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BTK Book Review > Stomach > Flashcards

Stomach Flashcards

1
Q

What are the four types of hiatal hernia?

A
  • type I (90%): sliding
  • type II: paraesophageal
  • type III: mixed
  • type IV: entire stomach and another organ (usually colon)
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2
Q

What are the five types of gastric ulcers?

A
  • type I: secondary to decreased mucosal protection along the lesser curve
  • type II: secondary to increased acid production along the lesser curve and a second in the duodenum
  • type III: pre-pyloric secondary to increased acid production
  • type IV: proximal lesser curve in the cardia secondary to decreased mucosal protection
  • type V: diffuse secondary to NSAIDs
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3
Q

After a distal gastrectomy, what is the vascular supply to the remnant?

A

the short gastrics

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4
Q

After an esophagectomy, what is the vascular supply to the conduit?

A

the right gastroepiploic

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5
Q

What are the three types of gastric volvulus?

A
  • organoaxial (most common) involve rotation along the axis of the stomach from the GEJ to pylorus
  • mesoaxial: rotation along the short axis from the lesser to greater curvature
  • combined
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6
Q

How is gastric volvulus treated?

A
  • typical treatment is emergent surgery for hernia repair, gastropexy, and possible partial gastrectomy if devitalized
  • endoscopic decompression can be attempted in frail patients with placement of double PEG tubes but carries a high risk of perforation
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7
Q

Gastric Volvulus

A
  • most often associated with hiatal hernias
  • they carry a high morbidity and mortality
  • organoaxial are most common and involve rotation around the long axis as opposed to mesoaxial which rotate around the short axis
  • emergent surgery with resection of devitalized tissue, hernia repair, and gastropexy is the gold standard
  • endoscopic decompression with double PEG gastropexy can be attempted in frail patients with high peri-operative risk
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8
Q

What are the alarm symptoms for GERD?

A
  • dysphagia
  • odynophagia
  • weight loss
  • anemia
  • GI bleeding
  • failure to improve on several weeks of PPI
  • all of which raise a suspicion for malignancy and necessitate an EGD
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9
Q

How is GERD medically managed?

A
  • weight loss
  • elevate HOB
  • avoid aggravating foods
  • initiate PPI
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10
Q

What are the indications for surgical evaluation of GERD?

A
  • failure of medical management
  • desire to avoid lifelong PPI
  • extra-esophageal manifestations including asthma, hoarseness, cough, chest pain, aspiration
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11
Q

What is the pre-operative workup for those with GERD and surgical indications?

A
  • barium swallow
  • upper endoscopy
  • ambulatory pH testing
  • esophageal manometry
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12
Q

What are the components of a 24-hr esophageal pH monitoring study? How are they interpreted?

A

Combined to form the Demeester score for which a score > 14.72 is diagnostic for GERD

  • percent total, upright, and supine time pH < 4
  • number of reflux episodes
  • number of reflux episodes > 5 min
  • longest reflux episode
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13
Q

What Demeester score is diagnostic for GERD?

A

14.72

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14
Q

What are the surgical goals for all GERD procedures?

A
  • reduction of any hiatal hernia and restoration of the normal position of the stomach and GEJ
  • closure of any defect in the diaphragmatic crura
  • recreation of an anti-reflux valve
  • 2cm long floppy fundoplication over a large, 54F bougie
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15
Q

What are the following types of fudoplication:

  • Nissen
  • Dor
  • Toupet
  • Thal
  • Belsey
  • Lind
A
  • Nissen: 360 degree
  • Dor: 180 degree anterior
  • Toupet: 270 degree posterior
  • Thal: 270 degree anterior
  • Belsey: 270 degree anterior transthoracic
  • Lind: 300 degree posterior
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16
Q

In the OR during a fudoplication, anesthesia starts having trouble ventilating a patient, what is likely going on and how is it treated?

A
  • likely a capnothorax
  • treat by initially enlarging the tear in the pleura and placing a RRC into the pleural space and into the abdomen to equalize the pressures
  • at the end of the case, bring the abdominal portion outside the abdomen and place it to water seal during valsalva
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17
Q

How are fundoplication patients managed in the immediate post-op setting?

A
  • scheduled anti-emetics to avoid retching
  • soft diet, avoiding meat, raw vegetables, bread, and carbonated beverages for 4-6 weeks
  • dysphagia is common but for severe cases or those persisting for more than 6 weeks, patients may need an esophagram
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18
Q

Describe the workup and differential for post-op dysphagia for patients that have undergone fundoplication.

A
  • very common in the post-op period up to 6 weeks
  • severe cases and those lasting more than 6 weeks should undergo esophagram to evaluate the etiology
  • differential includes hernia recurrence, slipped wrap, or too tight a wrap
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19
Q

What are the indications for operative repair of hiatal hernias?

A
  • asymptomatic type II-IV should all undergo elective repair if good surgical candidates
  • type I should be repaired for the same indications as GERD (failure of conservative management, desire to avoid lifelong PPIs, extra-esophageal manifestations)
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20
Q

What is the key step in hiatal hernia repair that decreases the rate of early recurrence?

A

mobilization and excision of the hernia sac

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21
Q

What kind of suture should be used to close the diaphragmatic crura during a hiatal hernia repair?

A

permanent

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22
Q

What is a Collis gastroplasty?

A

an esophageal lengthening procedure used in hiatal hernia repair when enough intra-abdominal esophagus cannot be mobilized

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23
Q

With what frequency is H. pylori seen in ulcerative disease?

A
  • 75% of gastric ulcers

- 95% of duodenal ulcers

24
Q

What is the standard treatment for H. pylori?

A

triple therapy (PPI, clarithromycin, and amoxicillin or metronidazole)

25
Q

How should a bleeding gastroduodenal ulcer be managed?

A
  • begin with resuscitation
  • should place an NGT and work for early endoscopy
  • repeat endoscopy for the 1st re-bleed
  • then consider IR
  • then consider surgery (also indicated for patients in hemorrhagic shock)
26
Q

What is the risk of re-bleeding for patients with gastroduodenal ulcers that are controlled endoscopically?

A
  • active bleeding and pulsatile vessel: 80%
  • visible vessel: 50%
  • adherent clot: 15-25%
  • clean base: <5%
27
Q

What are the most common causes of gastric bleeding?

A

H. pylori and NSAIDs

28
Q

What is the operation that should be performed to control a bleeding gastric ulcer?

A
  • midline laparotomy
  • anterior gastrotomy
  • oversew bleeding area and take biopsy
  • close gastrotomy
29
Q

What is the operation that should be performed to control a bleeding duodenal ulcer?

A
  • midline laparotomy
  • longitudinal anterior duodenotomy
  • control of bleeding with sutures placed superior and inferior to the ulcer while avoiding the CBD
  • if still uncontrolled, can ligate the GDA above the duodenum
  • approximate the ulcer crater
  • close the duodenotomy transversely
30
Q

How are perforated gastroduodenal ulcers treated?

A
  • fluid resuscitation
  • NGT decompression
  • acid suppression
  • broad spectrum antibiotics
  • omental patch repair
31
Q

What is the indication for an acid reducing operation?

A

can consider in a patient undergoing an operation for a complication of a gastroduodenal ulcer who has previously undergone treatment with a PPI and/or treatment of H. pylori

32
Q

What are possible acid reducing operations?

A
  • truncal vagotomy and pyloroplasty
  • highly selective vagotomy, which preserves motor innervation to pylorus
  • vagotomy and antrectomy, which carries a higher morbidity and is thus reserved for anatomic indications such as large astral ulcer or pyloric scarring
33
Q

What are the risk factors for gastric cancer?

A

H. pylori, smoking, alcohol use, high salt diet, nitrates

34
Q

What are the two types of gastric cancer?

A

intestinal or diffuse

35
Q

What is the cause, treatment, and associated risk for those with hereditary diffuse gastric cancer?

A
  • cause is an autosomal dominant germline mutation in CDH1
  • treated with prophylactic gastrectomy between age 18-40
  • also carries an increased risk of breast cancer
36
Q

What staging workup is indicated for gastric cancer?

A
  • routine labs
  • CT C/A/P and PET
  • EUS with FNA
  • also consider laparoscopic staging with peritoneal washing for clinical stage > T1b tumors if considering chemoradiation or surgery
37
Q

When is a staging laparoscopy indicated for gastric cancer?

A

for those with clinical stage > T1b being considered for chemoradiation or surgery

38
Q

Describe the staging of gastric cancer.

A
  • T1a: invades lamina propria or muscularis mucosa
  • T1b: invades the submucosa
  • T2: invades muscularis propria
  • T3: invades subserosa
  • T4: invades through serosa
  • N1: involves 1-2 nodes
  • N2: involves 3-6 nodes
  • N3: involves 7+ nodes
  • M1: distant metastases
39
Q

Gastric cancer is staged in the same way as what other kind of cancer?

A

esophageal except that the stomach has a serosa

40
Q

What is considered unresectable gastric cancer?

A
  • peritoneal involvement
  • distant metastases
  • root of mesentery involvement
  • encasement of major vascular structure other than splenic vessels
  • para-aortic nodal disease confirmed by biopsy
41
Q

When is neoadjuvant chemotherapy indicated for gastric cancer?

A

cT2 or higher and any N stage

42
Q

When is adjuvant therapy indicated for gastric cancer?

A

5-FU for T3, T4, and node-positive disease following R0 resection

43
Q

What are the three major surgical principles for gastric cancer?

A
  • 4cm margins
  • en bloc resection of involved structures for T4 disease
  • harvest of 15 LNs
44
Q

What type of resection should be pursued for gastric cancer?

A
  • need 4cm margins
  • subtotal gastrectomy is preferred for distal lesions
  • proximal tumors often require gastrectomy with esophagojejunostomy
45
Q

What is a D1 versus a D2 lymph node dissection for gastric cancer?

A
  • D1 is removal of N1 nodes (perigastric nodes along the greater and lesser curves - stations 1-6)
  • D2 is removal of N1 and N2 nodes (those along the left gastric, common hepatic, celiac and splenic arteries - stations 7-11)
  • D1 is the favored dissection in the US
46
Q

What is the difference between an R0, R1, and R2 resection for cancer?

A
  • R0 is negative microscopic margin
  • R1 is positive microscopic margin
  • R2 is positive gross margin
47
Q

Gastric Cancer

A
  • risk factors are H. pylori, smoking, alcohol, high salt diet, nitrates
  • two types are luminal and diffuse
  • staged with labs, CT C/A/P, PET, and EUS with FNA; laparoscopy and peritoneal washings indicated for T1b or greater disease being considered for chemorads or surgery
  • TNM staging is the same as esophageal except that there is serosa rather than adventitia
  • T2 or higher disease should get neoadjuvant chemo
  • T3, T4, or node-positive disease should get adjuvant
  • surgery requires 4cm margins and 15 LNs (D1 dissection of station 1-6 nodes along the lesser and greater curves
  • considered unresectable if there are distant mets, peritoneal involvement, positive para-aortic nodes, encasement of major vasculature other than splenic, involvement of root of mesentery
48
Q

What is retained antrum syndrome and how is it managed?

A
  • it is the presence of retained astral tissue within the duodenal stump after gastric resection
  • these cells are bathed in alkaline fluid and thus continuously secrete gastrin, leading to acid production and ulceration in the proximal stomach remnant
  • treated with PPI, vagotomy, and resection of retained antrum
49
Q

What is dumping syndrome? What is the difference in pathophysiology between early and late? How is it managed?

A
  • symptoms including tachycardia, diaphoresis, dizziness, and flushing
  • early occurs 20-30 minutes after a meal and is due to an abrupt hyperosmolar load to the small intestine
  • late occurs 1-4 hours after a meal and is due to rapid carbohydrate load to the small intestine resulting in insulin surge and rebound hypoglycemia
  • typically managed with small meals and no sugary drinks; can add on octreotide if refractory
50
Q

What’s the pathophysiologic difference between early and late dumping syndrome?

A
  • early is due to hyperosmolar load

- late is due to carb load, insulin surge, and hypoglycemia

51
Q

What is alkaline reflux gastritis?

A
  • alkaline reflux into the stomach after a Bilroth I or II reconstruction
  • it its diagnosed based on impedance studies
  • managed with pro-kinetics and bile acid binding resins; can convert to a roux-en-y if not improved (50cm length roux limb)
52
Q

What length roux limb is used to avoid bile reflux?

A

50cm

53
Q

What is afferent limb syndrome?

A
  • an acute or chronic obstruction of the afferent jejunal limb following Bilroth II reconstruction
  • increased luminal pressure leads to obstructive jaundice, cholangitis, pancreatitis, and duodenal stump blowout
  • bacterial overgrowth also leads to bacteria deconjungating bile acids leading to steatorrhea, malnutrition, B12 deficiency, and megaloblastic anemia
  • treat with conversion to roux-en-y or bilroth I
54
Q

What is a bilroth I versus bilroth II?

A
  • I is a duodenal-gastric anastomosis

- II is a jejunal-gastric anastomosis

55
Q

What are the possible complications of bilroth I and II reconstructions?

A
  • I: marginal ulcer, retained astral tissue, bile reflux

- II: above plus blind loop syndrome, afferent loop obstruction, duodenal stump blowout, and dumping syndrome

56
Q

If you perform a Nissen and the patient is unable to swallow secretions, what is the problem and management?

A
  • the wrap is too tight

- need to revise in the OR

57
Q

Describe the presentation of a gastric maltoma and the treatment.

A
  • it is a gastric mass with biopsy showing expansion of the marginal zone with development of sheets of neoplastic small lymphoid cells
  • treatment is with triple therapy for H. pylori and it will regress once H. pylori is eradicated

BTK Book Review (13 decks)

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