Comprehensive Study Guide on Esophagus, Stomach, and Nutrition in Surgery

Between what muscles do Zenker's diverticulum develop?

esophagus & cricopharyngeus muscle

MC location perforation in Boerhaave's syndrome

lower thoracic esophagus

parts of esophagus

cervical, thoracic, abdominal

The LES is a zone of high

pressure

Early sign of carotid hematoma is

dysphagia followed by hoarseness

Substernal burning discomfort may radiate to epigastrium or sternal notch

pain occurs 1-2 hrs AFTER eating

worse when pt lies down at night or after meal

GERD

Medical tx GERD

PPIs and H2 blockers

When may surgery be indicated for GERD?

pts dependent on medical tx for sx relief

Dx GERD (3)

endoscopy

24 hr pH monitoring

measurement of LES pressure/Manometry

Gold standard dx GERD

24 hour pH monitoring

Condition in which tubular esophagus is lined with columnar rather than squamous epithelium

intestinal metaplasia within sphincter-- loss of LES function --> free reflux & progressive mucosal injury

Barrett's esophagus

Complications of GERD (3)

erosive esophagitis, stricture, Barrett's

Tx of high-grade dysplasia in Barrett's esophagus

Esophagectomy

(40-50% pts will have invasive CA)

Surgery of choice GERD

laparoscopic Nissen Fundoplication

Benign esophageal tumors (2)

Leiomyoma & Hemangioma

MC benign esophageal tumor

Leiomyoma

MC malignant esophageal tumor

SCC

2 types of malignant esophageal tumors

SCC (MC) & adenocarcinoma

MC symptom esophageal carcinoma

dysphagia

Test of choice esophageal carcinoma

barium swallow & endoscopic evaluation

Definitive dx Esophageal Carcinoma

endoscopy with bx

If lymphadenopathy for esophageal carcinoma exists, what should be performed?

If nodes are positive, what is the prognosis?

FNA

6-9 month survival

Mucosal irregularity & shelf of tumor is consistent with (SCC/adenocarcinoma)

SCC

Lesion at GE junction is consistent with (SCC/adenocarcinoma)

adenocarcinoma

Esophageal carcinoma palliative tx

- Radiation

- intubation & stenting (<6 months to live)

- transthoracic resection

Transthoracic resection

(distal lesions- CA of distal esophagus & cardia)

pull stomach up & use as conduit more so than digestive organ--> add chest tube or pigtail catheter--> re-expand lung and ensure no leak from anastomoses--> swallow study (no leak- can remove tube)

removal is of blue pt in picture

Transthoracic resection

(proximal lesions-- middle or upper 1/3 esophagus tumors)

aka Ivor Lewis Esophagectomy

Pull stomach into chest, 1-2 pigtail catheters/chest tubes to re-expand lung, drainage for leak of anastomoses

Ivor Lewis Esophagectomy aka transthoracic esophagectomy requires what two incisions

Abdominal incision & right thoracotomy

What surgical approach for esophageal carcinoma minimizes poor results associated w/ transthoracic resection

Transhiatal resection

Why are there less poor results with transhiatal resection for esophageal CA?

anastomoses in the neck are less likely to break

Unlike transthoracic resection, Transhiatal resection involves incisions of the ______________ and _______________

abdomen, neck

Region of stomach distal to GE junction

cardia

Portion of stomach above and left to GE junction

fundus

Gastric ______________ is bounded distally by the pylorus

antrum

(T/F) stomach is highly vascular

True

Lymphatic drainage of the stomach mimics ______________ supply; therefore, diseases that spread through lymphatics extend to distal ______________ ____________ quickly

blood, lymph nodes

90% of Vagus is (afferent/efferent) from GI tract to CNS

afferent

NT of efferent vagal neurons

ACh

Tx of PUD is primarily (surgical/medical)

medical

MCC PUD

H. pylori

Risk factors PUD

smoking, NSAIDs, ASA,

Pts w/ PUD complain of burning, stabbing, gnawing ____________________ pain

epigastric

Gold standard dx PUD

endoscopy

PUD medical tx

PPI + abx

PPI (omeprazole)

+ clarithromycin

+ metronidazole/ amoxicillin

x 7-14 d

H2 blockers

Sucralfate

Antacids

Surgical tx of ulcers is indicated when?

complicated ulcer DZ--> hemorrhage, perforation, obstruction

Surgical procedures ulcers (3)

- Truncal vagotomy + drainage (pyloroplasty)

- Truncal vagotomy + antrectomy** procedure of choice!

(Billroth I and II)

- Proximal gastric vagotomy

Ulcer procedure involving denervation & elimination of sphincteric function

truncal vagotomy & drainage

Most definitive surgical tx ulcers

truncal vagotomy & antrectomy

Ulcer procedure that reduces receptive gastric relaxation (emptying of liquids faster), affects acid producing parts of stomach not the sphincter

proximal gastric vagotomy

Billroth I

Gastroduoden-ostomy

Attaches remaining stomach to the duodenum

Billroth II

Gastrojejunostomy

Which is preferred- Billroth I or II?

Billroth I

...but more difficult

Which is easier- Billroth I or II?

Billroth II

Leading cause of death related to ulcer disease

upper gastrointestinal hemorrhage

What is both diagnostic and therapeutic for UGIB?

endoscopy

Surgical tx UGIB

duodenotomy

+ direct ligation of bleeding vessel in ulcer base

+ procedure to reduce acid production (truncal vagotomy and pyloroplasty

OR truncal vagotomy + antrectomy)

sudden severe epigastric pain, may radiate to right scapula

duodenal perforation

Surgical tx Duodenal Perforation

omental patch (Graham patch)

+ tx for H. pylori and secretory agents

How does Graham patch procedure heal duodenal perforation?

mesenteric stem cells are used to heal rupture

Test of choice and treatment of gastric ulcer

endoscopy w/ biopsy (r/o gastric carcinoma)

Risk factors Gastric cancer

- H-pylori

- Chronic gastritis

- Adenomatous polyps

Gastric CA diagnosis

endoscopy w/ bx

- Barium studies

- CT

What lymph nodes are usually affected in gastric CA?

virchow's

sister mary joseph's

irish

Surgical tx gastric carcinoma

Laparoscopy/ Laparotomy

- subtotal gastrectomy w/ gastrojejunal reconstruction

- total gastrectomy w/ esophagojejunostomy

- esophago-gastrectomy w/ anastomosis in cervical or thoracic position

50% of gastrointestinal lymphomas occur in the _______________________

stomach

MC organ involved in extranodal lymphoma

stomach

Dx gastric lymphoma

endoscopy + biopsy

Surgery gastric lymphoma

partial/total gastrectomy

+ radiation & chemo

MC gastric sarcoma

Leiomyosarcoma

MC performed bariatric procedure

sleeve gastrectomy

To qualify for bariatric surgery an individual's BMI needs to be >__________ or ____________ with comorbid medical conditions

40, 35-40

Bariatric procedures

Restrictive

- LAGB (laparoscopic adjustable gastric banding)

- SG (sleeve gastrectomy)

Malabsorptive

- BPD (biliopancreatic diversion)

- DS (duodenal switch)

Combination

- Roux-en-Y gastric bypass

Involves placement of inflatable silicone band around proximal stomach

Band is attached to reservoir system & accessed through SQ placed port

LAGB (laparoscopic adjustable gastric band)

Roux-en-Y gastric bypass

Small pouch created from stomach

Part of small intestine bypassed

Restriction and malabsorption

Sleeve gastrectomy

Portion of stomach is removed, leaving a banana-shaped stomach pouch

1st muscle to waste in malnutrition

temporal (jaw)

Laboratory data malntutrition

- albumin

- total lymphocyte count

- transferrin

- prealbumin

- retinol binding protein

Preferred form nutritional support

Enteral

What equation is used to assess energy expenditure?

Basal Energy Expenditure (B.E.E.)

Complications of TPN

- infection

- gut atrophy

- hyperglycemia

- fatty liver

- acalculous cholecystitis

TPN composition

Carbs, lipids, proteins, vitamins, minerals, electrolytes

NPC:Nitrogen ratio is useful in determining

severity of illness

The sicker the pt. is the (larger/smaller) the NPC:N ratio

smaller

TPN special formulations

Hepatic

- Branched chain AAs

Renal

- Low protein

Pulmonary

- Dec. carbs, inc lipids

Immune enhancing

- impact

Enteral nutrition benefits

- decreases brush border atrophy

- decreases translocation of bacteria

What enteral formulation is used as a standard tube feed preparation?

polymeric

What enteral formulation is used for septic/malnourished pts?

oligomeric

Impact vs Oxepa

(immune enhancing formula)

Oxepa lacks Arginine