ABSITE REVIEW - SSAT · 2017. 8. 15. · rectum where taenia disappear • Low colostomy reversal...

ABSITE REVIEW2020

Upper GI, Lower GI, and Hernia

Suzie Hill, MD PGY-4

@suziehillmd@SSATnews

UPPER GI• GERD

• Esophageal dysmotility

• Esophageal Cancer

• Peptic Ulcer Disease

• Gastric Cancer

• GIST


www.SSAT.com@SSATNews

GERD

• 4 tests for work-up• Esophageal Manometry

• 24h pH study (or impedance)

• EGD

• Barium swallow

• Medical management: diet modification, H2 blockers, PPIs

• Anti-reflux surgery:• Assess for hiatal hernia

• Mobilization of esophagus (4cm intra-abd), Collis gastroplasty for more length if needed

• Reapproximation of diaphragmatic crura posterior to esophagus with non-absorbable suture

• Creation of fundoplication (Nissen 360º, Dor anterior 180º, Toupet posterior 270º)


Esophageal DysmotilityDisorder (incidence) Presentation,

pathophys, & w/uManometry Treatment

Achalasia(rare overall, MC esophageal dysmotility disorder)

• Dysphagia, regurgitation

• Failure of LES to relax

• Birdbeak contrast esophagram

AperistalsisIncreased LES pressure

• Medical (Nitrates, CCB) usually temporary relief

• Pneumatic dilation of LES

• POEM• Heller myotomy

Diffuse esophageal spasm

• Non-cardiac chest pain, globus, dysphagia

• Corkscrew appearance on barium swallow

Strong uncoordinated non-peristalticwaves,prematurecontractions

• CCB, nitrates minimally effective

• Modified Belsey-Mark IV myotomy but not very effective

Nutcracker esophagus • Pain MC sx• Barium usually

normal but can have corkscrew appearance

High amplitude contractions (>180mmHg) or long swallow(>7s)

• CCBs• Botox• Long thoracic

myotomy

Images from Current Surgical Therapy, 13Ed. @suziehillmd@SSATnews

Esophageal Cancer• SCC

• Upper to mid esophagus

• RF: EtOH, tobacco

• Propensity for submucosal spread

• Cisplatin-based neoad tx

• Stage: PET/CT, EGD + bx, EUS

• R Gastroepiploic a. main blood supply to conduit

• Adenocarcinoma

• Mid to lower esophagus

• 2/3rds of pts will p/w resectable dz

• Surgical Tx

• Tis/T1a (just mucosa): ablate

• T1b: surgery first

• T2+ or N1+: neoad CXRT


Type Transhiatal Ivor-Lewis 3 Hole/En Bloc

Incisions Neck + Abd Chest + Abd Neck, Chest, Abd

Anastomosis Neck Chest Neck

Limitations Limited LN dissection

Pts get sicker if leak Highest leak and morbidity rate

Peptic Ulcer Disease• Dx: EGD, H pylori testing,

fasting gastrin level

• Tx:• H pylori (3x therapy – PPI,

flagyl, clarithromycin)• PPIs (inhibit H/K ATPase in

parietal cells and prevents HCl release)

• Gastric ulcer >3cm may harbor cancer, need bx!

• Surgery (less common)• Gastric wedge• Graham patch / Thal patch• Bleeding DU – 3 pt ligation

(12, 3, 6 o’clock of GDA)• V+D ONLY in stable pt

Image credit Current Surgical Therapy 13 Ed

Acid hypersecretion


Gastric Cancer

• Work-up• EGD + bx, EUS, PET/CT

• Siewart class if GEJ

• Dx lap?

• MAGIC trial: progression-free and overall survival benefit to periop epirubicin+ 5FU + cisplatin

• CLASSIC trial: curative R0 resection + D2 LN dissection + adj CapeOximproved outcomes

• NCCN: R0 resection (w 5cm margins), >15 LNs

Image creditClinical Scenarios in Surgical Oncology

GIST

• Work-up• EGD showing submucosal

mass• EUS (+/- FNA)• CT AP

• TKI-therapy• Neoad. imatinib if

downsizing facilitates negative margins

• Assess response with CT (tumor changes from heterogenous/hypervaschomogenous, hypoattenuating, and cystic)

• High risk for recurrence = adjuvant imatinib

• MC sites of mets are liver + peritoneum

• 3 major factors predicting mets are tumor origin, size, and mitotic rate

• R0 resection (often can do wedge)

• Low incidence of nodal mets so often no lymphadenectomy


https://www.mskcc.org/nomograms/gastrointestinal

LOWER GI• Diverticulosis

• LGIB

• Volvulus

• IBD

• Colon Cancer

• Rectal Cancer

• Anal Cancer


Diverticulosis

• False diverticula (only mucosa protrudes)

• Often asx

• 10-20% have diverticulitis

• 15% have bleeding

• Diverticulitis management principles:

• Broad-spectrum abx

• Surgery is individualized pt decision (1st attack usually the worst)

• Sig colectomy, take to upper rectum where taenia disappear

• Low colostomy reversal rates, try to use DLI if possible

• Everyone needs cscope 6w post-attack to r/o ca

• Can result in fistula (colo-colonic, -enteric, -vesical, -vaginal, -cutaneous)

Image credit to Current Surgical Therapy13 Ed.


Lower GI Bleed

• 60% diverticulosis (75% stop spontaneously but then 25% rebleed)

• Other causes: • Angiodysplasias (MC R Colon, high

rebleed rate of 80%)

• Ischemic colitis (up to 16% of LGIB cases, usu from reperfusion injury)

• Neoplasia (<10%, cecal/R-sided more occult bleeding, L-sided/rectal more obvious bleeding)

• Hemorrhoids (5-20%)

• UGIB

• IBD

• W/u

• r/o UGIB first

• Nuc 99Tm: 0.1-0.5 mL/min

• CTa: 0.3-1 mL/min

• Angio: 0.5-1.5 mL/min

• Colonoscopy

• Tx

• Angioembolization

• Colonoscopy maneuvers

• Indication for surgery: if >6u pRBC requirement in 24h

• Resection (ideally segmental colectomy, poor outcomes w TAC)


Volvulus

Image credit to Radiopedia @suziehillmd@SSATnews

-----------------


IBD

Colon Cancer

• Work-up• Bx of primary lesion• Cscope to r/o synchronous

lesions• CT AP, CXR• Serum CEA

• Resection principles• Ligation at vessel take-off

• R colon (ileocolic)• T colon (usu. extended right or

left, take middle colic)• L colon (L colic at IMA origin)• Sigmoid colon (sigmoid a)

• Need 12 nodes• Polypectomy adequate if T1

lesion, 2-3mm margin, no neuro/LVI

• Treatment principles

• Can perform isolated

metastectomy

• Adjuvant FOLFOX for stage

III/IV (or stage II if <12 LN

harvest)

• No indication for XRT

• K-ras wildtype: can use

VEGF inhibitor (Avastin) or

EGFR inhibitor (cetuximab)

• Surveillance w qy CEA +

cscope


Familial Colon Ca Syndromes

TPC-end ileos. or TPC-IPAA*


Rectal Cancer

• Work-up• Rigid procto for distance

from anal verge

• Cscope to r/o synchronous lesions

• MRI pelvis to evaluate MRF, sphincter involvement, T/N status

• CT CAP to evaluate M status

• CEA

• Treatment Principles• Stage II/III dz gets

neoadjuvant CXRT (5FU + 50.4Gy to pelvis)

• Lower 1/3rd (0-5cm ): APR

• Upper 2/3rd (5-15cm): LAR

• Transanal excision if…

• If p/w obstruction, diverting loop colostomy first


• T1• <3cm• <1/3rd circumference• mobile and non-fixed

• well-differentiated• no neuro/LVI• no evidence of LN

involvement

Anal Cancer

• Anal SCC• Nigro protocol

5FU+mitomycin+XRT• Recurrent dz salvage APR,

palliation• MC mets to lung, liver• RF for recurrence – size >5cm,

>2/3rds circumference of anal canal involved

• Anal Intraepithelial Neoplasm (AIN)

• Precursor lesion for SCC• HRA, local ablation• Check for HPV 16/18

• Anal melanoma• WLE

• Historically answer was APR

• Paget’s (adenoca.)• Must cscope to r/o colon

adenoca.

• APR + 5FU

• Bowen’s (SCC in situ): WLE


HerniasTypes of Repair

Component Separation


Types of Hernias

• Ventral Hernias• Epigastric• Umbilical• Lumbar, Spigealian• Parastomal

• Groin Hernias• Inguinal• Femoral (McVay)• Obturator

• Incisional• 11-20% of laparotomy

incisions• Ports >10mm


Image credit to Nuem Blog

Ventral Hernia Repair Principles

• Weight loss, smoking cessation x4w, glucose control, improved nutrition

• <2cm: Primary repair

• >2cm: Mesh


Component Separation

● Complete LOA

● Elevate lipocutaneous

flaps 2cm lateral to linea

semilunaris at edge of

rectus

● Incise EO fascia +

separate EO/IO

● Incise 1cm lateral to linea

alba to release posterior

rectus sheath and

develop out to linea

semilunaris Image credit to Dimick, Clin Scenarios in Surgery, 2E


Inguinal Hernias

Image credit to Schwartz Principles of Surgery, 11Ed.

MC injured during open repair

MC injured during lap repair


Image Credits

• Cameron JL, Cameron AM. Current Surgical Therapy. 13th Ed. Philadelphia, PA. Elsevier. 2020.

• Khatri, V. Clinical Scenarios in Surgical Oncology. Philadelphia, PA. Lippincott Williams & Wilkins. 2005.

• Gold JS, Gonen M, et al. Development and Validation of a Prognostic Nomogram for recurrence-free

survival after complete surgical resection of localised primary gastrointestinal stromal tumour: a

retrospective analysis. Lancet Oncol . 2009 Nov;10(11):1045-52.

• Hacking C, Alwalid OAA. Sigmoid volvulus versus cecal volvulus. Radiopedia.

https://radiopaedia.org/articles/sigmoid-volvulus-versus-caecal-volvulus?lang=us. Accessed Dec 29,

2020.

• Steele SR, Hull TL, Read TE, et al. The ASCRS Textbook of Colon and Rectal Surgery. 3rd Ed. Springer

International Publishing. 2016.

• Trevino J, Farooqi S. Inguinal Hernia Imaging and Reduction. Published Aug 15, 2017.

http://www.nuemblog.com/blog/hernia-reduction. Accessed Dec 29, 2020.

• Dimick JB, Upchurch GR, Sonnenday CJ, Kao LS. Clinical Scenarios in Surgery, Decision Making and

Operative Techniques. 2nd Ed. Philadelphia, PA. Wolters Kluwer. 2019.

• Brunicardi FC, Anderson DK, Billiar TR et al. Schwartz’s Principles of Surgery. 11th Ed. McGraw Hill. 2019

https://radiopaedia.org/articles/sigmoid-volvulus-versus-caecal-volvulus?lang=us

http://www.nuemblog.com/blog/hernia-reduction

ABSITE REVIEW - SSAT · 2017. 8. 15. · rectum where taenia disappear • Low colostomy reversal...

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