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General Surgery > Part two - oesphagogastric > Flashcards

Part two - oesphagogastric Flashcards

1
Q

What 5 things make the GOJ an effective sphincter/valve?

A
  1. Circular fibres in diaphragm, right crus and oesophagus
  2. Phrenico-oesophageal ligament (fold of connective tissue)
  3. Angle of junction (Angle of His)
  4. Mucosal folds
  5. Intra-abdominal pressure acting to compress the intra-abdominal oesophagus (3cm)
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2
Q

Arterial supply of the stomach

A

Coeliac trunk (T12)

  • Left and right gastric arteries
  • Short gastric arteries
  • Left and right gastroepiploic arteries
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3
Q

Venous drainage of the stomach

A

Same as arterial supply except:

  • No GDA
  • Prepyloric vein of Mayo
    - Smal
    - No accompanying artery
    - Overlies pylorus
    - Drains into PV or RGV

Stomach drains int PV or its tributaries SV or SMV

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4
Q

Lymph drainage of the stomach

A

Eventually all reaches coeliac nodes

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5
Q

What is Troisier’s sign

A

Involvement of left supraclavicular node in gastric cancer probably secondary to posterior mediastinum spread

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6
Q

Nerve supply to the stomach

A 
SYMPATHETICS - Greater splanchnic nerves (T5-9)
*  Decrease motility
*  Vasoconstriction
*  Close pylorus
*  Sensation
PARASYMPATHETICS - Vagus nerves (CN X)
*  80% sensory & 20% motor
*  Increasing motility
*  Opening pylorus
*  Initiating secretions
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7
Q

Truncal vagotomy

A

Resection of 1-2cm of each vagal trunk as it enters stomach

  • Impaired gastric emptying so requires a drainage procedure like a pyloroplasty or gastrojejunostomy
  • May cause dumping and post-vagotomy diarrhoea
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8
Q

Selective vagotomy

A

Anterior vagal trunk cut distal to hepatic branch

Posterior vagal trunk cut distal to coeliac branch

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9
Q

Highly selective vagotomy

A

Cut only small branches to funds and body separating the main nerve trunks from the lesser curve

Main nerves of Laterjet are preserved

Antral and pyloric innervation are preserved

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10
Q

Muscular coats of the stomach

A

Outer - longitudinal
Inner - circular
Innermost - incomplete oblique

Mucosal rugae caused by muscle fibres

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11
Q

Define GORD

A

Gastro-oesphageal reflux refers to the abnormal exposure of the oesophagus to gastric contents, as manifested by symptoms, endoscopic/histologic or pH studies

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12
Q

Define reflux oesophagitis

A

Ulceration of the distal oesophagus

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13
Q

Symptoms of GORD

A 
HARD
H = heart burn
A = atypical symptoms
R = regurgitation
D = dysphagia

Atypical symptoms - cough, hoarseness, aspiration, wheeze

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14
Q

Classification of oesophagitis

A

SAVARY-MILLER CLASSIFICATION

  • G1 - 1+ non-confluent erosion
  • G2 - Confluent but non-circumferential erosions
  • G3 - Circumferential erosions
  • G4 - Deep ulcers, stricture, scarring, shortening
  • G5 - Barrett’s metaplasia
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15
Q

What is oesophageal cancer?

A

Malignant neoplasia of the oesophagus consisting mostly of adenocarcinoma and squamous cell carcinoma

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16
Q

Layers of the oesophageal wall

A 
Mucosa
- Stratified squamous epithelium
- Lamina propria
- Muscularis mucosae
Submucosa
Muscularis propria - inner circular & outer longitudinal layers
- striated in upper third
- mixed in middle third
- smooth in lower third

NO SEROSAL LAYER

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17
Q

Length of the oesophagus?

A

25cm muscular tube with three parts

  • Cervical (C6)
  • Thoracic
  • Abdominal (T10)
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18
Q

Where are the constrictions of the oesophagus?

A

Cricopharyngeus - 15cm
Aortic arch - 22cm
(Left main bronchus - 27cm)
Diaphragmatic hiatus (T10) - 38-40cm

Measurements from incisors

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19
Q

Blood supply to the oesophagus

A

Upper 1/3 - inferior thyroid artery
Middle 1/3 - oesophageal arteries from aorta and bronchial arteries
Lower 1/3 - keft gastric artery

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20
Q

Venous drainage of the oesophagus

A

Upper 1/3 - brachiocephalic vein
Middle 1/3 - azygos vein
Lower 1/3 -left gastric vein

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21
Q

Lymphatic drainage of the oesophagus

A

Cervical - deep cervical nodes
Thoracic - trancheobronchial & posterior mediastinal nodes
Abdominal - left gastric and coeliac nodes

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22
Q

Nerve supply to the oesophagus

A

Upper

  • RLN for somatic
  • Sympathetics from middle cervical ganglion

Middle/lower

  • Vagus nerves for parasympathetic
  • Thoracic sympathetic trunks and greater splanchnic nerves
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23
Q

Siewert classification for OGJ adenocarcinoma

A

Type I - tumour centre 1-5cm above GOJ

Type II - tumour centre 1cm above to 2 cm below GOJ

Type III - tumour centre 2-5cm below GOJ but invades into GOJ

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24
Q

Subclassification of the depth of superficial esophageal cancer

A

M1 - limited to epithelial layer
M2 - invades lamina propria
M3 - invades into but not through muscularis mucosa
SM1 - penetrates shallowest one third of submucosa
SM2 - penetrates into the intermediate one third of submucosa
SM3 - penetrates deepest on third of submucosa

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25
Q

Chance of nodal metastases in superficial oesophageal cancer

A

m1-2 -> no nodal involvement

m3-sm1 -> 10-15% nodal involvement

sm2-3 -> 40% nodal involvement

26
Q

What is the squamocolumnar junction ?

A

Also known as Z-line

Visible line formed by juxtaposition of squamous and columnar epithelia

27
Q

What is the gastro-osephageal junction?

A

Imaginary line at which the oesophagus ends and the stomach begins. The GOJ corresponds to the most proximal extent of the gastric folds

28
Q

What is superficial oesophageal cancer?

A

Invading no deeper than the submucosa

29
Q

What is early gastric cancer?

A

Invades no deeper than the submucosa, irrespective of lymph node metastases

30
Q

What is oesophageal cancer?

A

Malignant neoplasia of the oesophagus consisting mostly of adenocarcinoma and squamous cell carcinoma

31
Q

What is the pathogenesis of oesophageal adenocarcinoma?

A

Exposure of the distal oesophagus to gastric contents induces intestinal metaplasia which undergoes stepwise acquisition of genetic and epigenetic changes manifested as low grade dysplasia to high grade dysplasia to adenocarcinoma

32
Q

What is the distribute of oesophageal adenocarcinoma?

A

Distal third - 80%

Middle third - 20%

33
Q

What is the distribution of oesophageal SCC?

A

Middle third - 50%
Lower third - 35%
Upper third - 10%

34
Q

What size is significant on CT to suggest metastases to lymph nodes?

A

Thorax & abdomen - 1cm in short axis
Supraclavicular - 0.5cm in short axis
Retrocrural - 0.6cm in short axis

35
Q

Diagnosis of Barrett oesophagus

A

Endoscopic and histologic confirmation of specialised intestinal metaplasia = columnar epithelium with goblet cells

36
Q

Risk factors for Barrett’s oesophagus

A 
Older age
Male gender
Caucasian
Obesity especially centrally
GORD - strongest risk factor
37
Q

How is the extent of suspected oesophageal metaplasia described?

A

Prague criteria

  1. Ensure hiatus hernia distinguished from GOJ
  2. Measure Depth of GOJ
  3. Look for displacement of squamocolumnar junction above GOJ
  4. Measure depth at the MOST PROXIMAL CIRCUMFERENTIAL (C) extent of metaplasia
  5. Measure depth at MAXIMUM EXTENT (M)
  6. C = GOJ - C; M - GOJ - M

Prague C? M?

38
Q

What is the Seattle Protocol for biopsy of Barrett’s oesophagus

A
  • 4-quadrant biopsies
    * 1-2cm intervals
    * Irregularities separately biopsied

Nodularities associated with high risk of malignancy

39
Q

Risk factors for progression of Barrett’s oesophagus

A
  • Demographics - older males
    * Length of segment
    * Smoking
    * Nodularity
    * Grade of dysplasia
40
Q

Principles of oesophageal perforation management

A 
Close monitoring as can become septic
Source control
Consider underlying pathology
Plan nutrition
IVAbs and chest tube while therapeutic options considered
41
Q

Management options for oesophageal perforation

A

Non-operative

  • NBM
  • IVAbs +/- antifungal
  • Stent
  • Perc drains

Operative

  • Drainage
  • Debridement and primary repair
  • Oesophageal diversion and delayed repair
  • Oesophagectomy
42
Q

What is Mackler’s triad?

A

The classic triad of Boerhaave’s syndrome - chest pain, vomiting and subcutaneous emphysema which is rarely present (<20%)

43
Q

What is Boerhaave’s syndrome

A

Effort rupture of the esophagus that most commonly results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure caused by straining or vomiting.

Usually tears at the left posterolateral aspect of the distal esophagus and extends for several centimeters

44
Q

Postgastrectomy syndromes

A 
Dumping syndrome - early and late
Metabolic disturbances
Afferent loop syndrome
Efferent loop syndrome
Alkaline reflux gastritis
Gastric atony
45
Q

What is dyspepsia?

A

Indigestion or upper abdominal discomfort

46
Q

What is the pathology of hereditary diffuse gastric cancer syndrome?

A

Loss of expression of E-cadherin due to CDH1 mutation

  • Autosomal dominant
  • High penetrance
  • Lifetime cumulative risk up to 67% in men % 83% in women
  • Average age is 38
  • Poor prognosis
  • Prophylactic gastrectomy appropriate
  • Women at high risk of lobular breast cancer and should be encouraged to undergo screening
47
Q

Pathogenesis of intestinal type of gastric cancer

A

H. pylori infection (childhood)
Prolonged precancerous process over 40 years
- Chronic active non-atrophic gastritis
- Intestinal metaplasia
- Dysplasia
- Invasive carcinoma
Environmental risk factors influence this progression
Molecular pathogenesis remains unclassified:
- Beta-catenin - protein that binds to E-cadherin and APC
- MSI and hypermethylation of a variety of genes

48
Q

Pathogenesis of diffuse type gastric cancer

A

Loss of E-cadherin (contributes to epithelial intercellular adhesion) function is a key step in development of diffuse gastric cancer

  * Germline mutations in CDH1 associated with familial 
  * Mutations of CDH1 in 50% of sporadic 
  * Methylation of CDH1 promoter or other defect in the rest of sporadic diffuse type cases
49
Q

Morphology of diffuse type gastric cancer

A

Signet ring cells caused by large mucin vacuoles that expand cytoplasm pushing nucleus to periphery
Composed of discohesive cells
Mass may be difficult to appreciate instead a desmoplastic reaction stiffens the gastric wall
Large areas of infiltration gives a diffuse rugal flattening and a rigid, thickened wall imparting a leather bottle appearance = linitis plastica

50
Q

What is the Lauren classification of gastric cancer?

A

A histological classification dividing gastric adenocarcinoma into intestinal and diffuse types

51
Q

How can you detect damage to the thoracic duct intra-operatively?

A

During mobilisation of thoracic oesophagus, damage can be detected early by instillation via NJ of 100mL fresh cream during dissection. Egress of milky fluid diagnostic. Then repair or ligate with impunity.

52
Q

What do your always forget and what can you never say when it comes to upper GI haemorrhage

A

OMEPRAZOLE

Sengstaken-Blackmore tube

53
Q

Forrest classification

A

Risk of UGI rebleeding based on endoscopic findings:

ACTIVE BLEEDING
- Spurting -> high - 100%
- Oozing -> high - 53%
SIGNS OF RECENT HAEMORRHAGE
- Visible vessel -> high - 44%
- Adherent clot -> intermediate - 25%
- Black spot -> low -10%
NO SIGNS HAEMORRHAGE
- Clean ulcer -> low - 5%
54
Q

Rockall score

A

Risk of rebreeding and death for UGI bleed

PRE-ENDOSCOPY
- Age
- Comorbidities 
- Shock
POST-ENDOSCOPY
- Diagnosis
- Stigmata of recent bleeding

Score = 0 can discharge from ED
Score < 3 -> excellent outcome
Score > 8 -> high mortality

55
Q

Management of UGI bleeding due to varices

A

Resuscitation - tricky as rapid correction may exacerbate

IV /terlipressin for splanchnic vasoconstriction

IV ceftriaxone as underlying sepsis often underlying a rise in portal hypertension

IV omeprazole

Emergency OGD -> band or inject

Tamponade with Sengstaken-Blackmore tube

Transjugular intrahepatic portosystemic shunt (TIPS)

Crazy ass surgery

56
Q

Differential diagnosis for a perforated gastric ulcer

A

Peptic ulcer
Gastric cancer
Gastric lymphoma
Gastric GIST

57
Q

Risk factors for gastric volvulus

A

Age >50 years
Diaphragmatic abnormalities (eg, paraesophageal, hiatal, other diaphragm hernia)
Diaphragm eventration
Phrenic nerve paralysis
Other anatomic gastrointestinal abnormalities (eg, stomach, spleen)
Kyphoscoliosis

58
Q

Classification of gastric volvulus

A

AETIOLOGY
Primary - abnormalities of the gastric ligaments
Secondary - due to other abnormalities

AXIS OF ROTATION
Organoaxial
- most common
- long axis
- associated with secondary aetiology
Mesenteroaxial
- short axis
- greater curve above lesser curve
- not usually associated with anatomical defect
- less likely to vole 180 and strangulate
59
Q

Lymphadenectomy in gastric cancer

A

D2 lymphadenectomy stages patients more accurately and probably does improve overall survival. It should only be performed in high volume centres, however, to avoid unnecessarily high morbidity and mortality rates. Distal pancreatectomy and splenectomy should not be routinely performed for nodal harvest. Regardless, at least 15 nodes are required for adequate staging.

60
Q

Factors which protect stomach mucosa?

A 
Mucus and surfactant 
Bicarbonate
Prostaglandins
Blood flow
Epithelial repair
61
Q

Internal hernias after gastric bypass

A

Mesenteric defect at the jejuno-jejunostomy
Space between transverse mesocolon and Roux-limb mesentery (Peterson’s hernias)
Defect in transverse mesocolon if Roux-limb is retrocolic

General Surgery (25 decks)

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