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GS14 General Surgery and Thoracic Surgery Thoracic Surgery Toronto Notes 2019
Boerhaave’s syndrome: transmural esophageal perforation
Mallory-Weiss tear: non-transmural esophageal tear (partial thickness tear) Both are associated with forceful emesis
6Ss of SCC Smoking
Spirits (alcohol) Seeds (betel nut) Scalding (hot liquid) Strictures
Sack (diverticula)
Treatment
• lifestylemodification
■ stop smoking, weight loss, elevate head of bed, no meals <3 h prior to sleeping, smaller and more
frequent meals, avoid alcohol, coffee, mint, and fat • medical
■ antacid, H2-antagonist, PPI, prokinetic agent • surgical(<15%)
■ consider if: volume regurgitation, patient refuses to stay on PPI indefinitely, suboptimal medical therapy, complications of GERD such as pharyngitis, esophageal stricutre, recurrent nocturnal aspiration, Barrett's esophagus
■ hiatus hernia repair and fundoplication • anti-refluxprocedure(usuallylaparoscopic)
◆ fundus of stomach is wrapped around the lower esophagus and sutured in place ◆ 90% success rate
PARAESOPHAGEAL HIATUS HERNIA (TYPE II)
• seeFigure6
• herniationofallorpartofthestomachthroughtheesophagealhiatusintothethoraxwithan
undisplaced GE junction
• leastcommonesophagealhernia(<10%)
Clinical Features
• usuallyasymptomaticduetonormalGEjunction • pressuresensationinlowerchest,dysphagia
Complications
• hemorrhage,incarceration,strangulation(gastricvolvulus),obstruction,gastricstasisulcer(Cameron’s lesion – causes Fe-deficiency anemia)
MIXED HIATUS HERNIA (TYPE III)
• seeFigure6
• secondmostcommontypeofhernia
• includesgiantherniasorintrathoracicstomach
• highincidenceofgastricvolvulus
• majoritypresentwithlong-standingFe-deficiencyanemiaofunknownetiology
• symptomsrarelyincluderefluxorheartburn
• mostcommonsymptoms:abnormalpostprandialfullnessafternormal-sizedfood,chestpainor
retrosternal discomfort (gastric angina), and bloating
• canpresentwithgastricoutletobstructionorgastricnecrosissecondarytostrangulation • combinationofTypesIandII
Treatment
• surgerytoaddresssymptomsortreat/preventcomplications
• reduceherniaandexciseherniasac,repairdefectathiatus,andanti-refluxprocedure(e.g.Nissen
fundoplication)
• mayconsidersuturingstomachtoanteriorabdominalwall(gastropexy)
• inveryelderlypatientsathighsurgicalriskconsiderPEG(percutaneousendoscopicgastrostomy)to
anchor the stomach in the abdomen
TYPE IV HERNIA
• herniationofstomachandotherabdominalorgansintothorax:colon,spleen,smallbowel • Fe-deficiencyanemiaiscommon
Esophageal Perforation
Etiology
• iatrogenic(mostcommon)
■ endoscopic, dilatation, biopsy, intubation, operative, and NGT placement (rare)
• barogenic ■ trauma
■ repeated, forceful vomiting (Boerhaave’s syndrome)
■ other: convulsions, defecation, or labour (rare) • ingestioninjury
■ foreign body or corrosive substance • carcinoma
Clinical Features
• neckorchestpain
• fever,tachycardia,hypotension,dyspnea,andrespiratorycompromise
• subcutaneousemphysema,pneumothorax,pleuraleffusion,andhematemesis
Investigations
• CXR:pneumothorax,pneumomediastinum,pleuraleffusion,subdiaphragmaticair,andwidened mediastinum