Alimentary Tract

 The Esophagus

  • Dysphagia --> barrium swallow for diverticulum, obstruction (ring, barret, stricture, cancer), or motor disorde
  • Odynophagia --> infection v. inflammation, v. caustic injestion 

Esophageal Cancer

  • Dx: Patients often present with dysphagia and weight loss.
    • Start with a barium swallow to identify a mass or stricture.
    • Upper endoscopy is used for tissue diagnosis.
    • Endoscopic ultrasound determines level of invasion and the need for neoadjuvant therapy.
      • T2 invades muscularis propria
      • T3 invades adventitia
    • Preoperative workup includes pulmonary function test and stress test as indicated.

 

  • Tx: Is based on stage.
    • T2, T3, or N1 gets neoadjuvant therapy followed by re-staging and resection.
    •  Ivor-Lewis Esophagectomy versus transhiatal esophagectomy is used for resectable T1 disease. Transhiatal esophagectomy has anastamosis in the neck, which allows reopening of the cervical incision in the case of leak. It is also more difficult perform a complete en-bloc lymphadenectomy in the chest without a thoracic incision.
    • Chemo: 5FU, cisplain; XRT postop.

 

  • Special topics in esophageal cancer
    • Tracheal involvement is suspected for upper and middle third esophageal leaions and warrant bronchoscopy.
    • Postoperative leak is managed by opening the cervical incision at bedside for transhiatal esophagectomy. If septic in the abdomen or chest, will need operative drainage. May need a diverting esophagostomy if the leak is caught late.
    • Unresectable disease is determined by the presence of:
      • distant metastasis
      • paratracheal, celiac, or mediastinal lymph nodes (not paraesophageal nodes)
      • bronchoesophageal fistula or tracheal invasion
    • Neoadjuvant therapy is used for T2, T3, or N1 disease. Use 5FU, cisplatin, and XRT.

 

Zenker’s Diverticulum

  • Dx: Patients present with halitosis, regurgitation, and feeling of food sticking in neck, dysphagia.
    • Start with a barium swallow to identify a diverticulum versus obstruction versus motor abnormality.
    • Do not do endoscopy first due to risk of perforation
  • Tx: diverticulectomy and crycopharyngeus myotomy through a left neck incision.
    •  Diverticuli < 2cm can have myotomy along.
    • Diverticuli > 2cm need diverticulectomy.
    •  Endoscopic treatment is increasingly used for diverticuli >2cm
  • Special topics:
    • Esophageal perforation during myotomy should be closed in layers. The myotomy can be repeated in a separate area.
    • Leave a drain in cases of perforation.

Achalasia

§Dx: Patients present with dysphagia, regurgitation, weight loss, feeling of food getting stuck.

§  Start with a barium swallow to identify a bird’s beak esophagus.

§  Endoscopy with biopsy to rule out cancer.

§  Mannometry reveals LES > 30mmHg, incomplete relaxation of LES, and aperistalsis.

 

§  Tx: Heller myotomy of the LES extending 2cm onto stomach and 4cm along esophagus

§  Include a Dor (anterior) or Toupe (posterior) partial fundoplication over a bougie

§  Postoperative reflux occurs up to 40% and is treated with PPI and lifestyle changes.

§  Postoperative dysphagia requires reimaging with an upper GI and endoscopy. Biopsy to rule out cancer. May need dilation. May need re-myomectomy if incomplete myotomy. Esophagectomy is a last resort.

 Motor Disorders

  • Tx: ISDN, diltizem, can balloon for Hypertensive LES 
  • Hypertensive LES= LES > 45mmHg
  • Diffuse esophageal spasm= high amplitude simultaneous (not peristaltic) contrastions on mannometry in > 1 of 5 swallows alternating with normal peristalsis
  • Nutcracker esophagus= high amplitude contractions with normal peristaltic movement

Gastroesophageal Reflux Disease (GERD)

§  Dx: Patients present with reflux, frequent pneumonias, voice changes.

§  Start with a barium swallow to look for a lesion or hiatal hernia.

§  Endoscopy looks for Barrett’s changes or H pylori and gives stage; biopsy multiple locations in periphery and in any ulcer base.

§  Stage 1= erythema

§  Stage 2= mild ulceration

§  Stage 3= extensive ulceration, cobblestoning

§  Stage 4= stricture, fibrosis

§  Manometry is diagnostic for GERD if LES < 6mmHg, LES < 2cm in length, and LES < 1cm in intraabdominal length.

§  A 24hr pH probe confirms the presence of reflux if pH<4 for > 1.5hrs or any reflux at night and can establish relationship between symptoms and reflux.

 

§  Tx: Surgery is indicated for persistant symptoms > 6mo despite medical treatment or complications (pneumonia, Barrett’s changes, strictures).

§  Nissen improves symptoms and complications better than medication. It may also reverse Barrett’s changes but results are not definitive.

§  GERD with stricture should have several sessions of dilation preop. If the lesions is not able to be dilated, may need short segment esophagectomy.

Barrett’s Esophagus

§  5-10% of GERD can progress to low grade dysplasia.

§  2% of Barrett’s progress to esophageal cancer.

 

§  Dx: Patients can present with GERD symptoms.

§  Start with barium swallow to look for a lesion.

§  Endoscopy is used for biopsy diagnosis and to rule out cancer. Surveillance is q6mo EGD with biopsy; change to anually if no change twice.

§  Manometry and pH probe is used as for GERD.

 

§  Tx: Management depends on symptoms and pathology from endoscopy.

§  Symptomatic barretts not responsive to meds à Nissen.

§  Severe dysplasia confirmed by 2 pathologists à esophagectomy (25% have cancer).

§  Undilatable stricture à esophagectomy.

§  Perforation of Barrett’s à segmental esophagectomy, gastrostomy, cervical esophagostomy, and delayed reconstruction.

Esophageal Perforation

§  Dx: This often presents after endoscopy for a lesion or after dilation of a lesion. Symptoms are vague but include chest pain, tachycardia, fevers.

§  Start with gastrograffin swallow (less sensitive but less mediastinal inflammation if leak is present)

§  Can proceed to barium swallow if gastrograffin is normal.

 

§  Tx: Management depends on timing of perforation. All include antibiotics and drainage.

§  Early (<24 hours) perforation without shock can get esophageal repair. A mass or stricture will need resection or myotomy at the same time. The repair is bolstered with intercostals muscle flap or stomach wrap. Debride and drain mediastinum well with 2 chest tube. Use NG tube for decompression.

§  Late (>24 hours) will require damage control. Patients in shock will require a left posterolateral thoracotomy with drainage of perforation and chest tubes. Stable patients can undergo segmental esophagectomy, cervical esophagostomy for diversion, and feeding gastrostomy.

Esophageal Varices

§  Dx: Patients can present with acute bleeding, are often cirrhotic.

 

§  Tx: Surgical treatment is becoming rare, but emergency H type Mesocaval shunt (8mm prosthetic graft from IVC to IMV just distal to uncinate process) can be performed for acute bleeding.

§  Start with resuscitation and medical therapy (PPI, Abx, somatostatic/octreotide 50mcg then 50mcg/hr)

§  Next, perform EGD with sclerotherapy and banding.

§  If bleeding is not controlled, perform balloon tamponade and TIPS.

§  Consider liver transplant.

 

Stomach and Ulcer disease

 

Gastric Cancer

 
  • Dx: Patients can have risk factors like smoking, pernicious anemia, blood group A, heavy nitrate consumption, genetic predisposition. The can present with weight loss, GI bleeding, perforation.
    • Tissue diagnosis is with endoscopy.
    • CT chest / abdomen / pelvis are for staging.

 

  • Tx: Best option in the United States appears to be the gastrectomy with modified D2 lymphadenectomy (includes omentectomy, perigastric, periportal, and peripancreatic lymph nodes).
    • Neoadjuvent for T2 or N1.
    • Extent of gastrectomy depends on location of lesion. You need a 6cm margin.
    • Unresectable if peritoneal involvement, mets, local invasion, encasement of vessels.
    • Get frozen sections of the margins to ensure 6cm margin
    • Roux-en-y gastrojejunostomy or esophagojejunostomy is used for reconstruction. The Roux-en-y limb is ~30cm from the ligament of treitz and is a 45cm roux limb.
    • Adjuvent therapy for T2, N+, or R1; includes 5FU and Cisplatinand XRT 

Hiatal Hernias

 

§  Dx: Patients can present with epigastric pain, anemia, GERD, or gastric volvulus (unlikely with sliding hernia). Determine type of hernia with endoscopy.

§  Type 1= GE junction is in the chest (sliding hernia).

§  Type 2= normal position of GE junction.

§  Type 3= combined type 1 & 2 where esophageal shortening brought the GE junction into the chest.

§  Type 4= another organ enters the chest. 
 
§  Tx: Repair of the hernia defect, often with mesh. If stomach needs anchoring, do a stamm gastrostomy. Nissen wrap is also included. Type 3 hernia often needs Colles gastroplasty due to esophageal shortening.
 

Gastric Ulcer Disease

 

§  Dx: Determine location endoscopically.

§  Type 1= lesser curve

§  Type 2= body and duodenal (acid related)

§  Type 3= prepyloric (acid related)

§  Type 4= GE junction

§  Type 5= anywhere in stomach (NSAID related)
 

§  Tx: Can give PPI for 2 weeks, stop NSAID, treat H. pylori. Need EGD if symptoms not relived after 2 weeks.

§  Chronic ulcerà biopsy to look for malignancy.

§  If indeterminant repeat EGD in 6 weeks.

§  If not resolved in 6 weeks treatment, need resection.

§  H pylori à amoxicillin, clarithramycin, and PPI for 14 days

§  MALT à H. pylori treatment.

§  Bleeding à wedge resection, type 2 or 3 get pyloroplasty and vagotomy if stable.

§  Perforationà wedge resection and gram patch (can just biopsy and patch if not stable). Also consider pyloroplasty and vagotomy in type 2 or 3.

§  Resections:

§  Type 1à antrectomy and B1

§  Type 2/3à vagotomy and antrectomy, B1 or B2

§  Type 4à resection

 

Duodenal Ulcer Disease

 

§  Dx: Patients present with bleeding, perforation, or pain.

§  Free air is seen on CXR.

§  Endoscopy can identify and treat bleeding or H. pylori.
 

§  Tx: Management depends on presentation. All test for and treat H. pylori if present. Endoscopy is first line for bleeding if resuscitated.

§  Active bleeding gets 3 point U stitch to ulcer, pyloroplasty , and truncal vagotomy (need PPI if omit vagotomy). Criteria for operating on bleeding includes:

§  > 6 units blood transfusion in 24 hrs

§  Re-bleeding in the hospital

§  Rebleeding after endoscopic treatment

§  Shock

§  Chronic bleeding gets truncal vagotomy and antrectomy.

§  Perforated ulcers get Graham patch and proximal gastric vagotomy (needs PPI if omit vagotomy)

§  Obstructing duodenal ulcer gets NG tube for 5 days, upper GI series, PPI, electrolyte replacement, and truncal vagotomy and antrectomy once resuscitated.

§  Intractable ulcer gets proximal gastric vagotomy.

§  Difficult duodenal stump gets lateral duodenostomy.
 

§  Proximal gastric vagotomy has a 20% recurrence rate. Truncal vagotomy has a 5% recurrence rate.


Recurrent Peptic Ulcer Disease

 

§  Dx: Workup includes fasting gastrin, CMP, PTH, H. pyloi (biopsy or urea breath test for cure)

§  Elevated gastrin:

§  Secretin stim test = gastrinoma

§  Technetium scan = retained antrum

§  Protein load test = G-cell hyperplasia

§  Sham feeding test = incomplete vagotomy

§  Normal gastrin:

§  Hyperparathyroidism

§  H. pylori

§  Bile gastritis

§  NSAIDs

 

 

Small bowel

 

Small Bowel Obstruction

 

  • Dx: Patients present with obstipation, constipation, abdominal pain, nausea, vomiting.
    • Look for hernias or surgical scars.
    • X-rays can identify dilated bowel loops, air fluid levels, or free air.
    • CT scan with contrast can identify sites of obstruction. Oral contrast can also help differentiate a SBO that is likely to resolve on its own versus a high grade bowel obstruction that will need surgical treatment.
    • Obturator hernias can be difficult to diagnose, but have fluid outside the pubic ramus. 

 

  • Tx: Can wait 2-3 days with NG tube and IVF if there is previous surgery, no sign of bowel ischemia, or hernias.
    • Gallstone ileus is treated with longitudinal incision proximal to the stone and transverse closure.
    • Femoral herias can be treated with a transverse incision just above the bulge under the inguinal ligament, open sac and reduce bowel if viable. Then resect the sac and close cooper ligament to inguinal ligament. If bowel is not viable, hold the bowel and do lower midline incision for bowel resection.
    • Inguinal hernia with ischemic bowel is repaired without mesh using the modified Bassini repair where the conjoint tendon is approximated to poupart ligament. Imbricate the transversalis fascia with continuous 2-0 prolene. Close the conjoint tendon to iliopubic tract and inguinal ligament.
    • Cooper / McVay repair is done through a transverse groin incision. The external oblique fibers are separated. Internal oblique and internal ring/floor are opened. The preperitoneal tissue is imbricated. The conjoint tendon is closed to cooper’s ligament. A transition stitch is used from conjoint tendon to inguinal ligament to close femoral space. The internal ring is closed by joining conjoint tendon to inguinal ligament.
  • Tx: can wait 2wk non operative tx for early postoperative SBO.

Enterocutaneous Fistula

  • Dx: Find the cause, often revealed by the history. FRIEND = foreign body, radiation, infection, epithelialization, nelplasm, distal obstruction.
    • Quantify output (low output is < 600ml/day)
    • CT abdomen / pelvis evaluates for undrained abscess.
  • Tx: First resuscitate, contain infection, and optimize nutrition.
    • Medical management includes making NPO, TPN, octreotide, antibiotics for infection.
    • High output fistulas are unlikely to be controlled with medical management along.
    • Surgery is for failure of medical management, bleeding, uncontrolled infection, complete distal obstruction, or removal of foreign body.

Radiation Enteritis

  • Dx: Patient present with abdominal pain, diarrhea, and a history of radiation exposure. Colonoscopy and biopsy reveals obliterative endarteristis, necrosis, and ulceration.
  • Tx: Surgery is used for non healing fistula or obstruction
    • Consider ureteral stents.
    • Resect / ansastamose if possible; bypass if not.
    • Don't do stricturoplasty if resection is possible.
    • Can do a frozen section prior to anastamosis.
     
 

Carcinoid Tumors

  • Dx: Carcinoid syndrome is flushing, dermatitis, diarrhea, dementia (the 3 D’s) diagnosed with increased 24 hour urine 5HIAA and chromogranin A.
    • Localized with octreotide scan, MIBG, endoscopy, CT, MRI, IOUS.
    • Ask about MEN I symptoms
  • Tx:
    • Appediceal tumor < 2cm and not at base can get simple appendectomy. Right hemicolectomy if at base or > 2cm.
    • Rectal tumor <2cm can get local excision.
    • Rectal tumor > 2cm, invasion of muscularis mucosa, or recurrence requires APR.
    • Small bowel carcinoid gets resection with mesenteric lymph nodes.
    • Duodenal tumor < 2cm gets local resection unless it invades muscularis mucosa.
    • Duodenal tumor > 2cm, near the ampula, or invading muscularis mucosa requires Whipple.
    • Liver tumor can get resection or ablation
    • Palliation is with somatostatin, debulking, and cholecystectomy
    • Chemotherapy is streptozocin.
    • Can use XRT.

 Crohn’s Disease

  • Workup: AXR, colonoscopy (cx, biopsy)
    • Skip lesions, granulomas
    • Meckel’s scan can r/o bleeding from meckel
    • UGI with SBFT
    • CT a/p
  • Initial tx:
    • Sulfasalazine 0.5mg TID, or 5ASA
    • Prednisone for flares
    • Flagyl for rectal and anal dz
    • AZA or 6MP for resistance (results in bone marrow suppression and pancreatitis)
    • Steroid enemas
    • Lomotil
    • Low residue diet, B12
    • Remicade
  • Surgery for:
    • Obstruction
    • Bleeding
    • Perforation
    • Non-healing fistula
    • Abscess
  • In surgery:
    • Resect grossly involved bowel
    • Gastrojejunostomy to bypass involved duodenum
    • Fistula --> take down and resect small bowel (leave colon/bladder)
    • For intractable colon --> proctocolectomy with permanent ileostomy
    • Perianal complications --> I&D and fistulotomy, rarely do proctocolectomy

Ulcerative Colitis

  • Workup= AXR, colonoscopy (cx, biopsy)
    • rectum always involved, continuous proximally, mucosa and submucosa only
    • Toxic megacolon gets ICU, abx, IVF, T&C, steroids, npo, serial exam/xray
    • OR if no improvement in 24-48hrs
    • Get subtotal colectomy and ileostomy
    • Less acute gets: UGI with SBFT to r/o crohns
  • Medical Tx:
    • Sulfasalazine
    • 5ASA
    • Steroids
    • AZA
    • 6MP
    • Lomotil
  • Surgery for acute complications:
    • Perforation
    • Non-improving toxic megacolon
    • Severe bleeding
    • all get subtotal colectomy with end ileostomy.
  • Surgery for chronic disease
    • Get anal manometry before resection
    • Normal anal sphincter --> total colectomy with anorectal mucosectomy and ileorectal pull through.
    • Complications: 5-7BM per day, loose BM, anal leakage, incontinence, pouchitis, anastamotic leak, sexual dysfunction
    • Rectal incontinence or severe rectal disease --> total proctocolectomy with ileostomy.

Colon

 

Colon Polyps

  •  Colon polyps with cancer require surgery for:
    • <2mm margin
    • lymphovascular invasion
    • not well differentiated
    • sessile polyp
  • Rectal poylp that cannot be fully excised and <7cm from anal verge can have transrectal excision; however, if it is > T1 (submucosal invasion), it will need APR.
  • Transrectal excision (increased local recurrence) can be used for:
    • tumor < 4cm
    • < 1/3  the circumference
    • well differentiated
    • no lymphovascular invasion
    • poor surgical candidate

Colorectal Cancer

  • Dx: Patients present on screening exams, with blood per rectum, perforation, or obstruction.
    • Obtain CBC, CMP, CEA, CT abdomen/pelvis.
    • Complete colonoscopy for tissue diagnosis.
    • Transrectal ultrasound (TRUS) is required for staging rectal cancer.
  • Tx:
    • Use neoadjuvant chemo XRT for T3 or N1 rectal cancer: 5FU and XRT for 4wks, wait 4wks then surgery.
    • Colectomy includes 1 vessel above and 1 vessel below:
    •  Tumor Location Vessels required
       Cecum / ascending colon  right colic, right branch of middle colic a.
       Hepatic flexure / transverse colon  right colic, middle colic a.
       Splenic flexure  middle colic, IMA
       Descending colon  IMA, left branch of middle colic a.
       Sigmoid  sigmoidal and superior hemorrhoidal branches of IMA
       Rectal  sigmoidal and superior hemorrhoidal branches of IMA
     
    • Adjuvent chemo for rectal ca --> T3 or N+ (FOLFOX)
    • Adjuvent chemo for colon ca --> T3/4 with obstruction, perforation, or >50yo; any N+ (FOLFOX) for 6mo; XRT for T4 or recurrant dz.
    • Follow CEA postoperative every 6 months for 5yrs. If elevated CEA:
      • Repeat CEA in 2 weeks, check CT chest / abdmen / pelvis, colonoscopy, PET.
      • Unresectable disease needs chemotherapy.
      • If unable to localize, do exploratory laparotomy and look at liver, lymph nodes, retroperitoneum, and all surfaces.
      • Unresectable disease found during re-exploration needs intraoperative brachytherapy or intraoperative tumor marking for future XRT.
      • Avastin for metastatic or recurrent (do not operate on avastin for 4 weeks due to bleeding and poor healing)

Cecal Volvulus

  • Dx: Patient present with colonic obstruction, abdominal pain, and distention.
    • Abdominal series or CT scan can show volvulus
    • Colonoscopy can occasionally be used to de-tourse
  • Tx: Right hemicolectomy is standard treatment after resuscitation.
    • Colonoscopic de-toursion alone has high recurrence
    • Cecopexy or cecostomy can be used in high risk patients.
     

Analrectal

 

Anal Cancer

  • Dx: Patients may be immunosuppressed, presenting with trismus, bleeding, or a mass.
    • Perform a skin and lymph node exam.
    • Anoscopy, proctoscopy, and colonoscopy to define lesion, get tissue, and fully evaluate the colon.
    • FNA of any suspicious inguinal nodes.
  • Tx: Management depends on location.
    • Anal margin (intersphincteric groove to 5cm around perineum - or approximatly distal to dentate line) cancer needs a 0.5cm margin wide local excision
    • Anal canal (proximal to dentate line) gets Nigro protocol (XRT flanked with 5FU & mitomycin C).
      • Re-examine and biopsy and suspicious areas.
      • Can repeat Nigro once.
      • Re-examine and if biopsy is positive, will need APR. If inguinal nodes remain positive, will need lymph node dissection.
      • Superficial groin dissection:
        • Raise flaps just deep to scarpa's fascia.
        • lateral to sartorius.
        • medial to aductor magnus.
        • Inferior to apex above muscles and divide saphenous vein.
        • Superior above inguinal ligament.
        • Excise fatty tissue above the SFA adventitia.
        • Work inferior to superior, then lateral to medial.
        • Divide saphenofemoral junction.
        • Reach cloque's node under inguinal ligament.
      • Deep groin dissection:
        • Retroperitoneal dissection
        • Circumferential dissection of nodes off external iliac to common iliac artery.

Rectovaginal Fistula

  • Dx: Patients present with stool in the vagina.
    • Low fistulas are usually obstetric injury and less complicated.
    • High fistulas can be from diverticulitis, cancer, crohns, and are more complex
    • Workup includes CT abdomen / pelvis with rectal contrast, colonoscopy, and evaluation of internal sphincter function.
  • Tx: Management depends on location.
    • High fistulas likely need sigmoid colectomy.
    • Low fistulas can be treated with an advancement flap:
      • prone position, prep anus and vagina
      • elevated trapezoidal flap with the apex at the fistula to include mucosa, submucosa, and circular muscle (internal sphincter).
      • Mobilize surrounding internal sphincter to close longitudinally with 2-0 dexon (plication sphincteroplasty).
      • Excise flap excess including fistula and close with 3-0 dexon.

Anal Incontinence

  • Dx: Evaluate internal sphincter function.
    • Anal manometry.
    • Transanal ultrasound= can identify sphincter defects.
    • Pudendal nerve studies.
  • Tx: Use fiber (30g/day), caffeine avoidance, antidiarrheals, regular enemas prior to surgical therapy. Use surgery if a sphincter abnormality is found.
    • Plication sphincteroplasty:
      • Lithotomy position.
      • Semicircular incision anterior to anus.
      • Elevate anoderm in the submucosal plane.
      • Deep - Identify the internal sphincter.
      • Laterally - identify transverse perineal muscle.
      • Deep to intenal sphincters - identify levators.
      • Plicate levators.
      • Plicate transverse perineal muscle.
      • Plicate internal sphincter.

Rectal Prolapse

  •  Dx: Patient present with tenesmus, prolapse, incontinance, possibly constipation.
    • Physical exam give type of prolapse
    •  Type I  prolapsed mucosa only
       Type II  full thickness prolapse
       Type III  full thickness with perineal hernia
    • Colonoscopy to ensure no other lesions.
    • Anoretal manometry.
    • colonic transit study.
  • Dx: Start with medical treatment including biofeedback and fiber.
    • Surgical treatment is based on type of prolapse:
    •  Type I  hemorrhoidectomy
       Type II  transabdominal rectopexy, may need sigmoidectomy for redundant sigmoid
       Type III  modified altmeyer procedure
    • Modified Altmeyer procedure:
      • Prone jack-knife position.
      • Lone star retractor.
      • Full thickness incision 1cm above dentate line.
      • Open hernia sac anteriorly and free rectum circumferentially
      • Transect rectum / sigmoid when redundancy ends.
      • Plicate levator muscles.
      • Hand sewn anastamosis.
      • ** Can't do this after prior sigmoidectomy due to blood supply **
       

Special topics

  • Sengstaken-blakemore tube= for bleeding varicees. Inflate gastric baloon in stomach with 250ml air after check CXR to confirm placement. Apply 1kg traction. Inflate esopageal tube to 45mmHg for additional bleeding. Deflate esopageal 5min every 6hrs, can leave in for 24hrs.
  • Management of ureteral injury:
    • Below pelvic brim --> reimplant with a stent
    • Mid ureter --> repair over a stent; reimplant with psoas hitch and stent
    • Upper ureter --> transureteroureterostomy; nephrostomy, and wait for urology