Upper Gastrointestinal Surgery

If you don't put your finger in it, you'll put your foot in it

Dr Tom Browne (FY1 Breast & Vascular Surgery/General Medicine and Upper GI surgery)

Session Outline and Objectives

Outline GI surgery How To Deal with Dysphagia at the OSCEs GI surgical emergencies

Different Types of GI surgery

Hepato-Pancreato-Biliary (HPB) Oesophago-Gastric

Hepatectomy/Liver resection Cholecystectomy Pancreatectomy Duodenectomy

Oesophagectomy Gastrectomy Fundoplication Hiatus hernia repair Bariatric surgery

Interpret this Chest X-Ray

Hiatus Hernias

Problem Swallowing Case 1

68-year-old retired civil servant, who complained of difculty in swallowing. He noted that solid foods, but not liquids, were seeming to stick at the lower end of his chest (xiphisternum) Has been getting worse over the past couple of months. There was discomfort when he swallowed, but no actual pain. Appetite and Weight Loss He smokes 15 cigarettes a day, social drinker and had had no serious past illnesses.

Problem Swallowing Case 2

A 60-year-old civil servant complained of increasing difculty in swallowing, which had gradually become worse over the past 2 years. At rst it was quite mild but getting worse. He found that food, and now even uids, would tend to stick in his throat. In recent months he found that he might regurgitate food he had just swallowed. His wife has commented on his bad breath His weight had not changed no other past medical history. Clinical examination revealed a slim, healthy man, with no abnormal ndings. He was given a glass of water to drink, which made him splutter a bit, but nothing could be felt on the neck.

Problem Swallowing Case 3

A married canteen waitress aged 55 years with a history of difficulty in swallowing. This she had noticed 3 or 4 years previously. Food seemed stick behind the sternum. As there is no pain and it was not very severe, she put this down to indigestion. However, she is now worried that something serious was going on. She said that the difculty was especially marked if she swallowed food she had not chewed well and that, although at rst uids gave no problem, she was now having some difculty swallowing her drinks. No Appetite or Weight Loss She pointed to the middle of her sternum as the location of her problem. When her doctor examined her, she was of average build, with no evidence of weight loss or clinical anaemia. There were no masses to feel in the or the neck.

Features to ellicit from history

Interval: Difficulty initiating swallowing or food sticking Type of food: Liquids (usually pharyngeal), solids (mechanical oesophageal or both (oesophageal dysmotility) Pattern: Progressive, intermittent Weight loss Heartburn peptic stricture Cough aspiration (oropharyngeal dysphagia or achalasia) Odynophagia (pain on swallowing) oesophagitis, achalasia or diffuse spasm Risk Factor profile Red Flags: Dysphagia For solids alone Progressive Associated weight loss PMH:Neurological deficit; MND, Parkinsons, stroke

Dysphagia List to Learn

Cancer of oesophagus Peptic stricture from GORD Bulbar/pseudobulbar palsy Achalasia non-acidic regurgitation External compression bronchial ca, pharyngeal pouch, mediastinal lymph nodes, cervical spine osteophytes, aortic aneurysms Diffuse oesophageal spasm Schatzki ring small, distal, benign oesophageal web Plummer-Vinson syndrome postcricoid web with iron deficiency, glossitis and koilonychias Systemic sclerosis (CREST) Calcinosis, Raynauds oesophageal dysfunction, sclerodactyly and telangiectasia Neuromuscular MND, Parkinsons, myasthenia Anxiety globus hystericus

Dysphagia
INTRALUMINAL CAUSES Foreign body bolus obstruction Polypoid tumours Oesophageal infection (Candidiasis) EXTRALUMINAL CAUSES Pressure of enlarged lymph nodes Bronchial carcinoma. Aortic thoracic aneurysm. Retrosternal thyroid.

INTRAMURAL CAUSES Congenital atresia. Caustic stricture.  Inammatory stricture secondary to reux oesophagitis. Achalasia of the cardia. PlummerVinson syndrome with pharyngeal web. Tumours of the oesophagus or cardia of stomach. Pharyngeal pouch.

Systemic Causes Myasthenia gravis Multiple sclerosis Parkinsons disease Pseudobulbar palsy Psychological

Problem Swallowing Case 1

68-year-old retired civil servant, who complained of difculty in swallowing. He noted that solid foods, but not liquids, were seeming to stick at the lower end of his chest (xiphisternum) Has been getting worse over the past couple of months. There was discomfort when he swallowed, but no actual pain. Appetite and Weight Loss He smokes 15 cigarettes a day, social drinker and had had no serious past illnesses.

Case 1 Investigations

Bloods Imaging Endoscopy and biopsy Thoracoabdominal CT Functional Tests Barium swallow Preassessment tests

Case 1 Management Principles

Conservative Medical -Chemotherapy (Neo-adjuvant) and Radiotherapy Surgical Palliative

Case 1 Management
Aim is to relive dysphagia, prolong survival and cure a minority Fit patients <70yrs without evidence of local invasion- 30% operable Neoadjuvant chemo with epirubicin and 5FU Subtotal oesophagectomy Surgery has 15% mortality rate

Palliation (70%) Endoscopic dilatation stent insertion

May exacerbate high tumours, perforation, tube migration and occlusion

Endoscopic laser therapy Palliative radiotherapy

Oesophageal Cancer Notes

Signs of Spread Left supraclavicular lymphadenopathy (Virchow s nodes) Hiccups or midthoracic ache indicates diaphragmatic/mediastinal invasion Oesophagobronchial fistula Hoarseness if invaded into recurrent laryngeal nerve (upper 1/3)
Risk Factors Tobacco Alcohol (SCC) GORD/Barretts oesophagus Achalasia Plummer-Vinson syndrome Radiotherapy

Problem Swallowing Case 2

A 60-year-old civil servant complained of increasing difculty in swallowing, which had gradually become worse over the past 2 years. At rst it was quite mild but getting worse. He found that food, and now even uids, would tend to stick in his throat. In recent months he found that he might regurgitate food he had just swallowed. His wife has commented on his bad breath. His weight had not changed no other past medical history. Clinical examination revealed a slim, healthy man, with no abnormal ndings. He was given a glass of water to drink, which made him splutter a bit, but nothing could be felt on the neck.

Investigations
Barium Swallow First line investigation as risk of Pouch Rupture Endoscopy: Oesphageo-gastro-duodenoscopy

Management

Problem Swallowing Case 3

A married canteen waitress aged 55 years with a history of difficulty in swallowing. This she had noticed 3 or 4 years previously. Food seemed stick behind the sternum. As there is no pain and it was not very severe, she put this down to indigestion. However, she is now worried that something serious was going on. She said that the difculty was especially marked if she swallowed food she had not chewed well and that, although at rst uids gave no problem, she was now having some difculty swallowing her drinks. No Appetite or Weight Loss She pointed to the middle of her sternum as the location of her problem. When her doctor examined her, she was of average build, with no evidence of weight loss or clinical anaemia. There were no masses to feel in the or the neck.

Case 3 investigations

Management

Perforated Duodenal Ulcer

Shock

Air Under Diaphragm

General Upper GI bleed Management

Resus on arrival Patent airway 14-guage cannula Pulse >100 give 500-1000ml colloid over 30-60mins Transfuse blood Catheter is requires central venous line monitor fluid balance Nil by mouth NO NG tube Endoscopic Intervention For all patient with a peptic ulcer and active bleeding or non-bleeding visible vessel Sclerotherapy (adrenaline and thrombin) IV omeprazole for peptic ulcer (20-80mg in 250ml saline over 1h then 8 mg/h for 72h) Tranexamic acid may reduce rebleeding H.pylori test at time of endoscopy, using biopsy urease (CLO) test in patients with bleeding ulcer

Describe this Chest X-Ray

Oesphageal Rupture
Mostly Iatrogenic. May occur by forceful vomitting. Caused by a raised intralumenal pressure and a failure of the cricopharyngeal muscles to relax. The difference between a Mallory-Weiss tear? Mediastinitis- therefore broad spectrum Abx + antifungal may be needed. NBM, NG tube and ICU Surgery: Mediastinal Debridement + Insertion of TTube to create oesphageal cutaneous fistula (Drainage)

Final Case
A housewife aged 56 years was admitted acutely. Twelve hours before

admission, shortly after she had gone to bed, she suddenly experienced acute central abdominal pain and vomited up her supper. The pains recurred every few minutes, were getting worse and made her double up. She vomited several more times, now greenish uid. Her bowels had not acted and she had not passed atus since the pain began. Ten years previously she had her appendix removed as an emergency through a right paramedian incision. On examination, she was in obvious pain, which was coming on in spasms every few minutes she said like labour pains, but worse

What would you expect on examination

Her temperature was 37C, pulse 100 and blood pressure 130/78 mmHg. She was dehydrated with a dry, coated tongue. The abdomen was diffusely distended. Waves of peristalsis seen. No obvious hernias. No masses or free fluid. PR negative. Tender/rigid abdomen Absence of bowel sounds. Tinkling bowel sounds

Causes of Mechanical Bowel Obstruction

Extramural Adhesions Strangulated hernia Volvulus Extrinsic compression Intramural Tumours Infarction Strictures Inflammation (e.g. Crohns) Luminal Impacted faeces Foreign body Large polyps Intussusception

How Would you manage this patient?

Questions?