GEJ tumour, Hiatus Hernia and Esophageal Perforation Flashcards
(17 cards)
What are GEJ tumours?
Tumours with the epicenter
- Within 5cm of distal esophagus
- At the GEJ
- In the cardia, within 5cm of the distal esophagus, with extension into GEJ or esophagus
What are the classifications of GEJ tumours?
Siewert classification
- Type 1 – distal oesophagus (within 1-5cm above anatomic GEJ)
- Type 2 – cardia (within 1cm above and 2cm below GEJ)
- Type 3 – sub-cardial (2-5cm below GEJ)
What is the management of GEJ tumours?
Aggressive neo adjuvant therapy has been known to improve overall survival
- Eradicates micro-metastatic disease
- Tumour downsizing to improve R0 resections
- Better tolerance of intensive therapy prior to surgery
- Adjustment of treatment based on release
Treated with perioperative chemotherapy (UK) or perioperative chemo-radiotherapy (US)
What are the treatment approaches for GEJ tumours?
Type 1 – treat as per oesophageal cancer (esophagectomy)
- Type 3 – treat as per gastric cancer (total gastrectomy or proximal gastrectomy [possible if stage 1])
- Type 2 – debatable*
▪ Total gastrectomy + distal esophagectomy
▪ Esophagectomy + proximal gastrectomy
* determining factors – extent of oesophageal involvement (if <2-3cm: extended gastrectomy, if >2-3cm: esophagectomy), mediastinal
nodal involvement, T staging, patient’s fitness for operation
What is a hiatus hernia?
A hiatal (or hiatus) hernia is the abnormal protrusion of any abdominal structure/organ, most often a portion of the stomach, into the thoracic cavity through a lax diaphragmatic esophageal hiatus.
What are the types of hiatus hernias?
Type 1-4
Type 1: Sliding hernia - GEJ displaced into stomach
Type 2: Rolling hernia - Gastric fundus is displaced
Type 3 - Mixed between type 1 and 2
Type 4 - Giant hernia - herniation of an additional organ (mostly colon)
What is the clinical presentation of hiatus hernia?
Asymptomatic
- GERD symptoms
- Obstructive symptoms – transient obstruction of the GEJ (i.e. dysphagia, regurgitation), obstruction of distal stomach (i.e. nausea,
vomiting, palpitation, shortness of breath, dyspnoea, chest pain & early satiety)
- Cameron ulcers leading to bleeding and chronic iron deficiency anemia
- Acute gastric volvulus: Gastric Ischemia – septic shock, epigastric pain, multi-organ failure
- Borchardt’s triad of gastric volvulus – epigastric or chest pain, retching without vomiting and inability to pass a nasogastric tube
What are the managemnt of patients of varying hiatal hernias?
Type 1:
- Conservative management
- Lifestyle modifications
- Proton pump inhibitors (PPIs) or histamine H2-receptor antagonists if symptoms of GERD occur
- Surgery: laparoscopic/open fundoplication + hiatoplasty . Indications
- Persistence of symptoms despite conservative management
- Refusal or inability to take long-term PPIs
- Severe symptoms/complications of gastroesophageal reflux disease: bleeding, strictures, ulcerations
Type 2-4
- Conservative management: older patients or those with other comorbidities
- Surgery: laparoscopic/open herniotomy + fundoplication, hiatoplasty, and gastropexy/fundopexy Indications
- Asymptomatic, small hernias in patients < 50 years of age
- Symptomatic type II, III, IV hernias
What is esophageal perforation?
A true surgical emergency (mortality 10-40%) – most commonly at left lateral wall of oesophagus 3-5cm above GEJ
What are the risk factors of esophageal perforation?
- Iatrogenic - OGDs, dilatation, intra-esophageal tubes, traumatic intubation
- Spontaneous - Boerhaave’s syndrome (spontaneous esophageal perforation)
- Foreign body
- Caustic ingestion
- Trauma (Blunt/penetrating)
What is the clinical presentation of esophageal perforation?
- Pain – cervical area / substernal area
- Cervical crepitation / swelling (subcutaneous emphysema)
- Fever (after instrumentation of the oesophagus)
- Hamman’s sign – mediastinal crunching on auscultation (pneumomediastinum)
- Stony dullness on percussion over intercostal space (pleural effusion)
What is the differential diagnosis for esophageal perforation?
- Medical: Myocardial infact, pericarditis, pneumothorax, pneumonia, mallory weiss tear
- Surgical - pancreatitis, peritonitis, aortic dissection/aneurysm, mesenteric ischemia, perforated PUD
What investigations are carried out for esophageal perforation?
CXR for pleural effusion, pneumomediastinum, subcutaneous emphysema, hydropneumothorax, collapse or consolidation
- Distal esophageal rupture leads to left sided pleural effusion
- Mid thoracic rupture leads to right sided pleural effusion
CTAP + oral contrast
Contrast esophagram in lateral decubitus position to detect for extravasation and intraperitoneal air
What is the general management for esophageal perforation?
NBM + Resuscitation + IV fluids with monitoring of urine output
- Broad-spectrum antibiotics – coverage of UGI pathogens +/- Antifungals
- IV PPI
- NGT (placed under endoscopic or radiological guidance) - to decompress the stomach
- Early escalation of care, early referral to HD/ICU
- Enteral feeding assess (NJ feeding tube or feeding jejunostomy)
- Chest tube, if have significant pleural effusion – food debris / purulent discharge can establish diagnosis of rupture
- OGD – diagnostic & therapeutic (i.e. KIV stent placement)
▪ Stenting contraindicated in long tears (>6cm), delayed presentation due to substantial tissue necrosis (>24hrs), proximal
oesophagus (posterior pharynx) and distal oesophagus / GEJ (distal flare will not attach to stomach)
▪ Stenting is useful in setting of malignancy
When is non-surgical treatment indicated?
Small, contained perforation, demonstrated by:
Either a contained leak with the neck, within the mediastinum, or between the mediastinum and visceral lung pleura
Contrast can flow back into the esophagus from the cavity surrounding the perforation.
What is the non surgical treatment for esophageal perforation?
NBM, IV antibiotics, PPI
What is the operative managment for non contained perforation?
Indications
Hemodynamic instability
Patients who do not fulfill the criteria for conservative management
Clinical deterioration during conservative managemen
- < 24 hours (80-90% survival) → primary closure with drains + longitudinal myotomy +/- muscle flap
- > 48 hours with extensive contamination (< 50% survival)
▪ Neck → place drains, no esophagectomy
▪ Thorax → resection of diseased portion of oesophagus with end cervical esophagostomy or exclusion and diversion (i.e.
cervical esophagostomy, staple across distal esophagus, mediastinal washout, place chest tubes)
▪ Gastric replacement of esophagus when patient recovers
