Upper GI Surgery

Question 1

Oesophageal anatomy

Answer 1

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

Question 2

Achalasia

Answer 2

Degeneration of myenteric plexus (Auerbach’s)
↓ peristalsis
LOS fails to relax

Cause
primary/idiopathic (commonest)
2ndary - Chagas disease (T. cruzil)

Question 3

Achalasia Presentation + Comps

Answer 3

Presentation
 Dysphagia: liquids then solids
 Regurgitation (esp. @ night)
 Substernal cramps
 Wt. loss

Comps: Chronic → oesophageal SCC in 3-5%

Question 4

Achalasia Ix + Rx

Answer 4

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)

Question 5

Pharyngeal Pouch (Zenker’s Diverticulum)

Answer 5

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

Question 6

Diffuse Oesophageal Spasm

Answer 6

 Intermittent severe chest pain ± dysphagia

 Ba swallow shows corkscrew oesophagus

Question 7

Nutcracker Oesophagus

Answer 7

 Intermittent dysphagia ± chest pain

 ↑ contraction pressure c¯ normal peristalsis

Question 8

Plummer Vinson Syndrome

Answer 8

Severe IDA → hyperkeratinisation of upper 3rd of
oesophagus → web formation

 Pre-malignant: 20% risk of SCC

Question 9

Oesophageal Rupture

Answer 9

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

Question 10

Nissen Fundoplication

Answer 10

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

Question 11

Hiatus hernia

Answer 11

Sliding (80%)- gastro-oespophageal junction slides up into chest (GORD)

15% g-o junction remains in abdomen, bulge of stomach rolls into chest

Question 12

Peptid Ulcer Disease Surgery

Answer 12

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

Question 13

PUD Surgery Metabolic Complications

Answer 13

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

Question 14

Upper GI bleed

Answer 14

 PUD: 40% (DU commonly)
 Acute erosions / gastritis:20%
 Mallory-Weiss tear: 10%
 Varices: 5%
 Oesophagitis: 5%
 Ca stomach / oesophagus:<3%

Question 15

Rockall Score (Upper GI bleed)

Answer 15

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

Question 16

Variceal bleed

Answer 16

Initially IV terlipressin *splanchnic vasopressor)
Prophylactic Abx (ciprofloxacin 1g/24h)

(resus, fluid resus + maintenance)

Urgent Endoscopy

Question 17

Variceal bleeding Urgent Endoscopy

Answer 17

2 of: banding, sclerotherapy, adrenaline,
coagulation

Balloon tamponade c¯ Sengstaken-Blakemore tube
 Only used if exsanguinating haemorrhage or
failure of endoscopic therapy

TIPSS if bleeding can’t be stopped endoscopically

Question 18

TIPPS Transjugular intrahepatic porto-systemic shunt

Answer 18

IR creates artificial channel between hepatic vein and
portal vein → ↓ portal pressure.

Colapinto needle creates tract through liver
parenchyma which is expand using a balloon and
maintained by placement of a stent.

Used prophylactically or acutely if endoscopic therapy
fails to control variceal bleeding.

Question 19

Urgent Endoscopy (haemostasis of vessel or ulcer)

Answer 19

 Adrenaline injection
 Thermal / laser coagulation
 Fibrin glue
 Endoclips

Question 20

Peptic Ulcer Perforation

Answer 20

Presents
Sudden onset severe pain, beginning in epigastrium
Vom
Peritonitis

Perforated duodenal ulcer is commonest
 1st part of the duodenum: highest acid conc
 Ant. perforation → air under diaphragm
 Post. perforation can erode into GDA → bleed
 ¾ of duodenum retroperitoneal  no air under diaphragm if perforated.
Perforated GU
Perforated gastric Ca

Question 21

Peptid Ulcer Perforation Ix

Answer 21

Bloods
 FBC, U+E, amylase, CRP, G+S, clotting
 ABG: ? mesenteric ischaemia

Urine dipstick

Imaging
Erect CXR
 Must be erect for ~15min first
 Air under the diaphragm seen in 70%
 False +ve in Chailaditi’s sign

AXR
 Rigler’s: air on both sides of bowel wall

Question 22

Peptic Ulcer Perforation Mx

Answer 22

Resuscitation
 NBM
 Aggressive fluid resuscitation
 Urinary Catheter ± CVP line
 Analgesia: morphine 5-10mg/2h max
 ± cyclizine
 Abx: cef and met
 NGT

Conservative
 May be considered if pt. isn’t peritonitic
 Careful monitoring, fluids + Abx
 Omentum may seal perforation spontaneously
preventing operation in ~50%

Surgical: Laparotomy
 DU: abdominal washout + omental patch repair
 GU: excise ulcer and repair defect
 Partial / gastrectomy may rarely be required
 Send specimen for histo: exclude Ca

Test and Treat
 90% of perforated PU assoc. c¯ H. pylori

Question 23

Gastric Outlet Obstruction

causes + presentation

Answer 23

Causes
Late complication of PUD → fibrotic stricturing
Gastric Ca

Presentation
Hx of bloating, early satiety and nausea
Outlet obstruction
 Copious projectile, non-bilious vomiting a few hrs
after meals.
 Contains stale food.
 Epigastric distension + succussion splash

Question 24

Gastric Outlet Obstruction

Ix + Rx

Answer 24

Ix
 ABG: Hypochloraemic hypokalaemic met alkalosis
AXR - Dilated gastric air bubble, air fluid level
Collapsed distal bowel
OGD
Contrast meal

Rx
Correct metabolic abnormality: 0.9% NS + KCl

Benign
 Endoscopic balloon dilatation
 Pyloroplasty or gastroenterostomy

Malignant
 Stenting
 Resection

Question 25

Hypertophic Pyloric Stenosis

Answer 25

Presents 6-8 weeks - projectile vomiting minutes after feeding - RUQ mass (olive) - Visible Peristalsis Dx - Test feed - palpate mass + see peristalsis - hypochloraemic hypokalaemic metabolic alkalosis - USS Mx - Resuscitate and correct metabolic abnormality - NGT - Ramstedt pyloromyotomy - divide muscularis propria

Question 26

signet ring cell

Answer 26

diffuse gastric cancer

Question 27

Gastric Cancer Spread

Answer 27

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

Question 28

Gastric Cancer Mx

Answer 28

``` Medical Palliation  Analgesia: e.g. fentanyl patch  PPI  Secretion control  Chemo: epirubicin, 5FU, cisplatin  Palliative care team package ``` Surgical Palliation  Pyloric stenting  Bypass procedures Curative Surgery - EGC may be resected endoscopically - Partial or total gastrectomy c¯ roux-en-Y to prevent bile reflux.  Spleen and part of pancreas may be removed

Question 29

Gastric Lymphoma

Answer 29

MALToma chronic h pylori most common extranodal tumour

Question 30

Carcinoid tumours

Answer 30

gastric carcinoids arise from enterochromaffin cells

Question 31

Gsatrointestinal stromal tumour

Answer 31

50+% in stomach Arise from intestinal cells of Cajal (in muscularis propria, pacemaker cells) OGD - well demarcated spherical mass with central punctum ``` Presentation  Mass effects: abdo pain, obstruction  Ulceration: → bleeding Poor Prognosticators  ↑ size ↑ mitotic index  Extra-gastric location ``` Mx Medical  Unresectable, recurrent or metastatic disease  Imatinib: kit selective tyrosine kinase inhibitor Surgical  Resection

Question 32

Zollinger Ellison

Answer 32

Gastrin secreting Abdominal pain and dyspepsia Chronic diarrhoea / Steatorrhoea Refractory PUD Ix  ↑ gastrin c¯ ↑↑ HCl (pH<2)  MRI/CT  Somatostatin receptor scintigraphy ``` Rx  High dose PPI  Surgery  Tumour resection  May do subtotal gastrectomy c¯ Roux en Y ```

Question 33

Bariatric Surgery Indications

Answer 33

ALL of the following:  BMI ≥40 or ≥35 c¯ significant co-morbidities that could improve c¯ ↓ wt.  Failure of non-surgical Mx to achieve and maintain clinically beneficial wt. loss for 6mo.  Fit for surgery and anaesthesia  Integrated program providing guidance on diet, physical activity, psychosocial concerns and lifelong medical monitoring  Well-informed and motivated pt. BMI >50, surgery is 1st line Rx

Question 34

Laparoscopic Gastric Banding

Answer 34

 Inflatable silicone band around proximal stomach → small pre-stomach pouch.  Limits food intake  Slows digestion At 1yr 46% mean excess wt. loss

Question 35

Roux-en Y Gastric Bypass

Answer 35

Oesophagojejunostomy allows bypass of stomach, duodenum and proximal jejunum. Alters secretion of hormones influencing glucose regulation and perception of hunger / satiety. Greater wt. loss and lower reoperation rates. ``` Complications  Dumping syndrome  Wound infection  Hernias  Malabsorption  Diarrhoea  Mortality 0.5% ```