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