Upper GI Flashcards
Laparoscopic nissen fundoplication
- Divide the gastrohepatic ligament, avoiding injury to replaced L hepatic artery, expose R cruse
- Dissect esophagus, avoid injury to posterior & anterior vagus nerve, expose decussation of both crus, continue mediastinal dissection until 3 cm esophagus is in the abdomen
- Mobilize the fundus completely
- Close crura w nonabsorbable suture
- Create 2 cm long posterior, floppy fundoplication (270 degree Toupet) over 60F dilator using nonabsorbable sutures
GERD Work Up
- Barium swallow
- EGD
- Manometry → Functional assessment of UES, LES, & motility disorders; indicated if malignancy, stricture, & hiatal hernia have been ruled out
- Ambulatory pH probe & impedence testing (for pts with nonerosive disease on EGD and/or atypical symptoms once hernia has been ruled out to determine utility of anti-reflux surgery)
→ DeMeester score ≥ 14.7 indicates abnormal acid exposure
→ Fraction of time with pH <4 that >4% is abnormal
Laparoscopic paraesophageal hernia repair
Laparoscopic approach (5 ports, 1 liver retractor, 2 assistant, 2 working)
- Dissect & reduce hernia sac along crura, identifying anterior & posterior vagus nerves
- Control distal esophagus & nerves w penrose drain
- Dissect into mediastinum for complete reduction & 3 cm intra-abdominal esophagus
- Divide short gastrics if fundoplication
- Close crural defect posteriorly w nonabsorbable pledgeted sutures
- Fundoplication or gastropexy
If unable to gain enough esophageal length
–High mediastinal dissection to level of inferior pulmonary veins
–Gastropexy
–Collis gastroplasty
Symptomatic capnothorax management
- 14F red rubber catheter into abdomen after cutting holes in narrow portion.
- Narrow portion is inserted into pleural space & larger end is left in abdomen to equalize pressures. The large end is pulled out of left subcostal port while pneumoperitoneum is released and left to water seal while deep Valsalva breaths are administered.
Gastric cancer work up
Evaluate extent of disease
1. Upper endoscopy
2. PET/CT chest & abdomen/pelvis to assess for mets
3. EUS with FNA to assess for T & N stage
4. Staging laparoscopy w peritoneal washings +feeding tube
Preop risk stratification - Cardiac/EKG, Pulm/PFT’s
Siewert Classification of cancer
Upper 1/3 stomach cancer
I: 1-5 cm above anatomic EGJ → esophageal CA
II: 1 cm proximal to 2 cm distal EGJ → esophageal CA
III: 2-5 cm distal to EGJ → stomach CA
Gastric cancer management: Early
Goal is R0 resection & ≥16 lymph nodes
Tis, T1 (mucosa) → Gastrectomy with D1/D2 lymphadenectomy.
EMR for low risk features & <2 cm
Gastric cancer management: Locoregionally advanced resectable (≥T2 or N+)
Neoadjuvant chemotherapy with Cisplatin & 5-FU
Re-stage with PET/CT
Adjuvant chemoradiation following R0 resection
Gastric cancer: Surgical approach
R0 resection - microscopically negative margins. Ideally 5 cm negative.
Upper 1/3
Proximal (SI & SII): Transhiatal/transthoracic esophagectomy w proximal gastrectomy and gastric pull-up with cervical/thoracic EG.
Distal (SIII): Extended total gastrectomy with EJ.
Lower 2/3
Subtotal gastrectomy with BII or Roux-en-Y
D1 vs D2 lymphadenectomy
D1: Immediate perigastric lymph nodes
D2: Lymph nodes over named arteries of the stomach
Recommendation is D1 vs modified D2 with a minimum of 16 lymph nodes
Total gastrectomy
- Midline laparotomy & exploration
- Mobilize GEJ & esophagus, taking margin of diaphgragmatic crura (don’t injure replaced L)
- Omental bursectomy performed (Separate omentum & lesser sac lining from transverse colon)
- Divide short gastric vessels (don’t injury spleen) skeletonize celiac, splenic, common hepatic arteries, taking their lymph nodes
- Ligate L & R gastric/gastroepiploic arteries at their base (L gastroepiploic & splenic are preserved during subtotal)
- Divide esophagus with a TA & duodenum 2 cm distal to pyloric vein with GIA, ensuring 5 cm negative margin. Divide the jejunum 20 cm distal to LOT w GIA.
- Reconstruction with a roux-en-Y EJ using an EEA stapling device & JJ; Place a jejunostomy feeding tube vs corpak past the anastomosis & drains near duodenal stump & EJ
Total gastrectomy post-op management
- NGT to LIS, start TF’s vs J tube feeds POD#2
- Send amylase/bilirubin from drains & remove if <3x serum value
- Contrast swallow study 2 weeks later, then can start PO feeds
- Need multivitamin, B12, iron for life
- H&P w routine labs q3-6 months, semiannual CT for 5 years, then annually
GIST workup
Submucosal mass, usually no ulcer, no lymphatic spread. 60% stomach, 30% small intestine. Mets to liver & peritoneum.
Over-expression of KIT/CD117
Biopsy only if metastatic/not fit for surgery, or unclear dx; can bx w EUS & FNA
High quality CT chest/abd/pelvis → Large hypervascular, exophytic, heterogenous mass, central necrosis.
GIST management
Surgery is curative in 70%.
Goal is negative margins, can usually do wedge resection if it does not narrow the gastric lumen at incinsura/GEJ
Adjuvant imatinib increases recurrence-free survival
Imatinib
TK inhibitor that inhibits KIT & PDGFRA oncoproteins.
First line treatment for metastatic GIST. Sunitinib 2nd line, regorafenib 3rd line in case of resistance.
Adjuvant → increase recurrence-free survival. Need for at least 1 year.
Neoadjuvant → tumor downsizing reassess w imaging after 6 months
Predictors of metastasis/recurrence following GIST resection
- Tumor site of origin (stomach best px)
- Tumor size (2, 5, 10 cm)
- Mitotic rate (≤ or > 5 per 50 HPFs)
GIST excision
- Midline incision vs laparoscopy (if <8 cm)
- Explore for mets (peritoneum & liver)
- Obtain 1 cm gross margins (need microscopically negative margins). May need en-bloc resection if adherent to other organs
GIST Genotyping
Exon 11 is most common mutation → Target with Imatinib (400 mg qd)
Exon 9 is second most common mutation & can cause imatinib resistance, so may need higher dose (800 mg qd)
Indications for splenectomy in ITP
- Fail to respond to 4-6 weeks medical therapy (PO steroids, IV immunoglobulin) or relapse
- Severe bleeding related to thrombocytopenia
Indications for splenectomy in malignancy
Symptomatic portal HTN or spenomegaly, transfusion-dependent anemia, severe thrombocytopenia, uncontrollable hemolysis
Laparoscopic splenectomy
- Position in incomplete RL decubitus
- Hasson 12 mm ~3-4 cm below left costal margin in midclavicular line, two 5 mm trocars along costal margin between xiphoid & Hasson, additional 12 mm in L anterior axillary line
- EXPLORE for accessory spleen (splenic hilum, greater omentum, splenocolic)
- Divide splenocolic ligament & mobilize splenic flexure; divide short gastric vessels up to superior pole of spleen; mobilize inferior pole of spleen by dividing splenorenal & splenophrenic ligaments; mobilize superior pole to isolate hilum
- Divide splenic hilar vessels with endoscopic stapler
- Place spleen in endobag & exteriorize through Hasson trocar site so spleen can be morcellated
Elective splenectomy vaccination strategy
Pneumococcal (PCV13), Haemophilus influenzae type B (Hib), meningococcal (MenACWY & MenB) 2 weeks before surgery, then PPSV23 & MenACWY 8 weeks after PCV13 then q5 years for both.
Laparoscopic sleeve gastrectomy
- Mobilizing the greater curvature of the stomach ,continue this proximally and complete mobilization of the fundus, release any retrogastric adhesions, exposing both crura
- Evaluate esophageal hiatus & perform hiatal hernia repair if needed
- Pass 34F bougie along lesser curvature
- Longitudinal gastrectomy using linear cutting stapler beginning 5 cm proximal to pylorus along greater curvature, ending at angle of His
- Remove specimen, perform leak test
Laparoscopic roux-en-y bypass
- Supine, 4 ports including supraumbilical camera port, 2x 12 mm ports in R midclavicular line (RUQ/subcostal & periumbilical) for jejunojejunostomy & 12 mm port in RUQ & LUQ for GJ, L subcostal AAL assist port
- Exploration - liver for steatosis & safe retraction, hiatal hernia, normal anatomy
- Staple off 50 cm distal to LOT, divide mesentary to root to allow length to bring Roux limb to pouch. 100 cm roux limb traced distally, limb is brought to gastric pouch, & side to side stapled jejunojejunostomy created
- Close mesenteric defect
- Omentum divided to provide path for antecolic roux limb
- Liver retractor placed to expose stomach & hiatus, & a 25 mL lesser curve based pouch gastroplasty is created with a stapler starting 5 cm below GEJ
- GJ anastomosis with 36F tube & leak test performed
- Peterson’s mesenteric defect closed by sewing staple line of Roux limb to underlying mesentery of transverse colon
Ulcer work up - things to remember
NSAIDs, smoking, hx of uclers, steroids
Send Gastrin
Test for H Pylori w stool antigen or urea breath test
H pylori treatment
amoxicillin, clarithromycin, omeprazole for 2 weeks
test for eradication 4 weeks later
Pedicled omental patch
dont forget bx for malignancy & h pylori; if large may need jejunal serosal patch
Bleeding duodenal ulcer hemostasis
Ex lap
Kocher maneuver
Longitudinal pyloroduodenotomy
BIOPSY
Three point ligation of GDA, avoid CBD posteriorly
Close pylorus transversely in two layers
Leave drain
Forrest classification for endoscopic therapy
Truncal vagotomy & pyloroplasty vs antrectomy
Isolate distal esophagus, skeletonize distal 6 cm, identify anterior & posterior vagal nerves, excise & send for frozen
Mobilize duodenum
Heineke-Mikulicz pyloroplasty
Divide seromuscular layer 5 cm longitudinal across pylorus
Close transversely in 2 layers
Antrectomy
Excise antrum, pylorus, & 1 cm duodenum - send for frozen to ensure entire antrum removed
Reconstruct w Billroth II GJ - may need roux en y if complications arise
Parietal cell vagotomy
Divide gastrohepatic ligament, avoid injury to replaced L hepatic artery, expose distal 6 cm of esophagus
Encircle both vagal trunks w penrose, apply tension to expose branches
Dissect & ligate neurovascular branches of vagal trunks proximal to crow’s feet coming off the nerve of Latarjet, preserving 3 terminal branches both anteriorly & posteriorly
Ensure complete division of criminal nerve of Grassi posteriorly
Types of gastric ulcers
Laparoscopic heller myotomy
NGT prior to induction!!!
Expose GEJ, identify & protect vagus nerves
Divide longitudinal & circular muscle fibers for 6 cm onto esophagus & 2 cm onto stomach, separate edges of myotomy from underlying mucosa
Leak test with EGD
Dor fundoplication
Management of Barrett’s on EGD
Management if nondysplastic, LGD/indeterminate, & HGD
EGD random 4-quadrant biopsies of abnormal segments every 1 cm
Nondysplastic → Repeat EGD every 3-5 years w PPI
LGD or Indeterminate → Repeat EGD in 3-6 months w PPI
HGD=CIS (confirmed by 2 pathologists) → EMR, repeat EGD q3m
Zenker’s diverticulectomy & exposure of cervical esophagus
EGD, pack diverticulum, insert 54F bougie, NGT
Transverse incision along skin crease 4 cm above clavicle
Subplatysmal flap, retract SCM & strap muscles, divide anterior belly of omohyoid inferiorly
Identify/protect RLN as blunt dissection is used to expose pharynx, larynx, & esophagus; ligate thyroid vessels if needed
Retract carotid sheath laterally & retract thyroid, trachea (with RLN), strap muscles medially w finger
Expose diverticulum, perform long cricopharyngeal myotomy, excise pouch
Check hemostasis, close in layers
Primary repair of esophageal perforation
Harvest intercostal muscle flap
Exposure
Proximal → L neck
Middle → R thoracotomy 4-6th ICS
Distal → L thoracotomy 7th ICS
Debride pleura/mediastinum, mobilize esophagus, debride esophagus
Myotomy to expose entire mucosal injury
2 layer closure w buttress repair
Enteral access & DRAINS
Esophageal cancer staging
Work up includes
UGI, EGD, EUS, CT chest/abdomen/pelvis, PET
Siewert Classification of GEJ cancers
Type I: Distal esophagus, 1-5 cm above GEJ → Tx like esophageal
Type II: Cardia, 1 cm above & 2 cm below GEJ → Tx like esophageal
Type III: “Subcardinal”/Stomach, 2-5 cm below GEJ → Tx like stomach
Dysplasia
Low grade dysplasia → Endoscopy q6m
High grade dysplasia=CIS (must be confirmed by 2 pathologists) → EMR, Endoscopic surveillance q3m
Unresectable if T4b or presence/invasion of (determined by CT abd/pelvis):
RLN→ Hoarsness
Brachial plexus→ Horner’s
Phrenic nerve
Malignant pleural effusion
Malignant fistula (most die within 3 months due to aspiration)
Nodal spread outside area of resection (M1)
Management of early stage esophageal cancer
EMR ONLY if T1a (limited to lamina propria or muscularis mucosa), <2 cm, low grade, well to moderately differentiated, no LVI
ESOPHAGECTOMY ONLY (no neoadjuvant)
T1b (limited to muscularis propria), low grade, well to moderately differentiated, no LVI
Anything beyond needs neoadjuvant chemoradiation
Ivor-lewis esophagectomy
Laparotomy
1. Mobilize greater curvature of stomach, preserve gastroepiploic arcade
2. Perform Kocher maneuver to allow conduit to reach into chest
3. Complete mobilization of the stomach, preserve R gastric & R gastroepiploic arteries, ligate L gastric artery at origin & perform hiatal dissection, keeping lymphatic tissue with specimen
4. Create gastric conduit, transecting stomach 5 cm distal to tumor, suturing it to the specimen so it can be pulled into chest
Right thoracotomy with Thoracic Surgery
1. R lateral thoracotomy, mobilization of esophagus/lymphatic tissue up to & transected at the azygous vein.
2. Remove specimen, bring gastric conduit up from abdomen
3. Use circular stapler to perform upper thoracic anastomosis
4. Leave 2 chest tubes for drainage & close
