Upper GI Surgery - AS Flashcards

1
Q

Oesophageal anatomy

A
  • 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

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2
Q

What is plummer-vinson syndrome?

A

Severe IDA –>
- hyperkeratinisation of upper 3rd of oesophagus –> Web formation

  • triad of dysphagia, glossitis, iron-deficiency anaemia.
  • Pre-malignant: 20% risk of SCC.
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3
Q

What is an oesophageal rupture caused by?

A

Iatrogenic (85%-90%) - endoscopy, biopsy, dilatation

Violent emesis: Boerhaave’s syndrome

Carcinoma

Caustic ingestion

Trauma: surgical emphysema ± pneumothorax

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4
Q

What are the features of oesophageal rupture ?

A

Odonophagia
Mediastinitis: tachypnoea, dyspnoea, fever, shock
Surgical emphysema

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5
Q

Management of rupture of oesophagus?

A

Iatrogenic: PPI, NGT, Abx

Other: Resus, PPI, antifungals, debridement and formation of oesophago-cutaneous fistula with T-tube.

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6
Q

What is the epidemiology of oesophageal cancer?

A

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

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7
Q

What are the risk factors for oesophageal cancer?

A
  • ETOH
  • Smoking
  • Achalasia
  • GORD –> Barrett’s
  • Plummer-Vinson
  • Fatty diet
  • Decreased Vit A and C
  • Nitrosamine exposure
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8
Q

What is the pathophysiology of adenocarcinoma?

A

65% adenocarcinoma

35% SCC

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9
Q

Where does adenocarcinoma occur?

A

Lower 3rd

GORD –> Barrett’s –> Dysplasia –> Ca

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10
Q

Where does squamous cell carcinoma occur?

A

Upper and middle 3rd
Associated with ETOH and smoking. Achalsaia increases risk of squamous cell carcinoma
Commonest type worldwide.

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11
Q

Presentation of oesophageal cancer?

A
  • 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
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12
Q

Spread of oesophageal cancer?

A
  • Direct extension, lymphatic and blood

- 75% of pts have mets @ Dx.

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13
Q

Investigations of oesophageal cancer?

A

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.

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14
Q

Staging for TNM?

A
Tis: Carcinoma in situ
T1: Submucosa
T2: muscularis propria (circ/long) 
T3: Adventicia 
T4: adjacent structures 
N1: regional nodes
M1: distant mets
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15
Q

Management of oesophageal cancer?

A

Discuss in an MDT

  • Upper GI surgeon + gastroenterologist
  • Radiologist
  • Pathologist
  • Oncologist
  • Specialist nurses
  • Macmillan nurses
  • Palliative care
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16
Q

Surgical management of oesophageal cancer?

A

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.

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17
Q

Palliative treatment of oesophageal cancer?

A
  • 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
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18
Q

What are the benign oesophageal tumours?

A

Leiomyoma
Lipomas
Haemangiomas
Benign polyps

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19
Q

What is the pathophysiology of a perforated peptic ulcer

A

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.

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20
Q

Presentation of perforated peptic ulcer?

A
  • Sudden onset severe pain, beginning in the epigastrium and then becoming generalised
  • Vomiting
  • Peritonitis
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21
Q

Differential for perforated peptic ulcer?

A

Pancreatitis
Acute Cholecystitis
AAA
MI

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22
Q

Investigations for Perforated Peptic Ulcer?

A

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.

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23
Q

Management of Perforated Peptic Ulcer? Resuscitation

A

Resuscitation

NBM
Aggressive fluid resuscitation
- Urinary catheter ± CVP line

Analgesia: morphine 5-10mg/2hr max. ± cyclizine.

Abx: cef and met

NGT

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24
Q

Management of Perforated Peptic Ulcer? Conservative

A
  • May be considered if patient isn’t peritonitic
  • Careful monitoring, fluids +Abx.
  • Omentum may seal perforation spontaneously preventing operation in 50%.
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25
Q

Management of perforated peptic ulcer? Surgical?

A
  • 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.

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26
Q

Gastric outlet obstruction causes?

A
  • Late complication of PUD –> fibrotic stricture

- Gastric Cancer

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27
Q

Presentation of gastric outlet obstruction?

A

Hx of bloating, early satiety and nausea
Outlet obstruction
- Copious projectile non-bilious vomiting a few hrs after meals.

  • Contains stale food.
  • Epigastric distention + succussion splash.
28
Q

Investigations for Gastric Outlet Obstruction?

A

ABG: Hypochloraemic hypokalaemic met alkalosis

AXR: dilated gastric air bubble, air fluid level. Collapsed distal bowel.

OGD
Contrast meal.

29
Q

Management of Gastric Outlet Obstruction?

A

Correct metabolic abnormality: 0.9% NS + KCL.

Benign

  • Endoscopic balloon dilatation
  • Pyloroplasty or gastroenterostomy

Malignant

  • Stenting
  • Resection

In children with pyloric stenosis - consider ramstedt pyloromyotomy.

30
Q

Gastric cancer incidence?

A

23/100,000

Primary in 50s

Sex: M>F. Mainly in japan, eastern europe, china, S.america.

31
Q

Risk factors for gastric cancer?

A

Atrophic gastritis (–> Intestinal metaplasia)

  • Pernicious anaemia/AI gastritis
  • H.pylori

Diet: Increased nitrates –> smoked, pickled, salter (Increased in Japan). Nitrates –> carcinogenic nitrosamine in GIT.

  • Smoking
  • BLood group A (gAstric cAncer)
  • Low SEC
  • Familail: E.cadherin abnormality
  • Partial gastrectomy
    cancer.
32
Q

Pathology of gastric cancer?

A
  • Mainly adenocarcinoma
  • Usually located on gastric antrum
  • H.Pylori may –> MALToma

-Histology: Signet ring cells may be seen in gastric

33
Q

Classification of gastric cancer

A

Depth of invasion

  • Early gastric Ca; mucosa or submucosa
  • Late gastric ca: muscularis propria breached.

Microscopic appearance

  • Intestinal: bulky, glandular tumour, heaped ulceration
  • Diffuse: Infiltrativie with signet ring cell morphology
34
Q

Borrmann Classification of gastric cancer?

A
  1. Polypoid/fungating
  2. Excavating
  3. Ulcerating and raised
  4. Linitis plastica: leather bottle like thickening with flat rugae.

Tumours of gastro-oesophageal junction are classified below

  • Type 1 = True oesophageal cancer + may be associated with Barrett’s oesophagus
  • Type 2 = Carcinoma of the cardia, arising from cardiac type epithelum.
35
Q

Symptoms of gastric cancer?

A
  • Usually present late
  • Wt loss + anorexia
  • Dyspepia: epigastric or retrosternal pain/discomfort
  • Dysphagia
  • N/V.
36
Q

Signs of gastric cancer?

A
  • Anaemia
  • Epigastric mass
  • Jaundice
  • Ascites
  • Hepatomegaly
  • Virchow’s node (=Troisier’s sign)
  • Acanthosis nigricans
37
Q

Complications of gastric cancer?

A

Perforation
Upper GI bleed: haematemesis, melaena
Gastric outlet obstruction –> Succussion splash

38
Q

Spread of gastric cancer?

A

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

39
Q

Investigations for gastric cancer/

A

Investigations
- Bloods
FBC: anaemia
LFTs and clotting

Imaging

  • CXR: mets
  • USS: Liver mets
  • Gastroscopy + biopsy
  • Ba meal

Staging

  • Endoluminal US
  • CT/MRI (normally 1st line staging investigations)
  • Diagnostic laparoscopy
40
Q

Management of Gastric Cancer? Palliation

A

Medical palliation

  • Analgesia
  • PPI
  • Secretion control
  • Chemo: epirubicin, 5FU, cisplastin
  • Palliative care team
41
Q

Surgical palliation for gastric cancer?

A

Pyloric stenting

Bypass procedures

42
Q

Curative surgery for gastric cancer?

A

EGC may be resected endoscopically

Partial or total gastrectomy with roux-en-Y to prevent bile reflux
- Spleen and part of pancreas may be removed

Proximally sited disease greater than 5-10 cm from OG junction can be treated with subtotal gastrectomy

Total gastrectomy if tumour is <5cm from OG junction.

43
Q

What are the other gastric neoplasms? Benign

A

Benign polyps
Leiomyoma
Lipomas
Haemangiomas

44
Q

What are the malignant gastric neoplasms.

A

Lymphoma
Carcinoid
GIST

45
Q

What is a Gastrointestinal Stromal Tumour?

A

Commonest mesenchymal tumour of the GIT

>50% occur in the stomach.

46
Q

Pathology of GIST?

A

Arise from intestinal cells of Cajal

  • Located in muscularis propria
  • Pacemaker cells

OGD: well-demarcated spherical mass with central punctum

47
Q

Presentation of GIST?

A

Mass effect: abdo pain, obstruction

Ulceration –> Bleeding

48
Q

Poor prognosis of GIST?

A

Increased size
Extra-gastric location
Increased mitotic index

49
Q

Management of GIST?

A

Medical

  • For unresectable, recurrent or metastatic disease
  • Imatinib: kit selctive tyrosine kinase inhibitor

Surgical
- Resection

50
Q

Gastric lymphoma?

A

Commonest site for extranodal lymphoma
- Most commonly MALToma due to chronic H.Pylori gastritis

H.pylori eradication can be curative.

51
Q

What is Zollinger-Ellison Syndrome?

A

Pathophysiology

  • Gastrin secreting tumour most commonly found in the small intestine or pancreas
  • Increased Gastrin –> Increased HCL –> PUD + chronic diarrohea due to inactivation of pancreatic enzymes.

ECL proliferation can –> carcinoid tumours.

60-90% of gastrinomas are malignant

25% association with MEN1

52
Q

Presentation of Zollinger-Ellison Syndrome?

A
  • Abdo pain + dyspepsia
  • Chronic Diarrhoea/Steatorrhoea
  • Refractory PUD
53
Q

Management of ZE Syndrome?

A

High dose PPI
Surgery
- Tumour resection
- May do subtotal gastrectomy with Roux en Y

54
Q

Bariatric Surgery benefits?

A
Sustained weight loss
Symptom improvement 
- Sleep apnoea
- Mobility
- HTN
- DM
55
Q

Indications of bariatric surgery

A

All criteria must be met

  • BMI >40 or >35 with significant comorbidities that could improve with weight
  • Failure of non-surgical Mx to achieve and maintain clinically beneficial weight loss for 6 months.
  • Fit for surgery and anaesthesia
  • Diet, physical activity, psychosocial concerns medical monitoring

If BMI >50, surgery is 1st line Management

56
Q

What are the two types of bariatric surgery?

A

Laparoscopic Gastric Banding

Roux -en- Y

57
Q

Laparoscopic gastric banding?

A

Inflatable silicone band around proximal stomach - limits food intake + slows digestion

58
Q

Roux-en-Y gastric bypass

A
  • Oesophagojejunostomy allows bypass of stomach duodenum and proximal jejunum.
  • Alters secretion of hormones influencing glucose regulation + perception of hunger
  • Greater weight loss and lower reoperation rates

Complications

  • Dumping syndrome
  • Wound infection
  • Hernias
  • malabsorption
  • Diarrhoea
  • Mortality
59
Q

Raised Urea and normocytic anaemia?

A

Upper GI bleed.

60
Q

Imatinib?

A

GIST

CML

61
Q

Basiliximab?

A

Renal transplant

62
Q

Adalimumab, INfliximab, Etanercept?

A

TNF alpha inhibitor

Crohns
RA

63
Q

Trastuzumab?

A

HER receptor

Breast Cancer

64
Q

Cetuximab

A

EGF positive colorectal cancer

65
Q

Categorisation of a Upper GI bleed?

A

Ligament of Treitz.

Found at the duodenojejunal flexure.

Marks boundary between first and second parts of the small intestine and formal boundary of Upper GI and lower GI bleed.