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Today's topic is stomach. Again, a very high-yield topic for the ab site and the boards. So, as always, let's start with a little bit of, briefly, a little bit of anatomy. So with the stomach, they seem to like to break things up into types. There's types of hiatal hernias, types of gastric ulcers, types of Seward-Stein classification. So let's just go through those real quickly. What are the different types of hiatal hernias?
So for hiatal hernias, you can break these apart into four types. The first is the most common. Type 1 is a sliding hernia. These comprise 90%. The second type is purely a paraesophageal hernia. and these need repair. The third type is a combined sliding and periesophageal hernia, which also needs repair. And the fourth type, the entire stomach is in the chest. in addition to another organ, such as the colon or the spleen, and these also need to repair.
Right. So as you said, the type 1, if those are asymptomatic, those are okay too. Just the purely sliding hernia, the most common, you don't necessarily have to repair those. But the others have some degree of a paraesophageal hernia, which do need repair. Kevin, how about the different types of gastric ulcers? Yes, one of those things I'm always reviewing right before the ab site. So type 1 is just an ulcer on the lesser curve. Type 2, think of two ulcers.
So it's the lesser curve and in the duodenum. Type 3 is the pre-pyloric. And so it's kind of very distal in the stomach, the type 3. The type 4 is the proximal lesser curve or the cardia of the stomach. And then type 5 can be kind of anywhere and are considered to be NSAID related. And which of those are, a common question is which of those is associated with high acid output? Which of those is?
I believe that is type 2 and type 3. Correct. So you're thinking of your more distal ones, the ones that involve the distal stomach, involve the duodenum. So that's your type 2 or type 3. And of course, an easy way to remember type 2 is there's two ulcers, one at the lesser curve and one in the duodenum. So type 2 has two ulcers. And again, type 2 and 3. high acid output.
Whereas types 1, 4, and 5 are more associated with a decreased mucosal barrier, decreased mucosal protection. Okay, last for our little brief anatomy. stein classification so these are anatomic classifications of the location of um GE tumors and become important when you're starting to think about what type of resection, what type of management for those gastric cancers. So what are the three types of the Seward-Stein classifications?
So in this classification, you kind of move from on the esophagus down onto the stomach. So for type 1, you're on the distal part of the esophagus. from 1 to 5 centimeters above the GE junction. For type 2, you're on the cardio within 1 centimeter above and 2 centimeters below the GE junction. And for type 3, you're now onto the stomach.
two centimeters to five centimeters below the GA junction. Perfect. All right, well, let's move right into some clinically relevant disease processes. So, Kevin, tell me a little bit about gastric volvulus. What is a gastric volvulus? So... The majority of gastric phobiasis are associated with a peresophageal hernia, and there's a couple types of ways that these can rotate. The most common is what they call the organoaxial.
And believe it or not, I've actually seen questions and at least seen the question banks on these type of things. So this rotates along the axis of the stomach from the GE junction to the pylorus. So kind of in a vertical coronal plane is where it rotates. Then you have the mesoaxial rotation.
And this is along the short axis of the stomach bisecting the lesser and greater curvature yeah those can be a little bit confusing but if you just picture it you know draw an axis from the g junction to the pylorus and you imagine the stomach flipping around that axis, that's your organoaxial. And that's the most common form of a gastrovolvulus.
The other one is if you draw a line that bisects the stomach from the lesser to greater curvature and you imagine the stomach twisting around that axis, that would be your mesoaxial and less common. So what do we need to do about these and what's important to know about these? So these are very morbid conditions and have a high mortality rate. So if anyone is suspected to have this, they need emergent surgery.
What kind of, yeah, typically, you know, especially if you're given this on a test, you need to take these patients for surgery. What type of, what are you going to do in the operating room? So first you're going to reduce the hernia and evaluate how much of the stomach is viable still, and hopefully it still is.
And then at that point, you would perform a cruel repair to fix your hernia. And then generally a gastropexy. And then if needed, a partial gastrectomy or whatever portion is devitalized. Sure, absolutely. Those are our options. Now, they may give you something that's super frail, super sick, and they really lay it out there that this person is not fit for an operation. What's another option? So you can just do endoscopic decompression with a single or double peg tube.
Right. I think classical describes to do that double peg tube. That way you have two points of fixation so that prevents it from revolvulizing. But if they're capable of undergoing an operation, certainly I think repair is a better option. Okay, let's move on and let's move into a very common disease process. That's GERD, gastroesophageal reflux disease. So, woo. When I say, you know, you have to kind of delineate.
People are having GERD symptoms from just benign reflux versus something that's more ominous and associated with a malignancy. And we talk typically about alarm symptoms. What are some alarm symptoms for a gastroesophageal reflux? Yeah, so the alarm symptoms you're looking for in the question stem are dysphagia, odynophagia, weight loss, anemia, and GI bleeding. And these are clinically relevant because they may indicate a higher likelihood of malignancy.
So if people do have those, what are you going to do with them? What are you going to refer them for? What are you going to do yourself? So you're going to move them towards doing a workup for malignancy primarily with upper endoscopy. Right. Those are the patients that need upper endoscopy. But let's say they don't have any of those symptoms. They just have some reflux. What are your initial management steps?
So in these patients, you can start with just simple medical management, which includes lifestyle modifications such as weight loss, elevation of the head of bed, avoiding aggravating foods. You would add on a PPI, and if no improvement over several weeks on the PPI, then you would move the patient towards getting an EGD. And in patients who have failure of medical management or a desire to avoid lifelong PPI, these would be patients who meet indication for surgical consideration.
Right. I think we're seeing more and more of this in practice. We're doing more anti-reflux surgery simply for the fact that there are... downsides to being on a PPI for the rest of your life and we're finding out more and more of those adverse reactions to the medication and they're expensive and sometimes people don't want to be on it so certainly for surgically fit patients
undergoing some type of anti-reflux surgery. Even nowadays, you know, the links or the magnetic sphincter, I wouldn't answer that on a test yet, but certainly surgical. intervention is warranted in a large number of these patients. So let's say that we are considering doing an anti-reflex surgery. What type of workup do all patients who are undergoing anti-reflex surgery need? So for the workup,
without question, they need barium swallow, upper endoscopy, and esophageal manometry. And many times to help confirm the diagnosis, you'll do a pH testing. Yeah, so I think that's pretty standard that patients who are getting any type of anti-reflux surgery are typically getting all of these studies to rule out malignancy, look at other complications, confirm the reflux. and certainly you need to rule out what's the manometry for, what is that to rule out before you do any type of rap.
So you want to make sure there's no underlying motility disorder before you do a full wrap? Right. Very frowned upon to do a full wrap in somebody who's got a motility disorder. Something that comes up pretty frequently, Kevin, is this Demeester score when you're considering considering operating on somebody with reflux, what is a Demister score? What are the components of the Demister score? So what it measures is the percent of time that the pH in the esophagus is less than 4.
The percentage of upright time with the pH, that's less than four. And then also supine, when your supine is less than four. And then the number of reflux episodes. that are greater than five minutes and then the longest reflux episode. And so actually pressing a button when they're having these episodes to help this pH monitor determine this. And then so you add up this scoring system, and if they have a Demister score greater than 14.72, it indicates reflux.
Right. So again, total time, like a PhD lesson four. So total time, time upright, time supine, total number of episodes and longest episode. And then that magic number, 14.72, which I think if you just know 14, you're probably good, indicates that it's a good indicator that a person might benefit from an anti-reflux procedure.
So when we're thinking about all of these different, there's several different options that we'll get into, but what are the overall surgical goals, Kevin, of an anti-reflux operation? So you want to restore the normal anatomic position of the stomach in the GE junction. This is the primary goal of the surgery. And this helps recreate the anti-reflux valve by having that there's negative.
enter thoracic pressure and there's abdominal pressure and having the stomach in the abdomen it helps make this anti-reflex valve and then any hiatal hernia must be completely reduced and you really need to focus on a good high mediastinal dissection to free the esophagus and make sure it's freely mobile and the stomach is within the abdomen. And then the crura of the diaphragm should be closed. And like we said, you want to have a...
When you're doing, say, a Nissan on this, you want to have a two centimeter long floppy fun application performed over a large bougie, such as a 54 French bougie. Right, so that's kind of a description of your classic Nissen or your 360-degree wrap. Again, you want to be able to fully reduce any parasophageal hernia, recreate the natural anatomic position of the G-junction within the abdomen. clothes, any defects.
and really make sure you get enough mobilization to get that several centimeters of... the G-junction several centimeters below the diaphragm, the full 260 floppy route. two centimeter floppy wrap over a large bougie. But we talk a lot about the different parts. That's a full wrap. We talk a lot about different partial wraps and there's different clinical scenarios when that might be appropriate. What are some of the different partial wraps?
The ones I think are most pertinent are the door, which is the anterior 180 to 200 degree wrap, and then the toupee fund application, which is a posterior 270 degree wrap. These are the ones that... in a patient that you may be concerned that they have some motility disorder. Or a lot of times when you're doing a heller myotomy, you'll do a door over top of that. And these are other options rather than the complete fund application.
Right. So I don't think they'll get into the weeds of too much of this, especially in a board type scenario. There's not a whole lot of evidence to support one partial rap over the other. You know, some do show less post-optophagia with a partial lap compared to the 360 to wrap. However, the partial wrap might have, in fact, a control of the reflex. So certainly patients with esophageal motility shouldn't have a complete wrap, but the choice of one partial wrap over another.
is going to depend a lot on the institution and the individual surgeon experience. And as I mentioned before, there are newer technologies out there, these magnetic sphincters, the lynx. are gaining traction. There is some good five-year data on that, but I don't think that this is, maybe you guys disagree, but I don't think that this will make its way onto the boards
Quite yet. There is one sort of reflux that I think is important to be aware of. So say you have your pH monitor in and you don't get a good demyster score on it and they have a little bit of atypical symptoms. One thing you want to think of is bile reflux. as a source of GERD. We see that frequently in a lot of patients that have had previous GI surgery.
will be at highest risk for this, and sometimes you may have to do a Roux-en-Y to help prevent something like this. And what kind of test can you do to test for bile reflux into the esophagus? It wouldn't be your pH probe, but it would be something else. yeah here you could use impedance testing perfect absolutely Okay, so let's say that you just get done doing a beautiful Nissan full 360 wrap, and you get...
Interoperatively, anesthesia tells you that they're having a little bit of trouble ventilating the patient. What are you thinking about? So here, because of the vicinity of all the structures and the dissection to the mediastinum, you'd worry about capnothorax or CO2 insufflation making its way into the chest.
So to avoid tension capnothurox from developing, you want to enlarge the tear if you can find a tear. Additionally, you can place a red rubber catheter with one end into the pleural tear and the other end into the abdomen. And this essentially equalizes the pressures between the chest and the abdomen to help normalize this and prevent the tension capnothorax from developing. Finally you can also use a needle to decompress the chest intraoperatively.
And in order to do that, you want to make sure that the patient preoperatively is prepped. up to the lower chest. Okay, so that's somebody who has a little pleural tear during your dissection and has a symptomatic capnothorax intraoperatively. Alternatively, let's say your patient shows up to the PACU for whatever reason they get a chest x-ray because you're somebody who gets a routine chest x-ray on your mediastinal mobilizations post-op.
And you see a small two centimeter cap in the thorax, or the nurse calls you and says, the radiologist is saying they have a pneumo. What do you want to do with that patient? Yeah, so... Most of those, the capnothoraxes will resolve on their own, so no intervention is needed. I've created a number of these capnothoraxes myself, and the vast majority of them...
You don't cause any problems, even intraoperatively. But the thing you want to make sure is they may have a question where they say you're doing a mediastinal dissection and the CO2, the entitled CO2 goes up to 60. This would be concerning for the malignant hyperthermia and some other. conditions, but this is why it's important to have good communication with the anesthesiologist. Hey, we have a tear in the pleura. We are insufflating CO2 into the chest. And generally, there's no...
bad consequences of that and you just suck out the chest as you finish the case and close the pleural tears as best you can. So that could be a question is high CO2 and during a mediastinal dissection. Sure. You certainly have to start thinking about all those really bad things when you have an elevated CO2 and drop, hopefully. How about post-op management, Awu? What are some key principles for your routine post-op management after these anti-reflux procedures?
So, for all these patients, you should consider scheduling antiemetics immediately in the post-op period to avoid any nausea or retching that could compromise the wrap. They should be on a soft diet for a few weeks after the wrap, and they should avoid meat. raw vegetables, bread, carbonated beverages for four to six weeks post-operatively.
Okay, how about some management? You have a wrap that goes great. On post-op day one, day two, the patient's complaining of a little bit of dysphagia. They're having a little bit of difficulty swallowing. What do you think about that? So dysphagia postoperatively is very common. That said, if the patient has severe dysphagia, you would consider getting an esophagram to assess
uh, the wrap. Yeah. And I would say, I would say all these patients probably get some degree of dysphagia post-op. So a little bit post-op day one too. It's not that unsurprising. You can just kind of ride it out. As the swelling and everything goes down, it usually gets a little bit better. Certainly severe dysphagia, you need to investigate that. Especially, Kevin, how about you're given the situation on post-op day one that your patient can't even handle their own secretions?
what are you gonna do with that patient yeah this is very provider dependent but uh A lot of times, if it's that severe and there's nothing passing through, you may have to reoperate and redo the rep. Right. I think that'd be my answer on a board type scenario. If they give me that situation where post-op day one...
The patient can't handle their own secretions. They'll probably give you an option of a CT scan, a sophogram. I think I would answer just go back to the operating room because your wrap's likely too tight. Okay, moving on. Let's talk a little bit more about hiatal hernias. How do we typically find these? So a lot of times these are often seen on chest x-ray, but more sensitive than that, barium swallow, CT of the chest.
And EGD can be used in various combinations depending on the individual patient presentation. To manage these, you do not necessarily repair type 1 hernias, particularly if there's absence of reflux disease. Repair of these is not indicated. What's a type 1 again? What is a type 1 hiatal hernia? The type 1 was a sliding type hiatal hernia.
That said, all symptomatic parasophageal hernias should be repaired, especially those with obstructive symptoms or those who have undergone volvulus at some point. Asymptomatic parasophageal hernias should be repaired on a routine elective basis if the patient is a good surgical candidate. And watchful waiting is an option for asymptomatic or minimally symptomatic patients who are more surgical candidates.
Yeah, I think I would err towards repairing these, especially in a test type scenario. Any peresophageal hernia should likely undergo repair. It's just a question of if it's done on an urgent or routine basis. in real life. A 90-year-old lady who's had her peresophageal hernia for the last 40 years is incidentally found.
and she's a poor surgical candidate not necessarily all these are getting fixed but I think in a board type scenario I would err on the side of repairing these. Okay, Kevin, so how do we go about repairing these? What are some surgical principles? okay uh we've kind of discussed this but repetition is the key to adult learning here so
Generally, we're approaching these laparoscopically or with the robot now. And the biggest components, again, are to reduce the hernia and to reduce the hernia sac. And this should be completely mobilized. and brought into the abdomen. And then, like we said, you want to have good mobilization of the esophagus to re-approximate that gastroesophageal junction into the abdomen.
Yep, so we need to completely immobilize the hernia sac and excise the hernia sac. That's a key step to decrease recurrence rates. What about the use of mesh? When do we use mesh? When should we use mesh? So in patients that have very large hiatal hernias, mesh is a good option. And a lot of times in patients that have recurrent hernias. But if it's a small, simple hiatal hernia with a defect that's easily closed, I don't think you'd use mesh.
Yeah, this is one of those things where there's a lot of evidence one way or the other, and the practice varies widely by surgeon, so I... The good news for test takers is usually when there's controversy like that, it's unlikely that they're going to ask you whether or not you should be using your mesh with your hiatal hernia repairs.
Okay, and then so reduce it, maybe close a defect, maybe use a mesh, maybe not. What else? What's next? And so I think a question could be, you know, you want to use... permanent suture to close, a large permanent suture to close the crura sometimes with a pledge. And then you're going to do your fund application. And so generally you're going to do your Nissan fund application, a large floppy fund application over a large bougie, such as a 56 French bougie.
What are some options if you do that? You mobilize everything, but you just give me two options for you can't mobilize enough esophagus. You do a high mediastinal immobilization. You can't get enough esophagus. It's a little bit tight. It's pulling that down into the stomach. And so, yeah, you certainly don't want to stop here because you're going to have a recurrence.
So the Collis gastroplasty would be one of the first options. Yep, so an esophageal lengthening procedure. What's another option if it's just a little bit tight or a little concerned? I guess if you really can't get that length. A gastropexy or gastrostomy tube could help prevent the recurrence. Right, so if it's not bad enough where you think you need to do an esophageal lengthening, but you want a little added security against an early recurrence, a gastropexy is certainly a reasonable option.
Okay. So from GERD, hi, and already has a next natural step we're going to go into is talking about some gastroduodenal ulcerative disease. So tell us a little bit, just basics, epidemiology, that type of thing about gastroenteritis ulcers. Yeah, so one of the key risk factors you have to be aware of is that of H. pylori.
H. pylori is found in 75% of gastric ulcers and 95% of duodenal ulcer patients. So for these patients, you want to do a trial of triple therapy to include PPI, clarithromycin, and amoxicillin or metronidazole.
Yep, you want to have that triple therapy definitely memorized. That's something that's going to come up in written boards and oral boards, so make sure you have your regimen. There's a couple different regimens out there, but just pick one and stick with it and just know that off the top of your head. Very common in gastric ulcers, almost universal in duodenal ulcers, that H. pylori is the culprit. What's one of the complications that you can have from ulcer disease?
So one of the key complications that you would see on a test scenario is that of upper GI bleeding. So for these patients, you want to start with your typical resuscitative maneuvers. You want to place an NG tube and move the patient towards early rapid upper endoscopy, which is usually diagnostic and therapeutic. You can use endoscopic clips, thermocoagulation, injection of vasoactive or sclerosing agents to help control the bleeding.
Yeah, absolutely. So it'd be very quick with these upper GI bleeds. Endoscopy is usually the first step for both diagnosis and treatment. And endoscopy therapies are generally pretty effective, usually 90% or greater effective at stopping the bleeding. Oftentimes we'll see things graded as in increasing people's risks for recurrence of a bleed. So what are some things you can see on endoscopy and what does that say about?
the chances of having a recurrent bleed. Yeah, so the highest risk factor is that of an active bleeding pulsatile vessel. This gives you an 80% or higher than 80% risk of re-bleeding. Second is a visible vessel which gives you up to about a 50% chance of re-bleeding. Third is an adherent clot. which warrants about a 15 to 25 percent risk of re-bleeding. And then lastly is a clean base, clean ulcer base, which gives you less than a 5 percent chance of re-bleeding.
So let's say you have an endoscopic intervention. It works. 24 hours later, though, they have a recurrent bleed. What's the next step? So in these patients, the second step is, again, repeat upper endoscopy. Right, repeat endoscopy. Repeat endoscopy. Andiography is an option, but for first re-bleed, repeat endoscopy is going to be the answer. What do you have to worry about if you do your endoscopy, you stop your bleeding, but you see a large gastric ulcer? What are you concerned about?
So you want to consider biopsying this ulcer to evaluate for malignancy, as well as to obtain antral biopsies to test for H. pylori. So H. pylori and NSAIDs are generally the most common causes of gastric bleeding. You have to be aware that an underlying malignancy... could present as an ulcer like this in approximately 5% of cases. Right, especially with gastric ulcers. Like I said, duodenal ulcers, it's more common for H. pylori, high acid output, that type of thing. But for gastric ulcers...
You have to be very concerned for malignancy, so you should always consider and you should always obtain biopsies if possible. I think a good way to help remember for the rebleeding of what the next step should be, if the patient is stable. I think endoscopy and angiography will be your answers until they have made that clear that everything has failed. But if the patient is unstable in any way, that would lead to surgery to fix the problem.
Yeah, Kevin, so that's a great point. So let's talk about that then. So gastric ulcers, let's say they're unstable, can't be controlled endoscopically. What are you going to do? So it can't be controlled endoscopically, especially a gastric ulcer. I'm going to lean heavily on my IR doc to do some angiography. Okay, you don't have IR available.
and we've tried two attempts at endoscopy. Yep, and they're unstable and they're still bleeding. So at that point, I would take them to surgery. And what are you going to do? And I'm sorry, this is a gastric ulcer. Wow. Yeah, we did your endoscopy. You see a gastric ulcer. Okay, so midline laparotomy, anterior gastrotomy, and over-sowing the bleeding area with biopsy. Yep.
So midline laparotomy, anterior gastrotomy, oversell the bleeding area, be sure you biopsy, make sure you biopsy, and then close your gastrotomy. Okay, let's move on a little bit further down the GI tract and talk about those duodenal ulcers, so bleeding duodenal ulcers. How are you going to manage these, Will? So I'd say that the initial management is
basically the same as any upper GI bleeding or even a gastric ulcer. So you're going to resuscitate, place it in G2, a rapid EGD for diagnosis and treatment. You're going to try endoscopy. first line, second line, possibly consider angiography. and surgery would be reserved for any uncontrolled bleeding or any... hemodynamic instability. Yeah, and it's one of those things I think we, you know, surgery and surgery residents manage a lot, and
It shows up often on written and oral boards, and you just need to be sure that you re-verbalize everything. So you're going to put them in a monitored setting. You're going to get two large board IVs. You're going to type and cross them. All those things that you kind of intuitively do. You just need to be sure that you're verbalizing, especially if you're in an oral boards type scenario. Sick of face serums that promise the world and deliver nothing? Meet Power Trip by Verify Skin Care.
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So you said surgery reserved for uncontrolled bleeding and hemodynamic instability. We talked a little bit about surgery due for a bleeding gastric ulcer. What are you going to do for a bleeding duodenal ulcer? Yeah, so here you do a longitudinal anterior deunonomy. You would control the bleeding with sutures placed in the superior and inferior positions of the ulcer to take care to avoid this common bile duct.
and you can ligate the GDA above the duodenum if the bleeding continues after that you should then approximate the ulcer crater and close the deuteronomy transversely. Yep, absolutely. So yeah, that's a good option. You mentioned it there. If you can't control the bleeding from within the ulcer base, you can come up above the duodenum and ligate the GDA would be your next step there.
So this is kind of a deep, dark hole. This is a more advanced level question. But Kevin, what kind of, and this might come up on oral boards, what kind of suture and what kind of needle are you going to ask for?
In this situation, I would ask for an ovic rule, a UR6, to have that acute curve on the needle to really come around the... the vessel right i think that's a perfect answer that's that's what i would say too is you need that that curve that you are six needle to really get down in there and get around that bleeding vessel Okay, so aside from bleeding, what's another common complication from ulcer disease? So that would be perforation. Okay, what are you going to do about that?
So I'd start with the initial resuscitative measures, start fluid resuscitation, NG decompression, acid suppression. In this case, I'd add on antibiotics for empiric coverage of gram-negative rods, oral flora, anaerobes, and fungi. Again, don't forget that fungus one. It's a commonly forgot, but it was with esophageal and gastric perforations. You have to add fungal coverage. Absolutely.
So one of the go-tos could be ampicillin, ceftriaxone, metronizol, and fluconazole. And once this is initiated, then I would move the patient towards surgical management. And this I would do with an omental patch repair. Okay, this came up the other day actually in one of our morning reports, but is there ever a situation where you can manage these non-operatively?
Maybe a knot on the ab site, but if it's a very small contained perforation, a lot of times the body actually does the job for you of performing the gram patch. So if they have a swallow study and there's no leak and the patient is not peritoneal and they are not obviously septic, it might be a situation in which it can be performed.
non-operatively with antibiotics and gd compression yeah i think if you have a patient that they see a little bit of you see a little bit of free air on ct scan they're totally stable non-peritoneal uh they'll likely had a perforated you know ulcer that's sealed off and i think you said it that you
We've all been in a situation where we've peeled off nature's grand patches to put on our own. One thing I think is important to talk about here, and we may talk about bariatric complications later, but most of us now are... not seeing too many of these perforated duodenal ulcers, but we're seeing marginal ulcer perforations. And, you know, it's the same repair, but this is in the patients that are post-gastric bypass. You have stomach abutting jejunum.
where they don't have the normal defense mechanisms for acid. So a lot of these patients will have started taking NSAIDs, will be smoking, will be off their PPI, and it really puts them at risk for these. marginal ulcer perforations in which you'd perform the same procedure. Yeah, that's going to be more and more important for everybody to know as bariatric surgery shows no sign of slowing in our population.
And again, I wouldn't answer any of that on the boards. I wouldn't answer non-operative management of perforations. I'd be very hesitant to do that. They would have to very heavily lean me in that direction to answer that on boards. So we're talking about gram patches and elemental patches. Can you describe what we mean by that?
Yeah, so you essentially close the perforation. You would use a seromuscular bite if you're able to approximate it, and then you would secure omentum over the side of the perforation with three to four sutures. Okay. So let's say that this is a patient that actually has a complete medical record in the system. We know that they have been treated for H. pylori in the past.
with PPI, and they've had documentation of eradication of their H. pylori, but they have refractory ulcer disease, what are some things you should consider? So here you would consider doing a truncal vagotomy and pyloroplasty to help control the input of acid development.
Well, you can definitely consider an acid-reducing procedure, and that's one of your options is the truncal dichotomy and pyloroplasty, Kevin, or some other options. So you can do the highly... selective vagotomy where you preserve the motor innervation of the pylorus eliminating the need for a drainage procedure so this is where
You get very close to the lesser curve of the stomach and divide the branches of the vagus nerve innervating the stomach there. And then, of course, the more classic operation is the vagotomy and antrectomy. This has a high morbidity and you have to have generally a Bill Roth reconstruction after this. And so this is reserved for patients with anatomic indications such as large antral ulcer, pilaric scarring. And so the thought is you're removing...
both the innervation and the acid-producing cells of the stomach and the antrum. So this is really going to give you the best acid suppression and least risk of recurrence. But like we said... The reconstruction has a... problems on its own. Okay, that's a perfect segue into the next segment, which we talk about post-gastrectomy syndrome. So you've done your gastrectomy, you've done your gastrectomy for whatever reason.
what am i talking about when i say post gastrectomy syndromes like for instance what's what's retained antrum syndrome what does that mean yeah so here you have retained antral tissue within the duodenal stump after a gastric resection And the G-cells are bathed in an alkaline fluid that leads to continuous gastrin release. This then increases acid production in the proximal stomach remnant and leads to ulceration.
And that brings up a good point that we forgot to mention actually when we were talking about our duodenal and our gastric ulcers. So what else do you have to think about if they've been treated for H. pylori and they have multiple, especially multiple duodenal ulcers? What's
test or what blood test do you want to send? Yeah, you might consider checking a gastrin level. Right, check to see if they maybe have a gastrin-secreting tumor or some other hypergastrin disease process going on. Okay, so back to our retained antrum syndrome. How do you treat these?
So these patients, you would start on a PPI and you would refer them for vagotomy and resection of the retained antrum okay kevin moving on to some of the different dumping syndromes this shows up pretty frequently and there's a couple different kinds it can get a little confusing so clear it up for us
Yeah, so dumping syndrome. And like we said, this is in post-gastrectomy patients, generally with like a Bill Roth 2 reconstruction. Or like you said, the bariatric patients. You can definitely see these in a bariatric patient. So these are actually very common.
So after eating, patients will get symptoms such as tachycardia, diaphoresis, dizziness, and flushing. So now it's differentiate between the two types. And like I said, I don't know if it's the question banks or the actual ab site, but I've seen this all the time. So the early dumping syndrome, this is 20 to 30 minutes after a meal. This is due to the abrupt hyperosmolar load to the small intestine.
So the small intestine is not used to handling this type of load. And this is what causes those symptoms. The late dumping symptoms, this is significantly further after a meal, one to four hours. And this is due to rapid carbohydrate load. in the small intestines, resulting in a large insulin surge and rebound hypoglycemia. And so you can really help differentiate that by discussing with the patient when they're having these symptoms. And this leads to how you...
And generally, the majority of these are treated by adjusting their eating habits with small meals, no sugary drinks. And then if it's truly refractory, some patients can be put on octreotide. Okay, so let's say you have a patient who had previously undergone a partial gastrectomy in a Bill Roth 1 or a Bill Roth 2 reconstruction. What is a complication you can see with those patients when they get that bile reflux? Yeah, so this would be alkaline reflux gastritis.
You can diagnose it with impedance studies, as we've mentioned before. And you would start with medical therapy, such as prokinetic agents and bile acid binding resins. Perfect. Yep. So medical treatment is the first step. Prokinetic agents and bile acid binding resins. What's the surgical management of that if that's not working? So you would convert to a Roux-en-Y historically?
Patients could have a brawn enterostomy, but the ruin Y seems to be better. Yeah, so the answer on the test could be converted to a ruin Y. The brawn enterostomy, you may see that if you're operating for other reasons, because that used to be fairly common. Bonus points, what's a brawn enterostomy? on the Bill Roth 2 where the loop of jejunum is going up to the connection of the stomach, proximal and distal to that, you anastomose the afferent and afferent limbs so it actually bypasses.
The stomach, so the bile can go straight. past the stomach. Correct. That's theoretically how it should work is you create an estmosis between your affair and the affair and loom of your Bill Roth reconstruction. And this is important. A lot of times when you're doing a Roux-en-Y gastric bypass, you're measuring at least 50 centimeters for your Roux-en.
A big reason for that is you want to prevent bile reflux. If you have too short of a Rulin, you can still get bile reflux with a Ruin-Y gastric bypass. Another thing we see pretty frequently show up on tests are these afferent loop syndromes. Kevin, can you clear that one up for us? It might be a little confusing as well. Yeah. So this is when the, you know, especially thinking of a Bill Roth 2 anatomy, you have acute or chronic obstruction of an afferent limb.
following a biliroth 2 reconstruction. So if you're an intern and you forgot your biliroth 2, just go look at a picture of this. It'll really help you visualize this. So you have an obstruction, acute or chronic obstruction, and this can cause a number of problems. The problems are from the increased luminal pressure of the efferent limb, and they can cause obstructive jaundice, cholangitis, pancreatitis from the backup pressure. The most concerning problem, if this is an acute issue,
And this is why knowing surgical history in patients that come in with abdominal pain is so important as you worry about a duodenal stump blowout. And then kind of one of the more common questions we see in the patients that have a chronic afferent limb. syndrome is the bacterial overgrowth in that limb. So the bacteria deconjugate the bile acids, which can lead to steatorrhea, malnutrition, and vitamin B12 deficiency, leading to megablastic anemia.
So just to clarify for the bacterial overgrowth and the chronic afferent limb syndromes, first of all, remember these are in Bill Roth 2 anatomies and the bacteria that are... have overgrowth in the afferent limb, cause deconjugation of those bile acids. So now those bile acids are not helping absorb those fats. And that's what results in the steatorrhea, malnutrition, and vitamin B12 deficiencies.
Yeah, it's kind of a little bit confusing to distinguish between these, you know, because there's a couple different processes going on that can cause a patient to get sick. So if they have an obstruction of their afferent limb and it it's like a bowel obstruction. So those patients are going to present like a bowel obstruction. And those patients will need more kind of urgent
surgical intervention. And I think if I was given a patient that presented with those type of symptoms, I would be very quick. to get the CT scan, very quick to intervene operatively. If it's more the bacterial overgrowth, you get somebody who has statorrhea, malnutrition, vitamin B12 deficiency, I think the first step I would do would be treat with antibiotics.
There's a very high relapse rate with these patients, so they do generally need a conversion to a Roux-en-Y or a Bellroth-1, but I think if it was that type of question where I'm given what's the next step and they give me that type of patient, I would probably reach for antibiotics first.
Yeah, and I think this is an important question that they could ask, is giving you a patient with a bowel obstruction, and it may be leading you to the standard bowel obstruction regimen of NG tube decompressions. Absolutely. Anomal exams were the answer in a patient with a Bill Roth 2. with any kind of concerns of dilation of their afferent limb. would be emergent surgery. Yeah. Again, you see many correlations between this and the bariatric population where that's
That's the other, you know, something like an internal hernia. And they may be leading you to manage that, like your typical bowel obstruction with NGD compression. But as with afferent lip syndrome, Your NGA is not doing anything. It's not decompressing anything. So those patients need surgical intervention. Great point. Okay, so let's move on to a big one, gastric cancer. So, Wu, what are some risk factors for gastric cancer?
So H. pylori, smoking, heavy alcohol intake, high salt, and nitrates. Yep, those are your classic risk factors. There's a couple different types. What's the Loren classification? How are these gastric cancers broken up? So you can break them up into intestinal type or diffuse type gastric cancers. Okay. Well, how about the genetics? These oftentimes run in families. Can you talk to me a little bit about that?
Yeah, so actually most gastric cancers are sporadic, but there is about a 5% to 10% familial component with a 3% to 5% inherited syndrome. Briefly, just name off some of those hereditary syndromes associated with gastric cancer. So for hereditary diffuse gastric cancer, you want to think about... an autosomal dominant disorder secondary to germline mutation in CDH1. And that's a fairly common...
commonly tested one for whatever reason, this CDH1. You need to know that association and how do you treat these patients who have this autosomal dominant disorder. So between age 18 to 40, you want to take these patients for a prophylactic gastrectomy. And I think that's why that's important. That's why this one shows up on tests. it's a big deal that you need to do a prophylactic gastrectomy on these patients so definitely know that association and there's
It's also important to know that women with the CDH1 are at increased risk of breast cancer similar to BRCA patients. So that's one of the important ones to know. How about some other ones? Other hereditary syndromes, you want to think about Lynch syndrome, which is a DNA mismatched gene. You want to think about juvenile polyposis syndrome, which is attributed to this MAD4. You want to think about Pew Sager syndrome and FAP.
And what gene is associated with FAP? The APC gene on 5Q21. Yeah, it's painful to know those, but they're quick, easy points if you just memorize those. So, again, repetition just. eventually they'll sink into your brain to where you'll reflexively pick the right answer and you won't even know why I can remember CDH1 as the FAP of the stomach and for whatever reason that helps me
Perfect. Okay, so gastric cancer, how do you stage these patients? So these patients are staged with the standard kind of staging with the routine labs, the CT, chest, abdomen, pelvis, and then... It's similar in a lot of ways to esophageal cancer. You're going to get the EOS, the endoscopic ultrasound with FNA. And then a lot of times a PET scan is used at the time of staging. Yeah, so this is one of those cancers that will typically get a PET scan. How about the role of staging laparoscopy?
So for staging laparoscopy, the NCCN recommends laparoscopic staging with peritoneal washing for clinical stage greater than T1B tumors. if chemo radiation or surgery is being considered. And we'll get a little bit into some staging pearls, but that's another one of those important distinctions you need to know is a T1A, T1B. So what's a T1B? Yeah, so... T1B is when the tumor invades the submucosa.
whereas T1A is the tumor simply invades the lamina propria or muscularis mucosa but does not get into the submucosa. So it's the same as for esophageal. So this makes it, it's always nice when you can memorize a staging system and it's the same between two different locations. So yeah, the T1B, that's an important distinction. So walk us through the T staging. broad strokes. What do we need to know? So broadly again, T1A, you want to know about?
Whether it gets into the submucosa, T1B, it does get into that submucosa. T2, it's getting into the muscularis propria. T3, it's invading the subserosa. And T4, it invades through the serosa and into adjacent structures. again, differs from the esophagus in that the esophagus does not have a serosa, but the stomach does. Okay, and how about our nodal status? So here N1 is one to two notes, N2 is three to six notes, and N3 is seven or more notes.
Okay, and the M status is always my favorite. M0 is no metastasis. M1 is distant metastasis. I always find that one easy to remember. What constitutes, Kevin, what constitutes unresectable gastric cancer? So if you're laparoscopic... Staging, you find peritoneal involvement that would make it unresectable if you have distal met. If you have root of mesentery or periaortic nodal disease confirmed by a biopsy and then encasement of any major vascular structures.
and the splenic vessel is not considered a major vascular structure. Yeah, so that's an important one to know. They may give you that, that, you know... They, on your staging, you find out that the tumor is invading the splenic vessels and they'll ask you, you know, what you want to do if you want to give palliative, you know, or definitive chemotherapy or whether that's a surgical patient that's resectable disease.
and you can take the spleen if there's invasion of the spleen vessels. Who gets neoadjuvant therapy for gastric cancer? So neoadjuvant should be considered in any patient with with any nodal involvement, so even N1 disease, as well as any patient with T2 or higher. So again, look for invasion of the muscularis propria or anything beyond that. Those patients should get neoadjuvant therapy.
Great. So that's an important distinction there. Neoadjuvant therapy for T2 or higher disease and, of course, NEN. which is very similar to the esophagus. and even the rectum for that matter. Yeah, it's good to kind of make those associations, but you definitely need to memorize it for each individual and not get tripped up. So let's talk about surgical principles for resection of gastric cancer. Kevin, go.
So when you resect the stomach, you're going to get at least four centimeter margins. I've seen five in a lot of places. And you need a good lymph node harvest size. These are pretty... aggressive cancers with at least 15 nodes. So there's two types of gastrectomies that you can generally do.
You can do the total gastrectomy depending on the location of the tumor versus the subtotal gastrectomy. So the subtotal gastrectomy is preferred for distal lesions, like Dr. Doe was saying earlier, the C-word type 3. The proximal tumors will generally need a total gastrectomy, and that's because of the...
the submucosal spread of the tumor. You need those four to five centimeter margins. And so then when you do a total gastrectomy, you'll actually perform an esophago jejunostomy where the distal portion of the esophagus may need to be resected for adequate margins. Yeah, and then tumors that are going higher to that, the tumors crossing into the geodjunction are really treated like esophageal cancers, you know, with esophagectomy and falling under those algorithms.
Yeah, 4-centimeter margin. Like I said, you've seen 5 centimeters. I think this is all from the NCCN guidelines where they recommend 4 centimeters. And the 15 nodes, 15 nodes, that's an important, it's one of those buzz numbers you've got to know, 15 nodes with gastric cancer.
How about, what's the role of a splenectomy or prophylactic splenectomy when you're resecting gastric cancer? So prophylactic splenectomy should not be performed. Only consider this if the spleen or hilum is grossly involved with tumor. Right, so you don't need to do a prophylactic splenectomy unless there's tumor involvement of the splenic island. Okay, and what do we do with T4 disease, so invading into adjacent structures?
Yeah, so you want to remove those adjacent structures on block with the tumor. Okay, so an area of controversy, Kevin, is the level of lymph node dissection needed to do with gastrectomy for gastric cancer. We talk about the D1, the D2. What exactly does that mean? So the D1 dissection is really just the perigastric nodes along the greater and lesser curve. And so this is not a very extensive dissection.
That is what is generally done in the U.S. and a lot of places. But the D2 dissection is where you go for the N1 and N2 nodes. So not only are you removing the perigastric nodes in the lesser curve and the greater curve, but you're also... skeletonizing the vessels of the common hepatic, the celiac, and the splenic arteries and taking all the lymph node tissue down to essentially the aorta.
So we're talking about our nodal stations, and if you guys aren't familiar with this, just Google it, look at a picture. It's not that bad to memorize a different nodal station. So a D1 dissection, what nodal stations is that? That's 1 through 6. Yeah, so that's the perigastric nodes along to the greater and lesser curvature stages, the 1 through 6. And what's D2? What stations does that involve in addition to 1 through 6?
That is 7 through 11. This gets debated a lot, the D1 versus D2. What's really the heart of that whole controversy and debate? you know, is recurrence and preventing recurrence and currently in Asia. They've shown improved survival with the D2 dissection, but we have been unable to replicate that with studies in the US. Studies in the U.S. have not shown that D2 dissections have improved survival, but they do have increased morbidity and mortality with those.
Yeah, maybe we should have a journal club at some point about the different studies and some of the different critiques of the different studies going into the D1 versus D2. But again, that's the standard in Asia is the D2 dissection. Their studies have shown. a survival benefit. We have not been able to replicate that.
The current NCCN guidelines recommend for an R0 resection with at least a D1 or a modified D2 lymph node dissection. But again, basically the node, the number you need to know is 15. You have to get 15 nodes. So as long as you have an R0 resection, you got the 15 nodes. You're good. Sorry, Jason.
For a long time, I had a hard time figuring out what the R's are for these resections. Can we go over those? Sure. So an R0 resection is a negative microscopic margin. An R1 resection would be a negative gross. margin, but a positive microscopic margin, and an R2 would be a positive gross margin on your resection. So the goal is always an R0 resection. Okay, how about adjuvant therapy, Wu, for a guest?
adjuvant therapy for gastric cancer, what do we need to know? So if the patient had T3, T4, or any node positive disease, and they then underwent an R0 resection, then you should consider the patient for adjuvant 5FU chemoradiation. Yeah, so again, those are important distinctions now. T2 disease gets... neoadjuvant therapy.
You know, your lymph nodes, you need 15 nodes with a D1 or modified D2 and R0 resection. And then any patient who has a T3, T4, or node positive disease gets adjuvant therapy after their R0 resection. And that's... you know, 5-fluorosil or 5-FU-based chemo radiation regimen. Okay, that was all a lot. Gastric or stomach is a big topic, but let's wrap things up with a couple of quick hits.
Kevin, we covered it already, but again, we lack repetition, so you need a little bit more esophageal length during your esophageal hernia repair. What's an option? The Collis gastroplasty. Okay. Woo. You're unable to swallow your secretions after a Nissen fund application.
So the wrap was made too tight. You should return to the operating room. Go back to the operating room. That's your answer. Okay, types of ulcers associated with increased acid production. Type 2 and type 3. And what's type 2 and type 3 again? So type 2 is the two ulcers. So you're going to have the lesser curve and the duodenum. and then the type 3 is going to be the prepyloric. Okay, and your type of ulcer is associated with decreased mucosal protection? These are your type 1 and type 4.
Okay, what are you going to do if you're doing your sleeve gastrectomy and you see a little hiatal hernia? We said that you don't really need to fix hiatal hernias if they're asymptomatic, but if you're doing a sleeve and you see a hiatal hernia, what are you going to do? We're now repairing those heidel hernias at the time of the sleeve gastrectomy.
okay well we have a patient who has a history of an antrectomy with biliroth to reconstruction in the distant past he presents with intermittent abdominal pain And extension, which is relieved after bilious emesis, megablastic anemia, and laboratory workup. What's the diagnosis? Afferent limb syndrome. Afferent limb syndrome. Multiple duodenal ulcers and gastrin levels greater than 1,000.
This is when you want to think of Zollinger-Ellison syndrome. Yep, and I believe that's pathognomonic, the gastrin greater than 1,000. Well, gastric mass biopsy, which shows expansion of the marginal zone. compartment with the development of sheets of neoplastic small lymphoid cells. What's the diagnosis?
It's a maltoma. And what do you treat? Do you take these patients to surgery? How do you treat these patients? And maltoma is actually secondary to H. pylori, and so you can actually treat with antibiotics. triple therapy for H. pylori, and these will typically regress.
So that's a very common one. They'll try to get you to resect it. So it's a gastric mass. I'm not going to tell you it's maltoma. They're going to describe it. So look for expansion of the marginal zone and development of neoplastic lymphoid cells, and that's maltoma. And that wraps up our gastric abcite board review. Be sure to check out our website at www.behindthenknife.org for more great content. You can also follow us on Twitter at Behind the Knife and Instagram at Behind the Knife Podcast.
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