STOMACH Flashcards
Type 1 ulcer location
Lesser curve
Type 2 ulcer location
lesser curve + duodenal (2 ulcers)
Type 3 ulcer location
Pre pyloric
Type 4 ulcer location
Proximal lesser curve (cardia)
Type 5 ulcer location
Diffuse
Type 1 EGJ tumor
distal part of esophagus located between 1-5 cm above anatomic EGJ
Type II EGJ tumor
cardia within 1 cm above and 2 cm below EGJ
Type III EGJ tumor
subcardial stomach (2-5 cm below EGJ)
Distal gastrectomy - the remnant is supplied by?
Short gastrics
Overall surgical goals in surgical mgmt of GERD
-restoration of normal anatomic position of stomach and GEJ
-recreation of anti reflux valve
-any hiatal hernia must be completely reduced which requires mediastinal dissection to ensure adequate esophageal mobilization
-any defect in crura must be closed
-complete mobilization of fundus
-2 cm long floppy fundoplication performed over large 54F bougie
Dor fundoplication
anterior 180-200
Toupet fundoplication
posterior 270
Thal fundoplication
270 anterior
Belsey fundoplication
270 anterior transthoracic
Lind fundoplication
300 posterior
Capnothorax - what do you do?
Enlarge tear to avoid tension capnothorax
Place red rubber catheter with one end into pleural tear and other end into abdomen to equalize pressures
At end of procedure bring one end outside of abdomen and place to waterseal while valsalva administered
Repair of hiatal hernia - what is the key step that decreases early recurrence?
mobilization adn excision of hernia sac
What kind of suture to close the diaphragmatic crura
Permanent
Tx of H pylori
PPI, clarithromycin and amoxicillin vs flagyl for 2 weeks OR bismuth, flagyl, tetracycline and PPI (esp if PCN allergy!!!)
Risk of rebleeding in visible vessel
up to 50%
risk of rebleeding when adherent clot
15-25%
risk of rebleeding when ulcer iwth clean base
<5%
Benefit of highly selective vagotomy
Preserves motor innervation to pylorus and eliminates need for drainage procwedure
When to consider vagotomy and antrectomy?
Higher morbidity than vagotomy and pyloroplasty or HSV secondary to need for billroth recon, but reserved for stable pts with anatomic indications like large antral ulcers, pyloric scarring
Genetics behind hereditary diffuse gastric ca
AD disorder 2/2 germline mutation in CDH1 (cell adhesion molecular E-cadherin)
CDH1 carriers - how do you treat?
Prophylactic gastrectomy recommended between 18-40 y.o.
*note women with CDH1 are at increased risk of breast CA similar to BRCA pts
Hereditary syndromes with increased risk of gastric CA
Lynch syndrome (DNA mismatch genes)
Juvenile polyposis syndrome (SMAD4)
Peutz Jehgers
FAP (APC gene on 5q21)
NCCN recommends laparoscopic staging with peritoneal washing in gastric CA at what T stage
Stage >T1b
T1a gastric CA
invades lamina propria or muscularis mucosa
T1b gastric CA
submucosa
T2 gastric CA
muscularis propria
T3 gastric CA
subserosa
T4 gastric CA
serosa or into adjacent structures
N1 gastric CA
1-2 nodes
N2 gastric CA
3-6 nodes
N3 gastric CA
7 or > nodes
Wahat is unresectable disease in gastric CA?
Peritoneal involvement, distal mets, root of mesentery involvement or para aortic nodal disease confirmed by bx, encasement of major vascular structure excluding splenic vessels
Who gets neoadjuvant therapy in gastric CA
cT2 or higher and any N (similar to esophageal and rectal CA!)
Margins and LN goals in gastric CA surgery
> 4 cm and LN at least 15
D1 dissection
removal of N1 nodes (perigastric nodes along greater/lesser curve stations 1-6)
D2 dissection
removal of N1 and N2 nodes (nodes along left gastric, common hepatic, celiac and splenic arteries, stations 7-11)
When is adjuvant therapy recommended for gastric CA
Adjuvant 5-FU for T3, T4 or node positive disease following R0 resection
What is retained antrum syndrome
retained antral tissue within duodenal stump after gastric resection. G cells bathed in alkaline fluid –> continuous gastrin release –> acid production in proximal stomach remnant and ulceration
Tx of retained antrum syndrome
PPI, vagotomy and resection of retained antrum
Early dumping syndrome
abrupt hyperosmolar load to small intestine and release of serotonin, neurotensin, bradykinins, and enteroglucagon
Late dumping syndrome
rapid carb load to small intestine resulting in large insulin surge and rebound hypoglycemia
refractory dumping syndrome
octreotide (or Roux en y esp if late dumping)
alkaline reflux gastritis
typically with billroth II anatomy, can be dx with impedance studies
Tx of alkaline reflux gastritiis
medical: pro kinetics, bile acid binding resins
Surgical: conversion to RNY
How long of a roux limb to avoid recurrent bile reflux
50 cm
What is afferent limb syndrome
acute or chronic obstruction of afferent jejunal limb following bilroth 2 recon. Increased luminal pressure of afferent limb can lead to obstructive jaundice, cholanigtis, peancreatitis from back pressure up biliopancreatic system, duodeanal stump blow out, bacterial overgrowth in afferent limb
Tx of afferent limb syndrome
conversion to roux en y or bilroth 1 OR braun (enteroentero from afferent limb to efferent)– bacterial overgrowth can be managed first with antibiotics
the anterior vagal trunk divides into?
hepatic division and anterior gastric nerve (anterior nerve of latarjet)
Criminal nerve of grassi arises from whic hvagal trunk?
Posterior
post vagotomy diarrhea
dietary adjustment and cholestyramine. usually self resolves. usually not correlated with meals unlike dumping syndrome!
Refractory post vagotomy diarrhea
Interposition of an antiperstalitc 10 cm segment of jejunum 100 cm from LoT
efferent loop syndrome
Usually after B2 GJ. GOO caused by kinking of efferent jejunal limb, often because of herniation of limb posterior to anastomosis. Operative correctino usually by reducing efferent loop then closing the retroanastomotic space to prevent recurrence
type 1 gastric carcinoid
a/w chronic atrophic gastritis, small <1 cm and often multiple polypoid. Grow slowly and only rarely mets to regional nodes or distant sites
Type II gastric carcinoid tumors
a/w ZES and MEN type 1. Also grow slowly but more likely to metastatsize to regional LN
Type III gastric carcinoid
Sporadic and most biologicall y aggressive. Often large >1 cm and not assoc with hypergastrinemia. Type III lesions freuquently mets to regional nodes or liver.
what are the nerves involved in highly selective vagotomy
they innervate parietal cells which are located within the serosa of the stomach
selective vagoatomy
anterior and posterior gastric nn of Latarjet are ligated (DISTAL to hepatic/celiac branches) the pylorus is denervated and therefore pyloric drainage procedure is needed
truncal vagotomy
main trunk of vagus including celiac and hepatic branches is ligated and pylorus is denervated as a result. therefore a pyloric drainage porceudre or pyloric bypass procedure is needed
most common deficiency after RYGBP
iron deficiency anemia
Creation of a small gastric pouch also decreases production of IF leading to B12 deficiency
Rarely thiamine deficiency from excessive vomiting
Bypass of the duodenum leads to hypocalcemia
motilin receptors are located
in the smooth muscle cells of GI tract
parietal cells secrete
HCl, IF
Enterochromaffin like cells aid in gastric acid secretion via?
histamine release
MALT lymphoma
2:1 male to female ratio, lesions of B cell origin and stain positive for CD19, CD20 and CD22 and negative for CD5
First step after Dx of malatoma
EUs, lymphoma staging workup
High grade maltoma - treatment?
chemoXRT + surgery
Low grade maltoma - after h pylori eradication therapy. If minimal residuals?
Watch and wait - EGD with biopsy q3-6mo x 5 years
Failure of H pylori eradication or no regression of maltoma?
chemoXRT
surveillance after complete remission of maltoma
EGD + biopsy every 3-6mo x 1-2 years then every 6 mos 3-5 years then eyarly therafter
sserum gastrin levels are elevated in which gastric carcinoid
Type I and II
Type II carcinoid (gastric) what else should you check for
pituitary or parathyroid tumors (MEN 1 syndrome)
If fwer than 6 small (<1 cm) nodules and type I or II gastric carcinoids
endoscopic removal. If >6 can consider observation and surveillance every 1-2 yuears
MC gastric lymphoma
large b cell > MALT > Burkitt > mantle cell > follicular
Tx of gastric lymphoma
multimodality - mostly chemo with CHOP (cyclophosphamide, doxorubicin, oncovin.vincristine, prednisone)
pars flaccida technique with lap adjustable gastric band
dissection through fatty tissue posterior to GEJ to create a tunnel in which the band sits. This reduces chances that the posterior stomach which is relatively mobile will slip past the band.
What size is high risk GIST
> 3 cm
What margins desired in GIST?
Grossly negative
Steps of total gastrectomy
Examine for mets
Separate omentum from colon
R gastroepiploic and short gastrics are ligated in process of dsisecting ometntum from colon.
Proximal duodenum divided
Right gastric a ligated
Let gastric artery divided at origin
Esophagus divided
ideal length of roux limb in RNYGB
100-150 cm (100 for smaller 150 for fatter)
key steps of LRYGB
Small bowel run 30-50 cm distal to LoT and transected
Proximal bowel becomes biliopancreatic limb, distal bowel the roux limb
roux limb is measured up to 150 cm distally
Roux limb is aligned with biliopancreatic limb and jejunojejnostomy is created
Roux limb brought up retrocolic or anteocolic
10-15 mL gastric pouch created by entering the lesser sac 3-4 cm below GEJ
GJ is created
When do you usually do a toupet fundoplication?
Pts with abnormal esophageal motility and a BMI <35
When do you typically use a Dor fundoplication
Used after heller myotomy in mgmt of achalasia
Advantages of lap sleeve gastrectomy
technical simplicity
preservation of pylorus, preventing dumping syndrome
reduction of ghrelin levels
prevention of internal hernias and malabsorption
preserves ability to modigy to LRYGB or duod switch as revisional procedure
Where is the band placed in laparoscopic agjustable gastric banding?
Usually around the cardia close to the GEJ with approximate 45 degree angle (2-8:00 axis) towards L shoulder
Basics of duodenal switch
Create gastric pouch 200 mL, preserving pylorus (like a sleeve)
Transect distal ileum approximately 250 cm from ileocecal valve and anastomose to gastric pouch (ALIMENTARY limb)
BP limb anastomosed to ileum between 50-100 cm from ileocecal valve
Copper deficiency
skeletal demineralization, impaired glucose tolerance, pancytopenia
most common nutritional deficiency after BPD
protein malnutrition
selenium deficiency
cardiomyopathy and weakness
deficiency of vitamin E
hemolytic anemia, neurologic abnormalities
The surgeon must be aware of what 2 structures when dissecting the gastrohepatic ligament
aberrant left hepatic artery of Hyrtl
Hepatic branch of the vagus nerve
Remission of gastric MALToma typically takes how long
1-3 years
Which translocation for MALToma shows decreased response rate to H pylori
t(11;18) translocation
May need XRT or rituximab
Where in the stomach is gastrin produced
Antrum
Antral G cells act on parietal cells to produce Hal and chief cells to produce pepsinogen
Which hormones does pancreas secrete
Somatostatin (D cells)
Insulin (beta cells)
Glucagon (alpha cells)
Where is CCK secreted
duo and jejunum
from I cells
Where is secretin produced
duo and jejunum (K cells)
Risk of internal hernia is significantly higher in which approach to RYGB
retrocolic
MOA of sibutramine
Blocks presynaptic uptake of serotonin thereby potentiating anorexic effects n CNS
Mechanism of Orlistat
Pancreatic lipase is inhibited which lowers dietary fat absorption
Causes of hypergastrinemia WITH increased acid production
Gastrinoma
G cell hyperplasia
Retained antrum after distal gastrectomy
Renal failure
Gastric outlet obstruction
Hypergastrinemia with normal or low acid production causes
pernicious anemia
post vagotomy
use of acid suppressive medication
Chronic gastritis
Hypothyroidism is assoc with what gastrin level
LOW
Best test to confirm eradication of H pylori
Urea breath test
Pt given radio labeled urea PO
If H pylori present, urea –> ammonia and radio labeled bicarbonate –> exhaled as CO2
MC functional NE tumor in MEN type 1
gastrinoma
MC functional neuroenndocrine tumor
insulinoma
MC gastric volvulus
organoaxial
Twisting around xis between GEJ and pylorus
Best ulcer option to perform in the emergent setting
Truncal vagotomy + pyloroplasty
Lowest risk of re-bleeding
clean visible ulcer base
Which types of gastric polyps do not harbor malignancy risk
Hamartomatous
Inf;lammatory
Heterotopic
Usually fund
Risk of malignancy in typical hyperplastic polyp
2%
Dieulafoy lesion
congenital malformation in stomach, typically on lesser curvature, characterized by a submucosa artery that is abnormally large and tortuous
May erode through mucosa and become exposed to gastric secretions
Most sensitive and specific dx test for gastrinoma
Secretin stimulation test
increase in gastrin of 120 pg/mL or greater
Complication of truncal vagotomy
Loss of PS innervation not pylorus which prevents gastric emptying, primarily to solid foods
Complication of selective vagotomy
Lower rate of delayed gastric emptying but higher rate of recurrent ulcer disease
Complication of pyloroplasty
Can least rapid gastric emptying
How to treat SIBO
Labs for B12 deficiency, microcytic anemia
Confirm with lactulose breath test
Treat with abs like rifaximin
H pylori and gastric CA
PROTECTIVe against proximal gastric CA
Increased risk of DISTAL gastric CA
Which gastric CA rising the fastest
Proximal due to obesity and reflux
proximal gastric CA is 2x more common in
men
whites
In pts needing tx for H pylori but are PCN allergic what can you sub amoxicillin with
metronidazole
persistent non healing peptic ulcer
obtain 8 or more bx from base of ulcer
Giant duo perforation
Jejunal serosal patch
Pyloric exclusion
Feeding j
Petersen hernia
mesentery of Roux (Alimentary) limb and transverse mesocolon
What are the 3 types of internal hernias
Hernia through Petersen (space between Roux limb mesentery and transverse mesocolon)
Hernia through mesenteric opening at BP limb
Hernia through defect in transverse mesentery that is created to perform a retrocolic GJ
Recurrent reflux and weight re-gain after RYGB should make you think of
gastrogastric fistula
branches of anterior vagal trunk
hepatic division
anterior gastric division (anterior nerve of Latarjet)
Celiac division arises from which vagal trunk
POSTERIOR
PErsistent reflux after sleeve not treated with antacids
lap magnetic sphincter augmentation band
Best bariatric procedures to achieve DM remissio
BPD
RYGB
