Q3.Which is the most disabling complication after three field esophagectomy?
a) Bronchorrhoea
b) Recurrent laryngeal nerve palsy
c) Tracheal stenosis
d)
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
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
Another hypothesis suggests there is degeneration of the esophageal sphincter due to which it looses its elasticity and does not open completely.
Zenker’s diverticulum usually presents in patients older than 60 years.
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
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.
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%.
5.a
