Q26. In Carcinoma esophagus all are true except A. Distal Tumors have better prognosis than proximal Tumors B. Tumors are more common in the proximal part of esophagus C. Dysphagia is the most common symptom D.
Distal adenocarcinoma have better prognosis
Most common is squamous cell carcinoma Most common location wise Mc overall mid 1/3 Mc site for sq cc mid 1/3 Mc site for adeno carcinoma lower 1/3
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
Chyle is a milky white ﬂuid with a high concentration of triglycerides and chylomicrons and white blood
cells. It is nutritionally rich.
For oesophagectomy patients, chylothorax represents a serious complication with an incidence of 0.6–4.0%
After oesophagectomy, postoperative chylothorax can cause hypovolemia, metabolic and nutritional depletion, sepsis and mortality in excess of 50% if untreated
Conservative management includes high-protein, low-fat diet and diuretics or fasting with total parenteral nutrition
with or without somatostatin. A low-fat, medium-chain triglyceride diet combined with diuretics has been used successfully.
There are many predictors of failure of medical therapy. If chyle leak is more than 1l/day , it is unlikely to heal conservatively.
It is damaged in 1% to 2% of esophagectomies, resulting in a chylothorax. If there is suspicion for a thoracic duct injury postoperatively, with high pink, clear chest tube output, which becomes milky once fat is added to the patient’s diet, the thoracic duct should either be surgically ligated or embolized by interventional radiology to prevent complications associated with the loss of the protein and leukocyte-rich lymph
Operative intervention may be considered between days 7 and 14. Commonly ligation of thoracic duct
where it enters the chest through the diaphragmatic hiatus is achieved via a right thoracotomy or thoracoscopy. To reduce morbidity transabdominal approach can be done.
Q28 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-T4 level 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
28 ) a
a is true
The esophageal hiatus is situated in the muscular part of the diaphragm at the level of the tenth thoracic vertebra, and is elliptical in shape. It is placed superior, anterior, and slightly left of the aortic hiatus, and transmits the esophagus, the vagus nerve, the left inferior phrenic vessels, and some small esophageal arteries from left gastric vessels.
The aortic hiatus is the lowest and most posterior of the large apertures. It is located approximately at the level of the twelfth thoracic vertebra (T12).
Thoracic duct usually starts from the level of the twelfth thoracic vertebrae (T12) and extends to the root of the neck.
It traverses the diaphragm at the aortic aperture and ascends the superior and posterior mediastinum between the descending thoracic aorta (to its left) and the azygos vein (to its right).
b is wrong
At the level of the fifth thoracic vertebra, the thoracic duct inclines toward the left side to enter the superior mediastinum and ascends behind the aortic arch and the thoracic part of the left subclavian artery, between the left side of the esophagus and the left pleura, to the thoracic inlet.
c is wrong, both are same
Q29. Length of Esophagus (DNB 2018) A. 20cm B. 25cm C. 30-35cm D. 40cm
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 posteriormediastinum, being 30 cm. The retrosternal (32 cm) and the subcutaneous route (34 cm) proved to be
Ref Shackelford page 10
Q30) DES esophaus False in the management of this patient
a) Treatment is primarily medical management
b) Long myotomy necessary if surgery indicated
c) Nissen Fundoplication is recommended to prevent reflux
d) Endoscopic dilatation.
Today, the mainstay of treatment for DES is nonsurgical, and pharmacologic or endoscopic intervention is preferred.
Dor or Toupet fundoplication is added to prevent reflux
Proximal extent of myotomy as determined by manometric measurements. The distal extent of the myotomy is extended down onto the LES, but the need to include the stomach is not agreed on uniformly.
A Dor fundoplication is recommended to provide reflux protection as the surgery itself interrupts the phrenoesophageal ligament and encourages reflux
Rule out GERD (reflux monitoring or empiric PPI trial)