1. Esophagus
Pimp Session…

2. The esophagus has no _______.
Serosa.

3. It has an inner ____ muscle layer and an outer _____ muscle layer.
Circular
Longitudinal

4. Surgical approach to the upper thoracic esoph is via what incision?
Right thoracotomy – avoids the aorta

5. Surgical approach to lower thoracic esoph?
Left thoracotomy

6. Thoracic duct drains into what?
Left subclavian vein

7. What is the conservative management of a thoracic duct leak?
NPO, TPN, give short and medium FAs, avoid long chain FAs.
Short and medium chain fatty acids enter the portal system directly.
Long chain fatty acids enter the lymphatics and travel via the thoracic duct

8. Abdominal esoph is supplied by what arteries?
Left gastric
Inferior phrenics

9. The cervical esophagus is supplied by what artery?
Inferior thyroid artery

10. Normal LES pressure?
10-20 at rest

11. Most common site of esoph perforation during EGD?
Cricopharyngeus muscle

12. 3 anatomic narrowings: Cricopharyngeus muscle
Compression of L mainstem bronchus and aortic arch
Diaphragm

13. Aspiration with brainstem stroke is caused by what?
Failure of UES to relax

14. Normal UES pressure at rest?60

15. Normal LES pressure at rest?15

16. Procedure of choice to eval dysphagia?
Barium swallow

17. Plummer Vinson syndrome
Cervical esophageal dysphagia
Cervical esoph web
Fe-def anemia
Treat with dilation and Fe

18. Treatment of Zenker’s Diverticulum?
Cricopharyngeal myotomy

19. Achalasia gives you an increase risk of what kind of cancer?
Squamous cell

20. Achalasia Dec ganglion cells, Auerbach’s plexus
Aperistalsis, Failure of LES to relax
Bird’s beak on Ba swallow
Tx: lap vs thoracoscopic Heller myotomy

21. What is the main blood supply to stomach when performing a transhiatal esophagectomy?
Right gastroepiploic artery

22. What type of cancer is associated with Barrett’s?
Adenocarcinoma

23. What’s the difference between Mallory Weiss and Boerhaave’s?
Mallory Weiss – esoph tear, usually from retching (not rupture) leads to bleeding.
Boerhaave’s – esoph perf

24. What do you see on manometry for DES?
Hypertonic, simultaneous contractions

25. What do you see on manometry for Nutcracker?
Normal peristalsis
High amplitude and duration of contractions.

26. What do you see on manometry for DES?
Hypertonic, simultaneous contractions

27. What do you see on manometry for Nutcracker?
Normal peristalsis
High amplitude (>180 mm Hg) and duration of contractions (>6 sec).

28. What is pseudoachalasia?
Cancer, distal stricture, or tumor of cardia mimicking achalasia.

29. Alkali esoph: ______ necrosis
Liquefactive necrosis – worse than acid

30. Acid injury - ______necrosis
Coagulative

31. How hypertensive is a “hypertensive LES”?
>45 mm Hg

32. What’s the manometry for “Vigorous” Achalasia?
Partial or absent LES relaxation
And
Repetitive simultaneous contractions (like DES)

33. What are the indications to operate on paraesophageal hernias?
Ha Ha – trick question!!
Presence of paraesoph hernia is the indication to fix it operatively, for the purpose of the ABSITE.

34. GISTs – mutation of what oncogene...
C-kit

35. What esoph leiomyomas get operated on?
>5 cm
Symptomatic

36. What surgery do you do?
Enucleation

37. What’s the treatment for high-grade dysplasia?
Esophagectomy
After dx confirmed by 2 pathologists.

38. Type I-IV hernias? I – sliding hernia
II – paraesophageal (nml GE junction)
III - combined
IV – colon, spleen or some other organ

39. Where is a Schatzki’s ring?
Distal esophagus
Assoc with hiatal hernia and GERD
Treat with dilation, may need antireflux procedure.

40. Where’s a vascular ring?
Abnormality causing a vascular ring external to and compressing the esophagus (or trach)– treat with ligation.

41. What is the gold-standard test for GERD?
pH probe

42. What causes epiphrenic diverticula?
Esoph motility disorder
Distal 10 cm of esoph
Treat with diverticulectomy and long esoph myotomy on the opposite side.

43. Procedure to lengthen esophagus?
Collis gastroplasty

44. Mechanism of action of omeprazole?
Blocks H/K ATPase

45. Type I error Rejects null hypothesis incorrectly
Falsely assume there is a difference when no difference exists.

46. Type II error: Accepts null hypothesis incorrectly.
Because of small sample size
Treatments are interpreted as equal when there is actually a difference.

47. Type III error
Conclusions not supported by data

48. Null hypothesis:
Hypothesis that no difference exists.

49. 95% Confidence Interval – when is it not statistically significant.
If it includes 1 – it is NOT statistically significant.
The farther from 1 the greater the correlation.

50. Most frequently occurring value...
Mode

51. Middle value of set of data – (50th %ile)
Median

52. 2 types of qualitative variables...
Nominal
Named – (color)
Ordinal
On a scale – (pain from 1-10)

53. Prevalence
# of people having disease in population

54. Incidence
# of newly diagnosed cases in a population over period of time (usually a year)

55. What’s power? Probability of making the correct conclusion.
1 – probability of Type II error
Larger sample size increases power of test.

56. What’s relative risk?
Incidence in exposed/incidence in unexposed.

57. What’s sensitivity? Ability to detect disease. TP/(TP+FN)
Positive test
Negative test
Has disease TP FN
No disease FP TN
What’s sensitivity?
Ability to detect disease.
TP/(TP+FN)

58. What’s specificity? Ability to state that no disease was present
Positive test
Negative test
Has disease TP FN
No disease FP TN
What’s specificity?
Ability to state that no disease was present
TN/(TN+FP)

59. What’s PPV?
Positive test
Negative test
Has disease TP FN
No disease FP TN
Likelihood that with a positive result, the patient actually has the disease.
TP/(TP+FP)

60. Positive test
Negative test
Has disease TP FN
No disease FP TN
What’s NPV?
Likelihood that with a negative result the patient really doesn’t have disease.
TN/(TN+FN)

61. What’s accuracy? (TP+TN)/(TP+TN+FP+FN) Positive test Negative test
Has disease TP FN
No disease FP TN
What’s accuracy?
(TP+TN)/(TP+TN+FP+FN)

62. Esoph cancer with palpable supraclavicular node. What’s the treatment?
M1 disease – unresectable
Chemoradiation.

63. Clinical signs of unresectability for esoph cancer?
Hoarseness, Horner’s syn, phrenic nerve involvement, malignant pleural effusion, malignant fistula, airway invasion, vertebral invasion.