MCQs on Esophagus Questions 1-5 – Surgery MCQs

Surgery Questions on esophagus.

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

1. a

Zenker's diverticulum is a pulsion (false) diverticulum between the cricopharungeal muscle and inferior constrictor muscle in an area Killian's dehiscence.

There may be other areas of weakness as well such as Killian Jamieson area between the oblique and transverse fibres of cricopharyngeal muscle and Laimer's triangle formed between the cricopharyngeal muscle and most superior esophageal wall circular muscles.

(Zenker’s diverticulum) -most common esophageal diverticulum.

Occurs due to

1. Increased upper esophageal sphincter (UES) pressure

2. Failure of UES to relax

3.Incordination between hypophraynx and sphincter to relax

Treatment can be done endoscopically or surgically.

Surgery Esophagomyotomy and resection of the diverticulum- through an oblique left cervical incision

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

The transhiatal cervical anastomosis New leak rates (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

Now Orringer - stapled side to side esophagogastric anastomoses in THE has reduced the anatomotic 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

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

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 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

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 hyperemia

Grade 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.

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