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Q1) A 70 year old male presents with a diagnosis of Zenker's diverticulum and requires open surgery The usual incision given for surgery of Zenker's diverticulum of esophagus is?
a) Left Cervival
b) Right Cervival
c) Suprahyoid
d)MIDLINE
Ans 1. a
Zenker's diverticulum is a pulsion (false) diverticulum between the cricopharyngeal muscle and inferior constrictor muscle in an area Killian's dehiscence.
Zenker’s diverticulum is the most common esophageal diverticulum
3.Incordination between hypophraynx and sphincter to relax Treatment can be done endoscopically or surgically.
Surgery Option is --- Esophagomyotomy and resection of the diverticulum- through an oblique left cervical incision
The standard surgical treatment for ZD consisted of myotomy of the UES and resection or suspension (pexy) of the pouch, or even myotomy alone for small diverticula.
Also per oral endoscopic myotomy techniques, similar to those used at the LES for achalasia, have been applied for the treatment of ZD. If size is less than 1 cm than only myotomy If size is 2 cm , endoscopy is safe above 3 cm stapling of esophagus wall and diverticulum
Myotomy minimum size is 5 cm Complications of Surgery for Zenker's divertculum Salivary fistula 4-24% Recurrence of Zenker's diverticulum 2.5-20%
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
2. d
In transhiatal cervical anastomosis leak rates are (7.6% for transhiatal vs. 9.4% for transthoracic)
Transthoracic resections, have a higher incidence of pulmonary complications compared to THE
Operative blood loss is less during transhiatal esophagectomy compared with transthoracic esophagectomy
As per Orringer - stapled side to side esophagogastric anastomoses in THE has reduced the anastomotic leak rate to 3%
Postoperative complications, n (%) THE TTE Superficial wound infection 173 (10.2) 110 (4.7) < 0.0001 Deep wound infection 53 (3.1) 30 (1.3) < 0.0001 Anastomosis leaka 128 (7.6) 189 (9.4) 0.35 Pneumonia 234 (13.8) 396 (16.8) 0.01 PE/DVT 74 (4.4) 121 (5.1) 0.28 Cardiac complications 46 (2.7) 56 (2.4) 0.48 Bleeding requiring transfusion 196 (11.6) 363 (15.4) 0.0006Mortality 39 (2.3) 60 (2.5) 0.63 Transhiatal vs. Transthoracic Esophagectomy: A NSQIP Analysis of Postoperative Outcomes and Risk Factors for Morbidity.
Q3.Which is the most disabling complication after three field esophagectomy?
a) Bronchorrhoea
b) Recurrent laryngeal nerve palsy
c) Tracheal stenosis
d)
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
Respiratory problems are the main cause of major problems after esophagectomy, due to pneumonia and acute respiratory distress syndrome (ARDS).
There is risk to tracheobronchial tree and this may also occur in a delayed fashion if cautery has been used inadvertently in close proximity.
Similarly risk to the recurrent laryngeal nerve is increased with a more extensive lymph node dissection, as is risk to the thoracic duct and hence the possibility of
a significant chyle leak.
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Q4. What is the most common complication after esophagectomy
a) Arrhythmia
b) Pulmonary Collapse and Consolidation
c) Recurrent laryngeal nerve injury
d) Massive bleeding
4.b
Pulmonary complications occur in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%.
Q 5. Most important investigation for preoperative evaluation of extensive corrosive stricture is
a) Endoscopic ultrasound
b) Barium study
c) CT Thorax
d) Pharyngoscopy
5.a
The management of corrosive esophageal stricture depends on the timing :
Emergency (Immediate management)
Intermediate management and
chronic long term management.
In the early phase - Investigations ordered are X ray chest, X ray abdomen for perforation
Patients with fever, tachycardia, leukocytosis, metabolic acidosis need ICU care and resuscitated urgently, and have the endoscopic assessment performed under general anesthesia in the operating room.
Then after stabilization all symptomatic patients should undergo endoscopy.
Endoscope should not be passed across the 1st sign of injury.
Endoscopic Grading of Caustic Injury
Grade 1Mucosal edema or hyperemiaGrade 2
A: Friability, erosions, exudates
B: As above, plus deep or circumferential ulceration
Grade 3
A: Scattered areas of necrosis with black or grey discoloration
B: Extensive areas of necrosis
Barium and other imaging studies are of no immediate value.
