Boerhaave Syndrome- Barotrauma of esophagus

Q) Correct statement about Boerhaave syndrome is
A. May present with peritonitis
B. Forceful vomiting against open glottis
C. MOst common in upper 1/3 rd of esophagus
D. Most are managed conservatively

Answer for premium 

Esophagus Length DNB 2018

Q) Length of Esophagus

 A. 20cm
B. 25cm
C. 30-35cm
D. 40cm


Answer

29) b

The esophageal length is anatomically defined as the distance between the cricoid cartilage and the gastric
orifice. It ranges in adults from 22 to 28 cm (24
± 5 SD), 3 to 6 cm of which are located in the abdomen.

The shortest distance between the cricoid cartilage and the celiac axis is the orthotopic route in the posterior mediastinum, being 30 cm. The retrosternal (32 cm) and the subcutaneous route (34 cm) proved to be
longer

Ref Shackelford page 10

anatomy of esophagus

Q Which of the following is true about anatomy of esophagus?
A. Oesophageal hiatus is superior to aortic hiatus
B. Thoracic duct crosses esophagus at T3-T4level at the level of azygos vein arch
C. Laimer triangle is superior to the Killians triangle

D. In the mediastinum right vagus runs anteriorly and left vagus runs posteriorly

Answer

Post op chyle leak

Q 27 Postoperative chyle leak following esophagectomy which is true?
A. Intraoperative prophylactic ligation of thoracic duct reduce leak risks
B. Conservative management - almost all heal by 3 weeks
C. Transthoracic ligation only
D. Conservative treatment includes antibiotics, enteral nutrition only

Answer 

 

Oropharyngeal dysphagia

 Oropharyngeal dysphagia false is
A. Nasal twang in voice, ptosis
B. Treatment is most often not satisfactory if conservative
C. Associated with myesthenia gravis and Parkinsonism
D. Water brasch and regurgitation presentation

Answer 

Chyle leak after esophagectomy

Q After  esophagectomy ICD draining 800 – 1000ml chyle 5-7 days post operatively. Next management

a) NPO, TPN

b) Enteral feeding with medium chain

c) Re explore and suture the defect

Answer free 

c

Once the diagnosis is made, one should ensure the pleural space is completely evacuated; if needed, drainage is done by a chest tube or a radiologically directed catheter placement.

Feedings are stopped and total parenteral nutrition (TPN) is started. The amount of chest tube output is then monitored for several days in order to make a decision about the possible need for reoperation. Small leaks can seal with nonoperative therapy. Large initial daily outputs (typically greater than 1 L/day) often fail nonoperative therapy and require reoperation. An absolute amount of drainage for prediction of failure is unknown and one should consider also if there is a gradual reduction in daily output to continue with conservative therapy.

If the drainage is less than 500 mL per day and slowly decreasing, continued conservative therapy is frequently successful. Continued volumes more than 1 L after 2 days of TPN is a good indication of the need for reoperation. In general, it is better to be more rather than less aggressive in returning to the operation theater with a chylothorax. It was more common after THE and was associated with longer intensive care unit (ICU) and hospital stays. There was no difference in mortality between those with and without a chylothorax.

Patients with initial drainage exceeding 2 L within 2 days of starting conservative treatment all required reoperation.

Esophagus Perforation

Q) Elderly healthy male with impacted denture. Removed endoscopically. Pt developed fever, dyspnoea and respiratory distress over 24 hrs. X-ray revealed Lt hydrothorax and mediastinal emphysema.

a) ICD and NG feeds

b) ICD and TPN

c) Cervical esophagectomy, FJ, debridement, ICD

d) Debridement, primary repair with buttress and ICD

Premium answer

Management of GERD

Q. 40 yr old lady with symptoms of GERD. Endoscopy shows hiatus hernia. Symptoms controlled with PPI. Next step

a) Leave alone

b) Manometry with Ph study

c) Ba swallow with Manometry

d) Ba swallow with Ph study

Answer

Modified Nissen’s fundoplication

Q ) Modified Nissen's Fundoplication

a) 2700 anterior wrap around esophagus

b) 2400 wrap

c) 3600 wrap over > 52 Fr for 1 – 2 cm

d) 600 wrap over 42 Fr for 4 cm

Answer

c

Nissen fundoplication is complete 360 degree but has high incidence of gas bloat. To counter this modification done to wrap over 52 F tube for 1-2 cm

Belsey - Left thoracotomy, mobilization of distal esophagus and stomach, hiatus opened from above,  fundus is brought 270 degrees around distal esophagus. Then the whole assembly is brought down and crura is repaired.

Hill procedure - No fundoplication is done

Toupet is anterior fundoplication either 240 degree or 270 degree.

 

Foreign body esophagus

Q) True about foreign body in esophagus

a) Sharp objects should be operated and not retrieved

b) Lead batteries should be removed

c) Most common impacted foreign bodies are dentures

d) Contrast examination of esophagus should be done before endoscopy

 

Answer

b

Sharp objects can be removed over overtubes and not always require surgery. Lead batteries can corrode and decay in the stomach or intestine and should always be removed. Most common impacted foreign bodies are food boluses above a pathological narrowing and require endoscopic break up

Contrast examination is not always required and might complicate things

Bailey page 991