100+ Free TECAD Cirurgia Digestiva Practice Questions

Explanation: According to the Rezende Classification for Chagasic megaesophagus, Group II (moderate dilatation between 4 and 7 cm with contrast stasis and motor incoordination) is standardly managed with a laparoscopic Heller cardiomyotomy associated with a partial anterior fundoplication, known in Brazil as the Heller-Pinotti procedure. Extending the myotomy 5 to 6 cm onto the distal esophagus and 1.5 to 2 cm onto the gastric cardia relieves functional outflow obstruction while the partial fundoplication prevents post-myotomy gastroesophageal reflux. Esophagectomy and the Serra-Dória operation are reserved for advanced end-stage Group IV (dolichomegaesophagus) or recurrence after failed previous myotomies.

Explanation: Under the Chicago Classification v4.0, Type III (Spastic) Achalasia is characterized by premature, spastic contractions in the distal esophageal body in addition to impaired lower esophageal sphincter (LES) relaxation. Peroral Endoscopic Myotomy (POEM) is the treatment of choice for Type III achalasia because it allows the endoscopist to extend the proximal myotomy high into the mid-esophagus (often 10-15 cm) to divide the spastic circular muscle fibers responsible for chest pain, yielding significantly higher clinical success rates than standard laparoscopy or pneumatic dilation.

Explanation: In patients with severe esophageal dysmotility or Ineffective Esophageal Motility (IEM, > 50-70% ineffective peristalsis), a total 360-degree Nissen fundoplication carries a high risk of persistent, debilitating postoperative dysphagia. A partial posterior fundoplication (Toupet 270°) provides equivalent long-term reflux control with significantly lower outflow resistance, facilitating esophageal emptying in hypocontractile bodies. Hiatoplasty (crural closure) remains an essential component to restore anatomical hiatus competence.

Explanation: For superficial esophageal adenocarcinoma confined to the mucosa (pT1a) resected with negative margins (R0) and lacking adverse histological features (lymphovascular invasion, poorly differentiated histology), the risk of regional lymph node metastasis is less than 1-2%. Complete endoscopic eradication of the residual at-risk Barrett's segment using Radiofrequency Ablation (RFA) followed by structured endoscopic surveillance is the standard of care, avoiding the high morbidity of an esophagectomy.

Explanation: For locally advanced resectable squamous cell carcinoma of the thoracic esophagus (cT2-4a N+ M0), the landmark CROSS trial demonstrated significant overall survival benefit and high pathological complete response rates (nearly 50% in SCC) with neoadjuvant chemoradiation (carboplatin/paclitaxel and 41.4 Gy) followed by radical transthoracic esophagectomy (McKeown or Ivor Lewis) with two-field lymphadenectomy. Upfront surgery alone results in unacceptably high local recurrence rates.

Explanation: Under the Siewert classification of adenocarcinomas of the esophagogastric junction, Type III tumors have their epicenter located between 2 cm and 5 cm distal to the Z-line (subcardial/gastric tumors infiltrating the GEJ from below). The oncological standard of care for Siewert Type III tumors is a total gastrectomy with D2 lymphadenectomy and transhiatal resection of the distal esophagus to achieve an R0 proximal margin, reconstructed via a Roux-en-Y esophagojejunostomy. Siewert Type I tumors (epicenter 1-5 cm above GEJ) are treated as esophageal cancers with subtotal esophagectomy.

Explanation: In Boerhaave syndrome diagnosed early (within 24 hours of perforation) in a hemodynamically salvageable patient, the gold standard is emergent surgical exploration (via left thoracotomy or thoracoscopy/laparoscopy), extensive mediastinal and pleural debridement, primary two-layer repair of the muscular and mucosal defect over a nasogastric decompression tube, reinforcement with a pedicled tissue flap (intercostal muscle, pleura, or omentum/diaphragm), and generous pleural drainage. Primary repair within 24 hours achieves superior survival compared to late intervention.

Explanation: Epiphrenic diverticula are pulsion diverticula caused by distal esophageal functional outflow obstruction and elevated intraluminal pressure (hypertensive LES, achalasia, or distal spasm). Surgical management requires three mandatory steps: (1) diverticulectomy (resection of the pouch with an endostapler), (2) a long extramucosal myotomy on the contralateral esophageal wall extending across the LES onto the gastric cardia to eliminate the high-pressure zone, and (3) a partial fundoplication (Dor or Toupet) to prevent severe GERD while protecting the staple line.

Explanation: Zenker's diverticulum is a posterior pulsion pseudodiverticulum that protrudes through Killian's triangle (Killian's dehiscence), an area of natural muscular weakness in the posterior hypopharyngeal wall bounded superiorly by the oblique fibers of the thyropharyngeus muscle and inferiorly by the transverse fibers of the cricopharyngeus muscle (inferior pharyngeal constrictor).

Explanation: Comprehensive laparoscopic repair of a giant paraesophageal hernia / gastric volvulus requires: (1) complete reduction and excision of the mediastinal hernia sac from the pleural/pericardial attachments, (2) extensive mediastinal esophageal mobilization to restore at least 2.5 to 3 cm of tension-free intra-abdominal esophagus, (3) tension-free crural repair (posterior and/or anterior hiatoplasty +/- non-absorbable/absorbable mesh if indicated), and (4) an antireflux wrap (Nissen/Toupet) or formal gastropexy to secure the stomach in the abdominal cavity.