Upper GI Surgery - AS Flashcards
Oesophageal anatomy
- 25cm long muscular tube
- Starts at level of cricoid cartilage (C6)
- In the neck lies 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
For other dysphagia differentials - go to GASTRO
What is plummer-vinson syndrome?
Severe IDA –>
- hyperkeratinisation of upper 3rd of oesophagus –> Web formation
- triad of dysphagia, glossitis, iron-deficiency anaemia.
- Pre-malignant: 20% risk of SCC.
What is an oesophageal rupture caused by?
Iatrogenic (85%-90%) - endoscopy, biopsy, dilatation
Violent emesis: Boerhaave’s syndrome
Carcinoma
Caustic ingestion
Trauma: surgical emphysema ± pneumothorax
What are the features of oesophageal rupture ?
Odonophagia
Mediastinitis: tachypnoea, dyspnoea, fever, shock
Surgical emphysema
Management of rupture of oesophagus?
Iatrogenic: PPI, NGT, Abx
Other: Resus, PPI, antifungals, debridement and formation of oesophago-cutaneous fistula with T-tube.
What is the epidemiology of oesophageal cancer?
Incidence: 12/100,000, increasing (increased change of Barrett’s.
Age: 50-70 yrs
Sex: M>F = 5:1
Geo: increased in iran, transkei, china
What are the risk factors for oesophageal cancer?
- ETOH
- Smoking
- Achalasia
- GORD –> Barrett’s
- Plummer-Vinson
- Fatty diet
- Decreased Vit A and C
- Nitrosamine exposure
What is the pathophysiology of adenocarcinoma?
65% adenocarcinoma
35% SCC
Where does adenocarcinoma occur?
Lower 3rd
GORD –> Barrett’s –> Dysplasia –> Ca
Where does squamous cell carcinoma occur?
Upper and middle 3rd
Associated with ETOH and smoking. Achalsaia increases risk of squamous cell carcinoma
Commonest type worldwide.
Presentation of oesophageal cancer?
- Progressive dysphagia: solid leading to liquids
- Often altered dietary habits –> soft foods –> exacerbation of weight loss.
- Weight loss
- retrosternal chest pain
- Lymphadenopathy
- Upper 3rd
- Hoarseness: recurrent laryngeal nerve invasion
- Cough ± aspiration pneumonia
Spread of oesophageal cancer?
- Direct extension, lymphatic and blood
- 75% of pts have mets @ Dx.
Investigations of oesophageal cancer?
Bloods
- FBC: anaemia
- LFTs: hepatic mets, albumin
Diagnosis
- Upper GI endoscopy: allows biopsy
- Ba swallow: not often used, apple-core stricture.
Staging for oesophageal cancer
- CT
- EUS - Aids visualisation of local invasion as it displays layers of the wall.
Laparoscopy/mediastinoscopy: Mets.
Staging for TNM?
Tis: Carcinoma in situ T1: Submucosa T2: muscularis propria (circ/long) T3: Adventicia T4: adjacent structures N1: regional nodes M1: distant mets
Management of oesophageal cancer?
Discuss in an MDT
- Upper GI surgeon + gastroenterologist
- Radiologist
- Pathologist
- Oncologist
- Specialist nurses
- Macmillan nurses
- Palliative care
Surgical management of oesophageal cancer?
Only 25-30% habe resectable tumours
May be offered neo-adjuvant chemo before surgery to downstage tumour e.g cisplatin + 5FU
Approaches
-Ivor-Lewis (2 stages): abdominal + R thoracotomy
- McKeown (3 stags): abdominal + R thoracotomy + left neck incision
- Trans-hiatal: abdominal incision
Progronisis
- Stage dependent
~15% 5 yrs.
Palliative treatment of oesophageal cancer?
- Majority of patients
- Laser coagulation
- Alcohol injection + decreased ascites with spironolactone).
- Stenting and secretion reduction (hyoscine patch)
- Analgesia: e.g fentanyl patches
- Radiotherapy: external or brachytherapy
- Referral
Palliative care team
Macmillan nurses
Prognosis
- 5yrs <5%
- Median: 4 months
What are the benign oesophageal tumours?
Leiomyoma
Lipomas
Haemangiomas
Benign polyps
What is the pathophysiology of a perforated peptic ulcer
Perforated duodenal ulcer is commonest
- 1st part of the duodenum; highest acid conc
- Ant perofration –> air under diaphragm
- Posterior perforation can erode into GDA –> bleed.
- 3/4 of duodenum retroperitoneal therefore no air under diaphragm if perforated.
Perforated GU
Perforated Gastric Ca.
Presentation of perforated peptic ulcer?
- Sudden onset severe pain, beginning in the epigastrium and then becoming generalised
- Vomiting
- Peritonitis
Differential for perforated peptic ulcer?
Pancreatitis
Acute Cholecystitis
AAA
MI
Investigations for Perforated Peptic Ulcer?
Bloods: FBC, U+E, Amylase, CRP, G+S, clotting.
ABG: ?mesenteric ischaemia
Urine Dipstick
Imaging - Erect CXR Must be erect for ~15 mins first - Air under the diaphragm seen in 70% -False +ve in Chailaditi's sign - Chilaiditi syndrome is a rare condition when pain occurs due to transposition of a loop of large intestine
AXR
- Rigler’s: Air on both sides of bowel wall. This is indicative of pneumoperitoneum.
CT is preferred method for detecting free air in the abdomen. Whenever you see this THIS IS A PERFORATION.
Management of Perforated Peptic Ulcer? Resuscitation
Resuscitation
NBM
Aggressive fluid resuscitation
- Urinary catheter ± CVP line
Analgesia: morphine 5-10mg/2hr max. ± cyclizine.
Abx: cef and met
NGT
Management of Perforated Peptic Ulcer? Conservative
- May be considered if patient isn’t peritonitic
- Careful monitoring, fluids +Abx.
- Omentum may seal perforation spontaneously preventing operation in 50%.
Management of perforated peptic ulcer? Surgical?
- Surgical: laparotomy
DU: abdominal washout + omental patch repair.
Large bites using 0 Vicryl are taken above and below ulcer base to occlude vessel.
GU: Excise ulcer and repair defect. Partial/gastrectomy may rarely be required. Send specimen to histo: exclude Ca.
Test and treat
- 90% of Perforated PU associated with H.pylori.
Gastric outlet obstruction causes?
- Late complication of PUD –> fibrotic stricture
- Gastric Cancer