Surgery Marrow Pg 131-140 (GIT)

Prague C & M Criteria

• Determines the extent of disease and risk of cancer in Barrett's esophagus
• C: Circumferential extent (how much of the esophagus is affected)
• M: Maximum extent (the length of the affected area)

Seattle Biopsy Protocol

• Suggests taking biopsies every centimeter in all 4 quadrants of the esophagus when investigating Barrett's esophagus

Barrett's Esophagus

• Specialized intestinal metaplasia of the esophagus
• Caused by the replacement of squamous epithelium with columnar epithelium
• Pathognomonic findings: red velvety mucosa and goblet cells on biopsy
• Clinical features: similar to GERD, but less responsive to treatment, and an increased risk of adenocarcinoma
• Types: Long Segment (>3 cm), Short Segment (< 3 cm), Cardia Metaplasia/Microscopic Barrett's (identified with chromoendoscopy i.e Lugol's iodine or methylene blue)

Initial Examination for Barrett's Esophagus

• Repeat OGD + biopsy every 3-5 years
• If flat columnar mucosa is found, systematic cold biopsy is performed
• Dysplasia diagnosis requires confirmation by two independent pathologists

Management of Barrett's Esophagus based on biopsy

• No Dysplasia:

• OGD every 6 months until a consecutive evidence of non-dysplastic Barrett's esophagus is confirmed

• LGD (Low-grade dysplasia)

• MDT (Multidisciplinary team) discussion

• Therapeutic intervention

• HGD (High-grade dysplasia) or Cancer:

• Surgery: Esophagectomy

• Endoscopic RFA (radiofrequency ablation)

Esophageal Infections

• Esophageal Candidiasis:

  • Seen in immunocompromised patients
  • Commonly associated with oral thrush
  • Diagnosis: Endoscopy (shaggy deposits) and Barium swallow (worm-like ulcers)
  • Treatment: Antifungals

• CMV (Cytomegalo Virus):

  • Seen after organ transplant
  • Commonly associated with Immunosuppressants and GVHD (Graft vs host disease)
  • Appearance: Geographical/serpiginous ulcers

• Herpes Infection:

  • Associated with Herpes labialis
  • Appearance: Small ulcers & raised margins

Feline Esophagus

• GERD: Affects the upper 1/3 of the esophagus
• Eosinophilic Esophagitis: Most commonly affects the lower 1/3
• Clinical presentation: Chronic immune mediated disease with esophageal dysfunction
• Eosinophilia and fibrosis is caused when food antigens trigger an immune response
• Peak age: 20-30 years
• Investigations: Endoscopy (crepe paper mucosa, furrows, rings) & biopsy (eosinophilia: >15-20 eosinophils/HPF)

Gastroesophageal Reflux Disease (GERD)

• Protective factors:

• Intra-abdominal esophagus length (3–5 cm - most significant factor)

• Diaphragmatic Crura

• Angle of His

• Mucosal fold arrangement (least contribution)

• Pathogenesis:

• Intra-abdominal esophagus length below 2 cm

• Lower esophageal sphincter (LES) pressure below 6 mmHg (leading to GERD and increased TLOSR - Transient Lower Esophageal Sphincter Relaxation)

• Risk factors: Obesity and Decreased H.pylori rates

• Clinical Features:

• Retrosternal burn (Heartburn) - most common

• Water brash

• Pharyngitis/Laryngitis

• Dental caries

• Chronic cough and wheezing

Investigations for GERD

• Gold Standard: 24 hr pH monitoring
• Endoscopy: Indication: inconclusive endoscopy or planned intervention
• pH probe: Inserted 5 cm proximal to GE junction. Stop PPI 5-10 days before for accuracy.
• Demeester score: > 14.72 suggests GERD

GERD Treatment

• Lifestyle Changes:

  • Weight reduction
  • Avoid fried, fatty, spicy food, citrus, chocolate, mint
  • Eat small, frequent meals
  • Dine 2-3 hours before sleeping

• Medications:

  • PPIs (Proton pump inhibitors)
  • Prokinetics
  • Antacids

Surgical Management of GERD

• Indications:

  • Failure of medical management
  • GERD complications
  • Associated with sliding hiatal hernia
  • Patient wishes to discontinue medical management

• Surgeries:

  • Fundoplication
  • Collis Gastroplasty

Fundoplication

• Principles of Surgery:

• Restore intra-abdominal esophagus length to ≥ 3 cm

• Tighten diaphragmatic crura around the esophagus

• Wrap fundus around the esophagus

• Preserve the vagus nerve

• Re-establish the angle of His

• Types of Fundoplication:

• Complete wrap (Nissen's): 360° - Most common complication: Gas bloat syndrome

• Partial wrap: - Dor: 180° anterior wrap - Toupet: 180°-270° posterior - Belsey Mark: 270° anterior

Collis Gastroplasty

• Indication: Esophageal shortening

Newer Modalities for GERD

• Polymer injection around LES to tighten sphincter:
  • High recurrence, not preferred

Esophageal Motility Disorders

Achalasia

• Pathophysiology:

• Impaired relaxation of the LES, resulting in difficulty swallowing

• Chicago Classification of Achalasia:

• Type 1 (Classic Achalasia): 100% failed peristalsis without POP (Pan oesophageal pressurization)

• Type 2: 100% failed peristalsis with POP in ≥ 20% swallows

• Type 3: ≥ 20% swallows with premature spastic contractions, failed peristalsis, and POP may be present

• Clinical Features:

• Classic Triad: - Dysphagia (Initially liquids > solids) - Weight Loss - Regurgitation (Earliest Feature)

• Other Clinical Features: - Heartburn - Nocturnal coughing - Post-prandial choking

• Complications:

• Aspiration pneumonia (most common)

• Lung abscess

• Investigations:

• Manometry: 10C → ↑ IRP (Increased resting pressure), failure of LES relaxation

• Endoscopy: Rule out cancer

• Barium Swallow: To visualize the esophagus

• Achalasia - Eckardt Score:

  • Scores weight loss, dysphagia, retrosternal pain, and regurgitation (0-3 points each)

• Management:

• Medications:

  • Botox: Inject botulinum toxin to relax the LES (Highest rate of recurrence, repeat administration can lead to fibrosis)
  • Calcium channel blockers (CCBs) & Nitrates: Primarily for symptomatic relief

• Balloon (Pneumatic) dilation: - Deflated balloon inserted into the esophagus and inflated. Serial dilatations offer similar efficacy to surgical myotomy. - Best responders: Age > 45 years, Females, previously undilated esophagus, Type A achalasia. - Risk of perforation: Decreases with balloon < 30 mm

• Surgical Treatments:

  • Heller's Myotomy: Cuts the LES muscle 6 cm proximal and 2-3 cm distal to the GE junction
  • POEM (Per Oral Endoscopic Myotomy): A type of NOTES (Natural orifice transluminal endoscopic surgery) procedure. Cuts the LES muscle through the mouth

Distal Esophageal Spasm (DES)

• Features:

• 5x less common than achalasia

• Females > males

• Motor abnormality of the lower 2/3 of the esophageal body

• Contractions: Repetitive, simultaneous, and high amplitude (↑ DCI)

• Investigations:

• ECG: Rule out angina

• Barium Swallow: Rosary bead or corkscrew appearance

• Manometry: Confirmatory

• Treatment:

• POEM: Very good response

• CCB (Ca²⁺ channel blockers) / Nitrates

Approach to Motility Disorders

• Differentiating factors:

• Female: With regurgitation, nocturnal cough, dysphagia, and weight loss.

• Patient: With chest pain similar to angina, but normal cardiac enzymes.

• Differentials:

• Achalasia, Cancer: Endoscopy, Manometry, Barium swallow

• DES, Angina: ECG, Manometry, Barium swallow

Esophageal Diverticula

• Types:

  • Zenker's (Upper Esophageal):

    • Causes:
      • Pulsion (increased pressure)
      • Tuberculosis (TB), Histoplasmosis
    • Appearance: False diverticulum (only mucosa)
    • Rx: Large/symptomatic: Diverticulectomy

  • Mid Esophageal (Para-bronchial):

    • Appearance: True diverticulum of esophagus (traction diverticula)

  • Lower Esophageal (Epiphrenic):

    • Causes: Pulsion, False diverticulum
    • Rx: Symptomatic: Surgery

Zenker's Diverticulum (Crico-pharyngeal achalasia)

• Associated Risks: Increased risk of squamous cell carcinoma
• Pathophysiology: Outpouches through Killian's dehiscence created by discordant muscle contractions, increasing pressure.
• Clinical Features:
  • Regurgitation (Earliest symptom)
  • Halitosis (Bad oral odor)
  • Dysphagia (Difficulty swallowing)
• Complications:
  • Aspiration pneumonia (Most common)
  • Lung abscess
• Investigation: Barium swallow
• Management:
  • Diverticulectomy:
    • Large (>2 cm) & symptomatic cases
    • Linear stapler > LASER
  • Cricopharyngeal myotomy: Reduces recurrence
  • Endoscopic diverticulopexy with cricopharyngeal myotomy

Abbreviations

• BO: Barrett's esophagus
• HGD: High-grade dysplasia
• LGD: Low-grade dysplasia
• MDT: Multidisciplinary team
• OAC: Esophageal adenocarcinoma
• OGD: Esophagogastroduodenoscopy