Esophageal motility disorders and GERD Flashcards

Question 1

Q

what proportion of the population has GERD ?

A. 10-20%
B. 20-40%
C. 30-50%
D. 50-70%

Answer

A

Ans B -

GERD is a chronic progressive disease. When defined by the presence of symptoms that reach a point where they are considered troublesome, 20-40% of the population has GERD.

Approximately 70% of these are well controlled throughout life with PPI. Their disease does not seem to be progressive.

The remaining 30% have progressive disease in whom PPI therapy fails to control the symptoms.
There is no ability or attempt to prevent the progression of 30% of GERD patients into the stage of refractory GERD defined by treatment failure.
It is only when they reach this stage defined by failure of PPI to control symptoms or when they develop alarm symptoms such as dysphagia that endoscopy is indicated.

Shackleford 8e Pg 15.

Question 2

Q

which of the following statements is false?

A. Symptoms of GERD and Endoscopic findings are often non-concordant
B. Patients with Non-erosive reflux disease have symptoms that are well controlled with PPI
C. Endoscopy in patient who has failed PPI therapy changes management in only patient with Barrett Esophagus
D. Biopsy of normal squamocolumnar junction is not recommended
E. A significant number of patients can have intestinal metaplasia if biopsies are taken from “normal” appearing SCJ.

Answer

A

Ans B.
Statements A, C, D and E are true.
Statement B is false - patients with NERD have symptoms that are often resistant to PPIs.

Biopsy is currently not recommended by most societies in patients who donot have endoscopic abnormality at GEJ. Biopsy of the endoscopically normal squamous epithelium may show histologic changes of reflux, but these are not sufficiently sensitive or specific to have practical value. Biopsy of the “normal” SCJ is not recommended, although it is known that a small but significant number of patients will have intestinal metaplasia if biopsies are taken, particularly if the SCJ is slightly irregular.

Endoscopy in the patient who has failed PPI therapy changes management only in patient with Barrett esophagus, who enters an endoscopic surveillance program aimed at detecting early neoplastic changes.
Often symptoms are diminished in patients with Barrett Esophagus, and the efficacy of medical therapy to prevent Barrrett’s progression remains unproven. Progression to dysplasia and adenocarcinoma in all patients cannot be effectively prevented.

Symptoms of GERD and endoscopic findings are often non-corcodant. A person without symptoms of GERD can have long segment BE or present with an advanced GERD induced adenoca.
Conversely patients with symptoms of GERD can be endoscopically normal (NERD). Treatment of GERD with PPI can heal erosive esophagitis without completely resolving the symptoms.
Patients with NERD are more resistant to symptom control with PPIs than those with erosive esophagitis.

Shackleford 8e Pg 15.

Question 3

Q

A patient present with heartburn and regurgitation. Next step is -

A. Empiric acid suppressive treatment
B. Ambulatory pH monitoring
C. HRM
D. PFT

Answer

A

ans - A

GERD is generally diagnosed when typical reflux symptoms such as heartburn and regurgitation are present. Objective testing with ambulatory pH monitoring can confirm the diagnosis, but is infrequently done when patients first present with symptoms. Instead, most patients receive empiric acid suppressive treatment with the sole objective of symptom control. A positive empiric test of PPI therapy is commonly used to confirm the symptom based diagnosis of GERD.

However there is no symptom complex or test at present that can accurately predict which GERD patient under empiric treatment will progress to failure of PPI Therapy in the future. Failure is only recognized when maximum PPI therapy fails to control symptoms.

Also there is no symptom complex or endoscopic finding other than BE that can predict with sufficient accuracy to warrant surveillance endoscopy that a GERD patient will develop adenocarcinoma in the future.

Screening for BE is not recommended.

Shackleford 8e Pg 15.

Question 4

Q

what percentage of patients with Adenoca Esophagus have been previously diagnosed to have BE ?

A. 10%
B. 20%
C. 30%
D. 40%

Answer

A

Ans A - 10%

Shackleford 8e Pg 16.

Question 5

Q

based on the Pro-GERD study which of the factors were
Positively associated with progression to visible Columnar Lined Esophagus at 5 years ?

A. Female gender
B. Alcohol Intake
C. Erosive esophagitis
D. Regular PPI use

Answer

A

Ans - A Female gender.

The pro-GERD study was conducted by Astra-Zeneca which manufactures esomeprazole.
The study included patients with Non-erosive disease, Los Angeles A/B and Los Angeles C/D patients and they were started on regular PPI therapy.
The reversal of erosive esophagitis was impressive.
However 9.7% patients had progressed to vCLE at the end of 5 years. The factors significantly associated with progression were -
A. Female gender was negatively associated
B. Alcohol intake
C. Erosive esophagitis
D. Regular PPI Use.

Present medical treatment therefore commits 10% of all patients to irreversibility every 5 years.

Shackleford 8e Pg 17.

Question 6

Q

which of the following is not a histologic feature for reflux esophagitis?

A. Intracellular Edema
B. Basal Cell Hyperplasia
C. Papillary elongation
D. infiltration of eosinophils

Answer

A

Ans A.

Reflux esophagitis is characterised by intercellular edema (Dilated intercellular spaces), basal cell hyperplasia, papillary elongation and infiltration by eosinophils and neutrophils.
These changes do not have the necessary sensitivity or specificity for the diagnosis of GERD.
Histologic examination has no practical value in the diagnosis of GERD.

Shackleford 8e Pg 17.

Question 7

Q

Which of the following is the most dominant factor in development of visible columnar lined esophagus?

A. Male gender
B. Smoking
C. Alcohol
D. Severity of reflux

Answer

A

Ans D -

There is strong evidence that the risk of vCLE increases with increasing severity of reflux, duration of reflux, male gender, regular PPI therapy and possibly alcoholism and smoking.

The most dominant factors in the etiology of vCLE are the severity and duration of reflux.

Shackleford 8e Pg 18.

Question 8

Q

which of the following is not a criteria to define a defective LES that correlates with presence of sufficient reflux into the esophagus to produce clinical GERD

A. A decrease in the mean LES pressure to less than 15 mmHg
B. A decrease in the total LES length to <2cm
C. A decrease in the abdominal LES <1cm
D. None of the above

Answer

A

Ans A -

the criteria are -

Decrease in mean LES pressure to <6mmHg (Normal 15mmHg)
Decrease in total LES length to less than 2cm (Normal 4-5cm)
Decrease in the abdominal LES length to less than 1cm. (Normal 3-3.5cm)

At these levels of LES damage the sphincter failure occurs so frequently that it results in abnormal pH test and significant exposure of the squamous epithelium in the body of the esophagus.
Correlates with an increased probability of symptoms of GERD, severe grades of erosive esophagitis, and vCLE.

Shackleford 8e pg 19.

Question 9

Q

which of the following columnar epithelium is always present

A. Pure Cardiac Epithelium
B. Oxyntocardiac Epithelium
C. Gastric Oxyntic epithelium
D. intestinal epithelium

Answer

A

Ans C - gastric oxyntic epithelium is the normal columnar epithelium of the stomach and it is always present.

Metaplastic columnar epithelium is cardiac epithelium which can be of 3 types -

A. Pure cardiac epithelium - contains only mucous cells
B. Oxyntocardiac Epithelium - contains mucous cells with parietal cells
C. Intestinal Metaplasia which contains goblet cells.

Shackleford 8e Pg 23

Question 10

Q

Which of the following is most common form of cardiac epithelium -

A. Oxyntocardiac Epithelium
B. Intestinal epithelium
C. Pure Cardiac epithelium
D. All are found in equal proportions

Answer

A

Ans A

Intestinal epithelium is the least common
Oxyntocardiac epithelium is the most common.

The definition of the type of epithelium is applied to every unit of the epithelium which is defined as a single foveolar-gland complex. Multiple epithelial types can therefore be present in a small area.

Shackleford 8e Pg 23.

Question 11

Q

Most widely used definition of the EGJ is ?

A. SCJ
B. Z line
C. proximal limit of the rugal folds.
D. distal end of LES

Answer

A

Ans C - proximal limit of rugal folds.

Shackleford 8e Pg 23.

Question 12

Q

test of choice for oropharyngeal dysphagia ?

A. Barium Swallow
B. Endoscopy
C. MRI Chest
D. Videoflouroscopic evaluation

Answer

A

Ans D -

Videoflouroscopic evaluation of swallowing with digital high frequency recording is the test of choice.

Shackleford 8e Pg 158.

Question 13

Q

FEES is performed using ?

A. Flexible Esophagoscope
B. Flexible gastroscope
C. Flexible Laryngoscope
D. Rigid Esophagoscope

Answer

A

Ans C - Flexible laryngoscope.

FEES stands for fibreoptic endoscopic evaluation of swallowing using a flexible laryngoscope introduced transnasally while the patient is asked to swallow a variety of foods and liquids with a coloring contrast (Blue dye).
A bling period of 0.5s occurs when the epiglottis tilts backwards and the pharynx squeezes. FEES provides qualitative and subjective interpretation.

Shackleford 8e Pg 159. q

Question 14

Q

the first line of management in oropharyngeal dysphagia is -

A. Behavioral Intervention
B. Percutaneous Endoscopic Gastrotomy
C. Endoscopic Dilations
D. Botox

Answer

A

Ans A -
For patients with oropharyngeal dysphagia and/or cricopharyngeal dysfunction, treatment generally begins with behavioral intervention.

Most important modifications -

Texture
Viscosity
Consistency
Composition
Bolus size

The patient must be cognitively alert and therefore a large number of neurogenic cases may be excluded.

Shackleford 8e Pg 160.

Question 15

Q

Mendelsohn Maneuvre is related to -

A. ensure feeding safety in oropharyngeal dysphagia
B. allow easy micturition in anterior uretheral stricture.
C. aid in maintaining fecal continence in postoperative period.
D. none of the above

Answer

A

Ans A -

A variety of maneuvers and techniques are used to ensure feeding safety in patients with oropharyngeal dysphagia.

Supra-glottic Swallow
Super-supra-Glottic swallow
Mendelsohn Maneuvre (To promote pharyngeal and laryngeal elevation)
neck flexion
neck extension
head turning
tongue-base retraction.

Shackleford 8e Pg 160.

Question 16

Q

Ideally the length of cricopharyngeal myotomy should be ?

A. 2cm
B. 3cm
C. 5cm
D. 7 cm

Answer

A

Ans C -

The transverse fibers of the cricopharyngeal muscle are identified and the myotomy is performed from its upper border and the lower pharyngeal wall to the cervical esophagus, over a length of atleast 5cm.

A drain is left for 24 hours.

Division of the omohyoid and middle thyroid vein can aid exposure. Whereas division of inferior thyroid artery can also aid exposure and also prevent injury to the recurrent laryngeal nerve.

Shackleford 8e Pg 162.

Question 17

Q

All of the following are good prognostic signs for results of cricothyroid myotomy except -

A. Good control of laryngeal aditus with normal phonation
B. ability to accurately define the location of dysphagia
C. good control of tongue
D. absence of dysarthria

Answer

A

Ans B -

Intact voluntary oral-phase of deglutition with good control of tongue, good control of laryngeal aditus with normal phonation and absence of dysarthria are reliable prognostic factors for successful outcome.

Patients are often able to accurately describe the exact location of food sticking. however these features are also seen in patients who have esophageal dysphagia and therefore this is not a reliable indicator.

Shackleford 8e Pg 162,

Question 18

Q

which of the following is the most accepted theory of cause of Zenker diverticulum

A. Increased Resting pressure of the UES
B. Lack of complete relaxation
C. premature or discoordinated UES relaxation
D. Degenerative changes.

Answer

A

Ans - D

UES resting pressure is similar and even decreased in these patients compared with controls.

UES appears to properly relax on manometry during deglutition

Pharyngosphincteral inccordination is an infrequent finding.

Presently accepted theory -based on simultaneous Video-radiography and Manometry

significantly reduced sphincter opening despite a manometrically normal or complete relaxation.
greater intrabolus pressure
degenerative changes cause a lack of elasticity of the sphincter muscle preventing it from relaxing completely.
manometrically the appearance of a “shoulder” before the onset of pharyngeal contraction.

Shackleford 8e Pg 164.

Question 19

Q

histological basis of zenker diverticulum all except -

A. higher collagen
B. higher desmosine/isodesmosine ratio
C. Higher collagen/elastin ratio
D. none of the above

Answer

A

Ans B -

Histologic, electron microscopic and immunohistochemistry studies have shown that these patients have - higher collagen content, higher isodesmosine/desmosine ratio and higher collagen/elastin ratio in cricopharyngeal muscle and cervical esophageal muscularis propria.

This also supports why the proximal cervical esophageal muscle fibers also need to be divided for a length of about 2-3cm.

Shackleford 8e Pg 164.

Question 20

Q

most common symptom of zenker diverticulum is ?

A. Dysphagia
B. Regurgitation
C. Gurgling sound
D. Halitosis

Answer

A

Ans A - Dysphagia is the main symptom and present in nearly all cases. One can distinguish this intrinsic dysphagia from the extrinsic one, caused by the distension of the pouch.

Shackleford 8e Pg 164.

Question 21

Q

First line of investigation for Zenker Diverticulum is ?

A. Barium swallow
B. Endoscopy
C. CT neck
D. HRM

Answer

A

Ans A - Radiologic evaluation should precede any endoscopic examination in a patient with dysphagia and suspected ZD, given the risk of iatrogenic perforation.

Shackleford 8e 165.

Question 22

Q

Which of the following is the scope used in treatment of Zenker Diverticulum -

A. Zenker Scope
B. Clouse Scope
C. Weerda scope
D. Randall Scope

Answer

A

Ans C - Weerda diverticuloscope is a special endoscope used for treatment of Zenker Diverticulum.

Shackleford 8e Pg 165.

Question 23

Q

For a Zenker Diverticula measuring 1cm in size the treatment of choice is -

A. Cricopharyngeal myotomy
B. Diverticulopexy
C. Diverticulectomy
D. A and B together

Answer

A

Ans A -

Very small <1cm pouches can be safely left in place, since the myotomy alone suffices to reduce the pouch and alleviate the symptoms.

Shackleford 8e Pg 166.

Question 24

Q

During diverticulopexy the Zenker Diverticulum is preferentially sutured to the -

A. Posterior pharyngeal wall
B. Prevertebral fascia
C. Either A or B
D. None of the above

Answer

A

Ans A -

Should a diverticulopexy be performed it is important to suture the diverticulum to the posterior pharyngeal wall as opposed to prevertebral fascia to allow free vertical movement of the pharynx during deglutition.

Sabiston 20e Pg 1019.

Question 25

Q

Number of rows of staples used in esophageal diverticulostomy on each side of the trasection of septum -

A. 1
B. 2
C. 3
D. 4

Answer

A

Ans C -

Stapling sutures the posterior esophageal wall to the anterior wall of the diverticulum over a length of about 30mm and the tissue coming between three row of staples on each side is trasected.

Shackleford 8e Pg 167.

Question 26

Q

which of the following statements is true regarding flexible endoscopy treatment of zenker diverticulum ?

A Provides a single session treatment irrespective of the size of the diverticula.

B. Cannot be used for diverticula smaller than 2cm.

C. A nasogastric tube is usually placed for nutrition for 2 days.

D. Collard first proposed the flexible endoscopic treatment for Zenker Diverticulum

Answer

A

Ans C -

Only one session is usually needed for small diverticula smaller than 2cm, whereas repeated sessions may become necessary if they are larger.
At any one session 1.5-2cm incision is performed, and sessions are repeated in 1 weeks’ time.

A nasogastric tube is usually placed for nutritional purposes for 2 days.

Collard described the classical diverticulostomy using Weerda diverticuloscope.

Shackleford 8e Pg 168.

Question 27

Q

most common cause of mortality in patients undergoing surgical treatment for Zenker diverticulum

A. Hemorrhage
B. Esophageal Leak
C. Cardiopulmonary complications
D. DVT

Answer

A

Ans C -

Morbidity may involve some local hematomas and recurrent nerve palsy. Mortality rate of this procedure in frail, elderly patients is far from negligible, mostly due to cardiopulmonary complications.

Shackleford 8e Pg 168.

Question 28

Q

all of the following are complications more often seen with transcervical approach to treatment of Zenker diverticulum except

A. Recurrent Nerve Palsy
B. Mediastinitis
C. Hematoma
D. Fistula

Answer

A

Ans B -

A systematic review on available literature has been recently published -

Rate of failure was significantly higher with endoscopic techniques

Mediastinitis and emphysema are more common with endoscopic techniques.

Recurrent nerve Palsy, fistula and Hematoma are more common with transcervical approach.

Overall complications are more common with the transcervical approach.

Question 29

Q

Which is the recommended treatment in Zenker diveritcula measuring more than 5cm.

A. Endoscopic Diverticulostomy
B. Diverticulectomy
C. Diverticulopexy
D. Cricopharyngeal myotomy

Answer

A

Ans B - Diverticulectomy

Endoscopic stapling also has other drawbacks mainly related to the size of the diverticulum :
in the case of small diverticulum (2cm or less) the stapler anvil is too long to be properly accomodated inside the pouch, and the cricopharyngeal fibers cannot be transected completely.

On the other hand very large diverticula >5cm plunging into the mediastinum carry the risk of vascular lesions if they are transected blindly.

Shackleford 8e Pg 171.

In most patients with a good or large sac (>5cm), excision of the sac is indicated.

An alternative to open surgical repair is the endoscopic Dohlmann procedure. Because of the configuration of the inline stapling device this approach has been advocated for larger diverticula. The risk for an incomplete myotomy increases with diverticula smaller than 3cm.
Overall the postoperative course is slightly shorter for transoral approaches, which patients taking liquids the following day and requiring only a single overnight hospital stay. Thus, these techniques have gained favor and are advocated for patients with diverticula between 2 and 5cm.

For diverticula 3cm or smaller, surgical repair is superior to endoscopic repair in eliminating symptoms. For any diverticulum larger than 3cm, the results are the same.

Sabiston 20e Pg 1019, 1020.

Question 30

Q

Peroral flexible endoscopic techniques are recommended for use in Zenker Diverticula measuring -

A. 2-5cm
B. >3cm
C. 0-5cm
D. <3cm

Answer

A

Ans C -

New peroral flexible endoscopic techniques offer promise for patients with any size diverticulum but will probably be best for small or medium (0-5cm) diverticula.

Shackleford 8e Pg 171.

Question 31

Q

All of the following are true regarding epiphrenic diverticulum except =

A. Arises from the right side in majority
B. most common within distal 10cm of the esophagus
C. More common in women and elderly
D. Usually measures 4-7cm in maximal dimension
E. Single diverticular in majority

Answer

A

Ans C -

First described by Mondiere
Pulsion Pseudodiverticulum
Distal 10cm of Esophagus
Zenker diverticulum nearly 3 times more common than epiphrenic.
mostly single, 15% may have multiple
most often arise from right side in 70%
measure 4-7cm in size
more common in elderly
Equal gender distribution

Shackleford 8e Pg 173.

Question 32

Q

Most common motility disorder associated with epiphrenic diverticulum ?

A. Achalasia
B. DES
C. IEM
D. Hypertensive lower esophageal sphincter.

Answer

A

Ans A -

Named motility disorders associated with these diverticula include achalasia, diffuse esophageal spasm, nutcracker esophagus, and hypertensive lower esophageal sphincter, with the most common being achalasia followed by diffuse esophageal spasm. Shackleford 8e Pg 173.

Question 33

Q

Most common presentation of epiphrenic diverticula =

A. Asymptomatic
B. dysphagia
C. Regurgitation
D. Chest Pain

Answer

A

Ans A - most of the epiphrenic diverticula are wide mouther and asymptomatic.

Shackleford 8e Pg 173.
Sabiston 20e Pg 1021.

Question 34

Q

Most common symptom of epiphrenic diverticula ?

A. Dysphagia
B. chest pain
C. Regurgitation
D. Repeated aspiration

Answer

A

Ans A -
Symptomatic patients most commonly present with dysphagia (90%).

It is difficult to determine whether the symptoms are due to the diverticulum or the underlying motility disorder.

Diverticular more than 5cm in size are more likely to produce symptoms, irrespective of the presence or absence of a motility disorder.
Therefore symptoms early in the disease process are more likely to be due to the motility disorder whereas later in the disease they are more likely to be due to diverticula.

shackleford 8e Pg 173.

Question 35

Q

Best diagnostic tool for the diagnosis of Epiphrenic diverticulum -

A. Endoscopy
B. Barium Swallow
C. HRM
D. CECT Chest

Answer

A

Ans B -

Barium swallow is the best diagnostic tool for the diagnosis of epiphrenic diveritculum.

Shackleford 8e Pg 174.

Question 36

Q

Which of the following is not necessary during the workup for epiphrenic diverticulum ?

A. Endoscopy
B. Barium Swallow
C. CECT chest
D. HRM

Answer

A

Ans C -

Endoscopy, Barium swallow and HRM are the three required investigation for the workup of epiphrenic diverticulum.

In addition to the primary studies there are several additional studies that may provide additional information. A CT scan of the chest can be helpful in determining the proximal extent of the diverticulum. When the superior edge of the diverticulum is beyond the inferior pulmonary veins, it may be very difficult to access laparoscopically and suggests the need for the addition of a thoracoscopic procedure to completely resect the diverticulum.

Patients with symptoms of GERD may undergo pH testing if needed.

Shackleford 8e Pg 174, Sabiston 20e Pg 1021.

Question 37

Q

Which of the following investigations guides the length of myotomy needed to be performed in epiphrenic diverticulum -

A. Endoscopy
B. HRM
C. Barium swallow
D. Both A and C

Answer

A

Ans B - the length of the myotomy is best determined by the HRM.

Shackleford 8e Pg 175.

Question 38

Q

Traditional approach for surgical treatment of epiphrenic diverticula -

A. Right thoracotomy
B. Left thoracotomy
C. Laparoscopic
D. Right thoracoscopic

Answer

A

Ans B -

Traditionally, an epiphrenic diverticulum is approached via a 7th or 8th interspace left thoracotomy though both thoracic cavities have been used.

Shackleford 8e Pg 175.

Question 39

Q

All of the following are true regarding epiphrenic diveritculum except -

A. Partial fundoplication often added to diverticulectomy is Belsey Mark IV Fundoplication.

B. The myotomy is carried on from the inferior margin of the diverticulum on the same side

C. The myotomy is a long esophagomyotomy extending upto 2cm onto the stomach.

D. some may extend the myotomy proximally to the aortic arch

Answer

A

Ans B -

Statements A, C and D are true.

The myotomy is carried on the opposite side to the diverticulum, starting from the inferior aspect of the diverticulectomy and extended onto the stomach.

Shackleford 8e Pg 176.

Question 40

Q

which of the following is the preferred anti-reflux operation performed during laparosocpic repair of Epiphrenic diverticula -

A. Toupet
B. Belsey Mark IV
C. Hill
D. Nissen

Answer

A

Ans A -

Either a Toupet fundoplication is created posteriorly or Dor fundoplication is creater anteriorly.

Shackleford 8e Pg 178.

Question 41

Q

Laparoscopic approach should be avoided for epiphrenic diverticula if

A. Diverticula located more than 5cm proximal to the GEJ
B. Diverticula size more than 5cm
C. Diverticula’s superior edge is proximal to the inferior pulmonary vein.
D. both A and C

Answer

A

Ans D -

In the patient with a normal hiatus access, visualisation into the mediastinum can be limited. It is likely then that diverticula that are greater than 5cm from the GEJ will be inadequately addressed with a transhiatal dissection, with a higher propensity for incomplete resection or a staple line leak at the superior most aspect of the diverticulectomy.

For diverticula less than 5cm above the GEJ a laparoscopic transhiatal approach is likely to be succesful, whereas for those greater than 5cm above the GEJ or above the inferior pulmonary vein, a combined thoracoscopic-laparoscopic minimally invasive approach is likely necessary.

Shackleford 8e Pg 178, 179.

Question 42

Q

which of the following statements is false regarding Mid-esophageal diverticula ?

A. Found within 4-5cm of the tracheal carina.

B. Motility disorders are present in over 80% patients.

C. The initial test that identifies the diverticulum is more likely to be a computed tomography scan of the chest.

D. The preferred approach is left thoracotomy

Answer

A

Ans D -

middle one third of the esophagus, within 4-5cm of the tracheal carina.
In addition to the traction etiology there is most likely a pulsion component as motility disorders are present in over 80% of patients.
Mid esophageal diverticual are typically asymptomatic and wide mouthed with dependent drainage.
most symptomatic patients present with intermittent dysphagia, and some with retrosternal pain, heartburn, and/or acid reflux.
the initial test that identifies the diverticulum is more likely to be a CT scan of the chest.
Typical workup include - Endoscopy, Contrast study and HRM (if mediastinal pathology absent)
preferred approach - Right thoracotomy through 5th ICS.

Shackleford 8e Pg 182.

Question 43

Q

Which of the following is not a component of the Allgrove or Triple A syndrome ?

A. Alacrima
B. Achalasia
C. Anisocoria
D. ACTH resistant adrenal insufficiency

Answer

A

Ans C -

A genetic etiology is present in a fraction of patients with achalasia. The Triple-A syndrome or Allgrove disease is a rare condition presenting with achalasia, alacrima, ACTH resistant adrenal insufficiency.

Shackleford 8e Pg 184.

Question 44

Q

Which of the following statements is true regarding achalasia -

A. Peak incidence is > 65 years old.
B. There are no familial associations
C. May be associated with polymorphism in nitric oxide synthase gene.
D. Idiopathic achalasia was found to be associated with Class II HLAs.

Answer

A

Ans B -

A few familial cases have been reported of achalasia cardia.

Shackleford 8e Pg 184.

Question 45

Q

Most common presenting symptom of achalasia -

A. Progressive dysphagia to both solids and liquids
B. Intermittent dysphagia to both solids and liquids
C. Regurgitation of undigested food.
D. Intermittent dysphagia more for liquids.

Answer

A

Ans A -

Progressive dysphagia to both solids and liquids is the most common presenting symptom (90%).

Diagnosis is commonly delayed by a number of years after the onset of symptoms. Patients often accomodate to their dysphagia by changing their eating habits -

avoiding solid food
drinking liquids with their meals

Shackleford 8e Pg 184.

The classic triad of presenting symptoms of achalasia consists of dysphagia, regurgitation and weight loss.
The dysphagia begins from liquids and progresses to solids.
Eating is a laborious process - eat slowly and use large volumes of water. As the water builds up pressure, retrosternal pain is experienced which can be severe, until the LES opens, which provides quick relief.

Regurgitation of foul smelling food is common.
Pneumonia, bronchiectasis and lung abscess often result from long standing achalasia.

Sabiston 20e Pg 1017.

Question 46

Q

which of the following statements is false regarding achalasia

A. Corkscrew appearance can be seen

B. the height of the barium column in timed barium esophagography can be prognostic

C. best response to surgical treatment is seen in type II achalasia

D. There is no increased risk of cancer in patients treated for achalasia

Answer

A

Ans D

Although the typical appearance described for achalasia is Bird’s beak appearance, but Corkscrew appearance can be seen in patients with type III Achalasia.

If the height of barium column in timed barium esophagography fails to decrease after a therapeutic modality, there is a high likelihood of treatment failure. Also higher the barium column, more severe is the disease.

Best response to treatment is seen in patients with type II achalasia whereas the worst response to treatment is seen in patients with type III achalasia. The response to treatment is intermediate in type I, with poorer response with greater dilation.

Achalasia is known to be a premalignant condition of the esophagus, during a 20-year period, a patient will have up to an 8% chance for development of carcinoma. SCC is the most common type identified and is thought to tbe a result of long standing retained undigested fermenting food in the body of the esophagus, causing mucosal irritation. If the histology is adenocarcinoma, it tends to appear in the middle third of the esophagus, below the air fluid level, where the mucosal irritation is the greatest. In contrast to these theories of carcinogenesis, it appears that even in patients with treated achalasia, there is an ongoing cancer incidence risk.
Long term suveillance is strongly recommended for recurrent achalasia and cancer.

Sabiston 20e Pg 1017,
Shackleford 8e Pg 185.

Question 47

Q

which of the following is the main medical intervention for achalasia -

A. Balloon dilatation
B. Botox
C. Nitrates and Calcium Channel blockers
D. Stents

Answer

A

Ans A -

The main medical intervention for achalasia is pneumatic dilation.

Shackleford 8e Pg 187.

Question 48

Q

which of the following is not likely to have favorable response to pneumatic dilation in achalasia -

A. Age > 45 years
B. Male gender
C. LES pressure <10mmHg after PD
D. Type II achalasia

Answer

A

Ans B -

A number of variables are associated with a favorable response to PD, including older age >45 years, female gender, LES pressure of less than 10 mmHg following PD, narrow esophagus prior to PD, and type II achalasia.

Shackleford 8e Pg 187.

Question 49

Q

Which of the following is not a part of original description of Heller Myotomy

A. 8cm long myotomy
B. Two myotomies 180 degree apart
C. Partial fundoplication
D. Thoracotomy approach

Answer

A

Ans C -

Surgical myotomy was initially described by Heller in 1913, and was performed as a thoracotomy with two separate 8cm separated by 180 degree. The technique has undergone several modifications and now involves a single anterior myotomy with addition of a partial fundoplication.

Shackleford 8e Pg 189.

Question 50

Q

which of the following is the most commonly performed fundoplication during Laparoscopic Heller Myotomy -

A. Toupet
B. Dor
C. Nissen
D. Belsey Mark IV

Answer

A

Ans A -

Toupet is the most commonly performed partial fundoplication with laparoscopic heller myotomy.

The anterior partial fundoplication or Dor is used if there is -
- No hiatal hernia
- and, adequate intra-abdominal length for myotomy.
This requires minimal mobilisation of the fudus and minimizes mediastinal dissection.

Shackleford 8e Pg 190.

Question 51

Q

What is the usualy length of the Laparoscopic Heller myotomy

A. 4cm
B. 5cm
C. 6cm
D. 8cm

Answer

A

Ans D -

The myotomy is started 2cm above the GEJ and it is 4-5cm onto the esophagus and 2-3cm on the stomach.

Shackleford 8e Pg 190.

Question 52

Q

Which of the following is not one of the five classical findings of type I achalasia

A. Hypertensive LES with pressure >35 mmHg and IRP > 15mmHg.

B. Body of the esophagus will have pressure above the baseline

C. Simultaneous mirrored contractions with no evidence of progressive peristalsis

D. Low amplitude waveforms indicating lack of muscle tone.

E. None of the above

Answer

A

Ans E -

There are five classical findings in type I achalasia which are seen on Manometry. Two abnormalities of the LES and 3 of the esophageal body.

LES -

Hypertensive LES with pressure >35 mmHg
failure to relax with deglutition

Body -

Body of the esophagus will have pressure above the baseline from incomplete evacuation of air.
simultaneous mirrored contractions with no evidence of progressive peristalsis
low amplitude waveforms indicating a lack of muscle tone.

Sabiston 20e Pg 1018.

Question 53

Q

Which of the following is not a part of the follow up after laparoscopic heller myotomy -

A. Water soluble contrast esophagogram on POD 1

B. Routine postop visit is planned for 3-4 weeks postoperatively with endoscopy and Timed Barium swallow

C. pH testing planned for 6 months

D. Screening endoscopies for cancer every 2 years

Answer

A

Ans D -

Screening endoscopies are recommended due to the increased risk of squamous cell carcinoma and they are recommended every 5 years.

Shackleford 8e Pg 191.

Question 54

Q

which of the following is a relative contraindication to POEM ?

A. Large Hiatal hernia
B. Previous interventions
C. End- stage sigmoid achalasia
D. Previous Heller myotomy

Answer

A

Ans A -

There are no current absolute contraindications to POEM except the inability to tolerate general anesthesia.

No longer are patients with end stage “sigmoid” achalasia or those with prior interventions felt to be relative contraindications. The authors do consider large hiatal hernia to be a relative contraindication to POEM due to a higher risk of GERD post-procedure.

In patients with large hiatal hernia - a laparoscopic heller myotomy with hernia repair and partial fundoplication is preferred.

Shackleford 8e Pg 192.

Question 55

Q

what is the composition of the lifting solution used in POEM ?

A. 1mL Indigo Carmine Diluted in 500mL NS
B. Epinephrine 1:1000 dilution of 1mg/mL solution.
C. Both A and B

Answer

A

Ans C -

the site for mucosal incision should be 3-4cm proximal to the determined start of the myotomy. This can be done at the 2 o’clock or the 6 o’clock position.

The lifting solution is 1mL Indigo Carmine diluted in 500 mL NS with or without epinephrine 1:1000 1mg/mL

Shackleford 8e Pg 192.

Question 56

Q

which of the following is not true regarding POEM ?

A. Myotomy begins 3cm proximal to the high pressure zone

B. Longer myotomy is performed for Achalasia Type III

C. Mucosotomy is performed 3cm proximal to the proximal most level of Myotomy

D. Transition from orderly esophageal vessels to the submucosal palisade vessels is characteristic of gastric plane.

E. Mediastinal exposure due to splitting of longitudinal muscle fibers is suggestive of full thickness perforation

Answer

A

Ans E

A - The site for mucosal incision should be 3-4cm proximal to the determined start of the myotomy. The position for the myotomy can be Lesser curve position (2 o’clock) or posterior position (6 o’ clock)

B - For achalasia types 1 and 2, short myotomy is generally performed. The start of the myotomy is planned for 3cm proximal to the high pressure zone. For achalasia type 3, a longer myotomy is performed based on impedance planimetry and preoperative HRM.
For type 3 achalasia the extended proximal myotomy can be extended from a few centimeters from the cricopharyngeus to the gastric cardia.

C. - Myotomy begins 2-3cm distal to the most distal extent of the mucosotomy and proceeds antegrade.

D - the distal extent of dissection can be identified by encountering the tattoo placed previously or by visualising the transition from orderly esophageal vessels to the submucosal palisades characteristic of gastric plane.

E - The longitudinal fibers are very thin and splitting often occurs under the pressure of the dissecting cap, which will reveal mediastinal structures beyond the intact esophageal adventitia. This mediastinal exposure is common and does not indicate a full thickness perforation,

Shackleford 8e Pg 192,193.

Question 57

Q

Which of the following may be considered a contraindication to POEM ?

A. Previous heller myotomy
B. previous Botox injections
C. End-stage achalasia or sigmoid esophagus
D. inability to tolerate general anesthesia

Answer

A

Ans D -

Previous heller myotomy, botox injections, pneumatic dilations and end-stage achalasia were all considered contraindications to POEM in the past, POEM has been successfully completed with no increase in procedure length or perioperative complications after prior intervention.

In the setting of failed Heller myotomy, some recommend creation of the sub-mucosal tunnel in the posterior aspect or lateral wall of the esophagus.

End stage achalasia or sigmoid esophagus is more difficult technically to treat and has somewhat poorer clinical results, and it was considered a contraindication to POEM in the past, but successful therapy has been described in small subsets.

Shackleford 8e Pg 193,194.

Question 58

Q

Eckardt clinical score is used for ?

A. subjective assessment of achalasia symptoms
B. subjective assessment of dysphagia
C. subjective assessment of post-operative results of achalasia
D. Both A and C

Answer

A

Ans D -

Eckardt clinical score is used to evaluate subjective achalasia symptoms and postoperative results.
It is a validated tool that allows for symptom grading in severity and frequency of dysphagia, chest pain, regurgitation, weight loss.
Scores of 3 or less are used to define successful symptom relief.
Eckardt scores range from 5.5 to 8.8 before POEM and reduce to 0 to 1.4 after POEM.

Shackleford 8e Pg 194.

Question 59

Q

Which of the following is not a complication of POEM

A. Pneumothorax
B. Mucosal injuries
C. Mucosotomy dehiscence
D. full thickness perforation

Answer

A

Ans A -

Inadvertant mucosal injuries such burns and small perforation can occur in upto 25% of cases initially.

Full thickness perforation are very rare but can cause serious harm.

Mucosotomy dehiscence and postoperative bleeding are also very rare but can cause serious harm.

Pneumoperitoneum, Pneumothorax and pneumomediastinum are not felt to be complications but rather side effects of the procedure. As long as carbon dioxide is used for the procedure, these rarely require intervention due to reabsorption.
If necessary due to symptoms, sterile needle decompression, without indwelling drain placement, can be performed in the peritoneal cavity or the anterior chest during or after the procedure.

Shackleford 8e Pg 195.

Question 60

Q

which of the following is not a true statement

A. Most frequent abnormality causing GERD is increase in tLESR
B. Direct aspiration of gastric contents is most common cause of extra-esophageal symptoms of GERD
C. tLESR is pathological opening of sphincter without an antecedent swallow
D. Troublesome symptoms are defined as moderate symptoms atleast once a week

Answer

A

Ans C -

tLESR is a normal physiologic occurence of sphincter opening without an antecedent swallow that results in reflux of gastric contents into the esophagus.

Reflux is cleared by secondary peristalsis and neutralisation by salivary bicarbonate. Failure of either of these clearance mechanisms may contribute to injury.

Gastric emptying delay, central obesity can contribute to GERD.

Troublesome symptoms are defined as

mild symptoms atleast twice a week
moderate or severe symptoms atleast once a week.

Shackleford 8e Pg 197.

Question 61

Q

which of the following is not true regarding GERD

A. Women tend to present with NERD
B. Prevalence of GERD is higher in older age groups
C. Patients older than 65 years of age are more likely to present with higher grades of esophagitis.
D. GERD during pregnancy usually resolves with delivery

Answer

A

Ans B -

The current body of data does not show a difference in prevalence of GERD in aging patients, but esophageal sensitivity to acid decreases with increasing age and thus predisposing patients older than 55 -65 years to an increase in higher grade of esophagitis than younger patients.

There does not appear to be a large difference in symptoms of GERD among men and women, however some studies suggest that women tend to present with non-erosive disease, where as men tend to present with esophagitis and Barrett’s esophagus.

GERD prevalence in pregnancy ranges from 30-80%. GERD symptoms commonly resolve with delivery, but may start again at a later date in some patients.

Shackleford 8e Pg 199.

Question 62

Q

which of the following is not associated with a higher risk of erosive esophagitis?

A. Male 
B. regular alcohol consumption
C. increased BMI
D. H. Pylori
E. Smoking

Answer

A

Ans D - H pylori

Increased risk of erosive esophagitis

increased BMI
Male
Alcohol
Smoking
History of GERD >1year

Decreased risk of erosive esohagitis
- H. Pylori

Shackleford 8e Pg 199.

Question 63

Q

Which of the following is not a risk factor for presence and persistence of extra-esophageal symptoms of GERD -

A. Male
B. increased age
C. GERD history longer than 1 year
D. Severe esophagitis Grade C and D
E. Smoking

Answer

A

Ans A -

while erosive esophagitis is more likely present in males, extra-esophageal symptoms of GERD are present more commonly in females.

Risk factors for presence and persistence of symptoms include female gender, increased age, more severe esophagitis (Grade C and D), GERD history longer than 1 year, smoking.

Shaackleford 8e Pg 200.

Question 64

Q

Risk factors for the development of Barrett’s esophagus include all except -

A. Male gender
B. Duration of GERD
C. Central Obesity
D. Smoking
E. Erosive esophagitis

Answer

A

Ans D -

Having erosive esophagitis increases the likelihood of Barrett Esophagus.

Additional risk factors for the development of Barrett Esophagus are - 
Male gender
Duration of GERD
Central Obesity
Caucasian

Shackleford 8e Pg 200.

Answer 65

A

Ans - B

GERD is the most common foregut disease in the world and responsible for 75% of all esophageal pathology.

Progression to erosive disease occurs in 13% cases over 5 years.

Progression to BE occurs in 10% cases over 5 years.

Shackleford 8e Pg 204

Answer 66

A

Ans B -

In practice, it is common for primary care physicians to treat patients with GERD symptoms on their initial visit with a trial of PPIs. If symptoms are relieved they accept the diagnosis of GERD, despite studies showing that the “PPI trial” has a low accuracy for identifying patients with GERD.
In the absence of a complete response to a trial of PPIs, it is recommended that the dose of PPIs be doubled.
If this does not lead to symptoms resolution, a 24 hour esophageal pH monitoring study should be performed off medication to measure the esophageal acid exposure and to confirm the diagnosis of GERD.

Shackleford 8e Pg 204.

Answer 67

A

Ans C -

Although regular and consistent PPI Therapy can improve symptoms and heal erosive esophagitis, it does not stop progression to BE.

Absence of endoscopic esophagitis at presentation is not a positive prognostic factor since NERD can also progress on PPI.

The progression of GERD while on PPI therapy was likely due to progressive LES damage during therapy. The greater the LES damage, the less effective the PPI therapy.

Taken together the studies show -

Treatment of GERD with PPIs does not prevent the progression of disease
Stages of GERD severity correlate well to the altered mechanica features of the LES
damage to the LES is associated with altered hiatal anatomy, increased esophageal exposure to refluxed acid and bile.
PPI therapy does not protect against continuing LES damage.

Shackleford 8e Pg 205, 204.

Answer 68

A

Ans D =

If esophageal manometry done at rest, in recumbent position and after an overnight fast, shows the LES to have an abnormally low pressure, a short overall length, or a minimal length exposed to the abdominal pressure environment, it is called a permanent failure of LES.
One or more of the following indicates the presence of permanently failed LES

Average pressure of 6mmHg or less
Total length of LES 2cm or less.
Average intra-abdominal length of LES 1cm or less.

these are the lowest 2.5 percentile values.
Median abdominal LES length is 2.2cm, median overall length is 3.6cm.

shackleford 8e Pg 208.

Answer 69

A

Ans C - Mucosal injury is the highest when the refluxed gastric juice is a mixture of gastric acid and duodenal bile.

Acid alone in physiologic concentrations is not very damaging but in high concentrations the incidence of epithelial damage is substantial.
Similarly the reflux of duodenal juice alone does little damage but when combined with gastric juice becomes particularly noxious.

Patients with erosive esophagitis showed a 10 fold increase in bile acid concentrations compared to those who had no injury, while esophageal acid exposure was similar in both groups.
Patients with strictures or BE had more esophageal acid exposure than the other groups but had bile acid concentrations significantly greater than those with erosive esophagitis.

Shackleford 8e Pg 210.

Answer 70

A

Ans A -

When pH exceeds 4, heartburn and regurgitation diminish.

pH <2 - acidification of bile results in irreversible bile acid precipitation.

pH 3-5 : stimulates phenotypic differentiation of the cardiac mucosa towards intestinalization and proliferation of the mucosal glandular cells.

pH 4.5 or more : bacteria normally present in mouth begin to grow in stomach and deconjugate bile acids.

pH 3-6 : bile acids become soluble, and a portion dissociates into their ionized salt, while the remainder remains in lipophillic non-ionized form.

pH 7 : more than 90% of bile acid becomes soluble and completely ionized and non-toxic.

Danger zone is 2 to 6.5

Under normal physiologic conditions - bile acids in the stomach precipitate and have minimal effect.

In danger zone - non-dissociated non-polar bile acid molecules reflux into the esophagus and enter the mucosal cells. Once in the cell, where the pH is 7, they become completely dissociated into polar ions and are trapped intracellularly in nearly 7x their luminal concentrations. Become cytotoxic and function as comutagens or even direct mutagens.

Shackleford 8e Pg 211, 212

Answer 71

A

ANS C

Oxyntocardiac mucosa - contains chief cells and parietal cells and it is present in the distal most part of the esophagus.

Cardiac mucosa containing only mucous cells and no chief cells and parietal cells is between the oxyntocardiac and the intestinalized cardiac mucosa.

Intestinalized cardiac mucosa with a viliform surface, mucous glands, alcian blue staining goblet cells and no parietal or chief cells is the most proximal.

In the normal state, the squamous epithelial lining of the esophagus and LES changes abruptly to oxyntic mucosa of the gastric fundus without a “gastric cardiac mucosa”.

Shackleford 8e Pg 213.

Answer 72

A

Ans D -
clinical studies have shown a time lag of 5-7 years after the onset of reflux symptoms for intestinalized cardiac mucosa to appear in the adults.

Shackleford 8e Pg 214.

Answer 73

A

Ans B -

In the acute setting, the reflux of large volumes of gastric contents proximally into the airway can present a life threatening aspiration event, sometimes known as Mendelson syndrome.

Shackleford 8e Pg 221.

Answer 74

A

Ans E =

A host of factors may contribute to the change from physiologic to pathologic stage.
Lifestyle factors - alcohol, smoking, obesity
Medications - CCBs, Theophyllines
Diet - Fatty food, fried foods, chocolate, caffeine, acidic foods.
Eating habits - large meals before sleep
Hiatus hernia, pregnancy, rapid weight gain.

Shackleford 8e Pg 221.

Answer 75

A

Ans A -

American college of chest physicians defines chronic cough as one lasting greater than 8 weeks in a non-smoking, immunocompetent patient who takes no cough inducing drugs (Such as ACEi) and has a normal chest radiograph.

Shackleford 8e Pg 221.

Answer 76

A

Ans B -
The primary mechanisms for consideration are
- microaspiration
- esophagobronchial reflex
- increased sensitivity of cough reflex.

Microaspiration can be evidenced by detection of gastric contents in BAL.
At bronchoscopy the evidence of aspiration includes - subglottic stenosis, hemorrhagic tracheobronchitis, erythema of subsegmental bronchi.

Esophagobronchial reflex is mediated by acid sensitive TRPV1 channels and subsequent convergence of these sensory afferents with vagal efferent neurons. This provides a means by which refluxate in the distal esophagus may stimulate a vagal reflex.

Repetitive stimulation can lead to hypersensitivity and lower the threshold for cough.

Dynamic changes in the cough threshold may cause cough to become relatively stimulus agnostic such that non-reflux stimuli precipitate symptoms previously associated with GER.

Shackleford 8e Pg 222

Answer 77

A

Ans D - none of the above.

Although these findings may be sensitive for the diagnosis of LPR, they are often not specific because they are common findings in the general population, and are strictly not linked to exposure of the larynx to the gastric contents.

Shackleford 8e Pg 222.

Answer 78

A

Ans - C -

Detection of the reflux into the pharynx requires diagnostic strategies that differ from the detection of reflux into the esophagus, on account of neutralisation of refluxate as it ascends the esophagus into the more alkaline environment of the pharynx.

As such pharyngeal pH monitoring is of low sensitivity for the diagnosis of LPR. Currently, pH/Impedance monitoring offers a superior strategy for diagnosis.

Shackleford 8e Pg 222.

Answer 79

A

Ans D - 30-90%

Asthma is common in united states with approximately 24 million americans carrying the diagnosis. Of these patients with asthma, an estimated 30-90% of patients have GER. Systematic review revealed that 59.2% of asthamatics have evidence of GERD, whereas the prevalence in controls was 38.1%.
Abnormal esophageal pH, esophagitis and hiatal hernia are all more prevalent in patients with asthma.
GER is also a risk factor for asthma related hospitalisations in older adults.

Shackleford 8e Pg 223.

Answer 80

A

Ans D

GERD was independently associated with increased risk of COPD exacerbation.

A shared embryonic origin from the foregut of the respiratory and gastrointestinal systems contributes to the interplay between asthma, COPD and GER.

Shared vagal innervation and resultant converging visceral sensory neural input contributes to pulmonary symptoms at the time of stimulation of esophageal receptors by acid

Non-adrenergic neurons in the esophageal myenteric plexus communicate with the trachea.

In animal models, instillation of acid in the esophagus results in release of tachykinin like substances in the airways and bronchoconstriction. This finding can be terminated with vagotomy.

A single bolus of acid results in histopathological changes of neutrophil sequestration, epithelial damage, pulmonary edema and pulmonary hemorrhage.

Instillation of acid increases total lung resistance and leads to an aspiration pneumonia characterised by neutrophilic and lymphocytic peribronchiolar infiltrates, goblet cell hyperplasia, and thickening of the smooth muscle layer.

The chronic aspiration model results in a shift to Th2 inflammatory response.

Shackleford 8e Pg 223,224.

Answer 81

A

Ans D -

Three large randomized trials represent the best evidence that high dose PPI improves symptoms of asthma.
Two of these trials also show that PPI improve PEF, FEV1.

Although a significant fraction of patients with asthma may have clinically silent GER, the evidence does not support PPI therapy for patients with silent GER and Asthma.
Addition of PPI for patients with poorly controlled asthma and minimal or no symptoms of reflux does not improve episodes of poor asthma control nor does it improve PEF

Treatment of GER does provide a benefit with respect to management of asthma, no consistent improvement in secondary outcomes such as lung function, airway responsiveness or asthma symptoms was identified.

The role for anti-reflux surgery with asthma and GER is poorly defined and without high level evidence. Surgical therapy is associated with improved asthma symptom control, but improvements in pulmonary function have not been demonstrated.

Shackleford 8e Pg 224.

Answer 82

A

Ans B -

Erosive Esophagitis

PPI treatment success for potential GERD syndromes is variable, and the best chance for success is in treating those with erosive esophagitis.
Typical GERD symptoms also respond relatively well, particularly in patients with esophagitis or with abnormal pH testing off PPI.
Atypical symptoms and those with normal pH testing are less likely to respond.
Barrett’s Esophagus shows no response to PPI therapy.

Shackleford 8e Pg 229.

Answer 83

A

Ans A -

There are rare instances of true PPI failures - defined by persistence of abnormal acid exposure on adequate PPI therapy.
Compliance must be questioned, and optimisation of dosage and frequency of PPI therapy can be attempted.
In rare cases, reduced bioavailability, rapid metabolism and PPI resistance can be implicated for non-response and it is reasonable to switch to a different PPI.

However for vast majority of patients, the most likely cause of PPI non-response are the absence of GERD as an etiology of their symptoms or persistence of regurgitation and/or hypersensitivity - i.e. not inadequate acid supression.

In partial responders it appears the increased proximal reflux and hypersensitivity account for the lack of full reponse.

Shackleford 8e Pg 229.

Answer 84

A

Ans D -

A more useful recommendation is that of weight loss, particularly in patients with central obesity. Obesity promotes GERD by increasing intra-abdomninal pressure and the development of a hiatal hernia.
Metabolically active visceral fat may also promote Barrett metaplasia via a proinflammatory mechanism.
Reduction in BMI and central obesity result i better GERD symptom control.

Shackleford 8e Pg 229,

Answer 85

A

Ans B -

Alginates -
modest benefit in reducing the number of acid reflux episodes and the severity and frequency of heartburn, regurgitation and nighttime symptoms by creating a pH-neutral raft at the site of postprandial acid pocket.

Prokinetics such as metoclopramides, domperidone, and cisapride which promote gastric emptying, increase LES pressure and enhance esophageal clearance but their use has been limited by marginal efficacy and prohibitive safety concerns - potentially fatal cardiac arrythmias, irreversible neurological side effects - Tardive dyskinesia.

Baclofen - GABA-B receptor agonist has been used to modulate tLESR which are in part regulated by GABA. Can lead to improved symptoms and reduction in reflux events, acid exposure and tLESR rates.

Lesogaberan and arbaclofen failed to sufficient benefit in Phase IIb randomized trials.

Low dose anti-depressants modulate the TRPV1 mediated acid sensing. SSRI and TCA have been used, although SSRI may be more efficacious than TCA.

Shackleford 8e Pg 229, 230.

Answer 86

A

Ans C

Surgical treatment by way of a fundoplication, is the only intervention that targets competency of EGJ, eliminates hiatal hernia, and creates a barrier for prevention of reflux.

It is most effective in patients who have a favorable response to PPI therapy prior to surgery, good compliance with acid suppressive medications, typical symptoms, and objective evidence of acid reflux.

For patients with adequate symptom control on PPI therapy, continuation of PPI has fewer side effects, lower morbidity and similar efficacy compared with surgery and should be recommended.
Patients with persistent regurgitation as their main symptom, with at least partial response to PPI therapy (and proven abnormal pH testing), are the group most likely to benefit from anti-reflux surgery.

Shackleford 8e Pg 230.

Answer 87

A

Ans C -

Stretta is a radiofrequency ablation therapy which delivers radiofrequency energy to the EGJ via an endoscopically placed catheter, with the goal of mechanically altering the EGJ and/or modulating neural pathways using thermal energy.
Proposed mechanism was tissue necrosis and subsequent deposition of collagen leading to “tightening of the LES”
Alternative theory - neurolysis decreases sensitivity and reduces tLESR.

Esophyx is a transoral incisionless fundoplication technique.

Medigus ultrasonic surgical endostapler is similar to Esophyx in concept.

Linx is a magnetic sphincter augmentation device.

Shackleford pg 230.

Answer 88

A

Ans B -

EsophyX uses full thickness fasteners whereas Medigus is USG guided and uses transmural surgical staples.

Shackleford 8e Pg 231.

Answer 89

A

Ans C - Nissen fundoplication is the current gold standard for operative treatment of GERD.

Shackleford 8e Pg 234.

Answer 90

A

Ans D -

These patients should undergo cardiac evaluation,including a chest radiograph, electrocardiogram, and if indicated, pulmonary function test in addition to standard diagnostic evaluation for gastroesophageal reflux.

Shackleford 8e Pg 234.

Answer 91

A

Ans C -

24h ambulatory pH monitoring is essential for the evaluation of patients with NERD, extra-esophageal, or atypical symptoms, and those who do not respond to PPI therapy.
Patients with typical reflux symptoms and erosive esophagitis do not routinely need a pH study to prove the diagnosis of reflux preoperatively.

Shackleford 8e Pg 235.

Answer 92

A

Ans D -

The wireless non-catheter based BRAVO probe monitors distal esophageal pH for a duration of 48-96 hours. It has the advantage of being more comfortable than the standard 24 hour probes. May have greater sensitivity for GERD than does standard 24 hour moitoring.

Shackleford 8e Pg 235.

Answer 93

A

Ans E -
The best outcomes for Antireflux surgery are seen in patients with symptomatic relief with PPI, typical symptoms and a positive 24 hour pH study.

However patients who have complete relief of symptoms, may have increased morbidity if they undergo anti-reflux surgery related to dysphagia, inability to vomit or belch.

Therefore the ideal patients would be those with significant symptoms, and concomitant reflux events (Acid or Non-acid) while taking acid suppression therapy.

The primary indications for anti-reflux surgery in GERD are -

patients with esophageal or extra-esophageal GERD symptoms that are responsive but no completely eliminated by PPI
Patients with heartburn eliminated by PPI but continued regurgitation.
Patients with well documented reflux events preceding symptoms such as chest pain, cough or wheezing.
Patients with GERD complications such as peptic strictures, BE, Vocal cord injury while take PPI twice a day.
Patients with well documented GERD who desire to stop chronic PPI despite excellent symptoms controls - due to side effects, lifestyle, expense etc.

Shackleford 8e Pg 235.

The ideal patient for antireflux surgery is a non-obese individual with a relatively preserved esophageal peristalsis, documented abnormal pH testing with good symptom correlation, typical symptoms of GERD, and symptoms that are atleast partially relieved by PPIs.

Shackleford 8e Pg 269.

Answer 94

A

Ans C > D

At a minimum patients should undergo esophagoduodenoscopy. Performance of an esophageal motility study is currently a preoperative standard to detect esophageal motility disorders that may lead to troublesome postoperative dysphagia.

24h ambulatory pH monitoring is essential for the evaluation of patients with NERD, atypical symptoms, and those who do not respond to PPI therapy.
Patients with typical symptoms and erosive esophagitis (or BE or Peptic stricture) do not routinely need a pH study to prove a diagnosis of reflux disease preoperatively.

Shackleford 8e Pg 235,234.

Answer 95

A

Ans B -

Impedance planimetry has emerged as a novel physiologic assessment tool. Available commercially as EndoFLIP device.
This is a catheter based system that provides a geometric evaluation of luminal structures by measuring 16 adjacent cross sectional areas while simultaneously recording intra-balloon pressure using a solid state pressure transducer.
When placed across the EGJ, the minimum cross sectional area divided by the intra-balloon pressure allows the calculation of the distensibility index.
GERD patients were found to have a distensibility index of nearly 2-3 times more for EGJ when compared to asymptomatic controls.

Shackleford 8e Pg 235.

Answer 96

A

Ans B -

Preoperative endoscopic or medical treatment of esophageal stricture or peptic ulcer disease must be accomplished before surgery.
In a patient with esophageal stricture preoperative dilation to atleast 16mm or 48 Fr is advisable to minimize the chance that the customary postoperative dysphagia will be compounded by a tight stricture. If pre-operative dilation to 16mm is successful - several sessions are sometimes necessary - it is usually possible to extend the dilation intraoperatively to 18-20mm.

Shackleford 8e Pg 236.

Answer 97

A

Ans C -

In certain subgroups of GERD patients fundoplication may not be the optimal anti-reflux surgery.

Medically complicated, morbidly obese (BMI > 35) patients with significant GERD may be better served by undergoing Roux-en-Y gastric bypass - since they have a high failure rates following Nissen Fundoplication.

Patients with Barrett esophagus with high grade dysplasia/adenocarcinoma should be treated with mucosal ablation or esophageal resection.

Patients with severe strictures that are not responsive to dilation therapy should also be treated by esophageal resection.

GERD patients with previous gastric surgery such as gastric bypass, partial or sleeve gastrectomy and VBG cannot be treated by fundoplication because the fundus has been anatomically disrupted.

Patients with low grade dysplasia should be treated with high dose PPI for 3 months after which they should undergo repeat biopsy. Fundoplication may be considered in such patients if subsequent pathology shows no progression to high grade dysplasia or carcinoma.

Shackleford 8e Pg 236.

Answer 98

A

Ans A -

Nissen fundoplication is an effective therapy for GERD and is not associated with significant long term dysphagia, even in patients with IEM. These data combined with data suggesting that partial fundoplication is associated with a high long term failure rate, have led to a significant decrease in the application of partial fundoplication in patients with GERD, regardless of esophageal peristaltic function.
Currently partial fundoplication is reserved for patients with a “named” esophageal motility disorder, such as achalasia or scleroderma, those with both IEM and significant dysphagia and those patients undergoing revision of a prior 360 degree fundoplication for refractory dysphagia.

Shackleford 8e Pg 236.

Answer 99

A

Ans D -

Results of both open and laparoscopic fundoplication are equivalent. The laparoscopic approach is associated with a shorter hospital stay, less postoperative pain, fewer wound related complications, and earlier return to work.
Despite these advantages, selection of the open versus the laparoscopic approach should depend on surgeon experience and the patient’s previous surgical history.

Shackleford 8e Pg 237.

Answer 100

A

Ans D -

To prevent reherniation a variety of techniques have been used to decrease tension at the crural closure including-

buttressing with 1cm sq Teflon patches, felt strips, or a piece of absorbable or non-absorbable mesh
Diaphragmatic relaxing incisions have allowed for significant reduction in tension at the crural closure

Some authors advocate infra-diaphramatic fixation of the fundoplication to the crura to prevent reherniation but there is no evidence that this decreases failure rates.

Shackleford 8e Pg 241, 242.

Answer 101

A

Ans D -

The first stitch of the Nissen fundoplication is taken 1.5cm above the GEJ and then two more stitches are taken 1cm above and below, and therefore the fundoplication extends from 0.5cm above the EGJ to 2.5cm above the EGJ.

The repair is a floppy repair, and the tightness of the fundoplication is tested after placing each suture by gently sliding a blunt ended grasper between the esophagus and the wrap. The grasper should easily slide along the esophagus. In open procedure this is done using the Number 15 cervical dilator.
Lateral traction of the wrap should allow visualisation of the diaphragm between the wrap and the esophagus.

Shackleford 8e Pg 242, 243.

Answer 102

A

Ans D -

No combination of preoperative clinical variables reliably predicts the presence of a short esophagus, and the diagnosis of this entity continues to be made definitively at the time of operation, where it is defined as failure to achieve 2.5cm of intra-abdominal esophagus after maximal mediastinal dissection techniques.

Shackleford 8e Pg 243

Answer 103

A

Ans A -

Injury to the mediastinal pleura during mediastinal dissection can lead to capnothorax which is usually well tolerated. But it can cause immediate or delayed hemodynamic or respiratory consequences.

When a pleural tear is detected, the first step is to make the hole larger - to avoid a tension capnothorax created by a one-way valve like phenomenon.

If increased airway pressure and decreased blood pressure develops, then pneumoperitoneum is decreased and positive pressure ventilation setting increased.
A Chest tube is almost never necessary. At the end of the case, suction is applied to the mediastinum, as the pneumoperitoneum is released, and the patient is administered several vital capacity breaths.
A chest X ray is un-necessary unless the patient has specific cardiopulmonary issues requiring this diagnostic test.

Shackleford 8e Pg 245.

Answer 104

A

Ans A -

the failure rate of Nissen fundoplication is approximately 1% per year for the first 10 years.

Shackleford 8e Pg 245, 246

Answer 105

A

Ans C -

Upto 20% patients will experience transient dysphagia, which is usually caused by postoperative edema secondary to surgical manipulation of the GEJ.
These symptoms typically improve without intervention within 6 weeks. EGD or Barium swallow is indicated if symptoms persist.

Shackleford 8e Pg 245.

Answer 106

A

Ans A -

Chronic acid supression with PPIs can reduce the absorption of vitamin B12 and magnesium, as well as effectiveness of clopidogrel. There is also an increased risk of clostridium difficile infection.
PPI for long term also cause
- hypergastrinemia and ECL cells hyperplasia and parietal cell hypertrophy (leads to rebound acid hypersecretion)
- chronic acid supression may also be associated with increqased incidence of gastric cancer.

Shackleford 8e Pg 248.

Answer 107

A

Ans A -

The LINX device consists of a series of biocompatible titanium beads with magnetic cores hermetically sealed inside. The beads are interlinked with independent titanium wires to form a flexible and expandable ring.

The beads can move independent of the adjacent beads and create a dynamic implant that does not compress the esophagus and does not limit its range of motion upon swallowing, belching and vomiting.

For reflux to occur the intragastric pressure must overcome the resistance to the opening of both native LES and the magnetic beads.

The LINX is manufactured in different sizes and is capable of nearly doubling its diameter when all beads are separated.

The magnetic attraction force to be counteracted allow bead separation is independent of the number of beads contained in the device.

Once healing is complete after the implant the device is encapsulated in fibrous tissue but is not incorporated into the esophageal wall, this makes it possible to remove the device without damage to the esophagus.

The LINX has recently received magnetic resonance imaging approval for scanning in systems upto 1.5 Tesla.

Shackleford 8e Pg 248,

Answer 108

A

Ans B -

the main presenting symptom requiring device removal was recurrence of heartburn or regurgitation (46%), dysphagia in 37% and chest pain in 18%.

Shackleford 8e Pg 251.

Answer 109

A

Ans A -

The mainstay of therapy is medical with gastric acid supression through the use of PPIs. PPIs are recommended as first line therapy based on their rapid impact on symptoms and efficient control of esophageal inflammation.

Shackleford 8e Pg 253.

Answer 110

A

Ans D -

Due the limitations of endoscopic manipulation patients with hiatal hernias larger than 2cm and GERD are not candidates for endoscopic therapy and are best managed with a standard laparoscopic repair.

Los Angeles endoscopic classification grade C and D, as well as patients with Barett Esophagus have been excluded from most studies. Although these characteristics are not an absolute contraindication to Endoscopic approach, the efficacy for these patients is not yet known.

Shackleford 8e Pg 253.

Answer 111

A

Ans C - the first FDA approved method for treating GERD was endoscopic suturing method under the name EndoCinch. Involved partial thickness plication on the gastric side of EGJ. Clinical outcomes with EndoCinch were marginal.

Shackleford 8e Pg 253.

Answer 112

A

Ans C -

the MUSE system uses titanium 4.8mm staples. It is a single operator system with the fundoplication completed in supine position.
Anvil is located on the tip of the device, whereas the cartridge is located on the shaft of the device.

The most significant complications were empyema and pneumothorax.

staples at 60 and 180 degrees.
Shackleford 8e Pg 254, 255.

Answer 113

A

Ans C -

EsophyX is currently the most widely used endoscopic approach. Creates a fundoplication for 240 degree.

shackleford 8e Pg 255.

Answer 114

A

Ans B -

The device is composed of a flexible balloon basket assembly with 4 electrode needle sheaths introduced orally that delivers energy to the circular muscle layer of the distal esophagus.

Target temperature of 85C is achieved in the muscle layer, whereas the mucosa is protected from thermal injury by maintaining its temperature less than 50C using counter-current irrigation.

Serial applications are repeated every 0.5cm such that an area of approximately 2cm above and below the squamocolumnar junction recieves treatment.

Two primary mechanisms -
Anatomically, heating causes collagen contraction with an associated increase in smooth muscle fiber size with larger fibers and more smooth muscle cells per bundle. This effect can be seen immediately after the procedure, and the collagen deposition continues upto 12 months.
Physiologically there is ablation of aberrant esophageal nerve pathways, leading to an increase in LES pressure and gastric yield pressure, as well as decrease in tLESR.

In addition, an improvement in gastroparesis associated with GERD has been noted after ablation. It is not clear what the mechanism of this effect is, but likely it is related to vagal neurolysis.

Compared head to head with surgical therapy, fundoplication demonstrated improved symptomatic relief, elimination of PPI use and overall satisfaction, albeit with higher rate of adverse events.

Shackleford 8e Pg 257, 258

Answer 115

A

Ans D -

Enteryx - biopolymer augmentation of the LES, has been withdrawn due to poor durability and significant complications.
Intramuscular injection of 8% ethylene vinyl alcohol and dimethyl sulfoxide is used.

Gatekeeper reflux repair - expandable hydrogel prosthesis also has been removed from the market.

EndoCinch - has also been removed.

Stretta is currently available .

Shackleford 8e Pg 257,258.

Answer 116

A

Ans C -

ARMS is a new approach based on the experience in ESD and EMR in Japan.
Improved reflux symptoms thought to be related to the stricture formation along the resected segment. Currently ARMS is performed using EMR and ESD of atleast 3cm length - 1cm in the esophagus and 2cm in the stomach, with the length of the mucosal resection at the cardia measured in retroflexion from the gastric side.
In order to preserve the sharp mucosal valve at the cardia, a hemicircumferential crescentric resection is performed along the lesser curve of the stomach.

Shackleford 8e Pg 259.

Answer 117

A

Ans D

The gastric pacemaker is present along the greater curvature in the body of the stomach.
The electrodes of the Gastric Electric stimulator are therefore placed 10cm proximal to the pylorus along the greater curvature.
It generates high frequence low energy stimulations.
Risks of gastric stimulator placement include erosion of leads into the gastric lumen with resultant infection, lead dislodgement, intestinal obstruction due to wires and infection at the stimulator site.
Stimulator placement has been shown to improve quality of life, reduce hospital visits, improve glycemic control in diabetic patients, and reduce the need for parenteral and enteral nutrition. It is more effective if the predominant symptoms are nausea and vomiting, it is less effective if a patient’s primary complaints are pain, fullness, and early satiety.

Shackleford 8e Pg 264, 265.

Answer 118

A

Ans C -
Belsey Mark IV is a transthoracic fundoplication and it has become increasingly uncommon as a primary anti-reflux surgery.

Shackleford 8e Pg 269.

Answer 119

A

Ans - C -

In patients presenting for reoperation after failed anti-reflux surgery, the most common complaint is recurrent heartburn and regurgitation. These symptoms are present in 60% of patients. Dysphagia as a dominant symptom is present in 30% patients. Other complaints include hiatal hernia, gas bloat, and atypical symptoms such as chest or abdominal pain.

Shackleford 8e Pg 269. `

Answer 120

A

Ans A

Patients with concomtiant esophageal motility disorder such as Achalasia, DES, those in whom obesity contributes to reflux and those with non-acid reflux or atypical symptoms including laryngospasm, chest pain, and recurrent aspiration have demonstrably inferior outcomes following fundoplication. Similarly those with overlooked anatomic or functional abnormalities such as esophageal strictures, fistula or delayed gastric emptying are unlikely to have their symptoms relieved by fundoplication alone. Advanced age, female gender, and the presence of a large hiatal hernia have also been noted as potential risk factors for failure.

Shackleford 8e Pg 269, 270.

Answer 121

A

Ans A -

Migration of the fundoplication wrap was the most common anatomic defect encountered at the time of reoperation, occuring in approximately 2/3. These include transhiatal herniation of an intact wrap or herniation of the proximal stomach through the wrap into a supra- or infra-diaphragmatic position.

Causes of Fundoplication failure
- Hiatal hernia 40-65% (Regurgitation, dysphagia)

Slipped Wrap 4-16% (reflux, dysphagia, early satiety, postprandial pain)
Loose or disrupted wrap 3-23% (reflux)
Tight or twisted wrap 1-10% (Dysphagia)
Underlying esophageal dysmotility (dysphagia)

Shackleford 8e Pg 270.

Answer 122

A

Ans A -

The most dangerous cause of early failure is herniation of the wrap in the immediate postoperative period. This creates an iatrogenic incarcerated hiatal hernia with potential compromise of regional blood flow. An episode of violent coughing or retching with increase in intra-abdominal pressure may precede such an event. Without prompt intervention there is risk of necrosis of stomach leading to significant morbidity and mortality. If a portion of the stomach becomes infarcted, the reconstruction options are limited by the patient’s physiologic condition and the availability of viable conduit to restore alimentary continuity. A staged repair is sometimes necessary in this circumstance.

Shackleford 8e Pg 270.

Answer 123

A

Ans A -

Redofundoplication is the most common operation performed on patients after a failed attempt at antireflux surgery.

Shackleford 8e Pg 272

Answer 124

A

Ans C -

Patients presenting with two or more failed attempts have markedly worse outcomes with substantially increased risk. After secondary failure most surgeons would caution against repeated attempts at fundoplication.

The ideal patient for revision fundoplication is one who has had a single attempt at an anti-reflux procedure and now presents with recurrent reflux that can be attributed to technical failure of the primary surgery.
Patients with dysphagia, esophageal dysmotility, obesity, vague or discordant symptoms, or a history of multiple operations should be considered for medical management or an alternative procedure.

Shackleford 8e Pg 272.

Answer 125

A

Ans C - Roux-en-Y gastric bypass is the optimal primary antireflux surgery for patients with GERD and morbid obesity.

Roux limb prevents reflux of biliopancreatic secretions into the gastric pouch and esophagus. The GJ should be performed to a small gastric pouch to minimize inclusion of the acid producing cells of the gastric body.
A roux limb of 120cm is important to facilitate weight loss, which in turn decreases intra-abdominal pressure and reflux.
In patients with obesity and a prior failure, Roux-en-Y reconstruction is superior to revision fundoplication in supression of reflux, avoidance of dysphagia, and overall quality of life.

RYGB should be considered the revision anti-reflux procedure of choice in patients with -

Obesity
distal esophagus or fundus is unusable due to prior surgery

It should be strongly considered in patients with multiple prior attempts fundoplication.

Shackleford 8e Pg 273.

Answer 126

A

Ans B

Failure of Roux-en-Y construction was seen in 5% patients with the mechanism of failure being hiatal hernia in all cases.

Shackleford 8e Pg 273.

Answer 127

A

Ans B 50 cm

For normal weight patients a short Roux limb nearly 50cm should be constructed to prevent malabsorption.

In select patients a gastrostomy tube can be placed in the remnant stomach to ensure adequate enteral intake. The placement of this tube is facilitated by Retrocolic-Retrogastric placement of the Roux Limb.

Gastrectomy of the stomach remnant is necessary in only selected patients with profound gastric dysmotility or acid hypersecretion.

The primary disadvantages are - complexity of the procedure and the addition of 2 anastomoses.

Shackleford 8e Pg 273.

Answer 128

A

Ans D -

Esophageal resection for benign ds is reserved for patients in whom symptoms are intractable and no other good surgical option exists. Indications for esophageal replacement in patients with prior failed fundoplication include progressive esophageal ulceration or fistula, a non-dilatable esophageal stricture, or severe dysphagia with diffuse dysmotility of esophageal body.
Patients with multiple prior anti-reflux operations and continued symptoms should also be considered.

Shackleford 8e Pg 273.

Answer 129

A

Ans A

A gastric conduit is the preferred reconstruction option following resection of the esophagus for cancer - due to the ease and safety of the procedure combined with the modest life expectancy.

A short or long segment colon or jejunum interposition graft may provide superior quality of life.

junction of neoesophagus and stomach remain in the abdomen and preserves the reservoir function of the stomach.
Colonic mucosa appears to be reasonably resistant to changes associated with acid exposure.
the blood supply to the colon and jejunum is also robust and incidence of anastomotic leak is probably less than gastric conduit.

Disadvantages -

more technically challenging
atleast 3 anastomosis are needed.
colon is not always available due to intrinsic pathology
Jejunum does not reach the neck for a long segment esophageal replacement without the addition of a microvascular anastomosis.

Shackleford 8e Pg 274.

Answer 130

A

Ans B -

Gastrointestinal manifestations are the third most common presentation after Raynaud disease and cutaneous findings.

Shackleford 8e Pg 274.

Answer 131

A

Ans D

Systemic sclerosis or scleroderma

women are nearly 4x more likely
symptoms in 3rd-4th decade
Raynaud disease is the most common presentation
Nearly 50% of the patients will have symptomatic involvement of esophagus - dysphagia and GERD.
atrophy of the smooth muscles in the distal 2/3 of the esophagus and replacement with fibrosis.
transforms the esophagus from propulsive muscular tube into a static inflexible structure.
Absent or diminished peristalsis of body and weakening of LES on manometry
shortening of esophagus with hiatal hernia is common
debilitating GERD with or without Dysphagia
Symptoms exacerbated by associated autonomic nerve dysfunction, gastroparesis and co-existence of sicca syndrome (Absence of saliva)
stricture present in 15-30% of patients.

it is unknown if BE and esophageal carcinoma are more common in these patients but is presumed to be the case.

Shackleford 8e Pg 274,

Answer 132

A

Ans A -

The treatment of esophageal dysfunction in patients with scleroderma is typically medical. PPIs and other acid supressing medications are used along with lifestyle modifications.
Dysphagia is more difficult to manage. Promotility agents, laxatives and antibiotics to reduce bacterial overgrowth have been used.
Systemic treatment may delay the progression of the disease but does not reverse the end-organ dysfunction.

Surgery should be avoided in most patients.
Only used in severe symptoms refractory to medical management and those with complications of GERD including undilatable stricture, recurrent aspiration or esophageal erosion.

Laparoscopic fundoplication is the most common operation performed in these patients because it is most familiar to the majority of foregut surgeons and it avoids the morbidity of gastrointestinal anastomosis.

Although laparoscopic fundoplication is the most commonly performed surgery in these patients, but Roux-en-Y gastric bypass is hypothesized to be the most beneficial since it has decreased chance of dysphagia, resecting the stomach is beneficial in patients in whom gastroparesis contributes to reflux disease and the roux limb can reach upto the mid esophagus allowing resection of severe distal stricture or erosion.

Shackleford 8e Pg 275.

Answer 133

A

Ans D -

Shackleford 8e Pg 275.

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Esophageal motility disorders and GERD Flashcards

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