Upper GI

Question 1

What is first test after labs for any upper GI complaint?

Answer 1

UGI contrast study (no risks…)

Question 2

What tests do you get after “bird beak narrowing” on UGI contrast study?

Answer 2

Diagnostic of achalasia

Manometry - confirm inability of LES to relax, may also see disordered peristalsis

Question 3

Achalasia: What other test(s) after manometry?

Answer 3

EGD - rule out esophagitis/dysplasia/cancer

Could add 24hour pH probe if diagnosis is unclear

Question 4

Achalasia - describe operation

Answer 4

Lap heller-myotomy
Place subcostal ports
Place a liver retractor
Incise the phrenoesophageal ligament and mobilize the esophagus into the abdomen
perform myotomy at least 1 cm distal to the GE junction
Evaluate with Endoscope
Perform 270 posterior fundoplication (Toupet)

Question 5

Describe operation for Zenkers

Answer 5

Have upper endoscope available
Make an incision parallel to and just medial to the SCM
Stay lateral to avoid the RLN
Remove the sac with a TA stapler
perform a blunt myotomy 3cm above and below the diverticulum.

Question 6

Should you do a Nissen on a patient with a normal UGI contrast study?

Answer 6

Perfectly OK to do so.

Need EGD and possibly manometry/pH probe to establish the diagnosis.

Question 7

What do you do after making the diagnosis of GERD?

Answer 7

Non-operative management first!
PPI (omeprazole 40mg bid)
weight-loss
avoiding smoking/caffeine

Question 8

How do you do a Lap Nissen?

Answer 8

Place subcostal ports
take down short gastrics
perform a 360 degree posterior wrap.
Create wrap with 2-0 silk; avoid vagus

Question 9

Nissen: what do you do if wrap is too short?

Answer 9

Do a lengthening procedure:
Upsize to a hand-assist port in the midline
Introduce a 45Fr bougie
Staple a circle out of the upper stomach
Fire a linear staple load to complete the lengthening procedure.

Question 10

What is surveillance for Barrett’s Esophagus?

Answer 10

no dysplasia: one year, then q3 years if no dysplasia.
low grade dysplasia: six months then yearly
high grade dysplasia: surgery, or EMR followed by q 3 month surveillance;

Question 11

Nissen for Barrett’s?

Answer 11

I would never do one as it prevents you from creating a gastric conduit in the event of malignancy.

Question 12

GI calls you they think they perf’d someone during an EGD. What next?

Answer 12

Gastrografin UGI
If early and no contamination: primary repair with pericardial or omental buttress.
Need to fix the primary issue before leaving the OR if patient has Achalasia (myotomy) or cancer (resection with spit fistula v reconstruction.

Question 13

What two causes of ulcers SHOULD NOT get an elective peptic ulcer operation?

Answer 13

H. Pylori

NSAID abuse

Question 14

How whould you change your operative plan for PUD emergencies in setting of NSAID abuse or H. Pylori?

Answer 14

Would only address the perforation or bleeding.

Don’t need an anti-ulcer procedure as will likely improve with medical management alone.

Question 15

Describe main indication for highly selective vagotomy?

Answer 15

For recalcitrant duodenal ulcer disease that has failed maximal medical therapy and lifestyle modifications.

Contraindicated with significant antral/prepyloric disease.

Question 16

How do you perform a highly selective vagotomy?

Answer 16

1. upper midline incision
2. explore the abdomen
3. mobilize and expose the GE junction
4. open the peritoneum/phrenoesophageal membrane
5. encircle each vagus nerve with a vessel loop
6. From the “crows foot” splaying of the nerves of Laterjet ligate all the neurovascular tissue up to the proximal vagal trunk.
7. Clear the distal 7 cm of the esophagus of all neural tissue besides the anterior and posterior vagi.

Question 17

What is a quick explanation for a highly selective vagotomy?

Answer 17

careful division of the gastrohepatic ligament from the incisura/nerves of Laterjet to the main vagal trunks.

Question 18

When would you perform a Vagotomy and pyloroplasty?

Answer 18

As an adjunct to an emergent duodenal ulcer case where you need to do an acid supression procedure.

Question 19

What is a Finney procedure?

Answer 19

side-to-side gastroduodenostomy to the first portion of the duodenum

Question 20

What is a Jaboulay procedure?

Answer 20

side-to-side to the third portion of the duodenum

Question 21

What are treatments for dumping syndrome?

Answer 21

dietary modification, with long-acting somatostatin.

If this fails convert to a roux-en-Y anastamosis.

Question 22

Symptoms and treatment for bile reflux

Answer 22

persistent epigastric pain not relieved by vomiting of food and bile.
Medical Reglan, Actigall and Carafate
If no relief, convert to Roux-en-y

Question 23

What to include in workup for iron deficiency after gastric anastomosis?

Answer 23

EGD to rule out marginal ulcer

Question 24

Is gastric cancer associated with previous gastrectomy?

Answer 24

Yest, but risk doesnt start until 15-20 years after surgery. Would start EGD

Question 25

What operation for duodenal perforation?

Answer 25

Graham patch unless long history of PUD refractory to PPI

Question 26

What operation for gastric perforation?

Answer 26

Excise, or biopsy with a graham patch.

Only prepyloric ulcers are associated with high acid, so this is only case for an Antrectomy & Vagotomy.

Question 27

What is the initial procedure for a bleeding duodenal ulcer?

Answer 27

Bleeding duodenal ulcer should have at least two attempts at endoscopic control;

Question 28

What is the procedure for a bleeding duodenal ulcer after two failed endoscopies?

Answer 28

Medical history unclear: Limited duodenectomy with oversewing of ulcer

Clearly no NSAID abuse or H. Pylori: Antrectomy with vagotomy.

Question 29

How do you oversew a duodenal ulcer?

Answer 29

Need 2-0 silk at 12:00, 3:00 and 6:00 to control the GDA

Question 30

What is treatment for a gastric MALT lymphoma?

Answer 30

One year of H. pylori eradication with interval biopsies to show reversal of the MALT changes. After completion of treatment, the patient needs surveillance EGD every 6-12 months.

Question 31

What are the indications for bariatric surgery?

Answer 31

BMI >40

BMI >35 with obesity associated morbidity

Question 32

What ICU drugs can be used to temporize acutely bleeding varices?

Answer 32

High dose octreotide

Vasopressin with nitroglycerine.

Question 33

Bailout operation for unstable patient with stress gastritis?

Answer 33

Ligate Left and right gastric artery and left and right gastroepiploic artery.

Question 34

Emergency vessel ligation for stress gastritis:
Where is the origin of the left gastroepiploic?
What vessel remains to perfuse stomach?

Answer 34

Off the splenic artery

Perfusion via the short gastrics.