Surgery of the esophgeal malignany is currently undergoing a lot of advances and still the best treatment modality is not known. Three field esophagectomy has been a recent addition in managemnet of Carcinoma esophagus. We review the literature and show the available facts

1. Lymph node station of esophagus unlike stomach are not well defined 2. Conventional . . . → Read More: Three field esophagectomy]]> Three field esophagectomy

Surgery of the esophgeal malignany is currently undergoing a lot of advances and still the best treatment modality is not known.
Three field esophagectomy has been a recent addition in managemnet of Carcinoma esophagus. We review the literature and show the available facts

1. Lymph node station of esophagus unlike stomach are not well defined
2. Conventional thoracic esophagectomy is two field with removal of lymph nodes below the carina

3. Extended or total two field esophagectomy is standard two field + superior mediastinal

4. Three field is extended two field + Dissection of lymph nodes in the neck, the superior limit of disection is the cricoid cartilage

Rationale for three field Esophagectomy
Overal Cervical lymph node involvement -30%
Cancer of Upper esophagus- 60%
Cancer of middle esophgus-25%
Cancer of Lower Esophagus-12%

Morbidity and Mortality rates
Mortality is about 4% but morbidity remains high
Anastomotic leak 15%
Sepsis - 25%
Recurrent larygeal nerve injury can go upto 50%

Another point against three field esophagectomy is that, after two field esophagectomy, recurrence in the cervical lymph nodes is low. These patients die of recurrence in the mediastinum (26%) and systemic recurences (25%). The patients who undergo transhiatal resection also have low cervical lymph node recurrence (8%).

From mostly retrospective studies, it can be shown that survival advantage may not be demonstrable for lower-third tumors for patients who have positive nodes in all three surgical fields where intramural metastases are present, or in those who have five or more involved nodes.

To conclude The optimal lymphadenectomy for esophageal cancer remains controversial. En bloc resection and three-field lymphadenectomy have definite merits, but they are not suitable for all patients. Given their relatively high morbidity rates, appropriate patient selection is important and they should be performed in experienced centers.

I was surprised when I heard this on the rounds. The patient is a 70 year old case of Carcinoma lower 1/3rd of esophagus. He had undergone Transhiatal esophgectomy. On the 2nd post op day he developed surgical emphysema of the chest neck and face which was attributed to the faulty placement of chest tube. However . . . → Read More: Give him bananas]]>

I was surprised when I heard this on the rounds. The patient is a 70 year old case of Carcinoma lower 1/3rd of esophagus. He had undergone Transhiatal esophgectomy. On the 2nd post op day he developed surgical emphysema of the chest neck and face which was attributed to the faulty placement of chest tube. However it settled after Chest tube was repositioned.
On the 4th and 5th post operative day there was a leak from the neck anastomosis and it was amply demonstrated when water came leaking out of the neck wound.
All the sutures in the neck were promptly opened and patient advised to eat bananas . Simultaneously feeding jejunostomy was started. The fistula healed and patient went home in the 3rd week.

The bananas are supposed to keep the tract patent and prevent stricture which is inevitable but it is a cheap and easy option available.
What are your experiences

Answer b) Budd Chiari syndrome is a rare cause of post sinusoidal portal hypertension. It can present as an asymtomatic presentation to fulminanat liver failure. There is thrombosis at the level of three hepatic veins at the level of Inferior . . . → Read More: Budd chiari syndrome]]> Q Most common cause of Budd Chiari syndrome in Asia is?
a) Polycythemia
b) IVC obstruction
c) Myeloproilferative disorders
d) Bechet’s disease

Answer b)
Budd Chiari syndrome is a rare cause of post sinusoidal portal hypertension. It can present as an asymtomatic presentation to fulminanat liver failure. There is thrombosis at the level of three hepatic veins at the level of Inferior Vena Cava (IVC).
In the west, the disease is associated with hypercoagulable staes such as protein C, protein S deficiency, antithrombin III deficiency, polycythemia vera, lupus anticoagulant, estrogen exposure and Bechet’s disease.

]]> http://mcqsurgery.com/us/?feed=rss2&p=24 http://mcqsurgery.com/us/?p=12 http://mcqsurgery.com/us/?p=12#comments Fri, 30 Jan 2009 17:23:24 +0000 admin http://mcqsurgery.com/us/?p=12

Q which of the statements regarding gastric polyps is incorrect.. a) Most common gastric polyps are hyperplastic. b) 20% of all polyps are adenomtaous polyps c) Endoscopic polypectomy is done for polyps which do not contain invasive cancer d) Hyperplastic polps can harbour cancer in 2% cases.

Answer b) Hyperplastic polyps are the most common polyps in the stomach. They form 25-75% of . . . → Read More: Gastric Polyps]]>

Q which of the statements regarding gastric polyps is incorrect..
a) Most common gastric polyps are hyperplastic.
b) 20% of all polyps are adenomtaous polyps
c) Endoscopic polypectomy is done for polyps which do not contain invasive cancer
d) Hyperplastic polps can harbour cancer in 2% cases.

Answer
b)
Hyperplastic polyps are the most common polyps in the stomach. They form 25-75% of all gastric polyps. Chronic Atrophic gastritis mostly are responsible for these hyperplastic polyps. They by themselves are non neoplastic but adenocarcinomas have been detected in 2% of cases. Endoscopic polypectomy is the treatment of choice.
Only 10% of all polyps in stomach are adenomatous polyps. They are mostly antral, sessile, solitary and eroded. Adenomatous polyps harbour malignancy 20% of times and endoscopic polypectomy is required in all polyps. Operative excision is required for sessile polyps more than 2cm in size, other polyps found to harbour invasive malignancy and polyps that bleed or are painful.

a. Superior Mesenteric artery b. Gastroduodenal artery c. Coeliac artery d. Right hepatic artery

Answer (a) An accessory or aberrant Right Hepatic artery arises from the superior mesenteric artery commonly. It has to be preserved because it may be the only source of arterial supply to the right lobe of . . . → Read More: Accessory Right Hepatic artery]]> Q. Most common site of origin of accessory Right Hepatic artery is?

a. Superior Mesenteric artery
b. Gastroduodenal artery
c. Coeliac artery
d. Right hepatic artery

Answer (a)
An accessory or aberrant Right Hepatic artery arises from the superior mesenteric artery commonly. It has to be preserved because it may be the only source of arterial supply to the right lobe of the liver

a. Lymphovascular invasion b. Poorly differentiated adenocarcinoma c. Cancer in the upper 1/3rd of the submucosa d. Cancer with in 2mm of resected margin

Answer c) Malignant polyp is one in which the cancer has invaded beyond muscularis mucosa. 2-12% of . . . → Read More: Colonic polyp]]> Q. Which of the follwing is not an indication for resection of colon after endoscopic resection of adenomatious colonic polyp?

a. Lymphovascular invasion
b. Poorly differentiated adenocarcinoma
c. Cancer in the upper 1/3rd of the submucosa
d. Cancer with in 2mm of resected margin

Answer
c) Malignant polyp is one in which the cancer has invaded beyond muscularis mucosa. 2-12% of polyps removed endoscopically have cancers. Surgical resection of colon is required if there is lymphovascular invasion, poor differentiation, cancer with in 2mm of resected margin, invasion of lower 1/3rd of submucosa and if the lesion is flat or ulcerated.