The optimal treatment of an incidentally discovered 3 em leiomyoma of the upper esophagus in a 45-year-old otherwise healthy man is?
Despite their slow growth and limited potential for malignant degeneration, leiomyomas should be removed unless there are specific contraindications. The majority can be removed by simple enucleation. If, during removal, the mucosa is inadvertently entered, the defect can be repaired primarily. After tumor removal, the outer esophageal wall should be reconstructed by closure of the muscle layer. The location of the lesion and the extent of surgery required will dictate the approach. Lesions of the proximal and middle esophagus require a right thoracotomy, whereas distal esophageal lesions require a left thoracotomy. Videothoracoscopic and laparoscopic approaches are now frequently used. The mortality rate associated with enucleation is low, and success in relieving the dysphagia is near 100%. Large lesions or those involving the GEJ may require esophageal resection.
Following a night of heavy drinking, a 43-year-old otherwise healthy man has sudden onset of severe chest pain after vomiting. Esophagram confirms esophageal rupture just proximal to the GEJ. What is the preferred operative exposure?
The key to optimum management is early diagnosis. The most favorable outcome is obtained following primary closure of the perforation within 24 hours, resulting in 80 to 90% survival. The most common location for the injury is the left lateral wall of the esophagus, just above the GEJ. To get adequate exposure of the injury, a dissection similar to that described for esophageal myotomy is performed. A flap of stomach is pulled up and the soiled fat pad at the GEJ is removed. The edges of the injury are trimmed and closed primarily. The closure is reinforced with the use of a pleural patch or construction of a Nissen fundoplication.
A 34-year-old man presents to the emergency department (ED) after an episode of hematemesis. EGD confirms a Mallory-Weiss tear with no residual bleeding. Treatment should consist of:
Mallory-Weiss tears are characterized by arterial bleeding, which may be massive. Vomiting is not an obligatory factor, as there may be other causes of an acute increase in intraabdominal pressure, such as paroxysmal coughing, seizures, and retching. The diagnosis requires a high index of suspicion, particularly in the patient who develops upper gastrointestinal (GI) bleeding following prolonged vomiting or retching. Upper endoscopy confirms the suspicion by identifying one or more longitudinal fissures in the mucosa of the herniated stomach as the source of bleeding.
In the majority of patients, the bleeding will stop spontaneously with nonoperative management. In addition to blood replacement, the stomach should be decompressed and antiemetics administered, as a distended stomach and continued vomiting aggravate further bleeding. A SengstakenBlakemore tube will not stop the bleeding, as the pressure in the balloon is not sufficient to overcome arterial pressure. Endoscopic injection of epinephrine may be therapeutic if bleeding does not stop spontaneously. Only occasionally will surgery be required to stop blood loss. The procedure consists of laparotomy and high gastrotomy with oversewing of the linear tear. Mortality is uncommon, and recurrence is rare.
Successful treatment of a Zenker diverticulum involves:
When a pharyngoesophageal diverticulum is present, localization of the pharyngoesophageal segment is easy. The diverticulum is carefully freed from the overlying areolar tissue to expose its neck, just below the inferior pharyngeal constrictor and above the cricopharyngeus muscle. It can be difficult to identify the cricopharyngeus muscle in the absence of a diverticulum. A benefit of local anesthesia is that the patient can swallow and demonstrate an area of persistent narrowing at the pharyngoesophageal junction. Furthermore, before closing the incision, gelatin can be fed to the patient to ascertain whether the symptoms have been relieved, and to inspect the opening of the previously narrowed pharyngoesophageal segment. Under general anesthesia, and in the absence of a diverticulum, the placement of a nasogastric tube to the level of the manometrically determined cricopharyngeal sphincter helps in localization of the structures. The myotomy is extended cephalad by dividing 1 to 2 em of inferior constrictor muscle of the pharynx, and caudad by dividing the cricopharyngeal muscle and the cervical esophagus for a length of 4 to 5 em. If a diverticulum is present and is large enough to persist after a myotomy, it may be sutured in the inverted position to the prevertebral fascia using a permanent suture (ie, diverticulopexy). If the diverticulum is excessively large so that it would be redundant if suspended, or if its walls are thickened, then a diverticulectomy should be performed. This is best performed under general anesthesia by placing a Maloney dilator (48F) in the esophagus, after controlling the neck of the diverticulum and after myotomy. A linear stapler is placed across the neck of the diverticulum and the diverticulum is excised distal to the staple line. The security of this staple line and effectiveness of the myotomy may be tested before hospital discharge with a water soluble contrast esophagogram. Postoperative complications include fistula formation, abscess, hematoma, recurrent nerve paralysis, difficulties in phonation, and Horner syndrome. The incidence of the first two can be reduced by performing a diverticulopexy rather than diverticulectomy.
Which of the following disorders involves simultaneous nonperistaltic contractions of the esophagus?
The classic manometric findings in these patients are characterized by the frequent occurrence of simultaneous waveforms and multipeaked esophageal contractions, which may be of abnormally high amplitude or long duration (Table below). Key to the diagnosis of diffuse esophageal spasm (DES) is that there remain some peristaltic waveforms in excess of those seen in achalasia. A criterion of 30% or more peristaltic waveforms out of 10 wet swallows has been used to differentiate DES from vigorous achalasia. However, this figure is arbitrary and often debated.
The LES in patients with DES usually shows a normal resting pressure and relaxation on swallowing. A hypertensive sphincter with poor relaxation may also be present. In patients with advanced disease, the radiographic appearance of tertiary contractions appears helical, and has been termed corkscrew esophagus or pseudodiverticulosis. Patients with segmental or DES can compartmentalize the esophagus and develop an epiphrenic or midesophageal diverticulum between two areas of high pressure occurring simultaneously.
Manometric characteristics of the primary esophageal motil ity disorders:
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