Surgery of Esophagus- Free Esophagus test questions

Q1. The usual incision given for surgery of Zenker's diverticulum of esophagus is

a) Left Cervical incision

b) Right Cervical

c) Suprahyoid

d) Midline

Q2. In Transhiatal Vs Trans thoracic esophagectomy most common complication associated with THE (Trans Hiatal esophagectomy) is

a) Pulmonary complications

b) Anastomotic leak

c) Bleeding

d) Injury to recurrent laryngeal nerve

Q3.Which is the most disabling complication after three field esophagectomy?

a) Bronchorrhoea

b) Recurrent laryngeal nerve palsy

c) Tracheal stenosis

Q4. What is the most common complication after esophagectomy

a) Arrythmia

b) Pulmonary Collapse and Consolidation

c) Recurrent laryngeal nerve injury

d) Massive bleeding

Q 5.Most valuable investigation for preoperative evaluation of extensive corrosive stricture is

a) Endoscopic ultrasound

b) Barium study

c) CT Thorax

d) Pharyngoscopy

Answers

All references are from

1. a

The pharyngoesophageal diverticulum (Zenker’s diverticulum) (ZD) is the most common esophageal diverticulum. It is a blow out of the mucosa of esophagus through a defect in the posterior wall of esophagus between hypopharynx and esophagus. (Killian's triangle)

Pathophysiology

1. Increased upper esophageal sphincter (UES) pressure

2. Failure of UES to relax

3.Incordination between hypophraynx and sphincter to relax

Other mechanisms proposed are

1. Fibrosis of cricopharyngeal muscle

2. Spasm of Cricophayngeus due to abonormal reflux (GERD)

There is loss of ATPase and energy changes in patients with ZD.

Both neurogenic and myogenic abnormalities are present.

At this stage, poor UES compliance rather than cricopharyngeal incoordination appears to be the most plausible explanation

Treatment can be done endoscopically or surgically. A commonly used surgical approach is cervical esophagomyotomy and resection of the diverticulum performed through an oblique left cervical incision that parallels the anterior border of the sternocleidomastoid muscle or a transverse cervical incision centered over the cricoid cartilage.

Complications

Salivary fistula 3-25%

Recurrence 2.5-20%

2. d

The transhiatal cervical anastomosis predisposes to a higher rate of leaks (13.6% for transhiatal vs. 7.2% for transthoracic)

Transthoracic resections, which involve a posterolateral thoracotomy, have a higher incidence of pulmonary complications compared with the transhiatal approach

A review of the literature with a meta-analysis,has shown that operative blood loss is significantly less during transhiatal esophagectomy compared with transthoracic esophagectomy

Now Orringer the proponent of Transhiatal esophagectomy has published that the use of stapled side to side esophagogastric anastomoses in THE has reduced the anatomotic leak rate to 3%

This means now recurrent laryngeal nerve injury is more in THE group than TTE group

Ref: Transhiatal versus transthoracic esophagectomy for esophageal cancer

3. a

Three field esophagectomy involves lymph node dissection in the cervical, mediastinal and abdominal

region. In contrast to the standard two field esophagectomy, japanese surgeons argue that three field esophagectomy leads to better prognostication and survival benefits without significantly increasing the morbidity and mortality.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1356512

Cervical lymphadenectomy included the paratracheal lymph nodes (deep internal nodes). The nodes lateral from the sternocleidomastoid muscle, ie, lateral to the internal jugular vein and supraclavicular nodes

4.b

Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1356512

5.a