Esophageal, Gastric, and Colon Surgery Lecture Powerpoint

Question 1

Tenae coli

Answer 1

Longitudinal smooth muscle straps that travel along the wall of the colon existing along entire colon except for rectum where they become a splayed out form of continuous muscle, important surgically to determine the level of the rectum from the sigmoid colon, important to remove all diverticuli below

Question 2

What separates the ascending and transverse colon? What about the descending and transverse? What are the epiploica?

Answer 2

The hepatic flexture, the splenic flexture,
fatty extensions off of the colon that aren’t surgically relevant but can become torsed and mimic appendicitis or diverticulitis

Question 3

The blood supply to the small bowel and colon (4)

Answer 3

• The superior mesenteric supplies the entire small bowel and the right colon, hepatic flexture, and proximal 2/3 of the transverse colon
• the inferior mesenteric supplies the distal 1/3 of the transverse, descending colon, sigmoid, and part of the rectum
• the internal iliac supplies the distal rectum
• the venous supply enters the portal circulation before re-entering systemic,

Question 4

3 branches of the superior mesentaric artery

Answer 4

• Middle and Right Colic Arteries

- Ileocolic Artery

Question 5

3 branches of the inferior mesenteric artery

Answer 5

left colic artery, sigmoid artery and superior rectal artery

Question 6

Intracorporeal vs extracorporeal anastamosis

Answer 6

Intracorporeal is laproscopic leaving the bowel inside the body vs extracorporeal is drawing out the bowel to the outside of the body for anastamosing before reinserting into the body

Question 7

Why do hemicolectomies require large excisions beyond the boundary of the lesion?

Answer 7

Because of the mesenteric supply and 12 lymph nodes need to be sampled from a large section in determination of staging

Question 8

Rectal cancer surgical options (2)

Answer 8

• lower anterior resection (most of sigmoid colon to lower portion leaving cuff of rectum below, includes entire section of mesentery posterior to it)
• abdominal perineal resection (removing entire rectum including anal opening, includes transabdominal incision portion and anal incision portion, then freed thru transabdominal area leaving hole for colostomy for rest of patients life)

Question 9

Indocyanine green

Answer 9

IV dye that gives an image of the vascularization of a bowel to determine where to divide bowel so when anastamosed blood supply is accurate, used often in robotic approaches to colon surgery

Question 10

Different ways to perform an anastamosis (5)

Answer 10

• End to end
• end to side (for discrepencies in size)
• side to end (for discrepencies in size)
• functional end to end
• side to side

-typically done hand sown or with staple techniques

Question 11

What considerations exist for right and transverse hemicolectomy? (5)***

Answer 11

• Right ureter (travels at the base of the mesentery, we often need to remove the mesentary for its lymph nodes!)
• duodenum
• duodenal veins
• omentum
• gastrocolic ligament (connects greater curvature of stomach to the colon)

Question 12

What considerations exist for a left hemicolectomy (2)***

Answer 12

• spleen (splenocolic ligament can rip capsule of spleen)

- left ureter (travels at base of mesentery and we often remove the mesentery for its lymph nodes)

Question 13

What considerations exist for a rectal resection? (7)***

Answer 13

• total mesorectal resection
• bladder
• lateral stalks
• prostate
• urethra
• vaginal wall
• presacral venous plexus (buried in the waldayer’s fascia, used to be controlled with sterile thumb tacks)

Question 14

Should an NG tube be used after anastamosis?

What is ileus?

Answer 14

Not typically, after surgery the GI tract goes into ileus (cessation of peristalsis after surgical intervention) but we see faster return in patients who do not use an NG tube generally

Question 15

DVT prophylaxis in colon surgery (3)

Answer 15

• compression stockings
• chemical prophylaxis (fractionated heparin, lovonox) unless a contraindication everyone gets
• ambulation as soon as possible

Question 16

Primary indication for gastric surgery

Answer 16

Carcinoma of the stomach

Question 17

Blood supply of the stomach (3)

Answer 17

• Right gastroepiploic vessels that travel on the greater curvature which is a branch off the gastroduodenal artery - duodenal ulcers erode this
• left gastroepiploic attaches at the spleen,
• left and right gastric artery, which are branches of the celiac trunk and the common hepatic artery respectively and supply the lesser curvature

Question 18

Parts of the stomach (4)

Answer 18

• cardia (esophageal entrance)
• fundus (dome over top the cardia)
• body (has lesser and greater curvatures)
• antrum (lower area exiting at the pylorus, houses parietal cells that secrete acid - important if needs to be resected)

Question 19

Roux en y esophagojejunostomy/gastrojejunostomy

Answer 19

Division of the jejunum from the duodenum and bringing it up to anastamose with the esophagus (or the stomach in a gastrojejunostomy), then reanastamose the duodenum and biliary tree to the distal jejunum so secretions are maintained (jejunojejunostomy)

Question 20

Billroth I and billroth II procedures

Answer 20

• Removal of the distal stomach and pylorus by attaching the duodenum directly to the stomach
• Removal of the distal stomach and attachment of the jejunum sideways to end of the stomach so the duodenum floats proximally while being sealed off (its often too inflamed to do a billroth I in this case, can cause bile reflex gastritis)

Question 21

Postgastrectomy syndromes (4)

Answer 21

• Smaller capacity
• bile reflex gastritis
• dumping syndrome (high carb load in gut draws fluid into the lumen causing diarrhea and dumping)
• afferent/efferent loop syndrome (obstruction of portion leading up to stomach or portion after so see vomiting of food in efferent but not afferent as there is no flow of obstruction thru the GI tract, mechanical obstruction due to length or adhesion)

Question 22

Distance from incisors to gastroesophageal junction (GE junction)

Answer 22

35-40cm

Question 23

Gastroesophageal junction (Z line)

Answer 23

Transition point from squamous cells to columnar as the esophagus becomes the stomach with a physiologic sphincter existing just above it

Question 24

Vascular supply of the esophagus (3)

Answer 24

• Upper by branches of inferior thyroid artery
• middle from thoracic aortic branches
• lower from phrenic artery for GE junction

Question 25

Ivor Lewis approach

Answer 25

Right thoracotomy at 5th rib and abdominal incision for malignant middle and upper esophagus surgery that is difficult to reach any other way because of the great vessels

Question 26

Left thoracotomy

Answer 26

Used for malignant lower esopagus lesion via incision around the 7th intercostal space

Question 27

Transhiatal esophagectomy (orringer) procedure and one complication

Answer 27

Total esophagectomy involving division of esophagaus proximally, attach pentrose ring thru the esophagus, pull it thru the abdomen, divide the stomach, then attach stomach to tube, draw tube out of mouth to translocate stomach into the posterior mediastinum
-mediastinitus with leaked anastamosis

Question 28

Achalasia definition and surgical treatment

Answer 28

Aperistaltic esophagus or where the LES will not relax due to demyelination of the ganglions of the myenteric plexus, has characteristic birds peak finding on barium swallow, typically treated with muscle relaxants or botulinum toxin

-Heller myotomy (esophagocardiomyotomy with 6cm proximal and 2cm distal to GE junction divisions to take away the majority of the constricture away - the LES remvoal), vulnerable to GERD, some take the cardia of the stomach and wrap it creating a toupet as it will constrict and dilate helping to preserve some of the function of the LES

Question 29

Internal hemorrhoids are located just above the ___ line making them painless compared to external

Answer 29

Dentate line (separates analderm from rectal mucosa)

Question 30

Most common cause of small bowel obstruction

Answer 30

Adhesions

Question 31

What considerations exist for a sigmoid colectomy (3)***

Answer 31

• left ureter
• right ureter
• bladder

Question 32

Anterior to the rectum guarding the genitals is ____ fascia, between the rectum and the sacrum is the ___ fascia

Answer 32

denonviller’s, waldeyer’s

Question 33

Colon cancer with ovarian metastasis mortality rate

Answer 33

very very high, often indicates question of oopherectomy alongside colon resection

Question 34

Per oral Esophageal Myotomy (POEM) procedure

Answer 34

Endoscopic treatment for achalasia that involves penetration of the mucosa of the esophagus into the submucosa but within the muscle to then open a submucosal channel, draw it back up and divide the musculature with a cautery tool to divide the musculature all the way to the stomach and then seal the mucosa moving back out so this kills the functionality of the LES, does not assist with antireflex