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CHAPTER 7 Upper gastrointestinal surgery
272
Upper gastrointestinal endoscopy
There are four types of endoscopy looking at the upper gastrointestinal
(GI) and pancreaticobiliary tracts.
Gastroscopy
Correctly termed oesophago-gastro-duodenoscopy (OGD). Allows direct
visualization of pathology, small channel biopsies to be taken, and minor
interventions (e.g. injection).
Indications
• Investigation of dysphagia.
• Investigation of dyspepsia, refl ux disease, upper abdominal pain.
• Investigation of acute or chronic upper GI bleeding.
• Investigation of iron defi ciency anaemia (with colonoscopy).
• Therapeutic interventions for upper GI pathology:
Balloon dilatation of benign strictures.•
Endoluminal stenting of malignant strictures.•
Injection, coagulation, or banding of bleeding sources, including •
ulcers, varices, tumours, and vascular malformations.
Resection of early neoplastic lesions in stomach and oesophagus •
(endoscopic mucosal resection (EMR)).
Preparation and procedure
• Patient should be starved for 4h (except in emergency indications).
• IV access may be used.
• Always performed with local anaesthetic throat spray (lidocaine).
• Often performed with IV sedation (e.g. midazolam 3mg).
Risks and complications
• Perforation (usually of the oesophagus). Median risk approximately
1 in 3000; highest in elderly, with oesophageal pathology, during
therapeutic interventions.
• Bleeding. Commonest after biopsies or therapeutic procedures.
• Respiratory depression and arrest. Related to overmedication with
sedative; commonest in frail, low body weight, elderly patients.
Endoscopic ultrasound (EUS)
Utilizes a video endoscope with an ultrasound scanner in its tip.
Indications
• Staging of oesophageal, gastric, or pancreatic cancers.
• Investigation of pancreatic cysts/tumours.
• Investigation of possible distal common bile duct stones/sludge.
• Guided biopsy of pancreatic, peri-oesophageal, or perigastric masses/
lymph nodes.
• Guided drainage of pancreatic (pseudo)cysts.
• Guided coeliac plexus blockade.
UPPER GASTROINTESTINAL ENDOSCOPY
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Endoscopic retrograde cholangiopancreatography (ERCP)
Indications
• Investigation of possible biliary disease (common bile duct stones,
biliary strictures, biliary tumours, biliary injuries, intrahepatic biliary
disease) only where non-interventional imaging (e.g. magnetic
resonance cholangiopancreatogram (MRCP), CT cholangiography) is
not possible.
• Investigation of pancreatic disease (pancreatic duct strictures,
pancreatic duct abnormalities).
• Therapeutic interventions for pancreatico-biliary disease:
Stenting for common bile duct stones, strictures, and tumours, •
post-operative bile leak.
Sphincterotomy for the extraction of biliary stones.•
Preparation and procedure
• Patient should be starved for 4h (except in emergency indications).
• IV access required.
• Always performed with local anaesthetic throat spray (lidocaine).
• Always performed with IV sedation (e.g. midazolam 5mg) and
occasionally, analgesia (pethidine 50mg, fentanyl).
• Performed under X-ray screening guidance, often in X-ray department.
• May be performed under GA.
• LFTs and INR needed prior to procedure.
Risks and complications
• Perforation (of the oesophagus or of the duodenum). Median risk
approximately 1 in 1000; highest in elderly, with pathology, during
therapeutic interventions, especially sphincterotomy.
• Bleeding. Commonest after biopsies or therapeutic procedures,
especially sphincterotomy; usually controlled by balloon pressure, may
require open surgery.
• Post-ERCP pancreatitis.
• Post-ERCP cholangitis. Particularly in jaundiced patient in whom
procedure has been unsuccessful.
• Respiratory depression and arrest. Related to overmedication with
sedative; commonest in frail, low body weight, elderly patients.
Ileoscopy
Often termed ‘push endoscopy’. Performed with long length thin calibre
endoscope, aiming to intubate past the duodenojejunal junction and visualize the fi rst loops of the upper small bowel.
Indications
• Investigation of undiagnosed upper GI bleeding (possibly due to
proximal small bowel pathology).
• Investigation of abdominal pain.
• Investigation of upper small bowel Crohn’s disease.
Preparation and procedure As for gastroscopy.
Risks and complications As for gastroscopy.
273
CHAPTER 7 Upper gastrointestinal surgery
274
Oesophageal motility disorders
Key facts A spectrum of diseases involving failure of coordination or
contraction of the oesophagus and its related muscular structures.
Pathological features In some cases, degeneration of the inner and
outer myenteric plexuses can be demonstrated, but often no structural
abnormality is seen.
Clinical features
Achalasia
• Peak ages of incidence in young adulthood (idiopathic) and old age
(mostly degenerational).
• Slowly progressive dysphagia. Initially worse for fl uids than solids.
• Frequent regurgitation of undigested food common late in the disease.
• Secondary recurrent respiratory infections due to aspiration.
Diffuse oesophageal spasm
• Commonest in young adults; ♂ > ♀.
• Characterized by acute pain along the length of the oesophagus
induced by ingestion, especially of hot or cold substances
(odynophagia).
Diagnosis and investigations
Achalasia
• Video barium swallow. A characteristic failure of relaxation of the lower
oesophagus with a smooth outline ‘rat’s tail’ or ‘bird beak’.
• Oesophageal manometry. Hypertonic lower oesophageal high pressure
zone with failure of relaxation normally induced by swallowing; in
chronic cases, the proximal oesophagus may be adynamic.
• Oesophagoscopy. To exclude benign and malignant strictures.
Diffuse oesophageal spasm
• Video barium swallow. ‘Corkscrew’ appearance of the oesophagus
caused by discoordinated diffuse contractions.
• Oesophageal manometry. Diffuse hypertonicity and failure of relaxation;
little or no evidence of coordinated progressive peristalsis during
episodes, but normal peristalsis when asymptomatic.
• Oesophagoscopy. Required to exclude underlying associated
malignancy.
Treatment
Achalasia
• Endoscopically guided controlled balloon dilatation (fi xed pressure).
Successful in up to 80% of patients; low complication rates
(perforation); may need multiple procedures over time.
• Botulinum toxin injections. Success in some patients failing dilatation.
OESOPHAGEAL MOTILITY DISORDERS
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• Surgical myotomy (Heller’s cardiomyotomy). Usually performed
laparoscopically with division of the lower oesophageal circular muscle
fi bres; highly successful in resistant cases; mostly applicable to young
patients. Specifi c complications include refl ux, obstruction of gastrooesophageal junction, oesophageal perforation.
Diffuse oesophageal spasm
• Oral calcium channel blockers or relaxants, e.g. benzodiazepines.
• Long-acting nitric oxide donors (smooth muscle relaxant).
• Widespread oesophageal pneumatic dilatations (often repeated).
• Long surgical open myotomy, rarely undertaken.
Key revision points—anatomy and physiology of the
oesophagus
• Upper two-thirds. Stratifi ed squamous epithelial-lined (develops
squamous carcinoma), striated skeletal muscle, lymphatic drainage
to neck and mediastinal nodes, somatic innervation of sensation (e.g.
moderately accurate location of level of pathology).
• Lower third. Transition to columnar epithelium (develops
adenocarcinoma), transition to smooth muscle, lymphatic drainage to
gastric and para-aortic nodes, visceral innervation (poor localization
of pathology).
• Gastro-oesophageal junction is site of portosystemic anastomosis
(between left gastric and (hemi)azygous veins)—may develop gastric
or oesophageal varices.
• Upper oesophageal sphincter (UOS) = cricopharyngeus.
• Lower oesophageal sphincter (LOS) = functional zone of high
pressure above the gastro-oesophageal junction. Relaxants include
alcohol.
• Swallowing requires intact and coordinated innervation from vagus
(UOS, oesophagus, LOS) and intramural myenteric plexus.
275
CHAPTER 7 Upper gastrointestinal surgery
276
Pharyngeal pouch
Key facts
• An acquired ‘pulsion’ diverticulum arising in the relatively fi brous tissue
between the inferior constrictor and cricopharyngeus muscle—
‘Killian’s dehiscence’.
• Arises primarily as a result of failure of appropriate coordinated
relaxation of the cricopharyngeus, causing increased pressure on the
tissues directly above during swallowing.
• Typically occurs in the elderly.
• Associated with lower cranial nerve dysfunction (e.g. motor neuron
disease, previous CVA).
Pathological features
• Acquired diverticulum (fi brous tissue and serosa without muscle fi bres
in most of the wall).
• Tends to lie to one side of the midline due to the cervical spine
directly behind.
Clinical features
• Upper cervical dysphagia.
• Intermittent ‘lump’ appearing to the side of the neck on swallowing.
• Regurgitation of food—undigested.
• Nocturnal aspiration—‘waking up coughing’.
Diagnosis and investigations
• Diagnosis may be made on observed swallowing with a transient neck
swelling appearing.
• Video barium swallow will show fi lling of pouch.
2 Gastroscopy should be avoided unless there is a question of associated
pathology since the pouch is easily missed and easily damaged or perforated by inadvertent intubation.
Treatment
Endoscopic stapled pharyngoplasty—side-to-side stapling of pouch to the
upper oesophagus, which also divides the cricopharyngeus muscle.
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CHAPTER 7 Upper gastrointestinal surgery
278
Hiatus hernia
Key facts
The presence of part or all of the stomach within the thoracic cavity,
usually by protrusion through the oesophageal hiatus in the diaphragm
(see Fig. 7.1).
• Very common; ♀ > ♂; majority are asymptomatic.
• May or may not be associated with gastro-oesophageal refl ux disease
(GORD).
• Predisposing factors include obesity, previous surgery.
Clinico-pathological features
Sliding hernia
• Results from axial displacement of upper stomach through the
oesophageal hiatus, usually with stretching of the phrenicooesophageal membrane.
• By far, the commonest form; may result in GORD.
Rolling (para-oesophageal) hernia
Results from the displacement of part or all of the fundus and body of the
stomach through a defect in the phrenico-oesophageal membrane such
that it comes to lie alongside the normal oesophagus.
• Much less common.
• Symptoms include hiccough, ‘pressure’ in the chest, odynophagia.
• May result in volvulus or become incarcerated and cause obstruction.
Diagnosis and investigations
• Upper GI endoscopy (OGD). To exclude oesophageal mucosal
pathology
• Video barium swallow. Usually identifi es the type and extent.
• CT scanning of the thorax. Investigation of choice in acute presentations.
Treatment
Medical (mainly for GORD symptoms)
• Reduce acid production. Stop smoking, lose weight, reduce alcohol
consumption.
• Counteract acid secretion. Proton pump inhibitors (PPIs), symptomatic
relief with antacids, mucosal protectants.
• Promote oesophageal and gastric emptying. Promotilants, e.g.
metoclopramide.
Surgical
Rarely required. Indicated for:
• Persistent symptoms despite maximal medical therapy;
• Established complications of rolling hernia such as volvulus or
obstruction.
HIATUS HERNIA
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Elective procedure of choice is laparoscopic (or occasionally open) reduction of the hernia and fi xation (gastropexy), usually with plication of the
oesophageal opening (cural plication), occasionally with a fundoplication
(e.g. Nissen’s operation) if GORD symptoms predominate. Acute presentations may rarely require a partial gastrectomy.
279
Sliding hernia
Diaphragm
Fig. 7.1 Hiatus hernia—sliding and rolling. Reproduced with permission from
Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicine, 7th edn.
Oxford University Press, Oxford.
Rolling hernia
Peritoneal sac
CHAPTER 7 Upper gastrointestinal surgery
280
Gastro-oesophageal refl ux disease
Key facts
• Pathologically excessive entry of gastric contents into the oesophagus.
• Refl ux occurs in ‘normals’ up to 5% of the time.
• Commonest in middle-aged adults.
• Usually due to gastric acid, but also due to bile refl ux.
• Contributory factors include:
Reduced tone in the lower oesophageal sphincter. • Idiopathic, alcohol,
drugs, previous surgery, secondary to existing peptic stricture.
Increased intragastric pressure. • Coughing, delayed gastric emptying,
large meal.
Pathological features
Oesophagitis
• Results in infl ammatory changes in the squamous-lined oesophagus.
• Varies in severity from minor mucosal erythema and erosions to
extensive circumferential ulceration and stricturing (graded I to IV).
Stricture
• Chronic fi brosis and epithelial destruction may result in stricturing.
• Eventually shortening and narrowing of the lower oesophagus.
• May lead to fi xation and susceptibility to further refl ux.
Oesophageal metaplasia (‘Barrett’s oesophagus’)
• May develop as a result of gastro-oesophageal refl ux; possibly more
commonly in biliary refl ux.
• Normal squamous epithelium is replaced by columnar epithelium
(metaplasia).
• Dysplasia and premalignant change may occur in the columnar
epithelium.
Clinical features
• Dyspepsia may be the only feature; may radiate to back and left of
neck.
• True refl ux may occur with acid in the pharynx.
• Commonly worse at night, after large meals, and when recumbent.
• Dysphagia may occur if there is associated ulceration or a stricture.
Diagnosis and investigations
Under the age of 45 Symptoms are relatively common and can be treated
empirically. Investigation is only required if symptoms fail to respond to
treatment.
Over the age of 45 Refl ux can be confi rmed by 24h continuous pH monitoring. Peaks of pH change must correspond to symptoms. OGD should
be performed in all new cases over the age of 45 to exclude oesophageal
malignancy.
GASTRO-OESOPHAGEAL REFLUX DISEASE
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Treatment
Medical
• Reduce acid refl ux. d Smoking, d weight, d alcohol consumption.
• Counteract acid secretion. PPI (e.g. omeprazole 20mg od), symptomatic
relief with antacids (e.g. Gaviscon
®
10mL PO od).
• i Gastric and oesophageal emptying. Promotilants, e.g. metoclopramide
10mg tds PO.
Surgical
Procedure of choice is laparoscopic fundoplication, ‘Nissen’s operation’
(wrapping fundus of the stomach around the intra-abdominal oesophagus
to augment high pressure zone).
Rarely required. Indicated for:
• Persistent symptoms despite maximal medical therapy.
• Large volume refl ux with risk of aspiration pneumonia.
• Complications of refl ux, including stricture and severe ulceration.
Uncertain role in the prevention of progressive dysplasia in Barrett’s
oesophageal metaplasia in the absence of symptoms.
281
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