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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
Chance of nodal metastases in superficial oesophageal cancer
m1-2 -> no nodal involvement m3-sm1 -> 10-15% nodal involvement sm2-3 -> 40% nodal involvement
26
What is the squamocolumnar junction ?
Also known as Z-line Visible line formed by juxtaposition of squamous and columnar epithelia
27
What is the gastro-osephageal junction?
Imaginary line at which the oesophagus ends and the stomach begins. The GOJ corresponds to the most proximal extent of the gastric folds
28
What is superficial oesophageal cancer?
Invading no deeper than the submucosa
29
What is early gastric cancer?
Invades no deeper than the submucosa, irrespective of lymph node metastases
30
What is oesophageal cancer?
Malignant neoplasia of the oesophagus consisting mostly of adenocarcinoma and squamous cell carcinoma
31
What is the pathogenesis of oesophageal adenocarcinoma?
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
What is the distribute of oesophageal adenocarcinoma?
Distal third - 80% | Middle third - 20%
33
What is the distribution of oesophageal SCC?
Middle third - 50% Lower third - 35% Upper third - 10%
34
What size is significant on CT to suggest metastases to lymph nodes?
Thorax & abdomen - 1cm in short axis Supraclavicular - 0.5cm in short axis Retrocrural - 0.6cm in short axis
35
Diagnosis of Barrett oesophagus
Endoscopic and histologic confirmation of specialised intestinal metaplasia = columnar epithelium with goblet cells
36
Risk factors for Barrett's oesophagus
``` Older age Male gender Caucasian Obesity especially centrally GORD - strongest risk factor ```
37
How is the extent of suspected oesophageal metaplasia described?
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
What is the Seattle Protocol for biopsy of Barrett's oesophagus
* 4-quadrant biopsies * 1-2cm intervals * Irregularities separately biopsied Nodularities associated with high risk of malignancy
39
Risk factors for progression of Barrett's oesophagus
* Demographics - older males * Length of segment * Smoking * Nodularity * Grade of dysplasia
40
Principles of oesophageal perforation management
``` Close monitoring as can become septic Source control Consider underlying pathology Plan nutrition IVAbs and chest tube while therapeutic options considered ```
41
Management options for oesophageal perforation
Non-operative - NBM - IVAbs +/- antifungal - Stent - Perc drains Operative - Drainage - Debridement and primary repair - Oesophageal diversion and delayed repair - Oesophagectomy
42
What is Mackler's triad?
The classic triad of Boerhaave's syndrome - chest pain, vomiting and subcutaneous emphysema which is rarely present (<20%)
43
What is Boerhaave's syndrome
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
Postgastrectomy syndromes
``` Dumping syndrome - early and late Metabolic disturbances Afferent loop syndrome Efferent loop syndrome Alkaline reflux gastritis Gastric atony ```
45
What is dyspepsia?
Indigestion or upper abdominal discomfort
46
What is the pathology of hereditary diffuse gastric cancer syndrome?
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
Pathogenesis of intestinal type of gastric cancer
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
Pathogenesis of diffuse type gastric cancer
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
Morphology of diffuse type gastric cancer
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
What is the Lauren classification of gastric cancer?
A histological classification dividing gastric adenocarcinoma into intestinal and diffuse types
51
How can you detect damage to the thoracic duct intra-operatively?
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
What do your always forget and what can you never say when it comes to upper GI haemorrhage
OMEPRAZOLE Sengstaken-Blackmore tube
53
Forrest classification
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
Rockall score
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
Management of UGI bleeding due to varices
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
Differential diagnosis for a perforated gastric ulcer
Peptic ulcer Gastric cancer Gastric lymphoma Gastric GIST
57
Risk factors for gastric volvulus
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
Classification of gastric volvulus
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
Lymphadenectomy in gastric cancer
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
Factors which protect stomach mucosa?
``` Mucus and surfactant Bicarbonate Prostaglandins Blood flow Epithelial repair ```
61
Internal hernias after gastric bypass
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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