MSC - F. Surgery Answers 2025

oFailure of conservative management

12.Cicatricial strictures of the esophagus. Causes, clinic, diagnosis, treatment. Types of bougie of the esophagus. Indications for surgical treatment.

Cicatricial Strictures of the Esophagus: Brief Overview

Definition:

Narrowing of the esophagus due to scar tissue formation after injury or inflammation, leading to lumen constriction and deformation.

Causes:

Most commonly chemical burns (caustic ingestion).

Iatrogenic injury, foreign bodies, peptic esophagitis, post-infectious causes (e.g., diphtheria).

Localization:

Pharyngoesophageal junction (behind cricoid)

Aortic arch level

Diaphragmatic hiatus

Types:

Membranous vs. tubular strictures

Single vs. multiple

Complete vs. incomplete

Clinical Features:

Progressive dysphagia (solids → liquids)

Regurgitation, retrosternal pain

oGastric tube formed from stomach’s greater curvature.

Graft routes:

oAnterior mediastinum (behind sternum).

o Intrapleural.

oPosterior mediastinum.

13.Achalasia of the cardia. Etiology, classification, clinic, diagnosis, conservative treatment.

Esophageal achalasia is a rare, chronic esophageal motility disorder marked by:

Absence of normal peristalsis.

Failure of the lower esophageal sphincter (LES) to relax during swallowing.

Etiology & Pathogenesis:

Likely due to degeneration of Auerbach’s plexus (myenteric plexus).

Contributing theories: viral infections, autoimmune, neuropsychiatric disturbances, or congenital neural defects.

Secondary achalasia may be due to malignancies (pseudoachalasia).

Clinical Features:

Dysphagia: Initially for solids, then liquids. Paradoxical dysphagia may occur (liquids harder to swallow than solids).

Regurgitation: Especially at night; may cause aspiration.

Retrosternal pain: From esophageal spasm or overdistension.

Weight loss, halitosis, belching, and cough.

Esophageal vomiting brings relief.

Long-standing disease leads to megaesophagus (gross dilation).

Classification:

Petrovsky’s Staging (I–IV):

o I: Functional spasm only.

o II: Minimal esophageal dilation.

o III: Significant dilation and muscular changes.

oIV: Severe dilation, tortuosity, complications (esophagitis, ulcers).

Types (Radiologic):

oType I: Mild dilation, muscle hypertrophy.

o Type II: Marked dilation, muscle atrophy, S-shaped esophagus.

Diagnosis:

1.Barium swallow: “Bird-beak” tapering of distal esophagus; proximal dilation; S-shaped esophagus.

2.Endoscopy: Rules out cancer (especially pseudoachalasia); biopsy if needed.

3.Manometry (Gold standard):

o Incomplete LES relaxation.

o Absent peristalsis.

oElevated LES pressure (not always).

4.Pharmacological tests (e.g., carbachol): Hyperresponsiveness indicates denervation.

1.Non-Surgical:

Balloon Pneumatic Dilatation (first-line for many):

o Serial dilations under fluoroscopy.

oRisk: perforation (~2%), reflux, bleeding.

Pharmacotherapy (limited, adjunctive):

oNitrates, calcium channel blockers, antispasmodics, anxiolytics.

oBotulinum toxin injection into LES in non-surgical candidates

3.Lifestyle & Support:

Small, frequent meals.

Elevated head during sleep.

Avoid meals 3–4 hours before bedtime.

Psychological support as needed.

14. Achalasia of the cardia. Classification, clinic, diagnosis, differential diagnosis, surgical treatment

Differential Diagnosis:

Esophageal strictures (caustic, post-inflammatory)

Tumors (esophageal/gastric cardia cancer)

Diverticula

Benign motility disorders

Surgical:

Heller Myotomy (laparoscopic preferred):

o Longitudinal cut of LES muscle fibers.

oOften combined with anti-reflux procedure (e.g., Dor fundoplication).

Indications:

oFailed dilatation.

oAdvanced stage (III-IV), children, or complications like esophageal rupture

Prognosis:

Generally good with treatment.

Risk of recurrence exists.

Long-term risk: esophageal squamous cell carcinoma due to chronic stasis and irritation — warrants long-term surveillance in high-risk patients.

15. Diaphragmatic hernias. Etiology, classification, diagnostic methods. Traumatic hernias of the diaphragm, clinic, diagnosis, treatment.

A diaphragmatic hernia is the protrusion of abdominal organs into the thoracic cavity through a defect in the diaphragm, which may be congenital, acquired, traumatic, or iatrogenic.

Etiology and Pathogenesis

Predisposing factors:

Congenital diaphragmatic defects (e.g., failure of pleuroperitoneal canal closure)

Connective tissue weakness (congenital or acquired)

Muscular atrophy due to aging

Iatrogenic (postoperative weakening)

Producing factors:

Increased intra-abdominal pressure due to:

o Heavy lifting

o Chronic cough

o Obesity

o Constipation

o Pregnancy

o Abundant meals

Classification

A.By Etiology

1.Congenital Diaphragmatic Hernias (CDH) o Bochdalek hernia (posterolateral)

o Morgagni hernia (retrosternal/parasternal)

oCentral tendon defects

2.Acquired (Non-traumatic)

oHiatal hernia (esophageal hiatus hernia)

oIatrogenic (surgical or procedural injury)

3.Traumatic

oBlunt trauma (e.g., MVCs, falls)

oPenetrating injuries (e.g., stab wounds)

B.By Presence of Hernial Sac

True hernia: with peritoneal sac

False hernia: without sac

C.By Anatomical Site (Petrovsky Classification)

False congenital hernias

True hernias of weak zones (e.g., Larrey’s triangle, Bochdalek’s triangle)

True hernias of atypical localization

Natural opening hernias (e.g., esophageal, caval, aortic hiatus)

Clinical Presentation

Symptoms result from mechanical compression, organ displacement, and/or infringement:

Gastrointestinal Symptoms

Epigastric or chest pain (worse after meals)

Postprandial vomiting (relieves symptoms)

Bloating, dysphagia

"Gurgling" sounds in the chest

Respiratory/Cardiovascular Symptoms

Dyspnea (especially postprandial or supine)

Palpitations

Mediastinal shift signs

Decreased breath sounds

Physical Examination

Decreased breath sounds over affected hemithorax

Tympanic note or dullness on percussion

Audible bowel sounds in chest

Scaphoid or sunken abdomen (large hernias)

Displaced apex beat or cardiac dullness

Diagnostic Methods

1.Chest X-ray (Initial)

Air-fluid levels in thoracic cavity

Mediastinal shift

Intestinal loops in chest

Absent diaphragmatic contour

2.Contrast Radiography

Barium swallow: visualizes herniation of stomach/intestine

"Flow sign" or "hernial gate" symptom

3.CT or MRI

Defines content and site of herniation

Rules out associated injuries in trauma

4.Endoscopy

Useful for evaluating sliding hiatal hernias

5.Diagnostic Pneumoperitoneum (rare)

Outlines the diaphragmatic contour for difficult cases

Complications

Strangulation/Incarceration (common and dangerous)

Bowel obstruction

Volvulus (especially stomach)

Respiratory compromise

Mediastinal shift → hemodynamic instability

Differential Diagnosis

Diaphragm relaxation (eventration)

Myocardial infarction

Acute pancreatitis

Mesenteric ischemia

Pericardial cyst

Lung cyst/tumor

Traumatic Diaphragmatic Hernias

Etiology

Penetrating or blunt trauma to the lower thoracoabdominal region

Often associated with polytrauma (e.g., spleen, liver, lung)

Clinical Features

Initially asymptomatic or misdiagnosed

Progressive dyspnea, chest pain, or gastrointestinal obstruction

Often found late due to delayed diagnosis

Diagnosis

Chest X-ray: Elevated hemidiaphragm, air-fluid levels

CT thorax and abdomen: diagnostic gold standard

Nasogastric tube coiling in chest (if stomach involved)

Laparoscopy/thoracoscopy: diagnostic and therapeutic

Treatment

Surgical repair is mandatory

o Laparotomy (preferred in acute trauma)

oThoracotomy (for chronic cases or large defects)

Hernia contents reduced

Diaphragmatic defect closed with non-absorbable sutures ± mesh

Treatment of Diaphragmatic Hernia (General)

Indications: All symptomatic or large hernias; most asymptomatic congenital hernias

Surgical Approaches:

Transthoracic (4th or 7th intercostal space)

Transabdominal (especially for Morgagni or hiatal hernia)

Laparoscopic or thoracoscopic repair in stable cases

Procedure:

Reduction of herniated viscera

Excision of hernial sac (if present)

Primary closure or use of synthetic mesh for large defects

Emergency Surgery: Needed for strangulated hernias with signs of obstruction or ischemia