General Surgery - Oesophagus Flashcards
What is the pathophysiology of GORD?
- 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.
What are the RFs for GORD?
Think middle aged english man who likes a tikka masala:
Age, obesity, male gender, alcohol, smoking, caffeinated drinks, and fatty or spicy foods
What are the sx of GORD?
-
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
What classification is used for GORD?
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%)
What investigations are used for GORD? When are they used?
- 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
*
How is GORD pharmacologically and conservatively managed
- 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.
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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
How is GORD surgically managed? What are the indications for surgical intervention?
What are some of the side effects?
- 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
What types of hiatus hernia can you get? Which is most dangerous and which is symptomatic?
Sliding: GORD/ reflux common
Rolling GORD/ reflux uncommon common. More dangerous: repair
What is Baratts Oesophagus?
Metaplasia of oesophageal epithelial lining: stratified squamous to simple columnar
What are the clinical features of baratts oesophagus?
Persistent GORD
How is Baratts investigated?
- Histological diagnosis
- OGD + biopspy – oesophagus is red and velvety with some squamous islands
How often is endoscopy for Baretts oesophagus due to be performed?
What are the surgical options for Baratts Oesophagus?
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
What are the different types of oesphageal cancer?
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
What are the sx of oesphageal cancer?
- 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)
What investigations are used for Oesophageal cancer?
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)
How is oesophageal cancer managed?
- Curative: surgery +/- curative neoadjuvant chemo or chemoradiotherapy (CRT)
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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
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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.
What are the main surgical procedures used for oesophageal cancer?
- 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:
- Ivor-Lewis procedure: Right thoracotomy with laparotomy
- McKeown procedure: Right thoracotomy with abdominal incision and neck incision (termed a McKeown procedure)
- Others:
- Left thoracotomy with or without neck incision
- 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.
What is removed in an oesophogectomy
- Tumour
- Top of the Stomach
- Surrounding Lymph nodes
What palliative treatment is offered for patients with late oesophageal cancer?
- 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
How is Borhaves syndrome (oesophageal tears) managed?
- Management:
- Aggressive resuscitation
- Control of the oesophageal leak
- Eradication of mediastinal and pleural contamination
- Decompress the oesophagus (typically via a trans-gastric drain or endoscopically-placed NG tube)
- 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
How does Boerhaves syndrome commonly arise?
- Iatrogenic (such as endoscopy)
- After severe forceful vomiting
What is achalasia?
- 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.
What are the sx of achalasia?
- Dysphagia - solids and liquids
- Vomiting
- Chest discomfort
- Food stuck
- Coughing
- Weight loss
What investigations are used for diagnosis of achalasia?
- OGD
- Gold standard: oesophogeal manometry - pressure sensitive probe is inserted into oesophagus to detect pressure changes
- Barium swallow rarely used
How is achalasia managed?
- Conservative - sleeping with many pillows to minimise regurgitation, eating slowly and chewing food thoroughly, and taking plenty of fluids with meals.
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Pharmacological: CCB, PPIs + nitrates - temporary
- Endoscopic botox injections into the LOS (few months)
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Surgical
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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
-
Endoscopic balloon dilatation – insertion of a balloon into the LOS, which is dilated to stretch the muscle fibres
What is diffuse oesophageal spasm?
- 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.
What are of the clinical features of DOS?
- Severe dysphagia to both solids and liquids.
- Central chest pain - exacerbated by food.
- Pain from DOS can respond to nitrate
How is DOS investigated? What can be seen?
- 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
How is DOS managed?
- Medicines: CCB, PPI, nitrates
- Pneumatic dilatation of LOS
- Myotomy - rare
What are oesophageal tears and what causes them?
- 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
What is Boerhave syndrome + how does it differ from mallory weiss tears?
- 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
How does Boerhaves syndrome present?
- Severe sudden-onset retrosternal chest pain
- Respiratory distress
- Subcutaneous emphysema
- Severe vomiting or retching.
What investigations do you do for Boerhaves syndrome?
- Urgent bloods, GS, crossmatch
- CXR – pneumoperitoneum/ intra thoracic air fluid levels
CT Abdo chest pelvic IV contrast
How are oesophageal tears managed?
- Management:
- Aggressive resuscitation
- Control of the oesophageal leak
- Eradication of mediastinal and pleural contamination
- Decompress the oesophagus (typically via a trans-gastric drain or endoscopically-placed NG tube)
- Nutritional support
How must a pt prepare for endoscopy?
- 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
What does achalasia increase your risk of?
Risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia
