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Chapter 2: Foregut Surgery

Andrew Feczko

DISEASES AND CONDITIONS

  • GERD (c), hiatal hernia (c), antireflux procedures (c)

  • Achalasia (c), Heller myotomy (a)

  • Esophageal perforation (c), esophageal perforation repair/resection (a)

  • Barrett’s esophagus (c), upper endoscopy (c)

  • Esophageal cancer (c), esophagectomy (a)

  • Gastric adenocarcinoma (c), gastrectomy (c)

  • GIST (c)

  • Gastric volvulus

  • Gastroparesis (c)

  • Gastric foreign bodies (c), esophageal foreign bodies and caustic ingestion (a)

  • Morbid obesity (c), sleeve gastrectomy (a), Roux-en-Y gastric bypass (a)

  • Zenker diverticulum, cricopharyngeal myotomy with Zenker diverticulectomy (a)

GENERAL FOREGUT SURGERY TIPS

  • - Don’t forget to restage cancer patients after they receive neoadjuvant treatment, prior to operating.

  • - Advanced endoscopic techniques, such as esophageal stenting, per-oral endoscopic myotomy (POEM), and endoscopic submucosal dissection (ESD) may be applicable in certain foregut scenarios. Residents have variable exposure to these techniques during training. Avoid describing them in depth unless you have experience in performing the procedure and the management of any complications that may arise.

(c) = core topic (a) = advanced topic

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Disease Process

Relevant H&P

Work-up/Staging

Treatment

Key Surgical Steps

Post-Op Care

Tips & Tidbits

GERD, hiatal hernia (core)

Typical GERD symptoms: heartburn, regurgitation

Atypical GERD symptoms: cough, hoarseness, sore throat, SOB, chest pain

Alarm symptoms: dysphagia, GIB, weight loss, anemia

CBC, BMP

Always get ECG in a patient with chest pain

Recommended pre-op work-up for GERD:

  • - UGI

  • - EGD—biopsy with H. pylori testing

  • - pH monitoring, impedance testing

    • Demeester score > 14.7 is abnormal

    • Must be off PPI for at least 5 d for accurate test

  • - Manometry—evaluates motility

    • Avoid 360° wrap in a patient with poor esophageal motility

  • - Consider gastric emptying study to rule out gastroparesis if patient has bloating, N/V

  • - pH monitoring and manometry are of limited utility in patients with large PEH

Patients with GERD are frequently found to have a hiatal hernia

Hiatal hernia types:

  • - I: sliding (most common)—LES elevated into chest

  • - II: paraesophageal (PEH)—fundus herniated through the hiatus, but LES remains in anatomic position

  • - III: combined sliding and PEH

  • - IV: other organs herniating through hiatus

GERD:

  • - First line = 6 to 8-wk trial of PPI, lifestyle modification (weight loss, smoking cessation)

    • Alarm symptoms should prompt additional work-up immediately

  • - If patient fails medical management, obtain further work-up, consider surgery

Patients with symptomatic PEH should have them repaired

Patients with asymptomatic PEH—decision to repair depends on size of hernia and if patient is good operative candidate

  • - Strongly consider repair of type III and IV PEH to prevent incarceration/strangulation and need for emergent operation

Fundoplication options:

  • - Nissen—360° wrap

    • Best acid control but highest risk for dysphagia, inability to belch or vomit

  • - Toupet—270° posterior wrap

    • Less dysphagia, can still belch

  • - Dor—anterior 180° wrap

Paraesophageal hernia repair with Nissen fundoplication (core):

  • - Four fundamental steps of PEH repair:

  • Complete reduction and excision of hernia sac

  • Reduction of stomach and GEJ into abdomen without tension

  • Crural closure

  • Fundoplication and/or gastropexy

  • - Position patient in split ...

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