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מבחן גמר בכירורגיה > וושט > Flashcards

וושט Flashcards

1
Q

איזה סוג של סרטן אכלזיה מהווה גורם סיכון?

A

SSC of esopahous

failure of the lower esophageal sphincter (LES) to relax during swallowing and the absence of esophageal peristalsis.

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2
Q

What is the gold standart to dgx of acahalsia?

A

High-resolution manometry (HRM)
absence of peristalsis in the esophageal body and a lack of LES relaxation with swallowing.

pressue > 35 mmHg in rest

Endoscopy: Used to rule out malignancies and secondary causes of achalasia (pseudoachalasia).

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3
Q

What is the surgical treatment for Acalasia?

A

Heller Myotomy is the definitive treatment

במקרים חומרים- נשקול אזופגקטומיה

  • Laparoscopic Heller Myotomy (LHM): Surgical cutting of the LES to relieve obstruction. Often combined with a partial fundoplication (Dor or Toupet) to prevent reflux.
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4
Q

מהו הקו הראשון הלא ניתוחי לטיפול באכלזיה?

A

ניטרטים / CBB
הרחבה פניאומטית / הזרקה של בוטליניום

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5
Q

מהם האינדיקציות לאזופגקטומיה באכלזיה?

A
  • Mega-esophagus
  • Sigmoidal esopahous
  • failure of Heller procedure (more then 1 attamp)
  • stictures that are not repairable
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6
Q

A 45-year-old woman presents with a 6-month history of progressive dysphagia for both solids and liquids, along with significant weight loss. She reports regurgitation of undigested food and chest pain. A barium swallow study shows a dilated esophagus with a “bird-beak” narrowing at the gastroesophageal junction. Esophageal manometry reveals a failure of the lower esophageal sphincter (LES) to relax during swallowing and absence of peristalsis.

Which of the following is the most appropriate initial treatment?

A) Esophageal dilation
B) Laparoscopic Heller myotomy
C) Endoscopic botulinum toxin injection
D) Esophagectomy
E) Proton pump inhibitor therapy

A

Laparoscopic Heller myotomy

Achalasia is best diagnosed with esophageal manometry and presents with failure of the LES to relax and absence of peristalsis. The treatment of choice for long-term relief is laparoscopic Heller myotomy, which offers a durable solution. Esophageal dilation and botulinum toxin injections may be considered but provide shorter-term relief. Esophagectomy is reserved for advanced or refractory cases .

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7
Q

A 52-year-old man is diagnosed with type II achalasia after presenting with regurgitation, dysphagia, and chest pain. He undergoes pneumatic dilation. Two months later, his symptoms recur, and manometry shows continued elevated pressure at the lower esophageal sphincter.

What is the next best treatment option?

A) Repeat pneumatic dilation
B) Endoscopic botulinum toxin injection
C) Peroral endoscopic myotomy (POEM)
D) Laparoscopic Heller myotomy
E) Esophagectomy

A

Laparoscopic Heller myotomy

In patients with recurrent symptoms after pneumatic dilation, laparoscopic Heller myotomy remains the most effective option for long-term relief. POEM is an emerging option but still requires long-term comparative data. Esophagectomy is typically reserved for advanced cases or those with complications like megaesophagus .

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8
Q

What is Nutcracker esophagus?

Dgx, Tx

A

LES relaxation is normal

ההפרעה היפרמוטילית של הוושט, פריסלטיקה מוגזמת עם אמפליטודה גבוהה.

Dgx- תלונה על כאבים בחזה בבליעה + מונומטריה המדגימה כיווץ דיסטלי חזק מאוד
Tx- CBB/ nitrates

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9
Q

מהו % המטופלים עם סקלרודמה סיסטמית שהוושט תיהיה מעורבות. מה נראה במנומטרה ואיזה חלק של הוושט יהיה מעורב

A
  • 90%
  • בעיקר 2/3 תחתונים
  • מונומטריה- התכווצות מופחתת
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10
Q

GERD is a/w type of cancer?

A

Esopahgus adenocarcinoma

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11
Q

What is the surgical Tx for GERD
What are the 2 indications?

A

Nissen fundoplication
Indications:
1. עדות לעודף חומצה והמשכות סימפטומים למרות טיפול ב-PPI מקסימאלי
2. חולים צעירים, מאוד סימפטומתיים

Surgial prenciple:
1. מוביליזציה של קרורות הסרעפת ופונדוס הקיבה
2. שימור הווגאוס
3. מובילזציה של הוושט ( לפחות 3 ס”מ שתיהיה בטנית)
4. פונדופליקציה- שחזור הזוית ע”ש היס וחיזוק הסוגר התחתון

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12
Q
A
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13
Q

מהו הטיפול ב-
Barret’s esophagus?

ללא דיספלזיה
Low grade dysplasia
High grade

A
  • ללא דיספלזיה- גסטרוסקופיה שנתית
  • low grade- גסטרוסקופיה כל 6 חודשים + ביופסיה עד 2 דגימות שליליות ברצף. הטיפול הכי יעיל פונדופליקציה
  • High grade- ביופסיה חוזרת ולשקול צריבה / כריתת וושט
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14
Q

מהו סרטן הוושט הכי שכיח ומהם גורמי הסיכון?

A

SCC
גורמי סיכון
* עישון
* אלכוהול
* בליעת חומר קאוסטי
* גברים
* אכלזיה

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15
Q

פי כמה עולה הסיכון לאדנוקרצינומה של הוושט בברט אסופגוז וב-GERD

A

GRED- X7
Barrets- X 40

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16
Q

What are the T stages of Esophagus adenocarcinoma?
What is the Tx for each ?

A
  • T1a- invade lamina propria-** Endoscopic muscosal resection**
  • T1b- invade sbmucosa- Esophagectomy
  • T2- muscularis propria- Neoadjuvant chemoradiation&raquo_space; esophagectomy
  • T3- advetitia- Neoadjuvant chemoradiation&raquo_space; esophagectomy
  • T4- adbacent stractures (a- resetable, b- unresectable)- systemic chemotherapy

in T1b-T3- consider adding radiation + adjuvant chemo

17
Q

מה כולל ב-2 הגישות הניתוחיות במחלות דיברטיקולריות בוושט?

A

צורך במיוטמיה של השרירים במשושל קיליאן
דיברטיקולופקסיה- קיבוע הדיברטיקולום
דיברטיקולוטומיה- כריתה שלה

18
Q

Which condition is a/w boerhaave’s syndrome

A

פרפורציה של הוושט

19
Q

A 47-year-old man presents to the emergency department with sudden, severe chest pain and shortness of breath that began after an episode of forceful vomiting following heavy alcohol consumption. On examination, he has subcutaneous emphysema in the neck, tachycardia, and hypotension. A chest X-ray reveals pneumomediastinum and a left pleural effusion. What is the most appropriate next step in the management of this patient?

A) Broad-spectrum antibiotics and observation
B) Endoscopy to evaluate the esophagus
C) Chest tube placement and esophageal stenting
D) CT scan with oral contrast to confirm the diagnosis
E) Immediate surgical exploration

A

CT scan with oral contrast to confirm the diagnosis

surgical over stent- פרפורציה גדולה ופולשת למדיאסטנום והחלל הפליאורלי

This patient likely has Boerhaave’s syndrome, which is a spontaneous esophageal perforation caused by sudden increases in intraesophageal pressure due to forceful vomiting. The classic presentation includes severe chest pain, subcutaneous emphysema, pneumomediastinum, and pleural effusion. CT scan with oral contrast or a barium esophagram is the standard diagnostic tool for confirming esophageal perforation. Once diagnosed, treatment may involve antibiotics, drainage of any associated effusion, and definitive repair, either by stenting or surgical intervention, depending on the size and location of the perforation​​.

20
Q

מהי בדיקת הבחירה בנזק קאוסטי לוושט?

A

גסטרוסקופיה להערכת הנזק (תוך 12-24 שעות)
טיפול
TPN- אם אלבומין נמוך
הזנה דרך גסטרוסטום / גוגונוסטום
טיפול בסטריקטורות- הכנסת סטנט ל-21 יום והרחבות ימיות ואז שבועיות - אם לא מצליחים להגיע לחלל סביר תוך 6-12 חודשים נתקדם לניתוח

21
Q

Which type of Hiatal (diaphragem) hernia is the mosy common, what is the classic presenation?

A

type I- sliding hernia
GEJ
מתייצג כ-GERD

22
Q

Dgx of hiatal hernia?

A

בליעה בריום, אנדוסקופיה, מונומטריה טרם הניתוח

טיפול- ניתוח

23
Q

A 70-year-old man presents with dysphagia, regurgitation of undigested food, and halitosis. Barium swallow shows a posterior outpouching at the level of the cricopharyngeal muscle. What is the most likely diagnosis?

A) Epiphrenic diverticulum
B) Midesophageal diverticulum
C) Zenker’s diverticulum
D) Achalasia
E) Schatzki ring

A

Zenker’s diverticulum

Zenker’s diverticulum presents with regurgitation, dysphagia, and halitosis. The location at the cricopharyngeal muscle (Killian’s triangle) is characteristic.

24
Q

A 50-year-old woman undergoes evaluation for intermittent dysphagia and regurgitation. A barium esophagram reveals a wide-mouthed diverticulum in the distal third of the esophagus, adjacent to the diaphragm. Manometry reveals achalasia. What is the next best step in management?

A) Observation
B) Endoscopic balloon dilation
C) Myotomy with diverticulectomy
D) Antibiotics and observation
E) Diverticulectomy without myotomy

A

Myotomy with diverticulectomy

Epiphrenic diverticula are commonly associated with motility disorders like achalasia. The treatment involves both myotomy of the lower esophageal sphincter and diverticulectomy to relieve the outflow obstruction.

25
Q

A 65-year-old man presents with chronic cough and intermittent dysphagia. A barium esophagram shows a midesophageal diverticulum on the right side. The patient denies any significant respiratory or gastrointestinal symptoms. What is the most appropriate management?

A) Surgical excision
B) Diverticulopexy with myotomy
C) Observation
D) Endoscopic dilation
E) Antibiotics

A

Observation

Midesophageal diverticula are often asymptomatic and incidentally discovered. Observation is appropriate unless the patient becomes symptomatic, in which case surgical intervention may be needed.

26
Q

Which type of esophageal diverticulum can cause pneumonia?

A

Zenkers

27
Q

Tx for mid-esophageal diverticula?

A

< 2 cm = follow-up
> 2 cm / symptoms - Diverticoloflexia

same as for epiphernic diverticula

28
Q

Surgical Tx for Zenker?

A

< 2 ס”מ – דיברטיקולופלקסיה.
> 5 ס”מ – דיברטיקולוטומיה.

29
Q

How we dgx all diverticula types?

A

Barium swollow

30
Q

What is the most common etiologie for epiphernic diverticulum?

A

motility dysfunction

DES, IEM, acahlasia

מבחן גמר בכירורגיה (26 decks)

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