Surgery Pg No 126 -135
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Questions and Answers

What do the letters C and M in the Prague C & M Criteria denote?

  • Complications and Mechanism
  • Chronicity and Malignancy
  • Characteristics and Management
  • Extent of disease and Risk of cancer (correct)

    • The Seattle Biopsy Protocol recommends a 4 quadrant biopsy every 2 cm.

    False

    What is the management step if High-grade dysplasia (HGD) or cancer is detected?

    Esophagectomy and Endoscopic RFA

    If no dysplasia is found during examination, patients should have an OGD every ______ months until evidence of non-dysplastic BO.

    <p>6</p> Signup and view all the answers

    Match the following terms with their descriptions:

    <p>HGD = Significant risk for cancer and requires immediate intervention LGD = Requires regular monitoring and possible intervention OGD = A procedure used to visualize the upper gastrointestinal tract MDT = A collaborative team approach for patient management</p> Signup and view all the answers

    Which type of corrosive agent is associated with deeper penetration and more damage?

    <p>Alkali</p> Signup and view all the answers

    Prophylactic antibiotics are recommended in the management of corrosive injury.

    <p>False</p> Signup and view all the answers

    What is the most important management step within 48 hours of corrosive injury?

    <p>Early skilled endoscopy</p> Signup and view all the answers

    Zargar's Classification grades perforation as grade _____.

    <p>4</p> Signup and view all the answers

    Match the following grades of Zargar's Classification with their corresponding endoscopic findings:

    <p>Grade 1 = Superficial edema/erythema Grade 2A = Deep or circumferential ulceration Grade 3B = Extensive necrosis Grade 4 = Perforation</p> Signup and view all the answers

    Which of the following conditions is NOT part of the VICTERL mnemonic?

    <p>Tracheoesophageal fistula</p> Signup and view all the answers

    The Waterston criteria indicate that any infant with a birth weight greater than 2.5 kg must undergo upfront surgery without additional considerations.

    <p>True</p> Signup and view all the answers

    List one of the associated anomalies of the gastrointestinal and abdominal surgery mnemonic VICTERL.

    <p>Vertebral defects</p> Signup and view all the answers

    For infants weighing between 1.8 and 2.5 kg, a recommended action is to build ____.

    <p>weight</p> Signup and view all the answers

    Match the Waterston criteria birth weight ranges with their corresponding action plans:

    <blockquote> <p>2.5 kg = Upfront Surgery 1.8 - 2.5 kg = Antibiotics and Build weight &lt;1.8 kg = Further evaluation required All weights = Pneumonia assessment</p> </blockquote> Signup and view all the answers

    Which artery supplies blood to the upper third of the esophagus?

    <p>Inferior thyroid artery</p> Signup and view all the answers

    The esophagus contains a serosa layer.

    <p>False</p> Signup and view all the answers

    At what anatomical point from the upper incisor does the esophagus change its blood supply from the inferior thyroid artery to the descending thoracic aorta?

    <p>15 cm</p> Signup and view all the answers

    The most common site of iatrogenic esophageal perforation occurs at ______ cm from the upper incisor.

    <p>25</p> Signup and view all the answers

    Match the following esophageal segments with their respective arteries:

    <p>Upper 1/3 = Inferior thyroid artery Middle 1/3 = Bronchial artery Lower 1/3 = Ascending aorta</p> Signup and view all the answers

    What is the primary purpose of fundoplication surgery?

    <p>To restore intra-abdominal esophagus length and prevent reflux</p> Signup and view all the answers

    Collis gastroplasty is indicated for patients with an elongated esophagus.

    <p>False</p> Signup and view all the answers

    What is the most common complication following a complete wrap fundoplication?

    <p>Gas bloat syndrome</p> Signup and view all the answers

    The surgical procedure that involves wrapping the fundus around the esophagus is known as ______.

    <p>fundoplication</p> Signup and view all the answers

    Match the types of fundoplication with their respective details:

    <p>Nissen's = Complete wrap 360° Dor = Partial wrap 180° anterior Toupet = Partial wrap 180°-270° posterior Belsey mark = Partial wrap 270° anterior</p> Signup and view all the answers

    Which of the following is the gold standard investigation for diagnosing GERD?

    <p>24 hr pH monitoring</p> Signup and view all the answers

    Obesity is a protective factor against developing GERD.

    <p>False</p> Signup and view all the answers

    What is the most common clinical feature of GERD?

    <p>Retrosternal burn (Heartburn)</p> Signup and view all the answers

    A lower esophageal sphincter (LES) pressure less than _____ mmHg can lead to GERD.

    <p>6</p> Signup and view all the answers

    Match the following interventions with their purposes in GERD management:

    <p>Weight reduction = Decrease abdominal pressure Avoiding spicy foods = Prevent irritation of the esophagus Eating small, frequent meals = Reduce reflux episodes Dining 2-3 hours before sleeping = Prevent nighttime symptoms</p> Signup and view all the answers

    Which procedure is NOT suitable for patients with minimal or no hiatus hernia?

    <p>LINX device</p> Signup and view all the answers

    Barrett's esophagus is characterized by a transition from columnar to squamous epithelium.

    <p>False</p> Signup and view all the answers

    What are the pathognomonic findings on biopsy for Barrett's Esophagus?

    <p>Red velvety mucosa and goblet cells</p> Signup and view all the answers

    The type of Barrett's Esophagus that measures greater than 3 cm is referred to as ______ segment.

    <p>long</p> Signup and view all the answers

    Match the following diagnostic tools with their respective identification results:

    <p>Lugol's Iodine = Identifies squamous epithelium Methylene Blue = Indicates Barrett's Esophagus and adenocarcinoma Chromoendoscopy = Used for identification of Barrett's Esophagus Serial biopsies = Assessment of histopathological changes</p> Signup and view all the answers

    Which of the following conditions is associated with oral thrush?

    <p>Esophageal Candidiasis</p> Signup and view all the answers

    Eosinophilic esophagitis commonly occurs in patients aged 30-40 years.

    <p>False</p> Signup and view all the answers

    What type of ulcers are associated with Cytomegalo Virus (CMV) infection?

    <p>Geographical/serpiginous ulcers</p> Signup and view all the answers

    In esophageal candidiasis, a barium swallow may show ______ deposits.

    <p>worm-like</p> Signup and view all the answers

    Match the investigation technique with its findings concerning esophageal conditions:

    <p>Endoscopy = Shaggy deposits Barium swallow = Worm-like ulcers Biopsy = &gt;15-20 eosinophils/HPF</p> Signup and view all the answers

    What is the typical resting pressure of the Lower Esophageal Sphincter (LES)?

    <p>16-26 mmHg</p> Signup and view all the answers

    Primary peristalsis is a non-propulsive wave that occurs in the esophagus.

    <p>False</p> Signup and view all the answers

    What is the anatomical site for Zenker's diverticulum?

    <p>Killian's Dehiscence</p> Signup and view all the answers

    The condition characterized by frequent relaxation of the Lower Esophageal Sphincter leading to acid reflux is known as __________.

    <p>GERD</p> Signup and view all the answers

    Match the disorders of the esophagus with their characteristics:

    <p>Foreign Body = Most common in children Achalasia = Doesn’t relax GERD = Frequent relaxation Stridor = Coughing from airway obstruction</p> Signup and view all the answers

    Which situation requires immediate endoscopic removal of a foreign body in the esophagus?

    <p>Button battery in any site</p> Signup and view all the answers

    Secondary peristalsis occurs only if primary peristalsis fails.

    <p>True</p> Signup and view all the answers

    What is the common complaint (C/F) associated with a foreign body in the esophagus?

    <p>Dysphagia</p> Signup and view all the answers

    Which type of tracheoesophageal fistula is the most common?

    <p>Type C</p> Signup and view all the answers

    Excessive drooling of saliva is a feature that can appear after birth in patients with tracheoesophageal fistula.

    <p>True</p> Signup and view all the answers

    What is the confirmatory test for diagnosing tracheoesophageal fistula?

    <p>Contrast Study</p> Signup and view all the answers

    Esophageal atresia is associated with a mutation in the ______ gene.

    <p>N-myc</p> Signup and view all the answers

    Match the types of tracheoesophageal fistulae with their descriptions:

    <p>Type A = Esophageal Atresia (EA) Type C = Proximal EA with distal TEF Type D = Proximal and distal TEF Type F = Esophageal stenosis</p> Signup and view all the answers

    Study Notes

    Tracheoesophageal Fistulae (TEF) Types

    • Type A: Esophageal Atresia (EA) only.
    • Type B: Proximal TEF with distal EA.
    • Type C: Proximal EA with distal TEF (most common).
    • Type D: Proximal and distal TEF.
    • Type E: TEF without EA.
    • Type F: Esophageal stenosis.

    TEF Features

    • Associated with N-myc gene mutation.
    • Prenatal features include polyhydramnios, detectable on prenatal scans.
    • Postnatal features include excessive drooling and respiratory distress; organic (OA) tube insertion may be difficult.

    TEF Diagnosis

    • Confirmed via contrast study (Iodexol preferred over Dinosil).
    • Type H requires combined tracheo-esophagoscopy.
    • X-ray showing stomach gas indicates distal TEF.

    TEF Additional Notes

    • Coiling of the OA tube is common in Type C.

    Associated Anomalies (VACTERL)

    • Vertebral defects
    • Anorectal malformations
    • Cardiac abnormalities
    • Tracheoesophageal fistula
    • Renal anomalies
    • Limb abnormalities

    Waterston Criteria for TEF Management

    • Birth weight > 2.5 kg and no pneumonia: upfront surgery.
    • Birth weight 1.8-2.5 kg with or without pneumonia: antibiotics and weight gain before surgery.

    Corrosive Injury Causes

    • Alkali: causes saponification, deeper penetration, and more damage.
    • Acid: causes protein coagulation, less deep penetration, more gastric damage, and pylorospasm.

    Corrosive Injury Management

    • IV fluids, avoid blind NG tube insertion (perforation risk), no prophylactic antibiotics.
    • Early (within 48 hours) skilled endoscopy is crucial.
    • No steroids.
    • Definitive management includes stricture treatment (dilation or esophagectomy) and perforation repair (emergency surgery).

    Zargar's Classification of Corrosive Injury

    • Grade 0: Normal.
    • Grade 1: Superficial edema/erythema.
    • Grade 2: Mucosal/submucosal ulceration (superficial edema/erythema or deep/circumferential).
    • Grade 3: Transmural ulceration with necrosis (focal or extensive).
    • Grade 4: Perforation.

    Prague C & M Criteria

    • C & M describe the extent of disease and cancer risk, respectively.

    Seattle Biopsy Protocol

    • Four-quadrant biopsy every centimeter.

    Barrett's Esophagus Management Flowchart

    • Initial examination includes repeat OGD + biopsy every 3-5 years.
    • Findings include flat columnar mucosa, requiring systematic cold biopsy, and confirmation by two pathologists.
    • No dysplasia: OGD every 6 months until consecutive non-dysplastic findings.
    • Low-grade dysplasia (LGD): MDT discussion and therapeutic intervention.
    • High-grade dysplasia (HGD) or cancer: esophagectomy or endoscopic RFA. Follow non-dysplasia flowchart.

    Abbreviations

    • BO: Barrett's esophagus
    • HGD: High-grade dysplasia
    • LGD: Low-grade dysplasia
    • MDT: Multidisciplinary team
    • OAC: Esophageal adenocarcinoma
    • OGD: Esophagogastroduodenoscopy

    Esophageal Sphincters

    • Upper Esophageal Sphincter (UES): anatomical and physiological entity, 3-5 cm long, parts are thyropharyngeus and cricopharyngeus; Killian's dehiscence is a site for Zenker's diverticulum.
    • Lower Esophageal Sphincter (LES): physiological entity, resting pressure 16-26 mmHg, functions include frequent relaxation (GERD) and failure to relax (achalasia).

    Peristalsis Types

    • Primary: propulsive wave.
    • Secondary: propulsive wave if primary fails.
    • Tertiary: non-propulsive wave between meals, increases with age.

    Foreign Body (FB) in Esophagus

    • Most common in children.
    • Esophageal FB causes dysphagia.
    • Respiratory tract FB causes choking and stridor.
    • Management includes X-ray, endoscopic removal for impacted and symptomatic esophageal FB at C6, observation for asymptomatic FB beyond C6, and immediate endoscopic removal for button batteries regardless of location.

    X-Ray Images: Coin Location

    • Trachea: Requires AP and lateral views to determine side or end-on orientation.
    • Esophagus: Requires AP and lateral views to determine side or end-on orientation.

    Protective Factors Against GERD

    • Intra-abdominal esophagus length (≥3 cm, most important).
    • Diaphragmatic crura pinching effect.
    • Angle of His (gastroesophageal angle).
    • Mucosal fold arrangement (least contribution).

    GERD Pathogenesis

    • Intra-abdominal esophagus < 2cm.
    • Lower esophageal sphincter (LES) pressure < 6 mmHg, leading to increased transient lower esophageal sphincter relaxations (TLOSR) and GERD.
    • Central obesity increases Barrett's esophagus and adenocarcinoma risk.

    GERD Risk Factors

    • Obesity.
    • Decreased H. pylori rates.

    GERD Clinical Features

    • Retrosternal burning (heartburn, most common).
    • Water brash.
    • Pharyngitis/laryngitis.
    • Dental caries.
    • Chronic cough and wheezing.

    GERD Investigations

    • Upper GI endoscopy (10C).
    • 24-hour pH monitoring (gold standard), indicated if endoscopy is inconclusive or intervention is planned. pH probe placed 5 cm proximal to the gastroesophageal junction; PPI should be stopped 5-10 days prior. DeMeester score > 14.72 indicates GERD.

    GERD Treatment: Lifestyle Changes

    • Weight reduction.
    • Avoid fried, fatty, spicy foods, citrus, chocolate, and mint.
    • Eat small, frequent meals.
    • Dine 2-3 hours before sleep.

    GERD Medications

    • PPIs
    • Prokinetics
    • Antacids

    GERD Surgical Management Indications

    • Failure to respond to medical management.
    • GERD complications.
    • Associated sliding hiatal hernia.
    • Patient preference to discontinue medical management.

    GERD Surgical Procedures

    • Fundoplication (Nissen's - 360°, partial wraps such as Dor, Toupet, or Belsey Mark).
    • Collis gastroplasty (for esophageal shortening).

    Fundoplication Principles

    • Restore intra-abdominal esophagus length ≥ 3 cm.
    • Tighten diaphragmatic crura around the esophagus.
    • Wrap fundus around the esophagus.
    • Preserve vagus nerves.
    • Re-establish the angle of His.

    Nissen Fundoplication Complications

    • Gas bloat syndrome (most common).

    Newer GERD Modalities

    • Polymer injection around LES (high recurrence rate, not preferred).
    • LINX device (magnetic sphincter augmentation, suitable for minimal/no hiatal hernia).
    • Transoral incisionless fundoplication (NOTES procedure).

    Barrett's Esophagus

    • Specialized intestinal metaplasia (squamous to columnar epithelium change).
    • Pathognomonic findings include red velvety mucosa (on biopsy) and goblet cells.
    • Clinical features are similar to GERD but unresponsive to treatment; can be silent.
    • Increased risk of adenocarcinoma.

    Barrett's Esophagus Types

    • Long segment (>3 cm).
    • Short segment (<3 cm).
    • Cardia metaplasia/microscopic Barrett's (identified by chromoendoscopy).

    Barrett's Esophagus Imaging and Findings

    • Histopathology, serial biopsies, Lugol's iodine staining (normal squamous epithelium stains dark brown, Barrett's epithelium doesn't). Methylene blue stains adenocarcinoma and Barrett's.

    Esophageal Infections

    • Candidiasis: associated with oral thrush, seen in immunocompromised patients, diagnosed via endoscopy (shaggy deposits) and barium swallow (worm-like ulcers), treated with antifungals.
    • CMV: post-transplant (immunosuppressants), associated with GVHD, presents as geographic/serpiginous ulcers.
    • Herpes: associated with herpes labialis, presents as small ulcers with raised margins.

    Feline Esophagus

    • GERD (upper 1/3).
    • Eosinophilic esophagitis (lower 1/3, most common), a chronic immune-mediated disease with esophageal dysfunction triggered by food antigens, leading to eosinophilia and fibrosis. Peak age 20-30 years. Endoscopy shows crepe paper mucosa, furrows, and rings; biopsy shows >15-20 eosinophils/HPF.

    Esophageal Surgical Anatomy: Constrictions

    • Upper esophageal sphincter (UES).
    • 15 cm from the UES.
    • 25 cm from the UES.
    • 40 cm from the UES.

    Esophageal Surgical Anatomy: Diaphragmatic Openings

    • T8: IVC, phrenic nerve.
    • T10: esophagus, vagus nerve, left gastric artery.
    • T12: aorta, thoracic duct. This area is a common site for iatrogenic esophageal perforation.

    Esophageal Blood Supply

    • Segmental.

    • Upper 1/3: inferior thyroid artery and vein.

    • Middle 1/3: descending thoracic aorta, bronchial artery, and azygous vein.

    • Lower 1/3: left gastric artery (involved in Mallory-Weiss tears) and vein. Connects to portal circulation; involved in liver metastasis and porto-systemic shunts, and varices.

    Esophageal Lymphatics

    • Longitudinal spread; skip metastasis necessitates long (10 cm) proximal margins in esophagectomy to minimize recurrence.

    Esophageal Layers

    • Lacks serosa; submucosa is the strongest layer.

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    Test your knowledge on the Prague C & M Criteria and the Seattle Biopsy Protocol. This quiz covers key aspects of management steps and follow-up procedures related to dysplasia and cancer detection. Perfect for students and professionals in the medical field.

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