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Year 3 - Surgery > General Surgery - Oesophagus > Flashcards

General Surgery - Oesophagus Flashcards

1
Q

What is the pathophysiology of GORD?

A
  • Gastric acid from the stomach leaks up into the oesophagus due to episodic sphincter relaxation (relaxation of sphincter normal)
  • GORD these episodes become more frequent and allow the reflux of gastric contents into the oesophagus.
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2
Q

What are the RFs for GORD?

A

Think middle aged english man who likes a tikka masala:

Age, obesity, male gender, alcohol, smoking, caffeinated drinks, and fatty or spicy foods

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3
Q

What are the sx of GORD?

A
  • Burning retrosternal sensation, worse after meals, lying down, bending over, or straining
    • Additional sx: belching, odynophagia, a chronic cough, or a nocturnal cough
    • Check for red flag symptoms
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4
Q

What classification is used for GORD?

A

Los Angeles Classification

  • Grade A – breaks ≤5mm
  • Grade B >5mm
  • Grade C –breaks extending between the tops of ≥2 mucosal folds, but<75% of circumference,
  • Grade D – circumferential breaks (≥75%)
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5
Q

What investigations are used for GORD? When are they used?

A
  • OGD with 2WW:
    • With dysphagia OR
    • Aged 55 and over with weight loss and any of the following:
      • Upper abdominal pain
      • Reflux
      • Dyspepsia
  • If endoscopy normal: 24h oesophageal pH monitoring ± oesophageal manometry
    *
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6
Q

How is GORD pharmacologically and conservatively managed

A
  • Conservative: Weight loss; smoking cessation; small, regular meals; reduce hot drinks, alcohol, citrus fruits, tomatoes, onions, fizzy drinks, spicy foods, caffeine, chocolate; avoid eating <3h before bed. Raise the bed head.
  • Pharmacological:
    • Antacids e.g. magnesium trisilicate, alginates - gaviscon, + ppi, eg lansoprazole 30mg/24h po
    • H2 receptor antagonist: e.g. ranitidin
    • Avoid worsening drugs: (nitrates, anticholinergics, CCBs—relax LOS), (nsaids, k+ salts, bisphosphonates
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7
Q

How is GORD surgically managed? What are the indications for surgical intervention?

What are some of the side effects?

A
  • Indications:
    • Failure to respond to medical therapy
    • Patient preference to avoid life long meds
    • Pt w/ complications of GORD: respiratory complications e.g. recurrent pneumonia or bronchiecstasis
    • Patient preference to avoid life-long medication
  • Surgery: Laparoscopic Nissen fundoplication
    • GOJ and hiatus are dissected and the fundus wrapped around the GOJ, recreating a physiological lower oesophageal sphincter.
    • SE: dysphagia, bloating, and inability to vomit, however these often settle after 6 wks in most patients
  • New techniques:
    • Stretta®: endoscopic radio-frequency energy used to cause thickening of LOS
    • Linx®: a string ofmagnetic beadsis laparoscopically insertedaroundthe LOS laparoscopically totighten it
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8
Q

What types of hiatus hernia can you get? Which is most dangerous and which is symptomatic?

A

Sliding: GORD/ reflux common

Rolling GORD/ reflux uncommon common. More dangerous: repair

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9
Q

What is Baratts Oesophagus?

A

Metaplasia of oesophageal epithelial lining: stratified squamous to simple columnar

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10
Q

What are the clinical features of baratts oesophagus?

A

Persistent GORD

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11
Q

How is Baratts investigated?

A
  • Histological diagnosis
  • OGD + biopspy – oesophagus is red and velvety with some squamous islands
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12
Q

How often is endoscopy for Baretts oesophagus due to be performed?

A
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13
Q

What are the surgical options for Baratts Oesophagus?

A

High grade dysplasia

Endoscopic therapy:

  • Endoscopic mucosal resection: circumferential care because of the high incidence of stricture formation.
  • Radiofrequency Ablation: Consider following with an additional ablative therapy (radiofrequency ablation, argon plasma coagulation or photodynamic therapy) to completely remove residual flat dysplasia

Minimally invasive oesophagectomy: if pre malignant/ high grade dysplasia

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14
Q

What are the different types of oesphageal cancer?

A

Squamous cell carcinoma:

  • Typically occurring in the middle and upper thirds of the oesophagus
  • Associations: smoking and excessive alcohol consumption, chronic achalasia, low vitamin A levels and, rarely, iron deficiency

Adenocarcinoma (developed world)

  • Lower third of the oesophagus
  • Arises as a consequence of metaplastic epithelium (Barrett’s oesophagus) which progresses to dysplasia, to eventually become malignant
  • RFs: long-standing GORD, obesity, and high dietary fat intake
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15
Q

What are the sx of oesphageal cancer?

A
  • Dysphagia – progressive from solids (especially meats or breads) then liquids
  • Significant weight loss – due to both dysphagia and cancer-related anorexia (marker of late-stage disease)
  • Less common symptoms: odonyphagia or hoarseness
  • Other signs: recent weight loss or cachexia, signs of dehydration, supraclavicular lymphadenopathy, or any signs of metastatic disease (e.g. jaundice, hepatomegaly, or ascites)
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16
Q

What investigations are used for Oesophageal cancer?

A

NICE guidance: urgent endoscopy – dysphagia + any patient with 55 yo with weight loss, upper abdo pain, dyspepsia and reflux

  • Urgent OGD + biopsy + histology

Further investigations:

  • CT chest abdo pelvis + PET scan – distance metastasis
  • Endoscopic USS
  • Staging laparoscopy to look for intra abdo tumours
  • FNA (of palpable cervical lymph nodes)
17
Q

How is oesophageal cancer managed?

A
  • Curative: surgery +/- curative neoadjuvant chemo or chemoradiotherapy (CRT)
  • SCC
    • Upper oesophagus - CRT (as SCC hard to operate on)
    • Middle + lower – CRT or neoadjuvant CRT then surgery
  • Adenocarcinoma - Neoadjuvant CT or CRT then oesophageal resection

o Surgery: huge undertaking, as you cut through the abdo and chest cavities + one deflated lung for 2 hours. 6-9 months recovery time

  • Post op nutrition
    • Major problem for these patients as they lose the reservoir function of the stomach. Many centres will routinely insert a feeding tube into the small bowel (a “feeding jejunostomy”) to aid nutrition.
    • Most patients will need to eat 5-6 small meals per day and “graze” to meet their nutritional requirements as they physically cannot fit in 3 normal size but intermittent meals.
18
Q

What are the main surgical procedures used for oesophageal cancer?

A
  • Oesophagectomy - removal of the tumour, top of the stomach, and surrounding lymph nodes.
  • Stomach is then made into a tube (“conduit”) and brought up into the chest to replace the oesophagus. Specific approaches include:
    1. Ivor-Lewis procedure: Right thoracotomy with laparotomy
    2. McKeown procedure: Right thoracotomy with abdominal incision and neck incision (termed a McKeown procedure)
    3. Others:
      1. Left thoracotomy with or without neck incision
      2. Left thoraco-abdominal incision (one large incision starting above the umbilicus and extending round the back to below the left shoulder blade)
  • Endoscopic Mucosal Resection (EMR): very early cancers or high grade Barrett’s oesophagus. Removal of just the mucosal layer of the oesophagus.
  • EMR can be combined with radiofrequency ablation (RFA) or photodynamic therapy (PDT) afterwards to destroy any malignant cells that may be left.
19
Q

What is removed in an oesophogectomy

A
  • Tumour
  • Top of the Stomach
  • Surrounding Lymph nodes
20
Q

What palliative treatment is offered for patients with late oesophageal cancer?

A
  • Oesophageal stent
  • Radio/chemotherapy - reduce tumour size and bleeding
  • Photodynamic therapy - uses a photosensitizing agent, that when exposed to a specific wavelength of light produces a form of oxygen that kills nearby cells.
  • Nutritional support: Thickened fluid and nutritional supplements
  • Radiologically-Inserted Gastrostomy (RIG) tube: if dysphagia becomes too severe to tolerate enteral feeds
21
Q

How is Borhaves syndrome (oesophageal tears) managed?

A
  • Management:
    • Aggressive resuscitation
    • Control of the oesophageal leak
  1. Eradication of mediastinal and pleural contamination
  2. Decompress the oesophagus (typically via a trans-gastric drain or endoscopically-placed NG tube)
  3. Nutritional support

Surgery:

  • immediate surgery to control the leak and wash out of the chest via a thoracotomy.
  • On-table endoscopy
  • CT scan with contrast at 10-14 days before starting oral intake.
  • Feeding jejunostomy at the time of surgery for nutrition.

Non operative: resuscitation

  • HDU transfer; ABX and anti fungal cover
  • NBM 1-2 weeks
  • Endoscopic insertion of an NG tube on drainage
  • Large-bore chest drain insertion
  • Total Parenteral Nutrition (TPN) or feeding jejunostomy insertion
22
Q

How does Boerhaves syndrome commonly arise?

A
  1. Iatrogenic (such as endoscopy)
  2. After severe forceful vomiting
23
Q

What is achalasia?

A
  • Primary motility disorder of the oesophagus, characterised by a failure of relaxation of the LOS and progressive failure of contraction of the oesophageal smooth muscle.
  • Histological feature is progressive destruction of the ganglion cells in the myenteric plexus.
24
Q

What are the sx of achalasia?

A
  • Dysphagia - solids and liquids
  • Vomiting
  • Chest discomfort
  • Food stuck
  • Coughing
  • Weight loss
25
Q

What investigations are used for diagnosis of achalasia?

A
  • OGD
  • Gold standard: oesophogeal manometry - pressure sensitive probe is inserted into oesophagus to detect pressure changes
  • Barium swallow rarely used
26
Q

How is achalasia managed?

A
  • Conservative - sleeping with many pillows to minimise regurgitation, eating slowly and chewing food thoroughly, and taking plenty of fluids with meals.
  • Pharmacological: CCB, PPIs + nitrates - temporary
    • Endoscopic botox injections into the LOS (few months)
  • Surgical
    • Endoscopic balloon dilatation – insertion of a balloon into the LOS, which is dilated to stretch the muscle fibres
      • Good response but carries the risks of perforation
    • Laparoscopic Heller myotomy* – the division of the specific fibres of the LOS which fail to relax
      • Improvement in long term swallowing + lower side-effects compared to endoscopic treatment
27
Q

What is diffuse oesophageal spasm?

A
  • Diffuse oesophageal spasm (DOS) is a disease characterised by multi-focal high amplitude contractions of the oesophagus.
  • It is thought to be caused by the dysfunction of oesophageal inhibitory nerves
  • DOS can progress to achalasia.
28
Q

What are of the clinical features of DOS?

A
  • Severe dysphagia to both solids and liquids.
  • Central chest pain - exacerbated by food.
  • Pain from DOS can respond to nitrate
29
Q

How is DOS investigated? What can be seen?

A
  • Endoscopy - normal
  • Manometry - shows a pattern of repetitive, simultaneous, and ineffective contractions of the oesophagus. There may also be dysfunction of LOS
  • Barium swallow - rare but can show a “corkscrew” appearance
30
Q

How is DOS managed?

A
  • Medicines: CCB, PPI, nitrates
  • Pneumatic dilatation of LOS
  • Myotomy - rare
31
Q

What are oesophageal tears and what causes them?

A
  • Boerhaave’s syndrome - Oesophageal perforation full thickness rupture of the oesophageal wall (often due to vomiting)
  • Perforation -> leakage of stomach contents into mediastinum – inflammatory response – surgical emergency
  • Causes: iatrogenic (post endoscopy) or after vomiting
32
Q

What is Boerhave syndrome + how does it differ from mallory weiss tears?

A
  • Oesophageal tears are ruptures to any part of oesophageal wall.
  • Boerhaave’s syndrome - spontaneous full thickness rupture of the oesophageal wall/ oesophageal perforation
  • Mallory weiss - superficial mucosal tears only
  • Perforation - surgical emergency. Will result in leakage of stomach contents into the mediastinum and pleural cavity, which triggers a severe inflammatory response which will rapidly become overwhelming, resulting in a physiological collapse, multi-organ failure, and death
33
Q

How does Boerhaves syndrome present?

A
  • Severe sudden-onset retrosternal chest pain
  • Respiratory distress
  • Subcutaneous emphysema
  • Severe vomiting or retching.
34
Q

What investigations do you do for Boerhaves syndrome?

A
  • Urgent bloods, GS, crossmatch
  • CXR – pneumoperitoneum/ intra thoracic air fluid levels

CT Abdo chest pelvic IV contrast

35
Q

How are oesophageal tears managed?

A
  • Management:
    • Aggressive resuscitation
    • Control of the oesophageal leak
  1. Eradication of mediastinal and pleural contamination
  2. Decompress the oesophagus (typically via a trans-gastric drain or endoscopically-placed NG tube)
  3. Nutritional support
36
Q

How must a pt prepare for endoscopy?

A
  • Stop PPIs 2 weeks before (pathology masking)
  • NBM 4 hours before
  • Dont drive 24 hr after sedation
  • Sedation: midazolam 1-5mg IV
    • Deeper sedation: propofol
  • Pharync sprayed with local anaesthetic
  • Suction continuously to prevent aspiration
  • Warfarin” stop 5 days before pre op. LMWH start 48hr later
37
Q

What does achalasia increase your risk of?

A

Risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia

Year 3 - Surgery (10 decks)

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