer. Salt, which can act as a gastric irritant, and nitrates and nitrites, which can be converted to the active carcinogens N-nitrosamines, are implicated in the development of gastric cancer. H. pylori infection is associated with atrophic gastritis, a known precursor to gastric cancer. Important studies of large populations indicate that the majority of patients with gastric cancer are H. pylori positive. The bacteria produce toxins such as ammonia and acetaldehyde, which could lead to chronic inflammation and epithelial damage. Dietary ascorbic acid has been associated with overall improvements in diet and is not associated with the development of gastric cancer.

A. Pernicious anemia.

B. Multiple endocrine neoplasia type I (MEN 1).

C. Adenomatous polyps.

D. Chronic atrophic gastritis.

Answer: B

DISCUSSION: Adenomatous polyps are unusual but carry the distinct potential for malignancy. They occur most often between the fifth and seventh decades of life. The adenocarcinoma sequence in gastric polyps is thought to be analogous to that of colonic polyps. An adenomatous polyp is a marker for increased risk of carcinoma in the remaining stomach. Both pernicious anemia and chronic atrophic gastritis are associated with gastric cancer. Many of these patients develop chronic achlorhydria, a condition also associated with an increased risk of cancer. Neither multiple MEN 1 nor MEN 2, is associated with gastric cancer.

A. Distal gastric cancers are becoming more common.

B. Intestinal-type gastric tumors resemble colon carcinomas and have a better prognosis than diffuse type.

C. Early gastric cancers are confined to the mucosa and are lymph node negative.

D. Broders' histologic grading system correlates well with survival: patients with grade IV tumors have 5-year survival rates around 65%.

Answer: B

DISCUSSION: Distal gastric cancers are decreasing in incidence in several populations. Lesions of the gastroesophageal junction and cardia have increased in incidence over the past two decades. Early gastric cancers are confined to the mucosa and submucosa of the stomach. Six to 10% of these early lesions are lymph-node positive. The survival rates from early gastric cancer is related to node positivity, just as in advanced gastric cancer. Broders' histologic grades do correlate well with survival. Grade I and IV tumors are associated with a 65% and 11% 5-year survival, respectively. The Lauren classification system is divided into intestinal and diffuse-type tumors. The intestinal-type tumor is more analogous to colon carcinoma and has a better prognosis than the diffuse type.

A. Stage I.

B. Stage II.

C. Stage III A.

D. Stage III B.

Answer: B

DISCUSSION: The American Joint Committee on Cancer Staging system depends on primary tumor, lymph node involvement, and distant metastasis. The tumor described is a T2N1M0 tumor, which categorizes it as stage II.

A. Patients with tumors of the middle and proximal thirds should undergo total gastrectomy.

B. Adenocarcinoma of the cardia-gastroesophageal junction may require reconstruction in the abdomen, chest, or neck.

C. Palliative resection yields better results than palliative bypass.

D. Japanese patients who undergo gastric resection are, on average, 10 years younger and much leaner than their Western counterparts.

Answer: A

DISCUSSION: Depending on the size and extent of the tumor, cancers of the gastroesophageal junction may extend proximally into the esophagus for a varying distance. Reconstruction may be required in the abdomen, chest, or neck, depending on extension and whether the operation is to be palliative or curative. Palliative resection yields better results than palliative bypass, which is unreliable for relieving obstruction. Japanese patients typically are younger and thinner than their Western counterparts. In addition, they have a higher prevalence (up to 50%) of early gastric cancer. Depending on the size and particular location of the tumor, patients with small middle-third tumors or small lesions of the cardia may undergo subtotal proximal gastrectomy and reconstruction with a gastric tube. If 6-cm. margins can be obtained on either side of the lesion, total gastrectomy is unnecessary and may be associated with a higher risk of morbidity.

A. The 1983 Metropolitan Life Insurance Company tables for ideal body weight.

B. Hydroimmersion measurements of body fat composition.

C. Body mass index (BMI).

D. Skinfold thickness.

E. Waist to hip ratios (WHR).

Answer: C

DISCUSSION: The measurement of obesity is still an inexact science. The Metropolitan Life Insurance tables, although widely used, do not distinguish between lean muscle mass and fat. Accordingly, the BMI (weight in kg./height in meters) 2, was developed to place greater emphasis on “fatness.” The measure correlates linearly with mortality tables. Hydroimmersion data are still too sparse to relate to outcome tables. Skinfold thickness and waist-hip ratios have not been shown to have the accuracy or relevance of the BMI.

A. Intensive dieting with behavior modification.

B. A multidrug protocol with fenfluramine, phenylpropanolamine, and mazindol.

C. A gastric bypass with a 40-ml. pouch, a 10- to 20-cm. Roux-en-Y gastroenterostomy.

D. A gastric bypass with a 15-ml. pouch, a 40- to 60-cm. Roux-en-Y gastroenterostomy.

E. Daily exercise with strong emphasis on utilizing all four limbs.

Answer: D

DISCUSSION: Although the various nonsurgical measures listed in the question have proved effective for obese persons, they work only rarely for those who are morbidly obese. None have proved as effective as gastric bypass with a 15-ml. pouch and a 40- to 60-cm. Roux-en-Y gastroenterostomy.

A. The operation produced weight loss similar to that of the gastric bypass.

B. The operation produced severe metabolic disturbances, including hypocalcemia, increased bile salts and glycine synthesis.

C. Bacterial overgrowth in the bypassed segment led to liver failure.

D. The operation demonstrated that an adult human could survive with 40 to 50 cm. of small intestine.

Answer: ABCD

DISCUSSION: Unfortunately, all of the answers are true. Even though the intestinal bypass proved initially to be an effective procedure to induce weight loss, the side effects proved to be so severe that almost all of the operations had to be reversed or revised to gastric bypass to avert death from liver failure or severe illnesses due to malnutrition.

A. Diabetes mellitus.

B. Hypertension.

C. Pickwickian syndrome.

D. Failure to agree to long-term follow-up.

E. Sleep apnea.

Answer: D

DISCUSSION: The gastric bypass represents the best known therapy for diabetes mellitus, hypertension, the Pickwickian syndrome, and sleep apnea. In fact, no other therapy provides such complete control of hyperglycemia and hyperinsulinemia, reversal of hypertension, and total correction of the Pickwickian syndrome and most cases of sleep apnea. The only contraindication to bariatric surgery listed is failure to agree to long-term follow-up. The gastric bypass represents controlled malnutrition and, therefore, vitamin therapy is especially important. If patients are not followed closely, vitamin deficiencies, especially of B 6 and B 12, can develop with serious consequences including a Korsakoff-Wernicke syndrome.

A. Another bolus of crystalloids.

B. Posterioanterior and lateral chest films.

C. Obtain white cell count, differential count, and electrolyte values.

D. Call the operating room and warn them that you need to re-explore for a leak.

E. Increase her pain medication.

Answer: D

DISCUSSION: Morbidly obese patients are malnourished and brittle and have little resistance. Serious life-threatening infections may soil the peritoneal cavity without producing any sign except a persistently high pulse rate. The usual tests listed in A, B, and C, should be done, but the most likely explanation for a continued high pulse is soiling in the area of the surgery due to either a leak or contamination and development of sepsis. Because of the unreliability of clinical evaluation, the indications for re-exploration are very liberal, and this approach has saved a number of lives. The risk of such an exploration is small, whereas failure to contain the infection with lavage and drainage may be followed by a surprisingly rapid death.

A. Hypothyroidism.

B. Anemia.

C. Reactive hypoglycemia.

D. Dumping syndrome.

E. Metabolic bone disease.

Answer: BCDE

DISCUSSION: Anemia develops in as many as 30% of patients within 15 years of surgery. The cause is multifactorial and includes malabsorption of iron, folate, and vitamin B 12. A metabolic bone disease occurs in as many as 33% of patients, is similar to osteomalacia, and is probably a result of malabsorption of calcium and vitamin D. Reactive hypoglycemia occurs with rapid gastric emptying, resulting in increased glucose absorption immediately after a meal. Initially there is hyperglycemia, leading to hyperinsulinemia and subsequent rapid glucose clearance and symptomatic hypoglycemia. Dumping syndrome varies from very mild symptoms to significantly disabling ones. The severe syndrome occurs in fewer than 5% of patients. Small, frequent, dry meals of low osmolality reduces symptoms, and somatostatin analog has been of some clinical use.

Answer: a, c, d

Patients with normal esophageal length and normal esophageal body motility are best served by a transabdominal Nissen fundoplication. This is now normally done via the laparoscopic route. If the patient is very obese or requires concomitant surgery on the lung or esophageal body, the transthoracic approach is preferable. The presence of a motility disorder alters the operative strategy. If the peristaltic amplitude is low (20 mm Hg) in the distal third of the esophagus, a Nissen fundoplication would create too much resistance and lead to dysphagia. In this situation the Belsey fundoplication is a better choice. Moreover, it allows the surgeon to mobilize the esophagus to a much greater extent than is possible through the abdomen. In addition to extensive mobilization, a Collis gastroplasty can be created to produce an extra 5 cm of “neo-esophagus” around which a Belsey procedure can be added. End-stage reflux disease, for example, when there is an undilatable stricture or after previous unsuccessful anti-reflux operations or when Barrett’s esophagus leads to high grade dysplagia, is best served by esophageal replacement. The most durable substitute is the colon, and the functional results are especially good if the vagus nerves are intact.

Answer: a, b, c, d

The status of the lower esophageal sphincter (LES) has emerged as a significant factor in several long-term studies of gastroesophageal reflux disease, and serves as a predictor of a poor response to medical treatment. Barrett’s esophagus is almost always associated with a mechanically defective sphincter. Any defects in esophageal clearance which prolongs the contact time between the refluxate and the mucosa is likely to lead to increased esophageal injury. The presence of a hiatal hernia is also associated with more complications of gastroesophageal reflux disease. Finally, the composition of the reflux material also has an effect on the development of complications. In a clinical situation, complications of gastroesophageal reflux disease are more common when there is an alkaline component to the refluxate. In Barrett’s esophagus, the development of complications such as stricture and ulceration is strongly associated with increased alkaline exposure.

Answer: a, c, d

Esophageal manometry is an investigative tool in which a catheter containing pressure sensors is inserted into the esophagus and used to measure pressures in esophageal body and sphincters at rest and in response to swallowing. It is indicated in a number of clinical situations including nonobstructive dysphasia, noncardiac chest pain, and the assessment of gastroesophageal reflux disease.

The indications for manometry in patients with suspected gastroesophageal reflux are chiefly to assess the status of the LES and to identify a motility disorder of the body. A defective sphincter is predictive of a poor long-term response to medical therapy, but a good response to surgery. The presence of a motility defect profoundly alters the operative strategy in patients with GERD and should always be excluded by manometry prior to operative therapy. In assessment of the LES, three components are measured: the resting pressure, the overall length of the sphincter, and the abdominal length. A defect in the values for each of these components are determined when the lower limits of normal (fifth percentile) are determined. A defect in one or even two components of the LES may be compensated for by good esophageal body function, but when all three components are defective, excessive esophageal acid exposure is inevitable. All the pressures measured along the length of the sphincter and around its circumference during the pull-through may be treated as vectors having both magnitude and direction and hence integrated into a three-dimensional image, the volume (Vector Volume) of which is a measure of LES resistance. A Vector Volume below the fifth percentile of normal is the most sensitive measure of mechanical deficiency of the LES. The prevalence of a defective LES increases with increasing severity of GERD, being the lowest in patients without evidence of endoscopic injury and highest in patients with stricture or Barrett’s esophagus.

Answer: c

The x-ray demonstrates moderately advanced achalasia with a dilated esophagus with a narrowed tapering “bird’s beak” appearance of the distal esophagus. Achalasia is the best known primary motility disorder of the esophagus. It is characterized by failure of the esophageal body peristalsis and incomplete relaxation of the LES. It is generally thought to be caused by neuronal degeneration of the myenteric plexus of the esophageal wall, causing aperistalsis, and to loss of activity of the inhibitory neurons in the LES leading to incomplete relaxation. Patients with achalasia all have dysphagia, and most have regurgitation. Careful questioning is needed to distinguish the regurgitation from vomiting. Generally, it occurs during or at the end of a meal, and the material tastes bland rather than sour or bitter. Patients often have to leave the table to regurgitate, and are usually slow eaters.

Endoscopy frequently reveals residual liquid or food in the esophagus. Unlike a stricture, the narrowing of the lower end permits the passage of the endoscope, usually with a characteristic “popping” sensation. In every patient with presumed achalasia, it is very important to view the cardia from below with the endoscope retroflexed, as a small infiltrating gastroesophageal tumor may otherwise be missed. Manometry is required to establish the diagnosis of achalasia. The classic features on stationary manometry are: 1) Elevated LES pressure; 2) Incomplete LES relaxation; 3) Absence of esophageal body peristalsis; and 4) Positive intraesophageal body pressure. Although reports concerning the use of 24 hr pH monitoring appear in the literature, excessive acid exposure is rare.

Answer: a, e

The development of 24 hr pH monitoring was a major advance in unraveling the pathophysiology of GERD. It is now the principal method to make the diagnosis of GERD and has effectively replaced all other methods of measuring esophageal acid exposure. It is indicated in any patient with symptoms suggesting GERD, unless the symptoms are trivial, or permanently abolished by a short course of acid suppression therapy. Reflux episodes are defined as periods when the esophageal pH is less than pH 4. Normal (physiologic) reflux occurs in the form of short rapidly cleared postprandial episodes. A few episodes of long duration are more injurious than many brief episodes, even though total acid exposure time may be similar. In addition to the measurement of acid exposure, pH monitoring can also be used to detect excessive alkaline exposure (pH > 7) in the esophagus. The Bernstein test, in which hydrochloric acid is dripped into the esophagus via a nasogastric tube, is sometimes used to determine if a patient’s symptoms are reproduced by acidic exposure. It is basically a measure of esophageal mucosal sensitivity. It has been largely superseded by the use of 24 hr pH monitoring. Gastric emptying is affected by the composition and consistency of the ingested meal. Delayed gastric emptying may be an important etiologic factor in patients with GERD and a normal LES.

Answer: a, d

When patients are correctly selected and the operation performed with conformity with the basic surgical principles, long-term relief of symptoms is achieved by more than 90% of patients. A number of patterns of failure, however, can occur. The so-called Slipped Nissen may develop when the upper stomach rides up through the fundoplication, and causes both dysphagia and heartburn. It is more likely that the condition was created at the time of surgery because the surgeon did not mobilize the fundus, or because unrecognized esophageal shortening led to inadequate mobilization of the gastroesophageal junction, causing the surgeon to wrap the stomach around the upper stomach rather than the lower esophagus. Creating too tight a fundoplication leads to immediate postoperative dysphagia. Manometry shows a high pressure nonrelaxing sphincter which may be difficult to distinguish from achalasia. Such patients highlight the importance of manometry in all patients before proceeding with anti-reflux surgery. In a patient with normal preoperative motility, the cause is usually a fault in technique, and can be prevented by constructing the fundoplication over a 60 F Bougie. Disruption of the fundoplication that manifests clinically and physiologically by recurrent reflux can be caused by inadequate suture technique, unrecognized esophageal shortening leading to tension on the wrap, or poor choice of operation. All partial fundoplications, such as the Toupet procedure are more prone to disruption than a Nissen. This is because the integrity of the repair depends on sutures to the esophageal wall and not the stomach, and because all these repairs require much more abdominal length of esophagus than a Nissen, thus placing the repair under tension. Esophagectomy and esophageal replacement are occasionally indicated in the treatment of advanced GERD. The indications for esophagectomy are Barrett’s esophagus with high grade dysplasia and what is generally described “burned out esophagus” which includes failure of a third anti-reflux operation, a severe coexistent motility disorder, or the presence of an undilatable stricture. Either colon or stomach may be used to replace the esophagus. Colonic replacement is more difficult, requiring three anastomoses rather than one, but it has superior functional long-term results.

Answer: b, c, d

Endoscopy is generally the first investigation in patients with foregut symptoms. The exception is when the patient’s chief complaint is dysphagia, when a “road map” should first be obtained by a barium swallow. The locations of the esophageal landmarks are measured endoscopically from the incisor teeth. Three landmarks are measured in the region of the cardia: the level of the crura, the level of the anatomic gastroesophageal junction, and the level of the squamo-columnar junction (Z line). A hiatal hernia is present when the gastroesophageal junction is more than 2 cm above the crura. Barrett’s esophagus is suggested when the squamo-columnar junction is more than 2 cm above the gastroesophageal junction but may be diagnosed if any specialized epithelium is identified above the gastroesophageal junction histologically, regardless of measured length of the columnar segment. Three areas of esophageal narrowing are frequently noted on both barium esophogram and endoscopy. The first narrowing is at the site of the cricopharyngeus muscle. The left mainstem bronchus and aortic arch caused narrowing of the middle third of the esophagus. The most distal narrowing of the esophagus is at the diaphragmatic hiatus and is caused by the lower esophageal sphincter mechanism. These normal points of narrowing tend to retard swallowed foreign objects. Also, corrosive liquid ingestion results in prominent mucosal injury at these sites as the liquid is slowed at passage. CT scan of the esophagus is important in delineating the relationship of esophageal lesions to adjacent structures, especially the trachea, left main bronchus and aorta. The esophagus normally appears as a flattened hollow structure with a thin wall. A more circular cross-sectional appearance with a fluid level is evidence of distal obstruction.

Answer: b, c

The first requirement for consideration of anti-reflux surgery is the objective demonstration of the presence of GERD by 24-hour pH monitoring. Secondly, the patient must have either symptoms or complications of the disease. Thirdly, the disease should be caused by defect appropriate to surgical therapy, i.e., a mechanically defective sphincter. Some patients with increased acid exposure and a mechanically defective sphincter, and who have no complications of the disease respond well to medical therapy, but they require long-term medication for continued relief. These patients should be given the option of surgery as a cost effective alternative.

Atypical symptoms of reflux such as respiratory manifestations often respond well to anti-reflux surgery. When respiratory symptoms are combined with typical symptoms such as heartburn and regurgitation, the results of anti-reflux surgery are generally good.

Complaints of epigastric pain, nausea, vomiting, and loss of appetite may be due to excessive duodenogastric reflux which occurs in about 11% of patients with gastroesophageal reflux disease. This problem is usually, but not invariably, confined to patients who have previous upper gastrointestinal surgery. The coexistence of these gastric symptoms in a patient who also has typical symptoms of GERD should prompt a thorough evaluation of the stomach using a bile probe, 24 hour pH monitoring or radionucleotide scanning. In such patients, the correction of only the incompetent cardia can result in a disgruntled individual who continues to complain of nausea and epigastric pain on eating.

Answer: a, b, d

Disorders of the pharyngoesophageal phase of swallowing result from a discoordination of the neuromuscular events involved in chewing, initiation of swallowing, and propulsion of the material from the oropharynx to the cervical esophagus. The commonest causes of pharyngoesophageal dysphagia are neuromuscular diseases. The most important are cerebrovascular disease, myasthenia gravis, Parkinson’s disease, multiple sclerosis and muscular diseases such as myotonic dystrophy and polymyositis. In neuromuscular diseases, dysphagia is often worse for liquids than for solids. Choking, repetitive pneumonia, nasal regurgitation and hoarseness are also prominent features. The surgeon’s role in the treatment of cricopharyngeal disorders is to reduce outflow resistance by performing a cricomyotomy. Initially this was recommended only for patients with demonstrable failure of the upper esophageal sphincter relaxation. More recently, a number of reports indicate a wide variety of neuromuscular diseases that may be improved by cricomyotomy. The surgical options in Zenker’s diverticulum are either excision or suspension. Excision is sometimes recommended on the grounds that malignant change in the sac is prevented, but there is no evidence that excision carries any greater protective role than suspension, which effectively prevents stagnation of food material, thus removing the presumed cause of malignant change. Suspension also removes the risk of contamination of the operative site, the risk of subsequent breakdown of the closure site with fistula formation, and the risk of narrowing of the esophagus. In either case, recurrence is likely if cricomyotomy is not performed, because the underlying defect which predisposes to the diverticulum persists. All operations on the cervical esophagus carry the risk of hematoma formation and recurrent nerve paralysis. The venous pumping action of the lung can cause the development of a large hematoma in the mediastinum postoperatively, therefore meticulous hemostasis is critical for the performance of this operation.

Answer: a, c, d

Barrett’s esophagus is now recognized as a complication of advanced gastroesophageal reflux disease. The histologic hallmark of Barrett’s esophagus is the presence of “specialized” columnar epithelium, which shows features of intestinal metaplasia, easily recognized by the presence of goblet cells. The presence of specialized epithelium is now regarded as the pathonomonic feature of Barrett’s esophagus regardless of how high it extends into the esophagus. Barrett’s esophagus may exist on its own, or may be itself associated with ulceration, stricture, and malignant change. Once Barrett’s epithelium is present, medical therapy or anti-reflux surgery rarely causes it to regress. Unless it is actually ablated, for example with laser therapy, it persists. The most significant feature of Barrett’s esophagus is its malignant potential. The metaplastic epithelium usually undergoes dysplastic change prior to becoming frankly neoplastic. High grade dysplagia is synonymous with carcinoma in situ, and if the esophagus is removed for such a condition, up to 50% will demonstrate foci of invasive carcinoma.

In the past, the pathophysiology of Barrett’s esophagus was associated with alkaline reflux on esophageal pH monitoring. However, more recently using a bile sensor for monitoring bilirubin, this condition is frequently associated with excessive bile in the esophagus. Repetitive injury from noxious gastric juice can lead during the repair process to mutations in the p53 gene. Patients with adenocarcinoma arising in Barrett’s esophagus have a high incidence of p53 mutations.

Answer: d

The blood supply and venous drainage of the esophagus are largely segmental. The inferior thyroid artery provides the main blood supply to the cervical portion of the esophagus. The thoracic portion of the esophagus receives its blood supply from two sources; branches from two or three bronchial arteries provide the proximal arterial supply and branches directly from the aorta supply the more distal thoracic esophagus. Intrathoracic mobilization of the esophagus during performance of anti-reflux procedures often require ligation of these branches. The venous plexus in the submucosa collects capillary blood and delivers it into a periesophageal venous plexus. The left gastric vein or coronary vein provides the principal collateral in portal hypertension when esophageal varices develop. The submucosal veins become much more superficial in the most distal esophagus, 1–2 cm above the gastroesophageal junction, and are consequently the most common site of bleeding in portal hypertension.

The lymphatics of the esophagus form a rich submucosal network draining into regional lymph nodes in the periesophageal connective tissue. There is thus little barrier to longitudinal spread of cancer in the esophagus. Lymphatic drainage from the upper two-thirds of the esophagus is usually cephalad, but drainage from the lower one-third is in both directions. Although lymphatic metastasis in the esophagus generally involve the regional lymph nodes in proximity, nodal involvement may occur several centimeters away from the primary lesion because of the rich intramural lymphatic anastomotic channels. When a carcinoma is limited to the mucosa, the incidence of lymphatic metastases is low, but once into the submucosa, the incidence rises to 60%.

Answer: a, c

The cricopharyngeus muscle is a continuation of the inferior constrictor of the pharynx and receives its innervation via both the right and left recurrent laryngeal nerves. Although much attention is given to vocal cord dysfunction that accompanies recurrent laryngeal nerve damage, it is clear that cricopharyngeal sphincter dysfunction and motility problems of the cervical esophagus can occur with injury to these nerves. Serious aspiration following recurrent nerve injury is caused not only by the cricopharyngeal dysfunction, but also by additional morbidity incurred because of the inability to close the glottis during swallowing and loss of the protection afforded by effective coughing. Clinically, peristaltic defects of the esophageal body fall into one of to broad categories. One category is characterized by a defect in organization of peristaltic waves, and is primarily a neural phenomenon. The other notable defect is reduction of the power (amplitude) of peristalsis and is usually due to muscle damage secondary to severe reflux or replacement with fibrous tissue as happens in scleroderma and other connective tissue diseases or with severe reflux. The LES provides a pressure barrier between the esophagus and stomach. The sphincter normally remains actively closed to prevent reflux of gastric contents into the esophagus. Relaxation of the LES is mediated by inhibitory neurons. It occurs either to allow entry of food, or to allow exit of air during belching. The ability of the LES to remain closed in the face of a pressure gradient tending to promote reflux of gastric contents from the positive pressure environment of the stomach into the negative pressure environment of the chest depends on several features. The most significant is the resting pressure. However, of equal importance is the ability of the LES to respond to variations in intra-abdominal pressure associated with daily activities. Such elevations would normally be transmitted to the sphincter, causing it to collapse and remain closed, provided sufficient length of the sphincter remains exposed to the abdominal pressure and the compressive effect of the crura. The abdominal length is often reduced in hiatal herniation, because of attenuation of the pharyngoesophageal membrane. The overall length of the LES is also an important determinant of competence, much as the total resistance of a series of resisters in a circuit is the sum of the individual resistances. A mechanically-defective sphincter, however, is not always associated with increased esophageal acid exposure because it may be compensated by the clearance function of the esophageal body. The role of the esophageal body in limiting acid reflux is related to its ability to clear the esophagus of acid. This clearance has two components: volume clearance which requires peristalsis, and chemical clearance which requires saliva.

Answer: a, e

The mainstay of treatment in achalasia is either balloon dilatation or surgery. Balloon dilatation has an advantage that it can be performed as an outpatient and has minimal recovery time. It is less likely to be effective than surgical treatment, and frequently needs to be repeated. The risk of perforation of the lower esophagus is higher with this procedure than with any other form of esophageal instrumentation and varies from 2–10%. The risk of gastroesophageal reflux following dilatation is not known, but symptomatically the risk appears to be low.

All surgical procedures employ a variant of Heller’s myotomy, in which the circular muscle of the lower esophagus is divided. In the United States, most myotomies are carried out through the chest, but the abdominal approach is favored in Europe. Regardless of the route chosen, four key principles are important, namely: 1) adequate myotomy, 2) minimal hiatal disturbance, 3) anti-reflux protection without creation of obstruction, and 4) prevention of rehealing. The advent of minimally invasive surgery has led to the development of thorascopic and laparoscopic myotomy, and these are now being extensively performed with comparable results to open surgery. There is broad agreement that if a myotomy is performed through the abdomen, an anti-reflux procedure should be added, and that a full Nissen wrap, however floppy, leads to long-term failure. When approached through the chest, there is controversy about the need for an anti-reflux procedure, as it is claimed that less hiatal disturbance and more limited myotomy is possible by this route. Thoracoscopic myotomy, with enhanced view, enables a more precise determination of the distal myotomy and therefore may not require a anti-reflux procedure.

A single pneumatic dilatation achieves adequate relief of dysphasia and pharyngeal regurgitation in about 60% of patients. Repetitive dilatations increase this figure to about 70%. Only one controlled randomized study comparing the two modes of therapy has ever been performed. The results of this study as well as a number of retrospective studies would appear to support operative myotomy as the initial treatment of choice.

Answer: b

A detailed knowledge of the relations of the esophagus is essential for the surgeon to be able to identify the site and significance of lesions seen by indirect studies such as endoscopy, contrast radiography, and CT scanning, as well as the safe performance of surgical procedures. The cervical esophagus is about 5 cm long. It begins at the level of C6 and extends to the lower border of T1, curving slightly to the left in its descent. Consequently, although the surgical approach to this portion of the esophagus may be from either side of the neck through an incision along the anterior border of the sternocleidomastoid muscle, the left side is chosen if possible. Above the level of the tracheal bifurcation, the esophagus moves to the right of the descending aorta. It then moves to the left, passes behind the tracheal bifurcation and the left main bronchus and descends to the diaphragm. In the lower third, the esophagus courses anteriorly and to the left to pass through the diaphragmatic hiatus. The lower esophagus is covered only by a flimsy mediastinal pleura on the left, and it is this portion which is most commonly the site of spontaneous perforation in Boerhaave’s syndrome. In general, the lower esophagus is most easily approached through the left chest, but access to the supra-aortic esophagus is restricted. Thus, a left thoracotomy is most useful for performing procedures involving the lower esophagus. However, access to the entire thoracic esophagus can be obtained only from the right chest. This incision, however, limits access to intraabdominal organs by the position of the liver and therefore normally requires a separate upper abdominal incision. The abdominal esophagus begins as the esophagus enters the abdomen through the diaphragmatic hiatus. It is surrounded by a fibroelastic membrane, the phrenoesophageal ligament which arises from the subdiaphragmatic fascia. The lower limit of the pharyngoesophageal membrane anteriorly is marked by a prominent fat pad, which corresponds to the gastroesophageal junction. The lower esophageal sphincter (LES) is a zone of high pressure 3–5 cm long at the lower end of the esophagus. Although it does not correspond to any macroscopic anatomical structure, its function appears to be related to the microscopic architecture of the muscle fibers.

Answer: a, b

The barium esophogram of these two patients shows diffuse esophageal spasm resulting in a cork screw esophagus with multiple contractions. See Fig. 18-35. These primary motor disorders are characterized by substernal chest pain. In the nutcracker variety, as demonstrated in this x-ray, the pain is central crushing pain with no relation to food ingestion and differs from angina in that it more frequently comes on at rest. Dysphagia or classic heartburn may be present but tend to be overshadowed by the chest pain. Barium radiography and endoscopy are generally not helpful. The pathognomic feature of manometry is the presence of prolonged high amplitude waves, with a peak greater than 180 mm Hg. Diffuse esophageal spasm and nutcracker esophagus are benign conditions which rarely cause nutritional problems and do not lead to life-threatening complications. For this reason, symptom control is the only significant goal of treatment. Medical treatment for diffuse esophageal spasm and nutcracker esophagus is focused on abolishing strong simultaneous contractions and generally employs calcium channel blocking agents or long-acting nitrates. Surgery for these conditions are generally only considered when medical treatment is ineffective.

Answer: a, c

Ninety percent of acquired fistulas between the esophagus and tracheobronchial tree in adults are the result of malignant disease. Tracheoesophageal fistulas complicate the course of disease in about 5% of patients who have esophageal carcinoma. Nearly 80% of patients with malignant tracheoesophageal fistulas die within three months of the onset of symptoms and in 85% of these patients, the cause of death is aspiration pneumonia, not distant metastatic disease. For the most part, malignant tracheoesophageal fistula represents incurable disease for which resection carries significant mortality and is seldom indicated. Palliative relief of recurrent aspiration is the aim of therapy. Effective occlusion of the fistula may be achieved by insertion of one of a variety of available endoesophageal endoprostheses. These tubes are placed into the esophagus with the aid of an esophagoscope and may occlude the esophageal side of the fistula sufficiently to allow swallowing of liquids without aspiration into the tracheobronchial tree. More recently, expandable metal stents have been used successfully in the treatment of malignant tracheoesophageal fistulas.

Nonmalignant fistulas result from the erosion by contiguous infected subcarinal mediastinal lymph nodes; trauma; late sequelae of chronic mid-esophageal traction diverticulum; or erosion by an endotracheal or tracheostomy tube cuff in a patient requiring prolonged ventilatory support. Small fistulas, such as resulting from an endotracheal intubation injury, are approached through a cervical collar or oblique incision anterior to the sternocleidomastoid muscle. Although such cuff injuries usually produce circumferential tracheal damage which necessitates a tracheal resection, this can also be performed through a cervical collar incision.

Answer: b, d

Embryologically, the esophagus is lined by simple columnar ciliated epithelium, which is eventually replaced by stratified squamous epithelium. The esophageal cyst may therefore contain both of these types of epithelium as well as fat and smooth muscle. The esophageal duplication cyst is a variation of the foregut cyst, extends along the length of the thoracic esophagus, and is lined by squamous epithelium. More than 60% of esophageal cysts cause either respiratory or esophageal symptoms in the first year of life. Those located in the upper third of the esophagus tend to present in infancy, while the lower-third cyst may be asymptomatic initially and present later in childhood. Adults present with dysphasia, choking, retrosternal pain when previously asymptomatic cysts enlarge as the result of bleeding or infection. The diagnosis of an esophageal cyst can usually be made on the basis of atypical radiographic appearance. The PA and lateral chest x-ray, barium esophogram, and in some cases a CT scan, will confirm the diagnosis in almost all patients. Because esophageal cysts have a predilection for bleeding, ulceration, perforation, and infection, excision is generally recommended. This can generally be achieved with low morbidity by an extramucosal resection.

Answer: d

Chronic debilitation, immunosuppression, and prolonged use of antibiotics predisposes the development of infectious esophagitis with candida albicans being the most common cause. Candida albicans is a fungus that normally is a commensal inhabitant of the mouth, oral pharynx, and GI tract. This fungus may become pathogenic in patients who are severely debilitated or immunosuppressed. In recent years, the use of broad spectrum antibiotics, immunosuppression in organ transplant patients, and the wide use of chemotherapeutic agents have resulted in an increased number of patients with monilial esophagitis. As the disease progresses, transmural invasion of the esophageal wall occurs. Although the esophagitis can be controlled with antifungal therapy, if the patient survives the underlying illness, chronic stricture formation may result after healing. Minimally compromised patients with mild monilial esophagitis should receive oral nystatin suspension as a primary treatment. More immunosuppressed patients or those with severe cases warr