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
Presentation of gastric outlet obstruction?
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.
Investigations for Gastric Outlet Obstruction?
ABG: Hypochloraemic hypokalaemic met alkalosis
AXR: dilated gastric air bubble, air fluid level. Collapsed distal bowel.
OGD
Contrast meal.
Management of Gastric Outlet Obstruction?
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.
Gastric cancer incidence?
23/100,000
Primary in 50s
Sex: M>F. Mainly in japan, eastern europe, china, S.america.
Risk factors for gastric cancer?
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.
Pathology of gastric cancer?
- Mainly adenocarcinoma
- Usually located on gastric antrum
- H.Pylori may –> MALToma
-Histology: Signet ring cells may be seen in gastric
Classification of gastric cancer
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
Borrmann Classification of gastric cancer?
- Polypoid/fungating
- Excavating
- Ulcerating and raised
- 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.
Symptoms of gastric cancer?
- Usually present late
- Wt loss + anorexia
- Dyspepia: epigastric or retrosternal pain/discomfort
- Dysphagia
- N/V.
Signs of gastric cancer?
- Anaemia
- Epigastric mass
- Jaundice
- Ascites
- Hepatomegaly
- Virchow’s node (=Troisier’s sign)
- Acanthosis nigricans
Complications of gastric cancer?
Perforation
Upper GI bleed: haematemesis, melaena
Gastric outlet obstruction –> Succussion splash
Spread of gastric cancer?
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
Investigations for gastric cancer/
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
Management of Gastric Cancer? Palliation
Medical palliation
- Analgesia
- PPI
- Secretion control
- Chemo: epirubicin, 5FU, cisplastin
- Palliative care team
Surgical palliation for gastric cancer?
Pyloric stenting
Bypass procedures
Curative surgery for gastric cancer?
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.
What are the other gastric neoplasms? Benign
Benign polyps
Leiomyoma
Lipomas
Haemangiomas
What are the malignant gastric neoplasms.
Lymphoma
Carcinoid
GIST
What is a Gastrointestinal Stromal Tumour?
Commonest mesenchymal tumour of the GIT
>50% occur in the stomach.
Pathology of GIST?
Arise from intestinal cells of Cajal
- Located in muscularis propria
- Pacemaker cells
OGD: well-demarcated spherical mass with central punctum
Presentation of GIST?
Mass effect: abdo pain, obstruction
Ulceration –> Bleeding
Poor prognosis of GIST?
Increased size
Extra-gastric location
Increased mitotic index
Management of GIST?
Medical
- For unresectable, recurrent or metastatic disease
- Imatinib: kit selctive tyrosine kinase inhibitor
Surgical
- Resection
Gastric lymphoma?
Commonest site for extranodal lymphoma
- Most commonly MALToma due to chronic H.Pylori gastritis
H.pylori eradication can be curative.
What is Zollinger-Ellison Syndrome?
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
Presentation of Zollinger-Ellison Syndrome?
- Abdo pain + dyspepsia
- Chronic Diarrhoea/Steatorrhoea
- Refractory PUD
Management of ZE Syndrome?
High dose PPI
Surgery
- Tumour resection
- May do subtotal gastrectomy with Roux en Y
Bariatric Surgery benefits?
Sustained weight loss Symptom improvement - Sleep apnoea - Mobility - HTN - DM
Indications of bariatric surgery
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
What are the two types of bariatric surgery?
Laparoscopic Gastric Banding
Roux -en- Y
Laparoscopic gastric banding?
Inflatable silicone band around proximal stomach - limits food intake + slows digestion
Roux-en-Y gastric bypass
- 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
Raised Urea and normocytic anaemia?
Upper GI bleed.
Imatinib?
GIST
CML
Basiliximab?
Renal transplant
Adalimumab, INfliximab, Etanercept?
TNF alpha inhibitor
Crohns
RA
Trastuzumab?
HER receptor
Breast Cancer
Cetuximab
EGF positive colorectal cancer
Categorisation of a Upper GI bleed?
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.
