Surgical Recall: Ch. 41 Stomach

Question 1

Anatomy

1. What is the blood supply to the stomach?
2. What space lies behind the stomach?
3. What is the opening into the lesser sac?
4. What are the folds of gastric mucosa called?

Answer 1

Anatomy

1. L & R gastric a., L & R gastroepiploic a., short gastrics (from spleen)
2. Lesser sac; pancreas lies behind stomach
3. Foramen of Winslow
4. Rugae

Question 2

Physiology

1. Define the products of the following stomach cells:
   
   1. Gastric parietal cells
   2. Chief cells
   3. Mucous neck cells
   4. G cells
2. Where are G cells located?
3. What is pepsin
4. What is IF?

Answer 2

1. Products:
   
   1. Gastric parietal cells: HCl / IF
   2. Chief cells: Pepsinogen
   3. Mucous neck cells: Bicarb, mucus
   4. G cells: Gastrin
2. Antrum
3. Proteolytic enzyme that hydrolyzes peptide bonds
4. Protein secreted by parietal cells that combines with B12 and allows for absorption in terminal ileum

Question 3

GERD

1. What is pyrosis?
2. What are the causes (4)?
3. What disease must be r/o when sx of GERD are present?
4. What tests are included in workup?
5. What is medical tx?

Answer 3

1. Pyrosis = Medical term for heartburn
2. Causes:
   
   1. Dec. LES tone (>50% cases)
   2. Dec. esophageal motility to clear refluxed fluid
   3. Gastric outlet obstruction
   4. Hiatal hernia in 50% of pts
3. CAD
4. Tests:
   
   1. EGD
   2. UGI contrast study with esophagogram
   3. 24 hr acid analysis (pH probe in esophagus)
   4. Manometry, EKG, CXR
5. Medical tx:
   
   1. Small meals
   2. PPIs or H2 blockers
   3. Elevation of head at night and no meals prior to sleeping

Question 4

GERD

1. What is Barrett’s esophagus?
2. What is the major concern with Barrett’s?
3. Define the following surgical options for severe GERD:
   
   1. Lap Nissen
   2. Belsey Mark
4. How does the Nissen wrap work?
5. What are the post-op complications of Lap Nissen?

Answer 4

1. Columnar metaplasia from normal squamous epithelium
2. Adenocarcinoma
3. Surgical options:
   
   1. Lap Nissen: 360 fundoplication–2 cm long (laparoscopically)
   2. Belsey mark IV: 240 to 270 fundoplication performed through thoracic approach
4. Nissen wrap: improve LES
   
   1. Inc. LES tone
   2. Elongate LES ~3cm
   3. Returning LES into abdominal cavity
5. Postop complications:
   
   1. ​Gas-bloat syndrome (inability to burp/vomit)
   2. Stricture
   3. Dysphagia
   4. Spleen injury requiring splenectomy
   5. Esophageal performation
   6. Pneumothorax