Upper GI Flashcards
What is first test after labs for any upper GI complaint?
UGI contrast study (no risks…)
What tests do you get after “bird beak narrowing” on UGI contrast study?
Diagnostic of achalasia
Manometry - confirm inability of LES to relax, may also see disordered peristalsis
Achalasia: What other test(s) after manometry?
EGD - rule out esophagitis/dysplasia/cancer
Could add 24hour pH probe if diagnosis is unclear
Achalasia - describe operation
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)
Describe operation for Zenkers
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.
Should you do a Nissen on a patient with a normal UGI contrast study?
Perfectly OK to do so.
Need EGD and possibly manometry/pH probe to establish the diagnosis.
What do you do after making the diagnosis of GERD?
Non-operative management first!
PPI (omeprazole 40mg bid)
weight-loss
avoiding smoking/caffeine
How do you do a Lap Nissen?
Place subcostal ports
take down short gastrics
perform a 360 degree posterior wrap.
Create wrap with 2-0 silk; avoid vagus
Nissen: what do you do if wrap is too short?
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.
What is surveillance for Barrett’s Esophagus?
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;
Nissen for Barrett’s?
I would never do one as it prevents you from creating a gastric conduit in the event of malignancy.
GI calls you they think they perf’d someone during an EGD. What next?
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.
What two causes of ulcers SHOULD NOT get an elective peptic ulcer operation?
H. Pylori
NSAID abuse
How whould you change your operative plan for PUD emergencies in setting of NSAID abuse or H. Pylori?
Would only address the perforation or bleeding.
Don’t need an anti-ulcer procedure as will likely improve with medical management alone.
Describe main indication for highly selective vagotomy?
For recalcitrant duodenal ulcer disease that has failed maximal medical therapy and lifestyle modifications.
Contraindicated with significant antral/prepyloric disease.
How do you perform a highly selective vagotomy?
- upper midline incision
- explore the abdomen
- mobilize and expose the GE junction
- open the peritoneum/phrenoesophageal membrane
- encircle each vagus nerve with a vessel loop
- From the “crows foot” splaying of the nerves of Laterjet ligate all the neurovascular tissue up to the proximal vagal trunk.
- Clear the distal 7 cm of the esophagus of all neural tissue besides the anterior and posterior vagi.
What is a quick explanation for a highly selective vagotomy?
careful division of the gastrohepatic ligament from the incisura/nerves of Laterjet to the main vagal trunks.
When would you perform a Vagotomy and pyloroplasty?
As an adjunct to an emergent duodenal ulcer case where you need to do an acid supression procedure.
What is a Finney procedure?
side-to-side gastroduodenostomy to the first portion of the duodenum
What is a Jaboulay procedure?
side-to-side to the third portion of the duodenum
What are treatments for dumping syndrome?
dietary modification, with long-acting somatostatin.
If this fails convert to a roux-en-Y anastamosis.
Symptoms and treatment for bile reflux
persistent epigastric pain not relieved by vomiting of food and bile.
Medical Reglan, Actigall and Carafate
If no relief, convert to Roux-en-y
What to include in workup for iron deficiency after gastric anastomosis?
EGD to rule out marginal ulcer
Is gastric cancer associated with previous gastrectomy?
Yest, but risk doesnt start until 15-20 years after surgery. Would start EGD
What operation for duodenal perforation?
Graham patch unless long history of PUD refractory to PPI
What operation for gastric perforation?
Excise, or biopsy with a graham patch.
Only prepyloric ulcers are associated with high acid, so this is only case for an Antrectomy & Vagotomy.
What is the initial procedure for a bleeding duodenal ulcer?
Bleeding duodenal ulcer should have at least two attempts at endoscopic control;
What is the procedure for a bleeding duodenal ulcer after two failed endoscopies?
Medical history unclear: Limited duodenectomy with oversewing of ulcer
Clearly no NSAID abuse or H. Pylori: Antrectomy with vagotomy.
How do you oversew a duodenal ulcer?
Need 2-0 silk at 12:00, 3:00 and 6:00 to control the GDA
What is treatment for a gastric MALT lymphoma?
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.
What are the indications for bariatric surgery?
BMI >40
BMI >35 with obesity associated morbidity
What ICU drugs can be used to temporize acutely bleeding varices?
High dose octreotide
Vasopressin with nitroglycerine.
Bailout operation for unstable patient with stress gastritis?
Ligate Left and right gastric artery and left and right gastroepiploic artery.
Emergency vessel ligation for stress gastritis:
Where is the origin of the left gastroepiploic?
What vessel remains to perfuse stomach?
Off the splenic artery
Perfusion via the short gastrics.
