General Surgery
- General Surgery
- 🌯 Esophagus
- 🍤 Stomach (and Duodenum)🔒
- 🦑 Small Intestine 🔒
- 🥜 Colon 🔒
- 💩 Rectum and Anal Canal 🔒
- 🎾 Gallbladder and Bile Ducts 🔒
- 🧽 Pancreas 🔒
- 🍑 Liver 🔒
- 🥔 Spleen 🔒
- 🚑 Abdominal Emergencies 🔒
- 🔪 Bariatric Surgery & Informed consent 🔒
🌯 Esophagus
- cervical
- throacic
- abdominal
border betw. squamous + cylindrical epithelium (SCJ) at GE-junction
⇒ barrets esophagus! (b in picture)→ SCJ(Z-line) is above GEJ
From inside to outside:
- Mucosa and Submucosa
- Circular Muscle: Contraction increases luminal pressure.
- Longitudinal Muscle: Contraction causes shortening.
- Adventitia
- Innervation: (1) Meissner/Submucosal Plexus, (2) Auerbach/Myenteric Plexus, (3) Vagus Nerve.
abdominal → serosa instead
motor disorders → shows mobility + supplesness (softness)
hydrosoluble → prevent aspiration!
direct visualization + biopsy (+treatment
- motility disorders (esp after exclusion of structural lesions + when suspicion after barium swallowing)
- Dg achalasia (+treatment monitoring)
- pre-OP before fundoplication
evaluation peristalsis + sphincter p
- Amplitude
- Duration
- Speed of wave
- Spincter pressure
GE-reflux (GER)
- Penetration esophageal layers + surrounding tissue
- Lymphnode evaluation + biopsy
- dysphagia
- regurgitation
- pain
- Sialorrhea (excess salivation)
only for solids
regurgitation
→ progressive evolution = cancer
in achalasia
first liquids then solids
Corrosive esophagitis
characterized by caustic injury due to the ingestion of chemical agents: acids, bases + salts mainly alkaline substances such as detergents.
effortless involuntary retrograde flow of food in the oral cavity
dilation (above the obstruction)
second. infections → inflammation + ulceraion + pain
advanced stages
stenosis → unable to swallow saliva
Corrosive esophagitis
characterized by caustic injury due to the ingestion of chemical agents: acids, bases + salts mainly alkaline substances such as detergents.
BASES! → liquefying necrosis → transmural necrosis
Acids → coagulation necrosis → no/rare transmural necrosis
acids
→ more base ingestion is possible due to less pain
- acute phase: necrosis + inflammation
- granulation phase
- scarring phase → stenosis (esp. when dmg to entire mucosal thickness)
damage to esophagus: pain, dysphagia
inflammatory signs: fever, laryngeal edema
other damaged structure: recurr. laryngeal n, mediastinitis+peritonitis (when perforation)
later: esophageal stenosis
Endoscopy
0 = normal
1 = congestion + hyperemia
2 = Ulcer
2A = superficial ulcer, exudate
2B = Deep ulcer or circumferential ulcer
3 = Necrosis
3A = small necrotic area
3B = extended necrotic area
4 = perforation (not mentioned in the book)
- Perforation → mediastinitis + peritonitis
- laryngeal edema
- Stenosis
Drugs:
- Analgesics → also leads to ↓shock
- Steroids → in respiratory symptoms, prevention of stenosis, in deep lesions
- ABs + steroids → in deep lesions
Intevention:
- emergency surgery → peritonitis + mediastinitis
- periodic esophagoplasty or dilation → stenosis
- esophagectomy → stenosis (to prevent malignant transformation)
exhalation
<10mmHg
(normal = 16)
90%
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- gravity + peristalsis
- bicarbonates (from saliva) = chemical clearance
- ↑intra-abdominal pressure
- obesity
- pregnancy
- coughing
- ascitis
- gastric surgery
- smoking + nutrition (nitrates, alcohol, coffee, chocolate)
Savary-Miller ⇒ 📷
non-confluent breaks → confluent Ø circumferential → circumferential → complication
Elevation of the Z-line 📷
T
- Retrosternal pain = pyrosis (heartburn)→ esp. when lying + postprandially
- regurgitation
- pulmonary symptoms
- Ulcer + ulcer perforation
- Hemorrhage
- Stenosis
- Barretts (+dysplasia)
🚩-symptoms!!
- weight loss
- dysphagia + odynophagia
- anemia
- hemorrhage
- pH-metry → drop of pH<4 for 5min; 3x/ 24h
- Manometry → PES < 10mmHG
- Scintigraphy → Estimate reflux + clearance
- Esophagoscopy → Classification + DD!
alles was es halt dort gibt
- esophagitis
- achalasia
- cancer
- diffuse esophagea spasm (functional)
- diverticuli
endoscopy + biopsy
- Diet
- ↓fat
- ↓coffee, chocolatttta, alcohol, nitrates etc.
- quit 🚬
- Lie down in raised position + dont lie down directly after eating
- drugs that aggrevate:
- beta2-agonist + alpha adrenergics
- Ca-channel blocker
- ... etc.
- PPI
- H2-blocker
- prokinetics
- no response to drug therapy
- persistent esophagitis
- complications
- patient doesnt want long-term treatment
during remission moooofugga
- fundoplication
- reconstruction Hiss-angle (Gubaroff valve)
- Connect cardia → right pillar (crus) of diaphragm 📷
- obtain a 4-5cm esophageal abdominal segment
- hernia reduction
- prevent recurrance
- preserve deflutition, vomiting, eructation
- Nissen 360°
- Dor ant. hemivalve 180°
- Toupet post. hemivalve 270°
→ performed via laparoscopy or combined: laparo- + thoracoscopically
normal size + good contractibility → Nissen
faint peristalsis → Dor or Toupet
- cirrhosis (coagulation defects, portal hypertension and nutritional disorders)
- previous interventions (supra-mesocolic level) (probably bc. adhesion formation?)
male >60y
Cricopharingeal muscle contracts prematurely → pressure zone at pharingo-esophageal junction → progressive weakening of muscular tunica → herniation mucosa + submucosa
dorsal + lat
Hiatal hernia
- dysphagia
- regurgitation
- halitosis (bad breath)
- diverticulitis
- weird noise when liquid is swallowed??
barium swallow + radiography
- perforation
- malignant transformation
- aspiration pneumonia
- hemorrhage
- compression recurr. laryngeal → hoarseness
- intubation
- surgical regsection + reconstruction of the wall (suture in 2 layers)
- cricopharyngeal myotomy (prevention recurrance) [divide cricopharyngeal with laser via endoscopy or open neck ]
men + woman late 40's
After Infection with Koch Bacillus → Mediastinal lymphnode adhering to esophageal wall → retro-scarring retraction
- sharper form
- all layers involved!
- Traction diverticuli have a distinct shape and consist of all the layers of the esophagus.
- This type of diverticulum is common.
- Improve writing style to be more confident and academic.
- Retain medical terminology.
- Highlight keywords in bold.
asymptomatic 🤡
- coughing (due to adherence to trachea or bronchi)
- dysphagia (in diverticulitis)
- complication (see below)
- esobronchial fistula
- hemorrhage
- perforation
- pericarditis
- pleuritis
when symptomatic
reconstruction (suture in 2 layers)
interposing of healthy tissue → prevent recurrance
above diaphragm 📷
esophageal dyskinesia (prob. due to ↑pressure)
achalasia
hiatal hernia
- diverticulitis
- perforation
- malignant transformation
- hemorrhage
- dysphagia
- postprandial epigastric pain - relieved after regurgitation
- high epigastric pressure
the typical clinical presentation 🤡
Barium (Radiography + contrast) 📷
when pressure is to ↑↑↑
- compression
- dysphagia
- regurgitation
- perforation 🚑
thoracotomy → resection + suture in double layers 📷
also treat achalasia + hernia
- Failure of LES/cardia relaxation
- Ø well-coordinated persitaltic waves
unknown (infections?, Vit-defic.?, impairment vagal nuclei +trunk?) ⇒ degeneration Auerbach plexus
m+f; 30-50y
- Dysphagia → paradoxical , intermittend+ paroxistic (but over time becomes permanent)
- epigastric pain (in the beginning) → better after esophageal dilation
- Regurgitation → Esp. at night (clinostatism)
- Siallorhea
Stasis esophagitis
- esophagitis
- Ulcer
- Hemorrhage
- Cancer
- Aspiration pneumonia + lung abscess (esp. due to regurgitation)
true
barium swallow
endoscopy
⇒ bird-peak appearance
- terminal narrow portion
- lack of relaxation
- dilation (megaesophagus)
- uncoordinated or missing persitaslsis
iv glucagon → relaxation of cardia (in achalasia)
- DD benign stenosis + cancer → biopsy
- Manometry
- PES > 25mmHg → positive
- uncoordinated contractile wave
clinical presentation → confirmation with radiology and manometry
- Cancer → progressive dysphagia, rapid evolution, general state affected
- Epiphrenic diverticuli → barium (round, regular), normal manometry
- Hiatal hernia → barium (see above), low LES tonus on manometry
- avoid stress
- Ø too hot/cold food
- etc.
2-3 sessions Dilation (mechanic, pneumatic, hydrostatic) 📷
→ Ø result? → Heller esocardiomyotomy = longitudinal incision 6-8cm on esogastric junction + sectioning of muscles up to mucosa 📷
→ Fundoplication to prevent reflux → Nissen in hypermotility forms, Dor in hypo-
If high risk for surgery → Botulinum injection (in LES)
Leiomyoma
(Tumor originating from smooth muscle cells)
- Leiomyoma
- Inflammatory polyps
- granulomas
- papillomas
- congenital cysts
T
bleeding
leiomyoma develops within wall → extrinsic compression → stenosis → ulceration → bleeding
T
contrast xray
F: usually small only rarly large enough to cause obstruction
biopsy
F: may occur at every level + more freq. in the lower esophagus
Barium xray → spherical + regular contour 📷
twist of the polyp → infections, edema + bleeding
small → endoscopic resection
within wall (intraparietal) + malformations → surgery
- Malignant tumors of the esophagus 🔒
🍤 Stomach (and Duodenum)🔒