Stomach Flashcards
What are the four types of hiatal hernia?
- type I (90%): sliding
- type II: paraesophageal
- type III: mixed
- type IV: entire stomach and another organ (usually colon)
What are the five types of gastric ulcers?
- 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
After a distal gastrectomy, what is the vascular supply to the remnant?
the short gastrics
After an esophagectomy, what is the vascular supply to the conduit?
the right gastroepiploic
What are the three types of gastric volvulus?
- 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
How is gastric volvulus treated?
- 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
Gastric Volvulus
- 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
What are the alarm symptoms for GERD?
- 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
How is GERD medically managed?
- weight loss
- elevate HOB
- avoid aggravating foods
- initiate PPI
What are the indications for surgical evaluation of GERD?
- failure of medical management
- desire to avoid lifelong PPI
- extra-esophageal manifestations including asthma, hoarseness, cough, chest pain, aspiration
What is the pre-operative workup for those with GERD and surgical indications?
- barium swallow
- upper endoscopy
- ambulatory pH testing
- esophageal manometry
What are the components of a 24-hr esophageal pH monitoring study? How are they interpreted?
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
What Demeester score is diagnostic for GERD?
14.72
What are the surgical goals for all GERD procedures?
- 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
What are the following types of fudoplication:
- Nissen
- Dor
- Toupet
- Thal
- Belsey
- Lind
- Nissen: 360 degree
- Dor: 180 degree anterior
- Toupet: 270 degree posterior
- Thal: 270 degree anterior
- Belsey: 270 degree anterior transthoracic
- Lind: 300 degree posterior
In the OR during a fudoplication, anesthesia starts having trouble ventilating a patient, what is likely going on and how is it treated?
- 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
How are fundoplication patients managed in the immediate post-op setting?
- 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
Describe the workup and differential for post-op dysphagia for patients that have undergone fundoplication.
- 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
What are the indications for operative repair of hiatal hernias?
- 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)
What is the key step in hiatal hernia repair that decreases the rate of early recurrence?
mobilization and excision of the hernia sac
What kind of suture should be used to close the diaphragmatic crura during a hiatal hernia repair?
permanent
What is a Collis gastroplasty?
an esophageal lengthening procedure used in hiatal hernia repair when enough intra-abdominal esophagus cannot be mobilized
With what frequency is H. pylori seen in ulcerative disease?
- 75% of gastric ulcers
- 95% of duodenal ulcers
What is the standard treatment for H. pylori?
triple therapy (PPI, clarithromycin, and amoxicillin or metronidazole)
How should a bleeding gastroduodenal ulcer be managed?
- 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)
What is the risk of re-bleeding for patients with gastroduodenal ulcers that are controlled endoscopically?
- active bleeding and pulsatile vessel: 80%
- visible vessel: 50%
- adherent clot: 15-25%
- clean base: <5%
What are the most common causes of gastric bleeding?
H. pylori and NSAIDs
What is the operation that should be performed to control a bleeding gastric ulcer?
- midline laparotomy
- anterior gastrotomy
- oversew bleeding area and take biopsy
- close gastrotomy
What is the operation that should be performed to control a bleeding duodenal ulcer?
- 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
How are perforated gastroduodenal ulcers treated?
- fluid resuscitation
- NGT decompression
- acid suppression
- broad spectrum antibiotics
- omental patch repair
What is the indication for an acid reducing operation?
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
What are possible acid reducing operations?
- 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
What are the risk factors for gastric cancer?
H. pylori, smoking, alcohol use, high salt diet, nitrates
What are the two types of gastric cancer?
intestinal or diffuse
What is the cause, treatment, and associated risk for those with hereditary diffuse gastric cancer?
- 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
What staging workup is indicated for gastric cancer?
- 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
When is a staging laparoscopy indicated for gastric cancer?
for those with clinical stage > T1b being considered for chemoradiation or surgery
Describe the staging of gastric cancer.
- 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
Gastric cancer is staged in the same way as what other kind of cancer?
esophageal except that the stomach has a serosa
What is considered unresectable gastric cancer?
- peritoneal involvement
- distant metastases
- root of mesentery involvement
- encasement of major vascular structure other than splenic vessels
- para-aortic nodal disease confirmed by biopsy
When is neoadjuvant chemotherapy indicated for gastric cancer?
cT2 or higher and any N stage
When is adjuvant therapy indicated for gastric cancer?
5-FU for T3, T4, and node-positive disease following R0 resection
What are the three major surgical principles for gastric cancer?
- 4cm margins
- en bloc resection of involved structures for T4 disease
- harvest of 15 LNs
What type of resection should be pursued for gastric cancer?
- need 4cm margins
- subtotal gastrectomy is preferred for distal lesions
- proximal tumors often require gastrectomy with esophagojejunostomy
What is a D1 versus a D2 lymph node dissection for gastric cancer?
- 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
What is the difference between an R0, R1, and R2 resection for cancer?
- R0 is negative microscopic margin
- R1 is positive microscopic margin
- R2 is positive gross margin
Gastric Cancer
- 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
What is retained antrum syndrome and how is it managed?
- 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
What is dumping syndrome? What is the difference in pathophysiology between early and late? How is it managed?
- 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
What’s the pathophysiologic difference between early and late dumping syndrome?
- early is due to hyperosmolar load
- late is due to carb load, insulin surge, and hypoglycemia
What is alkaline reflux gastritis?
- 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)
What length roux limb is used to avoid bile reflux?
50cm
What is afferent limb syndrome?
- 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
What is a bilroth I versus bilroth II?
- I is a duodenal-gastric anastomosis
- II is a jejunal-gastric anastomosis
What are the possible complications of bilroth I and II reconstructions?
- I: marginal ulcer, retained astral tissue, bile reflux
- II: above plus blind loop syndrome, afferent loop obstruction, duodenal stump blowout, and dumping syndrome
If you perform a Nissen and the patient is unable to swallow secretions, what is the problem and management?
- the wrap is too tight
- need to revise in the OR
Describe the presentation of a gastric maltoma and the treatment.
- 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
