a. Diverticulectomy and myotomy b. Myotomy alone c. Diverticulectomy alone

1. The lesion pictured in the xray may be associated with dysphagia, regurgitation of food, and bad breath. All of the following techniques may be used for treatment EXCEPT • a.  Diverticulectomy and myotomy • b.  Myotomy alone • c.  Diverticulectomy alone • d.  Internal pharyngoesophageal myotomy • e.  Diverticulopexy with or without myotomy

2. Answer C • Zenker’s pharyngoesophageal diverticulum • Pulsion false diverticulum • Tx: indicated in symptomatic patients • diverticulectomy and cricopharyngeal myotomy to prevent recurrence • L cervical incision • Retract SCM/carotid sheath laterally, • thyroid/trachea medially • Divide inferior thyroid artery • 40-Fr bougie in esophagus, dissect pouch at • base • extramucosal esophagomyotomy in both • directions (7-10 cm from base of pouch) • excise diverticulum with stapler if > 2 cm Diverticulopexy in elderly/high-risk patients

3. Other esoph tics: • Midesophageal • Traction • true diverticulum • caused by external inflammation (e.g. TB) that pulls out esophagus • new evidence suggest also may be from pulsion • more common on right • Epiphrenic • distal esophagus • Pulsion • False • more common on right • Tx if symptomatic or > 3 cm • repair via L thoracotomy, diverticulectomy, esophagomyotomy opposite side

4. 2. A 67-year-old man has had progressive dysphagia over the past 2 years. For the past 24 hours, he has been unable to tolerate anything by mouth. Shortly after eating, he has epigastric abdominal pain that is relieved by vomiting of undigested food. In addition, he has a 2-year history of burning epigastric and substernal chest pain following meals and during the night. These symptoms are improved with over-the-counter H2 blockers. His medical history is otherwise unremarkable. The plain abdominal x-ray and barium swallow shown are performed. The most appropriate management would be • Proton pump inhibitors • Percutaneous endoscopic gastrostomy placement • Reduction of hernia and open crural repair • Reduction of hernia, crural repair, and antireflux procedure • e. Watchful waiting

5. 2. Answer D Paraesophageal hernia, type II hiatal hernia, GE jxn ok Workup: esophogram, endoscopy, manometry, pH testing to evaluate extent of GERD Tx: laparoscopic repair Mobilize greater curvature and fundus Divide short gastrics Expose left crus Reduce hernia contents into abdomen, transect sac at hiatus Reapproximate crura Antireflux procedure: fundoplication Type I: sliding hernia, GE junction above diaphragm, tx if symptomatic Type III: I and II

6. 3. Which of the following statements about Barrett’s esophagus is NOT true? a. Most patient who develop carcinoma in Barrett’s esophagus are men aged 55 to 60 b. Patients with high-grade dysplasia should undergo esophagectomy c. Endoscopic surveillance effectively reduces the stage at presentation to stage II or lower d. Barrett’s esophagus occurs in 10% to 15% of patients with symptoms of GERD e. Low-grade dysplasia should be treated with an antireflux procedure as well as antacids

7. 3. Answer: E Barrett’s esophagus: PREMALIGNANT Squamous columnar epithelium Esophagectomy for high-grade dysplasia Tx: antacids; antireflux procedure for symptomatic patients/not responsive to meds Continued endoscopic surveillance after surgery

8. 4. Which of the following statements about highly selective vagotomy for treatment of a 35-year-old man with a peptic ulcer is NOT true? a. The first 1 or 2 branches of the crow’s foot should be divided b. Each vascular pedicle and its associated nerve to the lesser curve should be divided c. 5 to 7 cm of esophagus is skeletonized d. The criminal nerve of Grassi is preserved e. The lesser curve may be oversewn

9. 4. Answer: D • HSV preserves vagal innervation of antrum so no drainage procedure required • Retract Anterior (left) and posterior (right) vagal trunks identified • Nerve of Latarjet retracted to right • Lesser curve dissected 7 cm from pylorus, divide branches of crow’s foot • Skeletonize 5-7 cm of esophagus proximal to GE jxn, dividing criminal nerve of Grassi • Devascularized lesser curve oversewn

10. 5. A 70-year-old man with a history of chronic obstructive pulmonary disease present to the ED with diffuse abdominal pain and distention. Labs show a WBC of 14,000 with a left shift of 90%. CT confirms a small amount of pneumoperitoneum and mild small bowel dilation. At laparotomy, diffuse small bowel diverticulosis of the proximal jejunum is noted. The surgical procedure of choice would be • irrigation of peritoneal cavity and drainage • jejunal resection and anastamosis of the perforated segment • jejunal resection and diverting ostomy • jejunal resection of the entire segment of diverticulosis • closure of perforated diverticulum

11. 5. Answer B SB tics usually asymptomatic Tx for perforation: resect perforated segment and anastamosis If perforation cannot be found, no resection Resection of all tics not indicated

12. 6. A 35-year-old man develops severe diarrhea 3 days after an emergency appendectomy. He is admitted for severe hypovolemia. Stool assay for C. diff is positive and enteral metronidazole is initiated. Two days later he develops worsening diffuse abdominal pain and distention, respiratory failure requiring intubation and mechanical ventilatory support, and renal failure. After initial resuscitation, the next step in management should be • intravenous metronidazole • oral vanco • intracolonic vanco • colonoscopic decompression and instillation of vanco • emergency laparotomy

13. 6. Answer E Tx: subtotal colectomy IV/PO metronidazole, PO vanco

14. 7. Which of the following statements about short bowel syndrome is TRUE? • Gastrin levels are decreased • Preservation of ileocecal valve decreases the likelihood that parenteral nutrition will be required • Nephrolithiasis is due to hypercalcuria • Jejunum is better able than ileum to adapt/increase absorptive capacity after massive bowel resection • Oral opioids should be avoided in treatment of diarrhea

15. 7. Answer B Gastrin levels elevated from hypersecretion, leads to diarrhea Nephrolithiasis from hyperoxaluria caused by increased absorption in remaining SB Proximal resection better tolerated as remaining ileum can increase absorptive capacity better than jejunum Diarrhea also due to bile acid malabsorption Treatment for diarrhea: fiber, opioids, H2 blockers, bile acid-binders Short bowel syndrome <120 cm remaining bowel < 60 cm require TPN, unless ileocecal valve preserved, may be ok with <45 cm

16. 8. The initial treatment of most patients with bleeding esophageal varices should be • Intravenous pitressin and nitroglycerin • Placement of a Sengstaken-Blakemore tube • Emergency esophagoscopy with sclerotherapy or variceal ligation • Transjugular intrahepatic portosystemic shunt (TIPS) • Intravenous octreotide

17. 8. Answer E Pitressin induces cardiac ischemia, which can be offset by nitro Octreotide is safer, acts by decreasing splanchnic blood flow 50 ug bolus, then 50 ug/h for 48-72 hours The modified Sengstaken-Blakemore tube. Note the accessory nasogastric (N-G) tube for suctioning of secretions above the esophageal balloon and the two clamps, one secured with tape, to prevent inadvertent decompression of the gastric balloon.