Comprehensive Notes on General and Cardiothoracic Surgery
Esophageal Surgical Techniques and Management of GERD
Esophagomyotomy is primarily performed for conditions such as Achalasia and Diffuse esophageal spasm. Another common surgical intervention is fundoplication, which is indicated for Gastroesophageal Reflux Disease (GERD). There are two primary types of fundoplication: the Nissen method and the Toupet method. Postoperatively, patients who undergo the Nissen procedure may experience some belching of air, a phenomenon that is not typically observed following the Toupet procedure. In cases of malignant tumors of the esophagus, the most frequently performed surgical procedure is a Total esophagectomy. For large Zenker's diverticula, Diverticulo-esophagostomy is the intervention of choice.
Bougienage is a method used to dilate the esophagus. Unlike balloon dilatation, it allows for a wider area of expansion. However, it is contraindicated in patients with mediastinitis and bronchoesophageal fistula. For erosive GERD (endoscopic positive), diagnostic criteria include reflux symptoms occurring daily or at least times per week for at least the last months, the presence of esophagitis during endoscopic examination, and the exclusion of other diseases that cause esophageal erosions. For non-erosive GERD (endoscopic negative), antacid tests and -metry can be utilized. Successful resolution of typical, atypical, and extraesophageal symptoms following treatment with Hydrogen pump blockers (HPB) confirms a diagnosis of non-erosive GERD. -metry is specifically recommended for patients who do not present with typical symptoms or those whose symptoms persist despite the use of HPB.
Esophageal Diverticula Classification and Etiopathology
Esophageal diverticula are classified based on their localization and structural type. In the upper part, pharyngoesophageal or Zenker's diverticula are categorized as false or pulsion diverticula. In the middle section, mid-esophageal or peribronchial diverticula are considered true or traction diverticula. At the lower end, epiphrenic diverticula are classified as false or pulsion diverticula. True diverticula, which are the traction type, can be caused by tuberculosis or sarcoidosis. They form when connective tissue pulls on the esophageal wall during the scarring of lymph nodes. Conversely, false diverticula form due to increased internal pressure within the esophagus.
Zenker's diverticula originate in an area known as the Killian or Ludow triangle, located between the m. cricopharyngeus and m. thyreopharyngeus muscles. The primary etiopathogenetic mechanism involves a spasm or achalasia of the upper esophageal sphincter (UES) and a lack of coordination between the UES and the pharyngeal muscles. The main symptom of Zenker's diverticula is odynophagia or painful swallowing. Objective clinical findings include a swallowing sound in the neck, a fermented or fetid odor from the mouth due to food stagnation in the diverticulum, a crunching sound during neck palpation, constant mucus in the throat, hypersalivation, and chest pain. Contrast radiography is the primary diagnostic tool, typically revealing a sac in the left paravertebral zone.
Treatment for Zenker's diverticula varies by size and severity. Myotomy, involving a longitudinal cut of the cricopharyngeal muscle, is performed for small diverticula (). Diverticulectomy combined with myotomy is considered the most radical treatment. For diverticula between and , an endoscopic stapler is used to cut and sew the partition between the diverticulum and the esophagus. If reflux disease is present, antireflux surgery must be performed before the diverticulum surgery to prevent aspiration. In true diverticula, asymptomatic cases () are simply observed, while symptomatic cases require diverticulectomy. For epiphrenic diverticula, management includes diverticulectomy, myotomy, and partial fundoplication to prevent reflux.
Esophageal Perforation and Boerhaave's Syndrome
Boerhaave's syndrome typically occurs on the left posterolateral wall of the distal esophagus. The most common cause of esophageal perforation overall is iatrogenic and is considered "early" if diagnosed within the first hours. Contrast radiography is the most immediate and informative diagnostic test, followed by esophagoscopy. Computed Tomography (CT) is highly accurate in diagnosing perforation and its associated complications. Unlike Boerhaave's syndrome, Mallory-Weiss syndrome does not cause hydrothorax or pneumothorax because it does not involve a full rupture.
The surgical approach for esophageal perforation depends on the timing and the state of the esophagus. In the early stage (first hours), the choice is suturing the perforation hole and drainage. If achalasia is the cause, an opposite-side myotomy and fundoplication are added. In the delayed stage (after hours) marked by local inflammation or sepsis, resection or isolation (diversion) is performed. However, if there is a pre-existing esophageal disease such as a malignant tumor, stricture, burn, or peptic ulcer, resection (resection + esophagostomy + jejunostomy) is the first choice regardless of the timing. If the patient is in a very critical condition, a stent and drainage are used, though stents are contraindicated in the pharynx, gastroesophageal region, or for perforations . Small, incomplete neck perforations affecting only the mucosa can be treated conservatively.
Chemical Burns of the Esophagus and Post-Burn Management
Chemical burns of the esophagus differ between acids and alkalis. Acids cause coagulation necrosis, which results in relatively superficial damage in the esophagus but more severe damage in the stomach. Alkalis cause liquefaction (colliquative) necrosis, leading to deeper damage primarily in the esophagus. Solid chemicals typically damage the neck section of the esophagus, whereas chemical liquids cause longitudinal damage along the entire length.
Burns of grades II and III progress through three phases. The first phase is the acute necrotic stage ( days), characterized by necrosis, general inflammation, and a high risk of aspiration as patients cannot swallow saliva. The second phase is the ulceration and granulation stage (within the first weeks), involving ulcers at the necrotic site and potential fistula or infectious complications. The third phase is the scarring stage (after weeks), leading to deformation, stricture formation, and a risk of malignancy. Clinical signs include edema and hyperemia of the lips, mouth, and throat, severe chest pain, and a characteristic exclusion of saliva from the mouth. CT is the initial diagnostic tool; if no perforation is seen, endoscopy is performed, specifically within the first hours.
Initial treatment for burns includes airway monitoring, cessation of oral feeding (moving from parenteral to enteral), and administration of analgesics, infusion therapy, and broad-spectrum antibiotics. In cases of severe edema, tracheostomy or intubation may be required. Vomiting should never be induced. For grade III burns, urgent laparotomy including transhiatal esophagectomy and feeding jejunostomy (not gastrostomy) is required, potentially followed by esophagoplasty weeks later.
Functional Disorders of the Esophagus
Functional disorders are categorized by the type of muscle affected. Striated muscle dysmotility causes oropharyngeal dysphagia, often diagnosed by sluggish contrast passage through the UES and managed by treating the underlying disease or through myotomy if the UES fails to relax despite normal pharyngeal contraction. Smooth muscle dysmotility is divided into primary and secondary forms. Primary forms include Achalasia, Diffuse and Segmental esophageal spasm, and Nutcracker esophagus. Secondary forms are associated with conditions like collagen vascular diseases and metabolic disorders.
Achalasia is classified radiologically into four stages: Stage I (no dilation), Stage II (longitudinal dilation), Stage III (one bend/kink), and Stage IV (multiple bends, resembling the sigmoid colon, "S-shaped"). Manometrically, it is divided into Type I (classic, no peristalsis, no Lower Esophageal Sphincter (LES) relaxation), Type II (compression, weak peristalsis ), and Type III (spastic, total spasm ). The most common complication is aspiration pneumonia. Cardiodilatation is the primary treatment. If ineffective or in stages III/IV, laparoscopic myotomy with fundoplication is indicated. For the spastic type, Peroral Endoscopic Myotomy (POEM) is preferred. Botulinum injections or calcium channel blockers are used if surgery is contraindicated. Esophagectomy is necessary if cancer is suspected, in S-shaped esophagi, or when other methods fail.
Diffuse esophageal spasm, also known as Barsony-Teschendorf syndrome, presents with a "beaded" or "corkscrew" esophagus on imaging. Pain is typically spontaneous and occurs at night. A defining characteristic is paradoxical dysphagia, where solids pass but liquids do not. Unlike Achalasia, where weight loss is common, patients with diffuse spasm maintain a normal weight, and LES tone remains normal. Treatment involves reflux management (HPB, antidepressants), antispasmodics (peppermint oil, calcium channel blockers), and potentially POEM or myotomy for refractory cases. Nutcracker esophagus involves high-amplitude, pressurized peristaltic waves with normal LES tone, for which surgical treatment is generally ineffective.
Esophageal Rings and Webs
Esophageal rings are classified into Type A (mucosal bulging due to muscle hypertrophy or spasm) and Type B (Schatzki ring, caused by mucosal hypertrophy and sub-mucosal fibrosis). They are often associated with hiatal hernias and eosinophilic esophagitis. Esophageal webs are found in Zenker's diverticulitis, iron-deficiency anemia (Plummer-Vinson syndrome), and dermatological changes. Initial approach for both involves wide dilatation using an endoscope, balloon, or bougie, along with HPB treatment.
Gastric Ulcers: Classification and Surgical Management
Gastric ulcers are classified using the Canson system. Type I occurs on the lesser curvature. Type II involves both gastric and duodenal ulcers. Type III involves prepyloric and pyloric ulcers. Type IV involves proximal or cardiac ulcers. Types II and III resemble duodenal ulcers clinically and are characterized by hyperacidity, whereas Types I and IV are not. Localization dictates the pain site: body ulcers cause epigastric pain, cardiac ulcers cause pain at the xiphoid process, and piloroduodenal ulcers cause pain epigastrically to the right of the midline. The Courvoisier triad for ulcers consists of epigastric pain, vomiting that provides relief, and ulcer bleeding. While gastric ulcers carry a risk of malignancy, duodenal ulcers do not.
Surgical indications for ulcers include complications like perforation or stenosis, failure of conservative treatment over weeks, or frequent recurrence. Vagotomy is standard for duodenal ulcers, while resection is preferred for gastric ulcers. Common surgeries include Billroth I and Billroth II gastrectomies. Billroth II involves resecting of the stomach and bypassing the duodenum. Variants include Moningom and Hofmeister-Finsterer methods. Billroth I variants include Shumaker and Haraley. Complications of vagotomy include hypergastrinemia (Zollinger-Ellison syndrome). Types of vagotomy include Truncal (requires drainage such as pyloroplasty due to atony), Selective gastric (affects only the stomach but still causes atony), and Proximal selective (denervates only the body and fundus, preserving antral motility; standard for non-healing duodenal ulcers).
Pyloroplasty methods include Jaboulay (antrum to pylorus), Finney (resects the pylorus), and Heyneke-Mikulicz ( antral and duodenal cuts with vertical suturing). Gastroenteroanastomosis is indicated for severe duodenal deformities or infiltrations. Common types include Welder, Hacker, and Braun.
Acute Stress and Drug-Induced Ulcers
Acute stress ulcers are marked by significant bleeding, while perforation and pain are rare. They are primarily driven by reduced mucosal defenses, except in burn cases where hyperacidity plays a role. Total gastrectomy is indicated if perforation occurs or if aspirin-induced ulcers do not respond to conservative care. Significant bleeding is most common in ulcers of the curvatures and the posterior duodenal wall.
Ulcer bleeding is graded from I to IV based on severity: Grade I (chronic hidden), Grade II (acute, small volume, ), Grade III (medium acute, tachycardia, shock index , ), and Grade IV (profuse, , pulse , shock index ). The Forrest classification for GI bleeding is as follows: Forrest I (active bleeding: 1a spurting, 1b oozing), Forrest II (recent bleeding: 2a visible vessel, 2b adherent clot, 2c flat pigmented spot), and Forrest III (clean ulcer base). Surgical principles for duodenal bleeding include gastroduodenal artery ligation and truncal vagotomy. For gastric ulcers, if hemodynamically stable, antrumectomy and vagotomy are performed; if unstable, excision or suturing of the ulcer is the priority. If surgery is contraindicated, embolization is attempted.
Ulcer Perforation
Duodenal ulcer perforations usually occur on the anterior wall and often lead to peritonitis. Posterior wall perforations may lead to penetration into nearby organs, most commonly the pancreas, causing back pain. Clinical signs include a "wood-like" rigid abdomen, stabbing pain, the Phrenicus symptom (referred pain to the shoulder/neck), and Spijarnı's symptom (loss of liver dullness). Contrast CT is the definitive diagnostic choice.
Surgical management of perforation depends on the presence of purulent peritonitis. If present, the perforation is covered with an omental patch (Graham's patch) and the area is cleaned. If not present and the patient is stable, ulcer excision and vagotomy are performed. Conservative management (Taylor's method) involving antibiotics, nasogastric aspiration, and infusion is indicated only if surgical risk is extremely high, the perforation occurred over hours ago without diffuse peritonitis, and no extravasation is seen on contrast studies.
Post-Gastrectomy and Post-Vagotomy Complications
Pyloric stenosis is graded as mild (contrast delayed hours), medium (delayed up to hours), or severe (total blockage, delayed hours). Management ranges from conservative treatment with proximal selective vagotomy for mild cases to urgent resection for severe cases.
Reflux gastritis following gastric surgery presents with burning epigastric pain not relieved by antacids, bile vomiting, weight loss, and anemia. Diagnosis is made via endoscopy. Surgical correction involves converting to a Roux-en-Y gastrojejunostomy. Afferent loop syndrome involves duodenal dilation, post-prandial abdominal pain, and bile vomiting without food residue, often relieved by vomiting. Treatment involves converting to Roux-en-Y. In contrast, Efferent loop syndrome presents with a dilated gastric stump and vomiting containing food residue, with no relief after vomiting.
Dumping syndrome is diagnosed by clinical history and contrast imaging. Early dumping occurs within minutes of eating due to hyperosmolarity and hypovolemia, presenting with tachycardia, weakness, and nausea. It is graded I to III based on severity (: mild, pulse increase of ; : severe, weight loss , symptoms for up to hours). Late dumping occurs hours post-prandial due to hyperinsulinemia and hypoglycemia, featuring tremors, bradycardia, and weakness. Treatment is primarily conservative, but if surgery is needed, Roux-en-Y is most effective.
Post-vagotomy complications include dysphagia, gastrostasis (common after truncal vagotomy), duodenostasis (treated with Roux-en-Y), and diarrhea. Gastrostasis management includes nasogastric suctioning and prokinetics; if no response within weeks, resection is required. Recurrent ulcers after vagotomy may be due to incomplete vagotomy (missing the Grassi nerve) or Zollinger-Ellison syndrome, evaluated using the Hollander insulin test.
Inflammatory Bowel Disease and Colorectal Conditions
Ulcerative Colitis (UC) is categorized endoscopically into mild, moderate, and severe stages. Mild UC shows diffuse hyperemia and small erosions primarily in the rectum. Moderate UC features a "granular" mucosa, multiple erosions, pseudopolyps, and fibrin/pus/mucus. Severe UC involves the entire colon, with microscopic abscesses and ulcers that may perforate. Complications include toxic megacolon (most dangerous), profuse bleeding, and various extraintestinal issues like sclerosing cholangitis, skin erythema, and arthritis. Crohn's disease is more likely to cause anal pathologies (fistulas, fissures, abscesses), whereas UC causes rectal damage. UC surgery includes total proctocolectomy with ileoanal anastomosis (Ravitch and Sabiston) or ileostomy (Brooke and Kock).
Crohn's disease most frequently requires surgery due to intestinal obstruction. Surgical treatments include resection, stricturoplasty (Heyneke-Mikulicz for , Finney for ), and abscess drainage. Diverticulitis is classified using the Hinchey scale (). Hinchey I (abscess ) and II (abscess ) are managed with antibiotics and percutaneous drainage; Hinchey III (purulent peritonitis) and IV (fecal peritonitis) require urgent Hartmann's operation.
Proctology: Hemorrhoids, Fissures, and Prolapse
Internal hemorrhoids occur above the dentate line and are covered by mucosa. External hemorrhoids are below the dentate line and covered by anal epidermis. They typically form at the , , and o'clock positions. Chronic hemorrhoids are graded I to IV depending on the degree of prolapse (: no prolapse; : permanent prolapse). Less invasive treatments include sclerotherapy and latex band ligation (though ligation is not used for external nodes). Surgical options include Milligan-Morgan (most optimal) or the Longo procedure. Hemorrhoidectomy is contraindicated in portal hypertension and Crohn's.
Anal fissures most commonly occur at the posterior commissure ( o'clock position); lateral fissures suggest Crohn's. Management includes conservative measures like the Recamye method (sphincter dilation) or surgical excision (Gabriel's method, laser vaporization, or internal sphincterotomy). Rectal prolapse is common in women due to multiple childbirths. Grade I involves prolapse only during defecation, while Grade III occurs upon standing. Clinical features include fecal incontinence. Surgical options range from the Tirsh ring ( days) for early stages to intraabdominal rectopexy (Zerenin-Kummel) for advanced cases.
Acute paraproctitis involves perirectal abscesses, most commonly subcutaneous. Pain often subsides if the abscess opens to the surface or into the bowel, but this is not a full recovery. Chronic paraproctitis manifests as fistulas, classified by their relation to the sphincter (intrasphincter, transsphincter, etc.). Treatments include fibrin glue ( effective), the LIFT procedure, and Seton (ligature technique).
Intestinal Obstruction (BK)
Intestinal obstruction is classified as Mechanical (obstructive, strangulation), Dynamic (spastic, paralytic), or Mixed (adhesion, intussusception). Superior Mesenteric Artery Syndrome (SMA syndrome) occurs when the duodenum is compressed between the SMA and the aorta. Strangulation is more severe and characterized by a lack of blood supply, caused by hernias or volvulus. Paralytic BK is commonly seen after surgery or with peritonitis. In the early stage of total BK, hypermotility and antiperistaltic contractions occur. The dehydration stage leads to hypovolemia. Early electrolyte changes include hypokalemia (alkalosis) due to vomiting, while later stages involve hiperkalemia (acidosis) as renal function drops.
Diagnostic signs include Bloemberger (Shchetkin-Blumberg) in late stages, Val's symptom (visible bowel loops in thin patients), Sklyarov's symptom (splashing sounds), and Spasokukotskiy-Vilms' (falling drop sound). Radiological signs include Kloiber's cups (liquid levels in mechanical BK). In spastic BK, the abdomen is drawn in rather than bloated. Management of strangulation involves detorsion and checking the viability of the loop using color, peristalsis, and arterial pulsation criteria. If necrotic, resection is performed ( proximal, distal).
Intussusception in children is often caused by hyperperistalsis and presents with "currant jelly" bloody stools. Management involves air inflation (pneumocolon) unless peritonitis is present. In adults, intussusception is usually caused by polyps.
Thyroid Gland Disorders
The thyroid gland is classified by growth form (diffuse, nodular, mixed), growth degree ( scale), and function (hyper, eu, or hypo-thyroid). Thyroidectomy and subtotal resection are common procedures. Post-operative complications include hypoparathyroidism and laryngeal nerve injury (superior nerve injury causes swallowing issues; recurrent nerve injury causes aphonia). Endemic goiter features decreased and increased . The Pemberton symptom involves cyanosis when the patient raises their hands above their head.
Graves' (Bazedov's) disease is characterized by a triad: diffuse goiter, exophthalmos (bulging eyes), and tachycardia. It is associated with TSİ-LATS antibodies. Numerous specific signs are noted: Mari's sign (tremor of extended fingers), Rosenbach's (tremor of closed eyelids), Telegraph pole sign (body tremor), Dalrymple's (wide eye opening), Graefe's (sclera visible when looking down), Kocher's (sclera visible when looking up), and Moebius' (impaired convergence). Treatment includes antithyroid drugs (PTU for pregnancy) and radioactive iodine, though iodine is contraindicated in children and during lactation.
Thyroiditis includes acute forms (pain radiating to the jaw/ear), subacute De Quervain's (viral, diagnosed with the Crail-prednisolone test), and chronic forms like Hashimoto's (autoimmune, presenting with Hashkenezahoyter cells on biopsy) and Riedel's goiter (iron-hard goiter, requires surgery due to malignancy risk and tracheal compression).
Acute Appendicitis and Peritonitis
Acute appendicitis is often caused by obstruction (fecalith) and bacterial infection (primarily and ). Forms range from simple (cataral) to destructive (phlegmonous, gangrenous). The sequence of symptoms is typically anorexia followed by pain and then vomiting. The Volkoviç-Koxer symptom describes pain starting in the epigastrum and shifting to the right iliac fossa after hours. Numerous diagnostic signs exist: Rovzing's, Sitkovski's (pain when lying on the left side), and Blumberger's. Gangrenous appendicitis may show a reduction in pain due to nerve death, but tachycardia persists. Atypical locations include retrocecal (presents with diarrhea and positive Obrazov's sign) and pelvic (diagnosed via rectal exam). Appendicular infiltrate is managed conservatively for weeks before a planned surgery months later.
Peritonitis is classified as primary (hematogenous or via fallopian tubes) or secondary (organ rupture). Secondary peritonitis moves from a compensated stage to sepsis and multi-organ failure. Symptoms include a "wood-rigid" abdomen and the Mendel symptom (pain during abdominal percussion). Diagnostic imaging includes ultrasound and CT, where free air under the diaphragm indicates perforation. Treatment involves urgent surgery for source control and extensive lavage ( of ).
Liver, Gallbladder, and Pancreas Surgery
Liver cirrhosis symptoms include jaundice, hypocoagulation, and portal hypertension signs like ascites and varices. Portal hypertension (PH) is confirmed if portal vein pressure is or the gradient between the PV and IVC is . Management of variceal bleeding involves endoscopic ligation or the Blakemore tube. Ascites is treated with sodium restriction, spironolactone, and potentially . Liver failure requires transplantation or bridge therapies like plasmapheresis.
Gallstones are mostly cholesterol stones () caused by bile saturation or stasis. Mirizzi syndrome occurs when a stone in the cystic duct compresses the common bile duct, causing jaundice. Laparoscopic cholecystectomy is the gold standard for symptomatic stones. Acute cholecystitis signs include Murphy's (interrupted inspiration during palpation), Ker's, and Ortner's. Charcot's triad (pain, jaundice, fever) and Reynolds' pentad (adding shock and confusion) indicate acute cholangitis, which requires urgent decompression if toxic.
Acute pancreatitis presents with girdle-like pain and specific skin signs: Grey-Turner's (side bruising), Cullen's (umbilical cyanosis), and Mondon's (face spots). Diagnosis requires a -fold increase in amylase or lipase. Severe cases are graded by Ranson and Balthazar criteria. Chronic pancreatitis is often due to alcohol or biliary issues, presenting with persistent epigastric pain. Complications include pseudocysts and fistulas. Management involves enzyme supplementation and drainage procedures like Puestow if the duct is dilated.
Hernias and Thoracic Conditions
Hernias consist of a ring, sac, and contents. Strangulation is the most dangerous complication. Specific types include Richter's (partial wall), Littre's (Meckel's diverticulum), Maydl's (retrograde), and Amyand's (appendix in the sac). Repair methods include Bassini's (posterior wall), Lichtenstein's (mesh), and McVay's. Umbilical hernias in adults are common in pregnancy and managed with Mayo's or Sapejko's procedures.
Thoracic conditions include lung abscesses (primarily due to aspiration), lung gangrene (extensive necrosis without demarcation), and bronchiectasis (dilated bronchi, often in the left lung). Pneumothorax is categorized as open, closed, or tension (the most life-threatening due to the valve mechanism). Management of tension pneumothorax involves needle decompression followed by drainage.
Cardiac Surgery and Mediastinitis
Cardiac surgeries include Coronary Artery Bypass Grafting (CABG), often using the Internal Mammary Artery (LIMA). Congenital defects include Fallot's Tetralogy (pulmonic stenosis, VSD, dextroposition of aorta, right ventricular hypertrophy). Heart valves are replaced with mechanical (requires lifelong warfarin) or biological valves. Mediastinitis is a serious inflammation of the mediastinum, often caused by esophageal perforation () and carrying a high mortality rate (). Chronic fibrotic mediastinitis is frequently caused by histoplasmosis and can lead to Superior Vena Cava (SVC) syndrome.