GEJ tumour, Hiatus Hernia and Esophageal Perforation Flashcards
What are GEJ tumours?
Tumours with the epicenter
- Within 5cm of distal esophagus
- At the GEJ
- In the cardia, within 5cm of the distal esophagus, with extension into GEJ or esophagus
What are the classifications of GEJ tumours?
Siewert classification
- Type 1 – distal oesophagus (within 1-5cm above anatomic GEJ)
- Type 2 – cardia (within 1cm above and 2cm below GEJ)
- Type 3 – sub-cardial (2-5cm below GEJ)
What is the management of GEJ tumours?
Aggressive neo adjuvant therapy has been known to improve overall survival
- Eradicates micro-metastatic disease
- Tumour downsizing to improve R0 resections
- Better tolerance of intensive therapy prior to surgery
- Adjustment of treatment based on release
Treated with perioperative chemotherapy (UK) or perioperative chemo-radiotherapy (US)
What are the treatment approaches for GEJ tumours?
Type 1 – treat as per oesophageal cancer (esophagectomy)
- Type 3 – treat as per gastric cancer (total gastrectomy or proximal gastrectomy [possible if stage 1])
- Type 2 – debatable*
▪ Total gastrectomy + distal esophagectomy
▪ Esophagectomy + proximal gastrectomy
* determining factors – extent of oesophageal involvement (if <2-3cm: extended gastrectomy, if >2-3cm: esophagectomy), mediastinal
nodal involvement, T staging, patient’s fitness for operation
What is a hiatus hernia?
A hiatal (or hiatus) hernia is the abnormal protrusion of any abdominal structure/organ, most often a portion of the stomach, into the thoracic cavity through a lax diaphragmatic esophageal hiatus.
What are the types of hiatus hernias?
Type 1-4
Type 1: Sliding hernia - GEJ displaced into stomach
Type 2: Rolling hernia - Gastric fundus is displaced
Type 3 - Mixed between type 1 and 2
Type 4 - Giant hernia - herniation of an additional organ (mostly colon)
What is the clinical presentation of hiatus hernia?
Asymptomatic
- GERD symptoms
- Obstructive symptoms – transient obstruction of the GEJ (i.e. dysphagia, regurgitation), obstruction of distal stomach (i.e. nausea,
vomiting, palpitation, shortness of breath, dyspnoea, chest pain & early satiety)
- Cameron ulcers leading to bleeding and chronic iron deficiency anemia
- Acute gastric volvulus: Gastric Ischemia – septic shock, epigastric pain, multi-organ failure
- Borchardt’s triad of gastric volvulus – epigastric or chest pain, retching without vomiting and inability to pass a nasogastric tube
What are the managemnt of patients of varying hiatal hernias?
Type 1:
- Conservative management
- Lifestyle modifications
- Proton pump inhibitors (PPIs) or histamine H2-receptor antagonists if symptoms of GERD occur
- Surgery: laparoscopic/open fundoplication + hiatoplasty . Indications
- Persistence of symptoms despite conservative management
- Refusal or inability to take long-term PPIs
- Severe symptoms/complications of gastroesophageal reflux disease: bleeding, strictures, ulcerations
Type 2-4
- Conservative management: older patients or those with other comorbidities
- Surgery: laparoscopic/open herniotomy + fundoplication, hiatoplasty, and gastropexy/fundopexy Indications
- Asymptomatic, small hernias in patients < 50 years of age
- Symptomatic type II, III, IV hernias
What is esophageal perforation?
A true surgical emergency (mortality 10-40%) – most commonly at left lateral wall of oesophagus 3-5cm above GEJ
What are the risk factors of esophageal perforation?
- Iatrogenic - OGDs, dilatation, intra-esophageal tubes, traumatic intubation
- Spontaneous - Boerhaave’s syndrome (spontaneous esophageal perforation)
- Foreign body
- Caustic ingestion
- Trauma (Blunt/penetrating)
What is the clinical presentation of esophageal perforation?
- Pain – cervical area / substernal area
- Cervical crepitation / swelling (subcutaneous emphysema)
- Fever (after instrumentation of the oesophagus)
- Hamman’s sign – mediastinal crunching on auscultation (pneumomediastinum)
- Stony dullness on percussion over intercostal space (pleural effusion)
What is the differential diagnosis for esophageal perforation?
- Medical: Myocardial infact, pericarditis, pneumothorax, pneumonia, mallory weiss tear
- Surgical - pancreatitis, peritonitis, aortic dissection/aneurysm, mesenteric ischemia, perforated PUD
What investigations are carried out for esophageal perforation?
CXR for pleural effusion, pneumomediastinum, subcutaneous emphysema, hydropneumothorax, collapse or consolidation
- Distal esophageal rupture leads to left sided pleural effusion
- Mid thoracic rupture leads to right sided pleural effusion
CTAP + oral contrast
Contrast esophagram in lateral decubitus position to detect for extravasation and intraperitoneal air
What is the general management for esophageal perforation?
NBM + Resuscitation + IV fluids with monitoring of urine output
- Broad-spectrum antibiotics – coverage of UGI pathogens +/- Antifungals
- IV PPI
- NGT (placed under endoscopic or radiological guidance) - to decompress the stomach
- Early escalation of care, early referral to HD/ICU
- Enteral feeding assess (NJ feeding tube or feeding jejunostomy)
- Chest tube, if have significant pleural effusion – food debris / purulent discharge can establish diagnosis of rupture
- OGD – diagnostic & therapeutic (i.e. KIV stent placement)
▪ Stenting contraindicated in long tears (>6cm), delayed presentation due to substantial tissue necrosis (>24hrs), proximal
oesophagus (posterior pharynx) and distal oesophagus / GEJ (distal flare will not attach to stomach)
▪ Stenting is useful in setting of malignancy
When is non-surgical treatment indicated?
Small, contained perforation, demonstrated by:
Either a contained leak with the neck, within the mediastinum, or between the mediastinum and visceral lung pleura
Contrast can flow back into the esophagus from the cavity surrounding the perforation.
