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