Mock Orals Flashcards
Acid Reflux Work Up/Initial Management
Barium Swallow
EGD w/ biopsies
24H pH test
Manometry: assess for achalasia or motility disorders
Medical Management of GERD
Small meals
Not eating at night
Decrease caffeine/trigger foods
PPI
When to operate on GERD
6 month medical management
Desire surgery/young
Complications of GERD (stricture, Barrett’s esophagus)
Extra-esophageal manifestations (Asthma, cough, aspiration)
Nissen Fundoplication
1) Obtain access via verses, insufflate
2) Camera port near umbilicus, remaining ports triangulated to the GEJ, liver retractor placed subxiphoid
3) Exposure and division of phrenogastric ligament, ultrasonic dissector used to divide short gastric superiorly to the angle of His
4) Gastrohepatic ligament opened at pars flaccida then divided superiorly avoiding injury to vagus nerves or aberrant left hepatic artery
5) retroesophageal window is made and a Penrose is placed around the esophagus
6) esophagus is then mobilized up to the level of inferior pulmonary veins and for a minimum of 3cm of intra-abdominal esophagus
7) Right and left crura are reapproximated with permanent suture
8) Placement of 60Fr Bougie
9) Creation of the wrap (posterior fungus passed behind esophagus left to right)
10) Shoe shine procedure, seromuscular sutures w/ ethibond
Techniques to lengthen esophagus
Unilateral vagotomy 1-2cm
Bilateral vagotomy 3-4cm
Stapled-wedge Collis gastroplasty
Nissen post op care
Clear liquid diet POD#0
Full liquid diet POD#1
Discharged on full liquid diet for 4 weeks
Avoidance of carbonated drinks
How to biopsy suspected Barrets
4 quadrant biopsies every 1cm the entire length of the lesion
Pathology of Barrett’s esophagus
proximal movement of squamocolumnar junction and goblet cells
Can you perform fundoplication in setting of Barrets
No dysphasia, intermediate –> yes
Low grade –> yes continue surveillance EGD q6m
High grade, adenocarcinoma –> wrap contraindicated, perform esophagectomy
Additional tests needed if High Grade Barretts or adenocarcinoma found
CT C/A/P w/ PO/IV
EUS
Work Up for Hiatal Hernia
Barium Swallow
EGD
Manometry
Chest CT (acute setting)
When to offer surgery in Hiatal Hernia
Type I w/ reflux
Type 2-4 if healthy enough for surgery
Signs of Gastric volvulus
Chest Pain
Unproductive retching
Inability to Pass NGT
Hiatal Hernia Repair
1) obtain access
2) Reduce contents back into abdomen and dissect hernia sac out of chest
3) dissect around esophagus protecting vagus nerve
4) Repair defect in diaphragm by suturing crus together with nonabsorbable suture
5) Reinforce with biologic mesh (tack to either side of diaphragm and at most inferior portion of repair
6) Perform nissen fundoplication
7) Consider gastropexy to anterior abdominal wall
Symptoms off Zenker Diverticulum
Dysphagia, Halitosis, Regurgitation of Undigested food
