Upper GI surgery

Ms. N. Bambury

12/02/2009

Overview Stomach Duodenum Oesophagus Pancreas

Anatomy of the stomach

Anatomy of the stomach

Physiology of the stomach Reservoir for digestion Endocrine functions

Secretion of gastrin(from antral cells) Gastrin acts on parietal cells to increase

acid production Exocrine functions

Acid secretion

Peptic Ulcer Disease Peptic ulcers are defects in the gastric

or duodenal mucosa that extend through the muscularis mucosa.

Occur when defensive mechanisms ie. tight intercellular junctions, mucus, and epithelial renewal, are overcome by aggressive factors

PUD Aggressive factors/Causitive factors

NSAIDS H.Pylori Severe physiologic stress

Burns CNS trauma Surgery

Hypersecretory states Gastrinoma (Zollinger-Ellison syndrome) multiple endocrine neoplasia (MEN-I)

Patient Factors 40-70 years Men Duodenal ulcers>gastric ulcers

Gastric ulcers Same age group Males Located in prepyloric pyloric or coexist 70% located in lesser curvature Risk factors

Smoking Alcolhol Burns Trauma NSAIDS/steroids

Gastric ulcers Symptoms

Epigastric pain Transiently relieved by food May be associated with nausea , vomiting

and decreased appetite

Duodenal ulcers Same age,sex Located mostly 2cm from pylorus-

duodenal bulb Caused by increase in gastric acid

Duodenal ulcers Symptoms

Burning or aching several hours after a meal

Haematemesis,FOB+ve Back pain Nausea, vomiting,decreased appetite

Differential Diagnosis Biliary Colic Cholecystitis Cholelithiasis Pancreatitis Pancreatic Cancer Acute Gastritis Myocardial Infarction Gastroesophageal Reflux Disease Mesenteric Artery Ischemia

Diagnosing ulcers Outpatient setting

Bloods OGD In the case of gastric ulcers biopsy should

always be taken to outrule carcinoma. Patient should be treated and rescoped in approx 6 weeks to ensure healing. Biopsies are taken on all walls at 2 cm intervals

Medical treatment Treat H pylori infection with triple

therapy PPI Clarithromycin penecillin PPI Metronidazole Ampicillin PPI Metronidazole Clarithromycin

Those not found to be H. Pylori free Treat with PPI or H2 receptor blockers

Complications of PUD Bleeding Perforation Pain Obstruction

Secondary to repeated inflammation and subsequent scarring namely gastric outlet obstruction

Indications for surgery Similar in both types of ulceration

Refractory to treatment Haemorrhage Perforation Obstructive symptoms

Surgery is less common now since the introduction of PPIs

Surgical management of Gastric ulcers Principles

Remove ulcer remove gastrin secreting antrum

Two operations described

Gastric Surgery Billroth 1-remove

distal third

of stomach and

anastomose

remainder to

duodenum

Gastric surgery Billroth 2- remove

distal 2/3rds of

stomach and perform

gastro-jejunostomy

Surgical management of Duodenal ulcers Principles

Reduce acid secretion by dividing the vagus nerve called a vagotomy.

Vagotomy denervates the stomach and therefore the pylorus which will lead to gastric outlet obstruction.

Therefore a drainage procedure is performed called a pyloroplasty.

2 surgical operations Truncal vagotomy and pyloroplasty Selective vagotomy and pyloroplasty

Vagotomy complications Decreased acid secretion (aim of the

game) Faster gastric emptying (loss of vagally

mediated) Diarrhoea Dumping syndrome

Gastric outlet obstruction(unless pyloroplasty performed)

Vagotomy complications Remember proximal vagotomy denervates

from the stomach to the distal transverse colon including the pancreas and gallbladder

Gallbladder denervation leads to stasis and which increases the chance of gallstones.

Decrease in pancreatic and gallbladder secreations leading to undigested fats-steatorrhoea

Complications of gastrectomy Dumping syndrome

Early v’s late Cardiovascular and GI symptoms due to

vagotomy and pyloroplasty or gastrectomy Early DS due to hypovolaemia Late DS due to hypoglycaemia

Early Dumping Syndrome No intact pylorus leads to dumping of large

amounts of chyme,biliary and pancreatic secretions into duodenum at once

Results in large fluid shift Occurs within 40 minutes of ingestion Symptoms include

Tachycardia Diaphoresis Palpitations Diarrhoea Abdominal pain

Late Dumping Syndrome Due to rebound hypoglycaemia Occurs 2-4 hours post op CHOenterglucagonsensitizes islet

cellsoverproduction of insulin Symptoms include

Tachycardia Palpitations Diaphoresis Dizziness

Complications of gastrectomy continued Anaemia( Intrinsic factor essential for binding

of Vit B12 for absorption in the terminal ileum) Early satiety Hypocalcaemia- reduced HCl prod interferes

with absorption of calcium and Fe in the duodenum

Gastric Stump carcinoma? Due to chronic irritation of stump by acid duodenal secretions

Specific management Patient presenting with Haematemesis

History and Examination Vital signs 2 large bore cannulae Bloods including

FBC U&E Coag screen Group and X match for 6 units Inflammatory markers Amylase

Specific management If greater than 6 units required urgent

scope warranted. Oversewing of bleeding vessel. In the case of gastric ulceration distal

gastrectomy may be warranted to excise the ulcer.

No vagotomy required

Perforated Duodenal Ulcer Presentation

Acute onset of epigastric pain Patients Vitals are ‘off’patient generally is unable

to settle Nausea, vomiting O/E decreased bowel sounds, tenderness/rigidity

of abdomen May complain of lower abdo pain as free fluid

tracks down the paracolic gutters and causes local irritative symptoms.

Management of Perforated DU 2 large bore cannulae Fluid resuscitation NG insertion Urinary catheter insertion Analgesia and antibiotics Bloods as before Erect CXR-Free air PFA- may see free air also

Perforated DU CT abdomen- use water soluble

contrast. Given 1 hour prior to scan to allow it to move along the GIT tract.

CT Abdomen findings include Free air Free fluid Contrast may not fill small intestine

Surgical Management Graham patch

Mini laparotomy from below umbilicus to epigastrium

Stomach is identified and duodenum Perforation sought Omentum mobilised so that it is easily applied to

site of perforation Suturedin 2 layers to peration site Closure

Definitions you should know Cushings Ulcer- ulcer associated with

trauma, tumour or neurology Curlings ulcer- associated with major

burns Marginal ulcer- ulceration at the site of a

GI anastomosis Dieulafoys ulcer-underlying gastric

malformation

Gastric Ca

Adenocarcinoma Risk factors

Blood group A, male Pernicious anaemia (Autoimmune disease) Hypogammaglobulinaemia Previous partial gastrectomy Helicobacter pylori infection Atrophic gastritis Intestinal metaplasia

Gastric Ca Presentation

Age group>60 Weight loss Loss of appetite Palpable epigastric mass Melaena Most present late and are not amenable to radical

surgery

Gastric Ca Investigations/Staging

CEA OGD confirms diagnosis with a tissue biopsy Endoscopic ultrasound may allow assessment of intramural

tumour penetration CT will assess nodal spread and extent of metastatic

disease Laparoscopy will identify peritoneal seeding

Survival Overall 5 year survival is approximately 5%

Gastric Ca Surgical options No real role for adjuvant therapy Billroth 2 or Roux en Y anastomosis

Antrum-Distal subtotal(75%) gastrectomy Body- total gastrectomy Proximal- total gastrectomy

Roux en Y anastomosisY-shaped anastomosisAfter division of thesmall intestine,thedistal end is implantedinto the stomach and the proximal end intothe small intestinebelow the anastomosisto provide drainagewithout reflux.

Gastric Ca Virchow’s node

Metastatic gastric carcinoma in the left supraclavicular fossa

Krukenburg tumour Gastric ca which has metastasized to the

ovaries

Gastric lymphoma The Stomach is the commonest extranodal primary

site for non-Hodgkin's lymphoma Secondary Lymphoma is commonly seen in stomach

from another site Accounts for 5% of gastric malignancies Presentation is similar to gastric carcinoma

Anaemia and epigastric mass are common Age of presentation is approx 60 years Investigations

EUS is the best modality

Gastric Lymphoma Treatment

70% of tumours are resectable 5-year survival is approximately 25% Treatment modalities are discussed on a case by

case basis at an MDT Treatments range from chemotherapy alone, H

pylori eradication or surgery and chemotherapychemotherapy may be useful

MALT lymphoma A type of primary gastric lymphoma The stomach does not usually contain

lymphoid tissue MALT follicles found in the stomach are

associated with H pylori infection Patients can be completely cured by H

pylori eradication or else use it in conjunction with chemotherapy

GIST tumours Gastrointestinal sromal tumours Previously classified as

Leiomyosarcomas, Leiomyomas or sarcomatous lesions ie they originate from smooth muscle.

There are classified according to the degree of differentiation towards different cells

GIST tumours Classification

Benign Differentiation toward muscle cells Differentiation toward neural elements

Malignant Dual differentiation Lacking differentiation 1% of stomach cancers

GIST tumours Presentation

Haemetemsis Melaena Epigastric mass

Investigation EUS + biopsy Endoscopy

GIST tumours Treatment

Surgery-local excision of tumour Lymph node clearance unnecessary as

spread is not common Large tumours may need formal

gastrectomy+/- adjuvant therapy Trials on a new drug Glivec have been

shown to be effective

Sister Mary Joseph Nodule

A 'nodule' in the umbilicus often associated with advanced malignancy

Presents as firm, red, non-tender nodule Results from spread of tumour within the

falciform ligament 90% of tumours are adenocarcinomas Commonest primaries are stomach and ovary Primary tumour is almost invariably inoperable

Oesophageal Anatomy Superior 1/3rd-smooth muscle Middle 1/3rd-mixed Inferior 1/3rd-smooth muscle Length -25cm

Oesophageal constrictions Superiorly: level of cricoid

cartilage, juncture with pharynx-cricopharyngeal sphincter @15 cm

Middle: crossed by aorta and left main bronchus @22cm

Middle; L main Bronchus@27cm Inferiorly: diaphragmatic sphincter

@37cm

Why are constrictions important

Areas where foreign bodies lodge Common sites of carcinoma Difficulty passing scope on OGD may

occur

Dysphagia Definition-difficulty swallowing Typical presentation in oesophageal Ca

is one of progressive dysphagia starting with solids followed by fluids

Odynophagia- pain on swallowing

Differential diagnosis -dysphagia Asnatomical causes

Intrinsic to wall Carcinoma Cricoid web Inflammatory lesions

Extrinsic lesions Bronchial Ca Mitral stenosis leading to L atrial enlargement

Differential diagnosis -dysphagia Functional lesions

Neurological causes Post CVA MND Globus hystericus-constriction of the lower part of the

oeophagus associated with anxiety Dysmotility

Achalasia Diffuse oesophageal spasm Scleroderma

Assessment-dysphagia History and Examination OGD+/-biopsy Barium swallow CT if suspect extrinsic compression is

the cause. Other tests

Oesophageal manometry pH studies

Oesophageal manometry NG tube passed into oesophagus Pressure transducer on tip of it measures

resting and squeezing pressures at different levels of the oesophagus

Normal peristaltic waves travel at a rate of 5cm/sec through oesophagus

Normal resting pressure of LOS is 10-15mmHg

Squeeze pressures should generate up to 100mmHg

pH studies Naos oesophageal wire containing a pH

probe is left in oesophagus for a 24 hour period

If oesophageal pH is greater than 4 for >4% of the time this indicates reflux

GORD 3 factors exist to keep gastric juices out

of the oesophagus LOS competence Oesophageal motility Clearance into stomach

GORD presentation Symptoms

Pain Epigastric Retrosternal Interscapular

Odynophagia Reflux of food especially on bending Pulmonary aspiration

Nocturnal coughing Hoarse voice

GORD Investigations

pH monitoring is the gold standard investigation

Rule out MI OGD + biopsy-5cm above GOJ shows

increased eosinophils and hypoplasia See if patient has a hiatus hernia (1/3 of

patients with h.h have GORD)

Complications of GORD Oesophageal stricture

Commonest cause Treat by balloon dilatation via OGD Surgery options-Lap Nissan fundoplication

Barrett’s oesophagus Increased risk of malignant transformation

Treatment of GORD Conservative mgt-

Antacids, lose weight, raise head of bed etc.

Metoclopramide,H2 blockers, PPIs Surgical Nissan fundoplication

Fundus of stomach is mobilised,wrapped around the oesophagus

Motility disorders Primary versus secondary Primary

Achalasia Diffuse oesophageal spasm

Secondary Autoimmune rheumatic disorders(scleroderma) Chagas disease(chronic infection with T cruzi

associated with mega disorders) DM Amyloid

Achalasia HighLOS pressure leading to failure of

the sphincter to relaxpoor peristalsis Presents with dysphagia and

retrosternal chest pain Affects 30-60 years age group Investigation;Barium swallow bird’s

beak, lack of gastric air bubble, contrast may not enter stomach

Achalasia Treatment

Balloon dilatation Heller’s cardiomyopathy-release of muscle

at the GOJ, reflux common post op Injection of botulinum toxin at ultrasound

Diffuse oesophageal spasm Part of the differential of MI Symptoms

Retrosternal chest pain radiating to jaw Invest;

Manometry-nutcracker oesophagus Management

Nifedipine

Scleroderma CREST syndrome

Calcinosis Raynauds Oesphagitis Scleroderma Telangiectasia

Scleroderma Srticture formation occurs due to

inflammation and GORD Investigations

Manometry- incompetent LOS Treatment

Partial fundoplication

Autoimmune diseases Rheumatoid Arthritis SLE Dermatomyositis Polymyositis May all be associated with oesophageal

dysmotility

Oesophageal carcinoma Adenocarcinoma>SCC Adeno seen in lower 1/3rd SCCs can be any site Males>Females Age;>40 Most common at sites of physiological

narrowing Lower 1/3rd and GOJ most common sites

Oesophageal carcinoma Risk factors

Adeno Barretts GORD Obesity Alcohol Cigarette smoking

Oesophageal carcinoma Risk factors

SCC Alcohol Smoking Coeliac Achalasia PUD

Oesophageal carcinoma Symptoms

Dysphagia Retrosternal pain Coughing during eating Pseudo-achalasia

Oesophageal carcinoma Pre-operative

U&Es, FBC Optimise nutrition-NG feed Stop smoking etc

Oesophageal carcinoma Surgical management

Ivor Lewis procedureLaparotomy and mobilisation of stomachRight thoracotomy- resection of tumour and

reanastomosis of stomach to healthy oesophagus

5 year survival 25% and only 30% patients suitable for surgery!

Oesophageal carcinoma Palliative treatment

Intubation with metal stent under radiological control

Chemotherapy-adeno Radiotherapy-SCC

Pancreatic Anatomy The pancreas is a retroperitoneal organ Consists of head body neck and tail Duct of Wirsung drains most of the pancreas Duct of Santorini drains the uncinate process

into the 2nd part of the duodenum Note the pancreas shares a common blood

supply with the duodenum!

Structure of the pancreas Exocrine

Serous secretory cells make up lobules which drain via ductules into main ducts

Endocrine Islets of Langerhans secrete insulin(Beta),

glucagon(Alpha) and somatostatin (Delta) directly into circulation

Pancreatitis Presentation

Epigastric pain Radiating through to back or interscapular

area Pain score 10/10 May be associated with nausea, vomiting

diaphoresis

Acute Pancreatitis Signs

Jaundice Ascites Grey-Turners sign Cullens sign Shock(Hypovolaemia) ARDS Renal failure(hypovolaemia)

Acute Pancreatitis Aetiology

Gallstones Alcohol Trauma Steroids Mumps Autoimmune(SLE) Hypothermia.↑Ca,↑lipids/TRG ERCP Drugs-Azathioprine,diuretics,thiazides, NSAIDS

Acute Pancreatitis Investigations

FBC U&E, Magnesium, Calcium Amylase, glucose LFTs Coag screen Albumin

Amylase and its role in diagnosis Amylase is a digestive enzyme that normally

acts extracellularly to cleave starch into monosaccharides,.

The pancreas and the salivary glands account for almost all serum amylase

Used as a diagnostic tool 10% of cases amylase is normal, especially in

acute on chronic pancreatitis Low specificity

Amylase and its role in diagnosis Renal failure and liver disease result in

decreased metabolic clearance IBD, mesenteric infarction-↑amylase

absorption Gut perforation-leaks into peritoneum and

absorbed across inflamed peritoneum Ectopic amylase production by lung, ovary,

pancreas, and colon malignanciesand breast cancer (increased pancreatic amylase) are miscellaneous

Acute pancreatitis Investigations

Erect CXR, PFA May see ‘sentinel node’ of proximal jejunum

CT pancreatic protocal Look for fat streaking around the pancreas,

fluid in the lesser sac, necrosis, pseudocyst U/S to o/r gallstones as cause ABG-hypoxia, lactic acidosis

Acute Pancreatitis Scoring systems

Ranson’s criteria At admission time and 48 hours into

admission A higher score is associated with a poorer

prognosis

Ranson’s admission criteria Glucose >11 Age >55 LDH >350 AST>250 WCC>16

Ranson’s criteria48 hours later Calcium <2 Haematocrit 10% pO2<60 Base deficit >4 BUN>1.8 >3 positivesevere attack

Sequelae Hypo/Hyperglycaemia Hypocalcaemia- saponification of

omental fat by pancreatic lipases chelates calcium

Hypomagnesaemia Chronicity DM

Sequelae ARDS/MODS Abscess formation Pancreatic necrosis Pseudocysts

Acute pancreatitis Management

Oxygen 2 large bore cannulae Fluid resuscitation Analgesia NG(large bore) for drainage if vomiting Urinary catheter- measure input output Bloods

Pancreatic Ca Management

Antibiotics only if evidence of pyrexia or positive blood cultures Imipenem antibiotic of choice

Surgery indicated only in presence of abscess /pseudocyst or massive infected pancreatic necrosis

Mortality significanty increased in the context of laparotomy

Pancreatic Carcinoma Ductal adenocarcinoma 60-80 years Risk factors

Smokers DM FAP Gardner syndrome

Pancreatic Carcinoma 70% occur at the head 20% in the body 10% in the tail Presentation

Weight loss Jaundice Pain Pancreatitis Trousseaus sign-superficial thrombophlebitis

assoc with Panc Ca

Pancreatic Ca Head tumours

Present with painless jaundice and earlier Palpable non tender

gallbladder(Courvosier’s sign) Body and tail

Presents later Tends to present as pain, weight loss and

hepatomegaly

Pancreatic Ca Investigations

Contrast enhanced CT-pancreatic protocol ERCP- useful for insertion of stent in

context of jaundice and tissue diagnosis MRI to seek extent of local invasion Endoscopic ultrasound Laparoscopy

Surgical management Head of pancreas/peri-ampullary

tumours Whipples operation

Resect specimen including distal stomach duodenum to jejunum head of pancreas

Gastroenterostomy Choledochojejunostomy Pancreaticojejunostomy

Pancreaticoduodenectomy

Surgical management Body and Tail tumours

Distal resection Resection rate <7% No place for adjuvant therapy Tissue diagnosis important

Neo adjuvant/adjuvant chemotherapy and radiotherapy have a role in the management of both tumours

Palliative care Alleviate symptoms only

Stenting via ERCP Bypass procedures Chemotherapy Radiotherapy

Other definitions you should know Annular pancreas

Pancreas surrounding the duodenum Congenital May present with duodenal obstruction

Pancreatic divisum Failure of the two ducts to fuse

Benign Panc TumoursMCQ stuff! Gastrinoma

Tumour of non beta islet cells May be multiple Overproduction of gastrin Leads to multiple metastases in some instances May also occur in duodenum 60% are malignant at diagnosis 30% are associated with MEN1

Gastrinoma Presentation

Peptic ulcers May be treatment resistant Diarrhoea Haematemesis Perforation

Gastrinoma Investigations

Pentagastrin secretory studies Fasting serum gastrin levels U/S, CT-localizes tumour

Treatment PPIS Resection only if localised Total gastrectomy if poorly defined

Insulinoma Solitary tumours of Beta cells of the

pancreas Presentation

Usually related to hypogylcaemia Altered consciousness Uncharacteristic behaviour

Insulinoma Diagnosis

Glucose Glucagon test Plasma insulin U/S, CT

Treatment Resection as malignant potential Distal pancreatectomy if tumour cannot be found

Next week Upper GI surgery to include

Liver Spleen Gallbladder and Biliary tree Small intestine