UGI Surgery Flashcards
Best evaluation of oesophageal LN
PET CT and endoscopic US
What is the minimum number of lymph nodes that need to be resected in a potentially curative D2 gastrectomy?
Removal of less than 16 nodes constitutes understaging and potentially under treatment.
Histology in oesophageal achalasia
The situation in achalasia is best considered as the reverse of Hirschprungs disease. Ganglion cells are absent or reduced in the dilated segment and it is Auerbachs plexus that the changes occur.
Placement of pH probe for pH study
5cm above the lower sphincter
Gastric lymphomas
Most comman are due to lymphomas not arising from the stomach (eg systemic)
The endoscopic appearances of gastric lymphoma are vague and non specific. Mucosal thickening is the earliest sign.
Treatment for proximal SCC
Early, localised, proximal tumours should be treated with chemoradiotherapy
Mid and distal oesophageal tumours can be treated with either surgery or chemo radiotherapy
More advanced proximal tumours without disseminated disease can be considered for McKeown type oesophagectomy
Reflux with gastric atrium involvement
Suggests H pylori infection
foveolar hyperplasia (gland tortuosity and dilatation - seen in gastritis
Usually due to chronic insult such as bile salt reflux
Endoscopic frequency for Barrett’s
Every 2-5yrs
Biopsy’s taken quadrantic every 1-2cm
Up to 40% of people with EMR upstaged from high grade dysplasia to invasive cancer
Mass encountered inoesphagus and cannot pass
Take bisopsys and withdraw
Order staging investigations
Distal extend not needed
DO NOT PERFORATE THE TUMOUR
Chyle leak
Chyle leaks are more common following transhiatal procedures and may cause considerable nutritional compromise. Significant fluid collections should be drained but repeated thoracocintesis may result in the development of infection. Lipid rich TPN is helpful as these patients may lose lipid. Lipid laden diets may worsen the condition. Refractory cases may require surgery.
How many biopsy’s should be taken in UGI cancer
6
Lymph nodes affected in gastric cardia
Station 1 &2 node sdrain the cardia
Most comman oesophageal problem in patients with CREST
Reflex - 70% of cases
Oesophageal involvement is therefore very common. Early features include atrophy of the oesophageal smooth muscle resulting a patulous and ineffective lower oesophageal sphincter. This results in reflux (occurs in 70% of cases). Over time this can result in ulceration, strictures, Barretts oeosphagus and adenocarcinoma.
Most sensitive test for staging oesophageal cancer
Endoscopic ultrasound
Schatzki rings
Most Schatzki are located at the OG junction. Characteristically the rings have esophageal mucosa above and gastric type columnar epithelium below.
Schatzki rings are an intrinsic occlusion of the lumen of either the distal esophagus or OG junction. They are seldom malignant but may cause symptoms of dysphagia. They are fairly common and may be identified in up to 14% of barium swallows. In patients with symptoms attributable to the ring, benefit may be gained from endoscopic dilation.
Type A Gastritis
Autoimmune
Circulating antibodies to parietal cells, causes reduction in cell mass and hypochlorhydria
Loss of parietal cells = loss of intrinsic factor = B12 malabsorption
Absence of antral involvement
Hypoclorhydria causes elevated gastrin levels- these stimulate enterochromaffin cells and these may form adenomas
Type B gastritis
Antral gastritis
Associated with infection with helicobacter pylori infection
Intestinal metaplasia may occur in stomach and require surveillance endoscopy
Peptic ulceration may occur
Reflux gastritis
Bile refluxes into stomach, either post surgical or due to failure of pyloric function
Histologically evidence of chronic inflammation, and foveolar hyperplasia
May respond to therapy with prokinetics
Erosive gastritis
Agents disrupt the gastric mucosal barrier
Most commonly due to NSAIDs and alcohol
With NSAIDs the effects occur secondary to COX 1 inhibition
Stress ulceration
This occurs as a result of mucosal ischaemia during hypotension or hypovolaemia
The stomach is the most sensitive organ in the GI tract to ischaemia following hypovolaemia
Diffuse ulceration may occur
Prophylaxis with acid lowering therapy and sucralfate may minimise complications
Menetriers disease
Gross hypertrophy of the gastric mucosal folds, excessive mucous production and hypochlorhydria
Pre malignant condition
Menetriers disease is a rare form of acquired gastropathy characterised by giant rugal folds in the gastric body, foveolar hyperplasia and markedly decreased or absent oxyntic glands with antral sparing. It typically presents with abdominal pain, vomting and peripheral oedema. Serum albumin is often low and hypochlorhydria is often present.
At endoscopy rugal hypertrophy is present. However, antral sparing of the disease is often seen. An enlarged gastric fold is defined as one which measures greater than 1cm endoscopically, that persists after air insufflation. Deep full thickness biopsies are needed for histological diagnosis as the pit to gland ratio cannot be determined on superficial biopsies.
The risk of malignancy in association with this condition is 10% during a 12 month period. Treatments include cetuximab and/ or gastrectomy
Arteria lusoria
An aberrant right subclavian artery is the most classic cause of dysphagia lusoria. The more common situation is compression by vascular ring such as double aortic arch
Sideropenic dysphagia
Iron deficiency anaemia may result in the development of Plummer Vinson syndrome. Some patients may also have oropharyngeal leukoplakia and this is reported to carry an increased risk of malignancy
Schatzki rings
Schatzki rings are an intrinsic occlusion of the lumen of either the distal oesophagus or OG junction. They are seldom malignant but may cause symptoms of dysphagia. They are fairly common and may be identified in up to 14% of barium swallows. In patients with symptoms attributable to the ring, benefit may be gained from endoscopic dilation.
They are usually located at the squamo-columner junction, the z line.
Optimal length of limb in Roux en Y
Short limbs increase the risk of reflux. Long limbs compromise absorptive function. A length of 40-60 cm is optimal.
Malignancy linked to achalasia
The risk of SCC of the oesophagus increases up to 30 fold after 15 years of symptoms. It is unclear whether surgery reduces this risk. The condition usually has a poor prognosis.
Types of gastric ulcer
