p. 330.)Upper gastrointestinal (UGI) surgery: overview
UGI surgery: multidisciplinary teams
UGI surgery: oesophageal disease
Upper GI surgery: bariatric surgery
Hepatopancreatobiliary (HPB) surgery: overview
UGI surgery specializes in conditions of the oesophagus, stomach, gall bladder, biliary system, and duodenum. Surgical management of splenic conditions often falls within the remit of a UGI surgeon. UGI surgical oncology, bariatric surgery, and some oesophagogastric surgery are centralized to specialist hospitals. There is some overlap with hepatopancreatobiliary (HPB) surgery.
Many conditions associated with UGI will present via the ED. Take initiative and clerk patients and present them to the on-call SHO/specialist registrar.
This is a high-yield activity, particularly in consolidating your anatomy learning with diagnostic radiology. As with HPB surgery, interventional radiology plays a role in managing patients including procedures such as percutaneous transhepatic cholangiography (PTC), image-guided aspiration/drain insertion, oesophageal stenting, radiologically inserted gastrostomy insertion, and fluoroscopy studies.
There are lots of drains and tubes—observe where they placed on the patient and look at what they are producing and how much. You will also learn about perioperative care and complications that can arise from surgery.
This is performed by gastroenterologists and some general surgeons. They have both diagnostic and therapeutic value and many UGI patients will have these procedures performed on them.
This is an exciting and often very rewarding place to spend time. Theatre activity includes emergency cases (CEPOD theatre, named after the Confidential Enquiry into Perioperative Deaths), day surgery, and elective operating lists. Be enthusiastic and you will be able to scrub and assist in cases. Read up on the patients prior to the operation and anticipate questions the seniors may ask you about the case (e.g. essential anatomical questions).
Surgical patients constitute some of the sickest patients in the hospital and often need to be managed in critical care. This is a great place to relearn your physiology and link it to clinical care.
UGI cancer MDTs will be useful in gaining exposure to cases of oesophageal and gastric malignancy. It is also a useful place to bring together your basic science (anatomy, pathology, tumour biology) and clinical science (GI, radiology, oncology, surgery).
Non-invasive, safe, and is particularly useful for evaluating liver, gall bladder, and biliary pathology.
This is a form of continuous X-ray imaging method to produce a live and dynamic study. Combined with an oral contrast agent such as barium, this can be used to investigate (1) oesophageal motility disorders (e.g. ‘birds beak’ sign in achalasia), (2) anatomical disorders (e.g. pharyngeal pouch), (3) hiatus hernia, (4) if a surgical anastomosis is leaking, or (5) where OGD is contraindicated.
OGD allows direct luminal visualization of the oesophagus, stomach, and duodenum. This confers great diagnostic value and can also be used to provide biopsies and minor interventions. This is a great learning opportunity to build your anatomical understanding of the UGI tract and observe pathologies.
(See p. 330.)
Endoscopic ultrasound (EUS)
This involves a transnasal insertion of a manometric catheter into the oesophagus to detect pressures within the lumen. This is the gold standard test in detecting motility disorders of the oesophagus including achalasia and oesophageal spasm. Occasionally used in assessing GORD.
This is usually performed in patients being considered for antireflux surgery, confirming the presence of GORD and avoiding operations on patients with functional heartburn. A transnasal catheter with a pH sensor is inserted above the lower oesophageal sphincter (5 cm above, position confirmed with manometric measurements).
Key anatomy: oesophagus
• Upper oesophageal sphincter: cricopharyngeus.
• Lower oesophageal sphincter: functional zone of higher pressure above gastro-oesophageal sphincter.
• Upper two-thirds: stratified squamous epithelium. Striated muscle fibres.
Pathological contraction or malcoordination of the oesophagus can result in conditions such as achalasia or oesophageal spasm.
Results in loss of inhibitory neurons required for lower oesophageal sphincter (LOS) relaxation and peristalsis of the oesophagus. The LOS fails to relax and the peristalsis of the oesophagus becomes disorganized.
Usually include gradual-onset dysphagia which initially is worse for fluids than solids. Regurgitation, chest pain, heartburn, and weight loss can occur.
Manometry is the gold standard for diagnosis and will demonstrate lack of coordination of peristalsis and a high integrated relaxation pressure. Barium swallow fluoroscopy classically shows smooth distal tapering with the ‘bird’s beak’ sign.
Can be treated endoscopically with balloon dilatation. Botulinum toxin injections have also been used in selected patients. Myotomy is the most definitive procedure with a success rate of 95%, and 85% of patients remaining symptom free at 5 years. Heller’s procedure is a type of myotomy, and may be combined with antireflux procedures to prevent reflux post myotomy.
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• Type 1 (classic): minimal oesophageal pressurization.
• Type 2: achalasia with oesophageal compression, pan-oesophageal pressurization.
• Type 3: premature spastic contractions or preserved fragments of distal peristalsis.
New onset of dysphagia must prompt you to think of a tumour as an important differential diagnosis, particularly in those patients aged >45 years. Can present with dysphagia to solids followed by liquids. Presentations with true dysphagia, ~25% have oesophageal cancer.
Dysphagia, ongoing reflux, regurgitation, odynophagia (painful swallowing), hoarse voice from recurrent laryngeal nerve invasion, cervical lymphadenopathy, cough, and haemoptysis and other systemic features such as weight loss, anorexia, and anaemia.
Adenocarcinoma and squamous carcinoma. Adenocarcinomas are increasing in the Western population and may be associated with GORD, Barrett’s oesophagus, and obesity. Most commonly affects the lower third of the oesophagus. Squamous carcinoma has a higher incidence in Japan and northern China. This can occur throughout the oesophagus and is associated with smoking, high alcohol intake, and diet low in fruit and vegetables.
OGD and biopsy with histopathological examination.
Most patients at time of presentation have incurable disease and treatment will be focused on palliative measures. Dysphagia from structuring or obstruction of the oesophagus may be treated with endoscopic luminal stents. Surgery with curative intent may involve neoadjuvant chemoradiotherapy and radical resection. Surgical approaches to removing oesophageal tumour include laparotomy plus right lateral thoracotomy (Ivor Lewis oesophagectomy), left thoracoabdominal oesophagectomy, and the transhiatal approach.
Key revision: Barrett’s oesophagus
• Oesophageal metaplasia: normal squamous epithelium in oesophageal mucosa replaced with columnar epithelium.
Also known as a Zenker’s diverticulum, this is an acquired diverticulum between the inferior constrictor and cricopharyngeus muscle (known as ‘Killians dehiscence’). This mostly occurs in the elderly and can present with an intermittent lump appearing in the neck on swallowing (usually deviated to one side), regurgitation of undigested food, halitosis, cervical dysphagia, chronic cough, and aspiration. Diagnosis can be made clinically or with barium swallow fluoroscopy, which will show contrast filling in the pouch. Treatment can include an endoscopic or external open approach.
The presence of hiatus hernia is common and is usually asymptomatic. It affects females proportionally more than males. By definition, this involves protrusion of the stomach into the thoracic cavity and is associated with a widening or weakness of the diaphragmatic crura. It can be classified as (1) sliding (commonest), (2) rolling (aka paraoesophageal), or (3) mixed (when both coexist).
Reflux, dysphagia, vomiting, post-prandial fullness, substernal pain, and dyspnoea if a large hernia is present.
Plain X-ray, OGD, barium swallow tests, or on CT imaging.
Reducing precipitating factors (smoking, obesity, alcohol, caffeine) and reducing acid secretion with PPIs. Indications for surgical treatment include failure of symptom control with maximal medical therapy, complications associated with hiatus hernia (e.g. gastric volvulus), and GORD associated with hiatus hernia. Surgical management reduces the herniating stomach/contents back through the hiatus and fixing the stomach to prevent migration (gastropexy). Hiatus hernia surgery is usually combined with antireflux procedures.
Affects up to 40% of the population.
Heartburn (retrosternal burning), regurgitation, waterbrash, or dyspepsia. May also present as chest pain, epigastric pain, cough, odynophagia, and a hoarse voice. Symptoms are often worse after eating or when lying down. It is important to learn how GORD presents, not just because it is very common but there are a wide range of differential diagnoses (including ones never to be missed—cancer, MI, aortic aneurysm). Pathological consequences include oesophagitis (inflammatory changes in squamous lines oesophageal lumen), stricturing, and Barrett’s oesophagus.
When protective mechanisms are lost, GORD can develop consequently. The mechanisms that normally prevent acid reflux are:
• the flap valve—formed by a fold of gastric mucosa that serves to occlude the oesophageal lumen
• the angle of His (acute angle between cardia at entrance of stomach and oesophagus)
• an intra-abdominal length of oesophagus
• relatively elevated intra-abdominal pressure surrounding the abdominal segment of oesophagus.
Further investigations may be performed if there are concerns around complications, non-response to treatment, diagnostic uncertainty, or if the patient is being considered for antireflux surgery. Reflux can be confirmed by continuous 24-hour pH monitoring. Changes in pH need to correspond to symptom episodes. An OGD may be performed to exclude malignancy.
Ask the boss: antireflux surgery
• Indications for antireflux surgery, medical vs surgical therapy (LOTUS trial).
• Antireflux surgery for Barrett’s oesophagus and reducing cancer risk.
GORD is normally treated in the community with proton pump inhibitors (PPI). Symptomatic response usually confirms the diagnosis.
PPI therapy can be effective (70–80%) and lifestyle modifications (smoking/ETOH/weight reduction, avoid eating 2–3 hours prior to bedtime, and eating small meals) can help in managing symptoms. Other medications that may be used include H2 receptor antagonists, antacids, sucralfate, and prokinetics. Only a few patients will need surgery, the commonest being the laparoscopic antireflux procedure (e.g. wrapping of the fundus around the oesophagus—Nissen fundoplication is a 360° wrap).
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Urgent ‘2-week wait’ referral for OGD in patients with dyspepsia with:
Most common form of gastric cancer is adenocarcinoma (from mucosal tissue). Other forms include gastrointestinal stromal tumours (GIST) arising from the connective tissue of stomach wall, neuroendocrine tumours, or lymphomas.
Upper abdominal pain, dyspepsia, weight loss, UGI bleed, and mass. Many gastric cancers are not amenable to surgical resection due to the local extent of metastatic disease.
Treatment goals in this setting are symptomatic and palliative. In potentially curative cases, surgical management includes either distal gastrectomy or total gastrectomy depending on the anatomical location with the aim of removing all neoplastic tissue with adequate margins. (See Fig 42.1.) (Neo-)Adjuvant chemotherapy is combined with surgery.
Fig. 42.1 Operative diagram of a total gastrectomy with a Roux-en-Y reconstruction. Reproduced with permission from Chris Callaghan et al, Emergencies in Clinical Surgery, 2008, Oxford University press
Acute UGI perforation can be caused by a duodenal ulcer, gastric ulcer, tumours, and traumatic origin (e.g. fishbone). Rarely, ischaemia can precipitate a perforation. Remember, the oesophagus can perforate too (e.g. Boerhaave syndrome).
Patient will be acutely unwell and present with acute-onset upper abdominal pain and peritonism. Erect CXR gives the diagnosis by free air under the diaphragm (pneumoperitoneum); however, beware that the absence of free air on CXR does not exclude a UGI perforation!
Immediate resuscitation (following acute life support principles). The definitive treatment is urgent operative intervention. This usually is a laparotomy; however, laparoscopy is sometimes favoured by some surgeons. A perforated duodenal ulcer is treated with an omental patch as is a pre-pyloric gastric ulcer. Ulcers on body of the stomach should be biopsied and closed. Patients will also be commenced on PPI therapy and receive empirical Helicobacter pylori eradication therapy.
Obesity represents one of the biggest public health challenges faced by developed countries. At present, the only effective treatment proven to achieve substantial weight loss is surgery. This surgical specialist interest is termed ‘bariatric surgery’; it is typically performed by UGI surgeons and is rapidly expanding as access to these services is being made more widely available.
Although many there are a multitude of different operations used for weight loss, the most commonly performed operations in the UK are (1) sleeve gastrectomy, (2) gastric bypass and (3) gastric band. (See Fig. 42.2.)
Was initially designed as the first stage of a more complex duodenal switch procedure but was found to be effective in its own right as a weight loss procedure. It is technically straightforward relative to the other operations and involves the removal of the greater curve of the stomach.
This is the most commonly performed (and perhaps the most effective) weight loss procedure globally. It involves the creation of a small 30 mL pouch of stomach using a linear stapler and then dividing the small bowel distally and bringing up the distal end to anastomose with the small pouch of stomach (gastrojejunostomy). This leaves the pancreatobiliary limb (proximal end of divided small bowel), which is anastomosed to the small bowel distal to the gastrojejunostomy completing the Roux-en-Y reconstruction.
Involves the creation of a small (~30 mL) proximal pouch of stomach by applying an inflatable silicone band around the stomach. The band is connected to a subcutaneous port, allowing inflation and release of the band to adjust for the patient.
Fig. 42.2 Types of bariatric surgery. (a) Adjustable gastric band—a small bracelet-like band is placed around the top of the stomach to create a small pouch, thereby limiting food intake; the outlet size can be varied by injecting/removing saline from a small reservoir connected to the band. (b) Roux-en-Y—works by restricting food intake and by 
the absorption of food; a small pouch (similar in size to the adjustable gastric band) is created; in addition, absorption is reduced by ‘excluding’ most of the stomach, duodenum, and upper small intestine and routing food directly from the pouch into more distal small bowel. (c) Vertical sleeve gastrectomy—works by reducing the capacity of the stomach and altering gastric emptying. Reproduced from Jolly, E., et al, Training in Medicine 2016, OUP, Fig 7.62.
HPB surgery is the surgical subspecialty concerned with diseases of the liver, pancreas, and biliary tree. It has become increasingly centralized to major centres, especially for major resections and complex cases (including liver transplant). That said, a great deal of the bread-and-butter surgical take is concerned with the more common HPB conditions.
Percutaneous intervention: this may be diagnostic (obtaining a biopsy of a liver lesion of liver parenchyma to establish a histological diagnosis or therapeutic such as a PTC to decompress the biliary system or an image-guided aspiration/drain insertion. Liver abscesses and peripancreatic collections can be drained with image guidance by the interventional radiology team.
ERCP: this is performed in endoscopy, often by the gastroenterologists, and is a key part of the investigation and management of patients with obstructive jaundice. Although performed at most acute hospitals, access is often limited in a district general hospital.
EUS: this is a combination of endoscopy and US scanning used in specialist centres to assess the UGI tract including pancreas and distal common bile duct (CBD), as well as being a method of radiologically guiding biopsies/FNAs (e.g. for pancreatic cyst lesions).
Cholecystectomy: laparoscopic or open, typically the former ± intraoperative cholangiogram. One of the most commonly performed elective and emergency general surgical procedures—this is a must-see! Make sure you have revised your biliary anatomy read the patient’s notes for indication, and LFTs, and reviewed the US report/images.
Liver resections: these are specialist procedures done laparoscopically or as open procedures. Typically carried out in major centres so it may be difficult to see much of this without going to a teaching hospital. If going to theatre—make sure you ask a specialist registrar to go over the scans and surgical anatomy with you before surgery.
Within HPB surgery there is a huge variety of activities and lots of opportunities for you to get involved—just turn up early and introduce yourself! These patients are also some of the sickest surgical patients you may encounter, often presenting with classic signs—so make sure you take the opportunity to examine these patients in ED or on the ward.
Common conditions with 100,000 gallstone-related admissions per year in the UK. Affects 10–20% of the population with majority asymptomatic. 1–4% of patients with gallstone per year will develop symptoms. Female >male incidence (2:1) and 
with age.
Clinical syndrome characterized by severe RUQ pain, typically colicky (usually constant in cholecystitis), radiating to the back or shoulder, which is for a short duration. Symptoms are related to the impaction of a gallstone in Hartmann’s pouch, cystic duct, or CBD. Diagnosis is made by a typical history of episodic RUQ pain after eating fatty meals combined with gallstones seen on USS/magnetic resonance cholangiopancreatography (MRCP). 10% seen on plain X-ray.
Biliary colic must be distinguished from other gallstone-related presentations and are associated with:
• acute calculous cholecystitis
Absence of jaundice and fever with Murphy’s sign negative in RUQ (this Charcot triad usually present in acute cholangitis).
Normal inflammatory markers, amylase and LFTs.
Initially conservative with analgesia and a low-fat diet, occasionally requiring admission for symptom control. Definitive management is elective laparoscopic cholecystectomy.
Occurs due to impaction of a gallstone in Hartmann’s pouch resulting in chemical cholecystitis which progresses to bacterial cholecystitis. This may progress to necrosis, perforation, or empyema. Acalculous cholecystitis may occur secondary to systemic sepsis, long-term total parenteral nutrition, DM, and hepatitis A.
RUQ pain (constant) for >24 hours, N&V, associated systemic upset (tachycardia and pyrexia), and a positive Murphy’s sign.
Elevated inflammatory markers (WCC—leucocytosis, CRP) but usually normal LFTs.
Gallstones and sludge present in the gall bladder plus thickening of gall bladder wall plus pericholecystic fluid/oedema.
Nil by mouth, IV fluids, IV antibiotics (with Gram-negative cover), analgesia (NSAIDs).
Ask the boss
Traditionally, patients were managed conservatively in the acute phase and offered delayed cholecystectomy 6 weeks later. However, latest guidelines and evidence now recommend early laparoscopic cholecystectomy (within 72 hours of onset or during the index admission); variation in practice still exists though—ask your boss about the pros/cons.
Any interruption in the flow of bile from liver to GI tract (ultimately, via the CBD) can be a cause of obstructive jaundice. A thorough history and examination coupled with basic blood tests will provide useful clues as to where the obstruction is likely to be and the underlying pathology.
These patients may be asymptomatic but often present with jaundice plus RUQ pain ± fever. These patients need to be monitored closely as they can quickly deteriorate, especially if elderly. An obstructed and infected biliary tree is a surgical emergency and needs urgent attention.
Honours
• Charcot’s triad: fever + RUQ pain + jaundice.
• Reynolds’ pentad: Charcot’s triad + septic shock + confusion.
Always check the calibre of the CBD (<9 mm is normal), also look for evidence of intrahepatic duct dilation.
Should be performed if stones are suspected and then proceed to ERCP decompression.
ERCP plus stone retrieval ± stent and sphincterotomy. Essentially the duct needs to be cleared prior to laparoscopic cholecystectomy.
It is important to be aware that obstructive jaundice may be the presentation of something more sinister! Always do your systemic enquiry and look for signs and symptoms of malignancy (weight loss, malaise, fatigue).
Ask the boss
Surgical CBD exploration is usually reserved for cases where ERCP is unavailable, contraindicated, or unsuccessful. However, some units routinely perform IOC and may go straight to surgery without ERCP. Ask your consultant about the pros/cons.
Common procedure. 50,000 cholecystectomies are performed every year in the UK so it is definitely worth getting to theatre and seeing this procedure.
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‘If a patient presents with painless mild obstructive jaundice and a palpable gall bladder, the cause is not gall stones!’ 
the implication is that this is a malignant process. Therefore, the patient will need a CT chest/abdomen/pelvis and tumour markers checked (carcinoembryonic antigen plus CA 19-9).
Fig. 42.3 Calot’s triangle. Reproduced from Agarwal, Anil, et al, Oxford Handbook of Operative Surgery 3e, 2017, Oxford University Press.
This is the anatomical location where the surgeon should reliably find the cystic artery (branch of the right hepatic artery) (Fig. 42.3). Boundaries are:
• common hepatic duct (medial).
Cholecystectomy (surgical removal of the gall bladder) can be performed laparoscopically or open, but the vast majority are now done laparoscopically (or at least start that way!). Once the surgeon has carefully dissected Calot’s triangle, exposing the anatomy of the key structures, they have established the ‘critical view of safety’ so that clips can be applied to the cystic duct and artery and these structures divided safely. The gall bladder is then carefully dissected off the liver bed (using an electrocauterizing hook—remember to ‘look, hook, cook’) and extracted from the abdominal cavity via an umbilical port.
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• Bile leak associated with an accessory cystic duct of Luschka.
• Iatrogenic CBD injury (Bismuth and Strasberg classification).
This is an uncommon malignancy that affects males more than females and has a peak incidence in the 70s. Most are adenocarcinomas with 90% being extrahepatic. Risk factors are PSC and congenital anomalies, with PSC having a 5–15% lifetime risk. Few cases are resectable with poor outcomes. Palliative stenting (via ERCP/PTC) relieves jaundice for symptom control, but can also present its own complications.
Rule number 1: ‘Don’t mess with the pancreas!’
This group of patients represents some of the sickest patients you will see and they can often end up on ITU requiring support for multiple organ systems.
This occurs within or around the pancreas early in acute, severe pancreatitis; it lacks an enclosing wall and will often resolve spontaneously without intervention. However, this can become infected creating an infected peripancreatic collection which can cause rapid deterioration and may require percutaneous US/CT-guided drainage (or another form of minimally invasive intervention).
This is a collection of pancreatic juice within or adjacent to the pancreas enclosed by a wall of fibrous or granulation tissue. This often succeeds a peripancreatic fluid collection and forms over 4–6 weeks. It should also be treated conservatively so long as it remains sterile. Once infected and the patient is unstable, intervention is necessary (US/CT/endoscopic drainage).
This is a well-circumscribed collection of pus in close proximity to the pancreas within the abdomen; it is usually the result of an infected peripancreatic collection or acute pancreatic pseudocyst. This needs to be drained.
This is an area of non-viable pancreatic parenchyma that may be focal or diffuse and associated with peripancreatic fat necrosis. This is a dangerous condition with a high mortality. If this previously sterile condition becomes infected it is (surprisingly) called ‘infected pancreatic necrosis’ and these patients can deteriorate rapidly needing aggressive resuscitation and management with IV antibiotics ± drainage where possible. Outcomes of intervention are poor and the traditional approach of open surgical necrosectomy (removal of necrotic pancreatic tissue) is increasingly controversial and less frequently performed, in favour of minimally invasive strategies. This is largely because it breaks rule number 1!
This a major operation performed in highly specialized units for patients with cancers affecting the head of the pancreas or invading duodenum.
It involves en block resection of the head of the pancreas, distal stomach, duodenum, CBD, and gall bladder.
Pancreaticojeunostomy (duct to mucosa), hepaticojejunostomy, gastrojejunostomy, jejunojejunostomy, and feeding jejunostomy. This 4–7-hour process of replumbing the flow of bile, pancreatic juices, and food into the small intestine is pretty physically demanding, so if you decide to go to theatre, make sure you have your Weetabix!
This is a variation of the classic Whipple’s procedure and was designed to avoid two of the challenging complications: postoperative dumping syndrome and bile reflux. In this procedure, the pylorus is preserved to maintain the physiological valve effect of the distal stomach.
For lesions of the tail of the pancreas (benign and malignant), a distal pancreatectomy may be recommended. This may also involve splenectomy. This procedure is increasingly done laparoscopically.
If the patient has a splenectomy they will require lifelong prophylactic antibiotics, usually penicillin (V), and they need to have vaccinations against:
• Haemophilus influenza type B
Honours
Meta-analysis and randomized controlled trials have shown no difference in cancer survival, morbidity, or mortality between these two procedures.
Ask the boss
1. Nutrition: early enteral nutrition vs parenteral nutrition.
2. Prophylactic antibiotics: is there a role?
3. Surgery for pancreatitis (necrosectomy): what (if any) are the indications? What is the optimal approach?
4. Timing for laparoscopic cholecystectomy for gallstone-related acute pancreatitis: when is it safe to operate?