Upper Gastrointestinal Surgery Flashcards
What are the risk factors associated with GORD?
GORD is associated with the western lifestyle. Most clinicians believe that smoking, drinking, and overeating are contributing risk factors. Other risk factors include family history, old age, or a hiatus hernia.
What is the role of the lower oesophageal sphincter is GORD?
The lower oesophageal sphincter is the high pressure zone interposed between the high pressure area of the abdomen and the low pressure area of the thorax. In some patients with GORD, the lower oesophageal sphincter has no recordable tone, and therefor appears to be patulous. However, it is possible to have GORD and have normal tone, so the loss of tone appears to be caused by the GORD related damage. The damage may then act as a perpetuating factor.
What is the role of oesophageal peristaltic activity in GORD?
Many patients with GORD have disordered motility and do a poor job of clearing the reflux material. This may be a consequence, rather than a cause, of GORD.
What are some of the complications of GORD?
Rarely, GORD may lead to fibrosis and stricture formation.
It may also cause chronic blood loss and iron deficiency anaemia.
GORD may also cause squamous mucosa to be replaced with gastric columnar mucosa (Barret’s oesophagus). This can cause a loss of typical GORD symptoms, but increases risk of Adenocarcinoma. (A barret’s ulcer is an ulcer that develops in the columnar mucosa).
Reflux is associated with what type of hernia?
Whilst the two can exsist independently, reflux tends to occur in patients that have a sliding hiatus hernia and visa versa (a sliding hiatus hernia tends to occur in patients who have reflux). It is believed that the loss of the angle of entry between the oesophagus and stomach takes away an anatomical barrier that would otherwise stop reflux.
What is a sliding hiatus hernia?
In order to be classified as a ‘sliding hernia’ the viscus must form part of the wall of the hernial sac. In a sliding hiatus hernia, this is due to the ‘bare area’ (an area of the stomach that doesn’t have peritoneal covering).Thus when the gastrooesophageal junction slides up through the hiatus, there is a layer of peritoneum on the front and sides, but not on the back.
What is a paraoesophageal hiatus hernia?
A paraoesophageal hiatus hernia is also known as a rolling hiatus hernia.It occurs when the gastro-oesophageal junction stays in place, but there is a rolling up of the stomach in front of the oesophagus into the mediastinum. Rolling hernias can be asymptomatic, or they can be associated with pain and discomfort after meals, as well as episodes of acute pain associated with intermittent twisting of the stomach. Patients may present as an acute emergency with strangulation of the hernia.
What are the different types of hiatus henias and what is the main differences between the two?
There are sliding hiatus hernias, paraoesophageal hiatus hernias, and mixed hiatus hernias. In sliding hiatus hernias the gastrooesphageal junction moves, whereas the gastrooesphageal junction is fixed in paraoesophageal hernias. Sliding hernias are associated with GORD, paraoesophageal hernias are associated with pain and strangulation.
How do you treat GORD?
First line: Proton Pump Inhibitors (omeprazole, esomeprazole, pantoprazole), as well as elevation of the bed head, avoid late night eating, weightloss, and avoid aggravating foods. H2 antagonists (ranitidine, cimetidine) can be added to PPI's to help alleviate nighttime symptoms. Also consider surgical options.
What are the presenting symptoms of GORD?
Retrosternal burning after eating, bending down, or lifting heavy things. May be exacerbated by certain foods. May be worse when lying down, after ETOH, or overeating.
Regurgitation of gastric contents into mouth. May cause iron deficiency anaemia, recurrent halitosis, hoarseness of voice, or loss of tooth enamel.
What is the main surgical procedure used to treat GORD?
GORD can be treated surgically via a fundoplication. A funduplication is where the fundus of the stomach in drawn round behind the oesophagus and then is stitched to itself in front of the oesophagus. It is done laparscopically,
What are the complications of antireflux surgery?
The complications of antireflux surgery include dysphagia (occurs if the wrap is too tight). It is common for patients to be unable to burp after the surgery, leading to feelings of bloating. In some patients, the wrap breaks down and there is a return of reflux (15% of patients).
Describe the post op care after laparoscopic fundoplication.
Post op fluids are reintroduced immediately. A soft diet is then introduced when the patient can handle it. Discharge after 2-3 days. Advise patient to avoid lifting weights, or from doing anything that raises their intrabdominal pressure for 8 weeks.
What are the different types of benign oesophageal cancers?
Benign oesophageal cancers only make up 1% of all oesophageal cancers. The most common type is a leiomyoma (a cancer of the smooth muscle). Other types include papillomas, fibrovascular polyps. granulocellular tumours, adenomas, heamangiomas, neurofibromas, and lipomas.
What is the most common type of oesophageal cancer in the western world? What is the most common type of cancer in the world?
Adenocarcinomas (associated with GORD) are the most common type of cancer in the western world. Squamous cell carcinomas are the most common type in the world.
30% of patients with Barrett’s oesophagus have adenocarcinoma. There is a hypothesis that high rates of helicobacter pylori in the east are protective against GORD and therefore adenocarcinoma, however this is controversial.
What is the typical location of squamous cell carcinomas of the oesophagus?
Oesophageal Squamous Cell Carcinomas typically occur in the middle to lower oesophagus.
What is the typical location of an adenocarcinoma?
Adenocarcinomas typically occur in the cardia. However, with the rise in incidence of adenocarcinomas, they are now being seen in the lower oesophagus as well.
What are the different divisions of the Oesophagus?
Cervical Oesophagus (cricopharyngeus to thoracic inlet) = 18cm
Upper 1/3 thoracic Oesophagus (thoracic inlet to tracheal bifurcation) = 24 cm
Middle and Lower thirds of Thoracic Oesophagus (Tracheal bifurcation to stomach) = 40cm. The division between the two is halfway at 40cm.
What is the typical clinical presentation of Oesophageal Cancer?
Most patients are >50 years old and are male. They present with dysphagia with is rapid in onset, that first affects foods and then solids, progressing within a matter of weeks. Other symptoms include: regurgitation, weightloss, substernal pain, discomfort. If hoarseness is present then there is a recurrent laryngeal palsy from tumour infiltration.
Coughing or choking from aspiration is caused by vocal cord palsy, or the development of an oesophageal respiratory fistula.
NB: SCC’s of the oesophagus rarely bleed. If there is bleeding from the oesophagus, it is likely to be an adenocarcinoma of the gastrooesophageal junction.
How would you investigate a suspected oesophageal carcinoma?
Barium Swallow (identifies location and length of oesophageal narrowing, mucosal irregularity, dilatation of proximal oesophagus, and the ‘shouldering’ made by the upper border of the tumour.
Biopsy, brush cytology and application of Lugol’s iodine stain.
Bronchopsy can be used if the tumour is near the tracheobronchial tree.
Endoscopic ultrasonography to stage the tumour
CT and PET scan to identify mets.
How do you treat oesophageal cancer?
Treat early disease with surgical resection. if there is locally or regionally advanced disease, give chemo and radiotherapy, and then surgically resect if possible.
Surgical resection is contraindicated if there is infiltration of the aorta or tracheobronchial tree, or if there are distant nodes or metastases.
What is a Lewis-Tanner (Ivan Lewis) operation?
The Lewis Tanner (Ivan Lewis) operation is used for tumours in the middle and lower oesophagus. The stomach is mobilised via laparotomy (this affects the right gastric and right gastroepiploic arteries). A pyloroplasty or pylorotomy is performed to enhance gastric drainage. The oesophagus is then resected through a right thoracotomy. The stomach is delivered up into the thorax via the diaphragmatic hiatus to anastomose with the oesophagus through a right thoracotomy. For a type two or type three tumour that is around the gastro-oesophageal junction, an extended total gastrectomy with a distal oesophageal resection is performed.
What is a McKeown’s procedure?
McKeown’s procedure is used for tumours of the upper thoracic oesophagus. An oesophagectomy can be performed via a right thoracotomy. Then, simultaneous incisions can be made in the left cervical and abdominal areas. These incisions are used to prepare the stomach and deliver it up to the neck for anastomoses.
What are the two surgical procedures that are commonly used to treat oesophageal cancer?
The Lewis Tanner is used for tumours in the middle and lower oesophagus (most tumours). A McKeown’s is used for tumours of the upper thoracic oesophagus.
An endoscopic mucousectomy can be used for a shallow lesion.
What are the complications of surgery for an oesophageal tumour?
Pulmonary complications are the most common, followed by cardiac.
Pulmonary complications include atelectasis, pneumothorax, bronchopneumonia, pleural effusion, sputum retention, PE.
Cardiac complications include atrial arrhythmia, MI, cardiac failure. Other complications include anastomotic leakage, damage to the recurrent laryngeal nerve, damage to the tracheobronchial tree, wound infection, empyema, and intra- or post operative haemorrhage.
What are the various treatment choices for oesophageal cancers?
Non surgical: Conservative management, external beam radiation, chemoradiotherapy, palliative radiotherapy, brachytherapy and intraluminal radiotherapy. NB neo adjuvant or adjuvant therapy with surgery is not used.
Laser therapy.
Surgical: Lewis Tanner, McKeown’s procedure, or Endoscopic mucosectomy (used for early mucosal lesions)
Where do peptic ulcers classically occur?
Peptic ulcers classically occur in the first part of the duodenum, the angula incisura of the stomach (just before the pyloric sphinter), the lower end of the oesophagus in patients with GORD, the efferent limb of a gastroenterostomy, and inside a Meckel’s diverticulum if it has ectopic gastric mucosa.
What causes peptic ulcers?
Peptic ulcers occur when there is an imbalance between acid pepsin digestion, and the defence mechanism of the mucosa is disturbed. The main cause of peptic ulcer disease is helicobacter pylori (gram negative organism that lives in the antrum of the stomach), NSAID intake, reflux of bile into the stomach, and mucosal ischeamia. Peptic ulcers are also associated with Zollinger Ellison syndrome.
