Upper GI Surgery Flashcards
Oesophageal anatomy
25cm long muscular tube (40cm from GOJ → lips)
Starts at level of cricoid cartilage (C6)
In the neck lies in the visceral column
Runs in posterior mediastinum and passes through right
crus of diaphragm @ T10.
Continues for 2-3cm before entering the cardia
3 locations of narrowing
Level of cricoid
Posterior to left main bronchus and aortic arch
LOS
Divided into 3rds: reflects change in musculature from
striated → mixed → smooth.
Lined by non-keratinising squamous epithelium.
Z-line: transition from squamous → gastric columnar
Achalasia
Degeneration of myenteric plexus (Auerbach’s)
↓ peristalsis
LOS fails to relax
Cause
primary/idiopathic (commonest)
2ndary - Chagas disease (T. cruzil)
Achalasia Presentation + Comps
Presentation Dysphagia: liquids then solids Regurgitation (esp. @ night) Substernal cramps Wt. loss
Comps: Chronic → oesophageal SCC in 3-5%
Achalasia Ix + Rx
Ix
Ba swallow: dilated tapering oesophagus
Bird’s beak
Manometry: failure of relaxation + ↓ peristalsis
CXR: widened mediastinum, double RH border
OGD: exclude malignancy
Rx:
Med: CCBs, nitrates
Int: botox injection, endoscopic balloon dilatation
Surg: Heller’s cardiomyotomy (open or lap)
Pharyngeal Pouch (Zenker’s Diverticulum)
Outpouching betw/ crico- + thyro-pharyngeal
parts of inf. pharyngeal constrictor.
Area of weakness = Killian’s dehiscence
Defect usually occurs posteriorly but swelling usually
bulges to left side of neck.
Food debris → pouch expansion → oesophageal
compression → dysphagia.
Pres: Regurgitation, halitosis, gurgling sounds
Rx: excision, endoscopic stapling
Diffuse Oesophageal Spasm
Intermittent severe chest pain ± dysphagia
Ba swallow shows corkscrew oesophagus
Nutcracker Oesophagus
Intermittent dysphagia ± chest pain
↑ contraction pressure c¯ normal peristalsis
Plummer Vinson Syndrome
Severe IDA → hyperkeratinisation of upper 3rd of
oesophagus → web formation
Pre-malignant: 20% risk of SCC
Oesophageal Rupture
Iatrogenic (85-90%): endoscopy, biopsy, dilatation
Violent emesis: Boerhaave’s syndrome
Carcinoma
Caustic ingestion
Trauma: surgical emphysema ± pneumothorax
Features
- Odonophagia
- Mediastinitis - tachypnoea, dyspnoea, fever, shock
- Surgical emphysema
Mx
Iatrogenic: PPI, NGT, Abx
Other: resus, PPI, Abx, antifungals, debridement +
formation of oesophago-cutaneous fistula c¯ T-tube
Nissen Fundoplication
Prevent reflux and repair diaphragm
Usually laparoscopic approach
Mobilise gastric fundus and wrap around lower
oesophagus
Close any diaphragmatic hiatus
Complications
Gas-bloat syn.: inability to belch / vomit
Dysphagia if wrap too tight
Hiatus hernia
Sliding (80%)- gastro-oespophageal junction slides up into chest (GORD)
15% g-o junction remains in abdomen, bulge of stomach rolls into chest
Peptid Ulcer Disease Surgery
Vagotomy
- Truncal
↓ acid secretion directly and via ↓ gastrin
Prevents pyloric sphincter relaxation
must be combined c¯ pyloroplasty (widening of
pylorus) or gastroenterostomy
- Selective
Vagus nerve only denervated where it supplies
lower oesophagus and stomach
Nerves of Laterjet (supply pylorus) left intact
Antrectomy c¯ Vagotomy Distal half of stomach removed. Anastomosis: Billroth 1: directly to duodenum Billroth 2 /Polya: to small bowel loop c¯ duodenal stump oversewn
Subtotal Gastrectomy c¯ Roux-en-Y
Occasionally performed for Zollinger-Ellison
PUD Surgery Metabolic Complications
Dumping syndrome
Abdo distension, flushing, n/v, fainting, sweating
Early: osmotic hypovolaemia
Late: reactive hypoglycaemia
Blind loop syndrome → malabsorption, diarrhoea
Overgrowth of bacteria in duodenal stump
Vitamin deficiency
↓ parietal cells → B12 deficiency
Bypassing proximal SB → Fe + folate deficiency
Osteoporosis
Wt. loss: malabsorption of ↓ calories intake
Upper GI bleed
PUD: 40% (DU commonly) Acute erosions / gastritis:20% Mallory-Weiss tear: 10% Varices: 5% Oesophagitis: 5% Ca stomach / oesophagus:<3%
Rockall Score (Upper GI bleed)
Prediction of re-bleeding and mortality
40% of re-bleeders die
Initial score pre-endoscopy
Age
Shock: BP, pulse
Comorbidities
Final score post-endoscopy - Final Dx + evidence of recent haemorrhage Active bleeding Visible vessel Adherent clot
Initial score ≥3 or final >6 are indications for surgery
Variceal bleed
Initially IV terlipressin *splanchnic vasopressor) Prophylactic Abx (ciprofloxacin 1g/24h)
(resus, fluid resus + maintenance)
Urgent Endoscopy
Variceal bleeding Urgent Endoscopy
2 of: banding, sclerotherapy, adrenaline,
coagulation
Balloon tamponade c¯ Sengstaken-Blakemore tube
Only used if exsanguinating haemorrhage or
failure of endoscopic therapy
TIPSS if bleeding can’t be stopped endoscopically
TIPPS Transjugular intrahepatic porto-systemic shunt
IR creates artificial channel between hepatic vein and
portal vein → ↓ portal pressure.
Colapinto needle creates tract through liver
parenchyma which is expand using a balloon and
maintained by placement of a stent.
Used prophylactically or acutely if endoscopic therapy
fails to control variceal bleeding.
Urgent Endoscopy (haemostasis of vessel or ulcer)
Adrenaline injection
Thermal / laser coagulation
Fibrin glue
Endoclips
Peptic Ulcer Perforation
Presents
Sudden onset severe pain, beginning in epigastrium
Vom
Peritonitis
Perforated duodenal ulcer is commonest
1st part of the duodenum: highest acid conc
Ant. perforation → air under diaphragm
Post. perforation can erode into GDA → bleed
¾ of duodenum retroperitoneal no air under diaphragm if perforated.
Perforated GU
Perforated gastric Ca
Peptid Ulcer Perforation Ix
Bloods
FBC, U+E, amylase, CRP, G+S, clotting
ABG: ? mesenteric ischaemia
Urine dipstick
Imaging Erect CXR Must be erect for ~15min first Air under the diaphragm seen in 70% False +ve in Chailaditi’s sign
AXR
Rigler’s: air on both sides of bowel wall
Peptic Ulcer Perforation Mx
Resuscitation NBM Aggressive fluid resuscitation Urinary Catheter ± CVP line Analgesia: morphine 5-10mg/2h max ± cyclizine Abx: cef and met NGT
Conservative
May be considered if pt. isn’t peritonitic
Careful monitoring, fluids + Abx
Omentum may seal perforation spontaneously
preventing operation in ~50%
Surgical: Laparotomy
DU: abdominal washout + omental patch repair
GU: excise ulcer and repair defect
Partial / gastrectomy may rarely be required
Send specimen for histo: exclude Ca
Test and Treat
90% of perforated PU assoc. c¯ H. pylori
Gastric Outlet Obstruction
causes + presentation
Causes
Late complication of PUD → fibrotic stricturing
Gastric Ca
Presentation
Hx of bloating, early satiety and nausea
Outlet obstruction
Copious projectile, non-bilious vomiting a few hrs
after meals.
Contains stale food.
Epigastric distension + succussion splash
Gastric Outlet Obstruction
Ix + Rx
Ix
ABG: Hypochloraemic hypokalaemic met alkalosis
AXR - Dilated gastric air bubble, air fluid level
Collapsed distal bowel
OGD
Contrast meal
Rx
Correct metabolic abnormality: 0.9% NS + KCl
Benign
Endoscopic balloon dilatation
Pyloroplasty or gastroenterostomy
Malignant
Stenting
Resection
Hypertophic Pyloric Stenosis
Presents 6-8 weeks
- projectile vomiting minutes after feeding
- RUQ mass (olive)
- Visible Peristalsis
Dx
- Test feed - palpate mass + see peristalsis
- hypochloraemic hypokalaemic metabolic alkalosis
- USS
Mx
- Resuscitate and correct metabolic abnormality
- NGT
- Ramstedt pyloromyotomy - divide muscularis propria
signet ring cell
diffuse gastric cancer
Gastric Cancer Spread
w/i stomach: linitis plastica
Direct invasion: pancreas
Lymphatic: Virchow’s node
Blood: liver and lung
Transcoelomic
Ovaries: Krukenberg tumour (Signet ring morph)
Sister Mary Joseph nodule: umbilical mets
Gastric Cancer Mx
Medical Palliation Analgesia: e.g. fentanyl patch PPI Secretion control Chemo: epirubicin, 5FU, cisplatin Palliative care team package
Surgical Palliation
Pyloric stenting
Bypass procedures
Curative Surgery
- EGC may be resected endoscopically
- Partial or total gastrectomy c¯ roux-en-Y to prevent bile
reflux.
Spleen and part of pancreas may be removed
Gastric Lymphoma
MALToma
chronic h pylori
most common extranodal tumour
Carcinoid tumours
gastric carcinoids arise from enterochromaffin cells
Gsatrointestinal stromal tumour
50+% in stomach
Arise from intestinal cells of Cajal (in muscularis propria, pacemaker cells)
OGD - well demarcated spherical mass with central punctum
Presentation Mass effects: abdo pain, obstruction Ulceration: → bleeding Poor Prognosticators ↑ size ↑ mitotic index Extra-gastric location
Mx
Medical
Unresectable, recurrent or metastatic disease
Imatinib: kit selective tyrosine kinase inhibitor
Surgical
Resection
Zollinger Ellison
Gastrin secreting
Abdominal pain and dyspepsia
Chronic diarrhoea / Steatorrhoea
Refractory PUD
Ix
↑ gastrin c¯ ↑↑ HCl (pH<2)
MRI/CT
Somatostatin receptor scintigraphy
Rx High dose PPI Surgery Tumour resection May do subtotal gastrectomy c¯ Roux en Y
Bariatric Surgery Indications
ALL of the following:
BMI ≥40 or ≥35 c¯ significant co-morbidities that could improve c¯ ↓ wt.
Failure of non-surgical Mx to achieve and maintain clinically beneficial wt. loss for 6mo.
Fit for surgery and anaesthesia
Integrated program providing guidance on diet,
physical activity, psychosocial concerns and
lifelong medical monitoring
Well-informed and motivated pt.
BMI >50, surgery is 1st line Rx
Laparoscopic Gastric Banding
Inflatable silicone band around proximal stomach →
small pre-stomach pouch.
Limits food intake
Slows digestion
At 1yr 46% mean excess wt. loss
Roux-en Y Gastric Bypass
Oesophagojejunostomy allows bypass of stomach, duodenum and proximal jejunum.
Alters secretion of hormones influencing glucose regulation and perception of hunger / satiety.
Greater wt. loss and lower reoperation rates.
Complications Dumping syndrome Wound infection Hernias Malabsorption Diarrhoea Mortality 0.5%
