Stomack and Duodenum Upper Gastrointestinal Surgery

1. Stomack and DuodenumUpperGastrointestinalSurgery

2. Upper gastrointestinal endoscopy • There are three types of endoscopy looking at the upper GI and pancreaticobiliary tracts.

3. Gastroscopy • Correctlytermedoesophago-gastro-duodenoscopy (OGD). • Allowsdirectvisualizationofpathology and letssmallchannelbiopsiesbetaken. • Indications: • Investigationofdysphagia. • Investigationofdyspepsia, refluxdisease, upperabdominalpain. • Investigationofacute or chronicupper GI bleeding. • Investigationofirondeficiencyanaemia (withcolonoscopy).

4. Gastroscopy • Therapeuticinterventionsforupper GI pathology: • balloondilatationofbenignstrictures; • endoluminalstentingofmalignantstrictures; • injection, coagulation, or bandingofbleedingsourcesincludingulcers, varices, tumours, and vascularmalformations.

5. GastroscopyPreparation and procedure • Patient should be starved for 4h (except in emergency indications). • IV access required. • Always performed with local anaesthetic throat spray (lignocaine). • Often performed with IV sedation (e.g. midazolam 5mg).

6. Gastroscopy Risks and complications • Perforation (usually of the oesophagus)median risk approximately 1/3000. Highest in elderly, with oesophageal pathology, during therapeutic interventions. • Bleedingcommonest after biopsies or therapeutic procedures. • Respiratory depression and arrestrelated to overmedication with sedative. Commonest in frail, low body weight, elderly patients.

7. Endoscopic retrograde cholangiopancreatography (ERCP) Indications • Investigation of possible biliary disease (common bile duct stones, biliary strictures, biliary tumors, biliary injuries, intrahepaticbiliary disease). • Investigation of pancreatic disease (pancreatic duct strictures, pancreatic duct abnormalities). • Therapeutic interventions for pancreatico-biliary disease: • stenting for common bile duct stones, strictures, tumours; • sphincterotomy for the extraction of biliary stones.

8. Preparation and procedure • Patientshouldbestarvedfor 4h (except in emergencyindications). • IV accessrequired. • Alwaysperformedwithlocalanaestheticthroat spray (lignocaine). • Alwaysperformedwith IV sedation (e.g. midazolam 5mg) and occasionallyanalgesia (pethidine 50mg, fentanyl). • PerformedunderX-rayscreeningguidance, usually in X-ray department. • Maybeperformedunder GA.

9. Risks and complications • Perforation (of the oesophagus or of the duodenum)median risk approx 1/1000. Highest in elderly, with pathology, during therapeutic interventions especially sphincterotomy • Bleeding: commonest after biopsies or therapeutic procedures, especially sphincterotomy. Usually controlled by balloon pressure; may require open surgery. • Respiratory depression and arrest: related to overmedication with sedative. Commonest in frail, low body weight, elderly patients.

10. Ileoscopy • Oftentermed ˜pushendoscopy. Performedwithlonglengththincalibreendoscopeaiming to intubatepasttheduodeno-jejunaljunction and visualizethefirstloopsoftheuppersmallbowel. • Indications • Investigationofundiagnosedupper GI bleeding (possiblydue to proximalsmallbowelpathology). • Investigationofabdominalpain. • InvestigationofuppersmallbowelCrohn'sdisease.

11. Ileoscopy • Preparation and procedure • Asforgastroscopy. • Risks and complications • Asforgastroscopy.

12. Oesophageal motility disorders Key facts • A spectrum of diseases involving failure of coordination or contraction of the oesophagus and its related muscular structures. Pathological features • In some cases degeneration of the inner and outer myenteric plexuses can be demonstrated but often no structural abnormality is seen.

13. Clinical features Achalasia • Peak ages of incidence in young adulthood (idiopathic) and old age (mostly degenerational). • Slowly progressive dysphagia: initially worse for fluids than solids. • Frequent regurgitation of undigested food common late in the disease. • Secondary recurrent respiratory infections due to aspiration.

14. Clinical features Diffuse oesophageal spasm • Commonest in young adults; • Characterized by acute pain along the length of the oesophagus induced by ingestion, especially of hot or cold substances (odynophagia).

15. Diagnosis and incestigations Achalasia • Video bariumswallow. A characteristicfailureofrelaxationoftheloweroesophaguswithasmoothoutline 's tail or birdbeak. • Oesophagealmanometry. Hypertonicloweroesophagealhighpressurezonewithfailureofrelaxationnormallyinduced by swallowing. In chroniccasestheproximaloesophagusmaybeadynamic. • Oesophagoscopy. To excludebenign and malignantstrictures.

16. Diagnosis and incestigations Diffuseoesophagealspasm • Video bariumswallow. Corkscrewappearanceoftheoesophaguscaused by dyscoordinateddiffusecontractions. • Oesophagealmanometry. Diffusehypertonicity and failureofrelaxation. Little or no evidenceofcoordinatedprogressiveperistalsisduringepsiodesbutnormalperistalsiswhenasymptomatic. • Oesophagoscopy. Required to excludeunderlyingassociatedmalignancy.

17. Treatment Achalasia • Endoscopicallyguidedcontrolledballoondilatation (fixedpressure)—successful in up to 80% ofpatients. Lowcomplications rate (perforation). Mayneedmultipleprocedures over time. • Botulinumtoxininjections: success in somepatientsfailingdilatation.

18. Treatment Achalasia • Surgicalmyotomy (Heller'scardiomyotomy). Open or thoracoscopicallyperformeddivisionoftheloweroesophagealmusclefibres. Highlysuccessful in resistantcases. Most applicable to youngpatients. • Specificcomplicationsincludereflux, obstructionofgastro-oesophagealjunction, oesophagealperforation.

19. Treatment Diffuseoesophagealspasm • Oral calciumchannelblockers, or relaxants, e.g. benzodiazepines. • Long-actingnitric oxide donors (smoothmusclerelaxant). • Widespreadoesophagealpneumaticdilatations (oftenrepeated). • Longsurgicalopenmyotomyrarelyundertaken.

20. Treatment Diffuseoesophagealspasm • Keyrevisionpointsanatomy and physiologyoftheoesophagus • Upper 2/3. Stratifiedsquamousepithelial-lined (developssquamouscarcinoma), striatedskeletalmuscle, lymphaticdrainage to neck and mediastinalnodes, somaticinnervationofsensation (e.g. moderatelyaccuratelocationoflevelofpathology). • Lower 1/3. Transition to columnarepithelium (developsadenocarcinoma), transition to smoothmuscle, lymphaticdrainage to gastric and para-aorticnodes, visceralinnervation (poor localizationofpathology).

21. Treatment Diffuseoesophagealspasm • Gastro-oesophagealjunctionis site ofporto-systemicanastomosis (betweenleftgastric and (hemi)azygousveins) maydevelopgastric or oesophagealvarices. • Upperoesophagealsphincter (UOS) = cricopharyngeus. • Loweroesophagealsphincter (LOS) = functionalzoneofhighpressureabovethegastro-oesophagealjunction. Relaxantsincludealcohol. • Swallowingrequiresintact and coordinatedinnervationfromvagus (UOS, oesophagus, LOS) and intramuralmyentericplexus.

22. Pharyngeal pouch Key facts • An acquired pulsiondiverticulum arising in the relatively fibrous tissue between the inferior constrictor and cricopharyngeus muscle: ˜Killian's dehiscence. • Arises primarily as a result of failure of appropriate coordinated relaxation of the cricopharyngeus causing increased pressure on the tissues directly above during swallowing. • Typically occurs in the elderly. • Associated with lower cranial nerve dysfunction (e.g. motor neuron disease, previous CVA).

23. Pharyngeal pouch Pathological features • Acquired diverticulum: fibrous tissue and serosa without muscle fibres in most of the wall. • Tends to lie to one side of the midline due to the cervical spine directly behind. Clinical features • Upper cervical dysphagia. • Intermittent ˜lump appearing to the side of the neck on swallowing. • Regurgitation of foodundigested.

24. Pharyngeal pouch Diagnosis and investigations • Diagnosis may be made on observed swallowing with a transient neck swelling appearing. • Video barium swallow will show filling of pouch. • Gastroscopy should be avoided unless there is a question of associated pathology since the pouch is easily missed and easily damaged or perforated by inadvertent intubation. Treatment • Endoscopic stapled pharyngoplasty: side to side stapling of pouch to the upper oesophagus, which also divides the cricopharyngeus muscle.

25. Hiatus hernia Key facts • The presence of part or all of the stomach within the thoracic cavity, usually by protrusion through the oesophageal hiatus in the diaphragm . • Very common; majority are asymptomatic. • May or may not be associated with gastro-oesophageal reflux disease. • Predisposing factors: obesity, previous surgery.

26. Hiatus hernia Clinico-pathological features • Sliding hernia • Results from axial displacement of upper stomach through the oesophageal hiatus, usually with stretching of the phrenico-oesophageal membrane. • By far the commonest form. May result in GORD.

27. Rolling (paraoesophageal) hernia • Results from the displacement of part or all of the fundus and body of the stomach through a defect in the phrenico-oesophageal membrane such that it comes to lie alongside the normal oesophagus. • Much less common. • Symptoms include hiccough, ˜pressure in the chest, odynophagia. • May result in volvulus or become incarcerated and cause obstruction.

28. Rolling (paraoesophageal) hernia Diagnosis and investigations • Video barium swallow usually identifies the type and extent. • CT scanning of the thorax is the investigation of choice in acute presentations.

29. Treatment Medical (mainlyfor GORD symptoms) • Reduceacidproduction. Stop smoking, loseweight, reducealcoholconsumption. • Counteractacidsecretion: protonpumpinhibitors, symptomaticreliefwithantacids. • Promoteoesophagealemptying : promotilants, e.g. metoclopramide.

30. Treatment Surgical • Rarelyrequired. Indicatedfor; • persistentsymptomsdespitemaximalmedicaltherapy; • establishedcomplicationsofrollingherniasuchasvolvulus or obstruction. • Electiveprocedureofchoiceisopen or laparoscopicreductionofthehernia and fixation (gastropexy), usuallywithplicationoftheoesophagealopening (curalplication), occasionallywith a fundoplication (e.g. Nissen'soperation) if GORD symptomspredominate. Acutepresentationsmayrequire a partialgastrectomy.

31. Sliding hernia, Rolling hernia

32. Gastro-oesophageal reflux disease Key facts • Pathologically excessive entry of gastric contents into the oesophagus. • Reflux occurs in ‘normals’ up to 5% of the time. • Commonest in middle-aged adults. • Usually due to gastric acid but also due to bile reflux.

33. Gastro-oesophageal reflux disease Contributory factors include: • reduced tone in the lower oesophageal sphincter: idiopathic, alcohol, drugs, previous surgery, secondary to existing peptic stricture. • increased intragastric pressure: coughing, delayed gastric emptying, large meal.

34. GORD Pathological features Oesophagitis • Results in inflammatory changes in the squamous lined oesophagus. • Varies in severity from minor mucosal erythema and erosions to extensive circumferential ulceration and stricturing. (graded I to IV). Stricture • Chronic fibrosis and epithelial destruction may result in stricturing. • Eventually shortening and narrowing of the lower oesophagus. • May lead to fixation and susceptibility to further reflux.

35. Oesophageal metaplasia Barrett´s oesophagus • May develop as a result of gastro-oesophageal reflux; possibly more commonly in biliary reflux. • Normal squamous epithelium is replaced by columnar epithelium. • Dysplasia and premalignant change (metaplasia) may occur in the columnar epithelium.

36. Oesophageal metaplasia Barrett´s oesophagus Clinical features • Dyspepsia may be the only feature; may radiate to back and left neck. • True reflux may occur with acid in the pharynx. • Commonly worse at night, after large meals, and when recumbent. • Dysphagia may occur if there is associated ulceration or a stricture.

37. Oesophageal metaplasia Barrett´s oesophagus Diagnosis and investigations • Under the age of 45 • Symptoms are relatively common and can be treated empirically. Investigation is only required if symptoms fail to respond to treatment. • Over the age of 45 • Reflux can be confirmed by 24h continuous pH monitoring. Peaks of pH change must correspond to symptoms. OGD should be performed in all new cases over the age of 45 to exclude oesophageal malignancy.

38. Oesophageal metaplasia Barrett´s oesophagus Treatment Medical • Reduce acid production: smoking, weight, alcohol consumption. • Counteract acid secretion: proton pump inhibitors (e.g. omeprazole 20mg od), symptomatic relief with antacids (e.g. Gaviscon 10mL PO od). • oesophageal emptying: promotilants, e.g. metoclopramide 10mg tds PO.

39. Oesophageal metaplasia Barrett´s oesophagus Treatment Surgical • Procedure of choice is laparoscopic fundoplication, ‘Nissen'soperation’ (wrapping fundus of the stomach around the intraabdominaloesophagus to augment high pressure zone).

40. Oesophageal metaplasia Barrett´s oesophagus Treatment Surgical • Rarely required. Indicated for: • persistent symptoms despite maximal medical therapy; • large volume reflux with risk of aspiration pneumonia; • complications of reflux including stricture and severe ulceration. • Uncertain role in the prevention of progressive dysplasia in Barrett's oesophagealmetaplasia in the absence of symptoms.

41. Oesophageal tumours Keyfacts and pathologicalfeatures • There are severaltypesofoesophagealtumours. • Adenocarcinoma • Rapidlyincreasingincidence in Western world: 5:1. • Commonest in Japan, northernChina, and SouthAfrica, • Associatedwithdietarynitrosamines, GORD, and Barrett'smetaplasia. • Typicallyoccurs in thelowerhalfoftheoesophagus.

42. Oesophageal tumours Keyfacts and pathologicalfeatures • Squamouscarcinoma • Incidenceslightlyreducing in Western world: 3:1. • Associatedwith smoking, alcoholintake, diet poor in freshfruit and vegetables, chronicachalasia, chroniccausticstrictures. • Mayoccuranywhere in theoesophagus.

43. Oesophageal tumours Keyfacts and pathologicalfeatures • Rhabdomyo(sarco)ma • Malignanttumourofskeletalmusclewalloftheoesophagus. Veryrare. • Lipoma and gastrointestinalstromaltumours • (GIST ) are rare.

44. Oesophageal tumours Clinicalfeatures • Dysphagia. Any new symptomsofdysphagia, especially over theageof 45, shouldbeassumed to beduetotumouruntilprovenotherwise. • Haematemesis. Rarelythepresentingsymptom.

45. Oesophageal tumours Clinicalfeatures • Incidental/screening. Occasionallyidentifiedas a resultoffollow-up/screeningforBarrett'smetaplasia, achalasia, or refluxdisease. Presenceofhighgradedysplasia in Barrett'sisassociatedwiththepresenceofanoccultadenocarcinomain 30%. • Symptomsofdisseminateddisease. Cervicallymphadenopathy, hepatomegalydue to metastases, epigastricmassdue to para-aorticlymphadenopathy.

46. Oesophageal tumours Clinicalfeatures • Symptomsoflocalinvasion. Dysphonia in recurrentlaryngeal nerve palsy, cough and haemoptysis in trachealinvasion, neckswelling in SVC obstruction, Horner'ssyndrome in sympatheticchaininvasion.

47. Oesophageal tumours Diagnosis and investigations • Diagnosisusually by flexibleoesophagoscopy and biopsy. • Bariumswallowonlyindicatedforfailedintubation or suspectedpost-cricoidcarcinoma (oftenmissed by endoscopy).

48. Oesophageal tumours Diagnosis and investigations • Staginginvestigations • Localstaging: endoluminalultrasoundscan to assessdepthofinvasion. • Regionalstaging: CT scanning to evaluatelocalinvasion, locoregionallymphadenopathy, liverdisease. • Disseminateddisease. PET scanningmaybeused to excludeoccultdisseminateddisease in patientsotherwiseconsideredforpotentiallycurativesurgery.

49. Oesophageal tumours Treatment • Palliative • Most patientspresentwithincurabledisease and requirepalliation. • Dysphagiacanbetreated by endoluminalself-expanding metal stenting (SEMS), externalbeamradiotherapy. Surgeryisveryrarelyindicatedforpalliation. • Metastases: systemicchemotherapyifsymptomatic.

50. Oesophageal tumours Treatment Potentiallycurative • Squamouscarcinoma: radicalexternalbeamradiotherapyfollowed by surgery (radicalresection). • Adenocarcinoma (large): neoadjuvantchemoradiotherapyfollowed by surgery (radicalresection). • Adenocarcinoma (small) or highgradedysplasia in Barrett's: surgicalresection.