Common operations on the digestive tract

operations on the digestive tractEsophagoscopy is the insertion of a tubular instrument for direct visualization of the inside of the esophagus. This is a common diagnostic procedure performed under local (topical) or general anesthesia. This is done with the patient lying down and the lighted esophagoscope is easily inserted as the operator inspects the esophageal lining. This provides an added diag­nostic aid where disease of the gullet is sus­pected, but the procedure may also serve as a therapeutic measure when foreign bodies be­come lodged in the esophagus. In this instance a grasping forceps is inserted through the instru­ment to extract the foreign object. This situation is more common in children and obviates the need for open operation. Therapeutic esopha­goscopy is also of value in the case of strictures from ingested caustic substances. Here the esoph­ageal dilators are inserted through the scope to stretch the constricted areas, again usually precluding open operation.

Gastroscopy is quite similar to esophagoscopy, but in this case the instrument is inserted down to within the stomach. This is mainly a diagnostic procedure but also may serve as a therapeutic tool for the removal of foreign bodies and for biopsy of any lesions encountered.

Esophageal resections may be with removal of a short or long segment of the esophagus. With removal of short sections, end-to-end esophago-esophagostomy (esophagus-to-esophagus opening) is used for reconstruction. When longer segments are removed it may be necessary to displace the stomach or a portion of it up into the chest to re-establish continuity of the tract; or, in total esophagectomy it may be required to utilize a loop of small intestine to replace the esophagus from throat to stomach.

Esophagogastrostomy (esophagus-to-stom- ach opening) may be the means of reconstruction after removal of the lower portion of the esoph­agus, or the upper part of the stomach, or both. This anastomosis may be beneath the diaphragm or above it, depending on the amount of esoph­agus sacrificed.

Esophagojejunostomy (esophagus-to-jeju- num opening) is usually the method of re-establishing the tract after total removal of the stomach. Esophagoduodenostomy (esophagus-to-duodenum opening) is also employed occasionally.

Esophageal diverticuli are frequently en­countered. They occur in the upper portion of the esophagus, most frequently where approach is by neck incision. Those in the lower portion of the organ necessitate chest incision. Opera­tion is usually done in one stage but may require two stages. Usually the diverticulum pouch can be removed and the opening repaired, to estab­lish an esophagus normal in caliber. Diagnosis is usually confirmed by x-ray study.

Gastrostomy is a procedure to establish an opening on the abdominal wall extending into the stomach. A rubber or plastic tube may be inserted. This operative procedure is done for feeding purposes as a preliminary stage to other operations on the digestive tract or for palliative feedings in a person afflicted with inoperable obstructing disease above the stomach.

Pyloroplasty is an operation on the pylorus, or outlet of the stomach, where obstructive dis­ease has developed. This is frequently from long-standing or recurrent duodenal ulcer. A condition called congenital hyper­trophic pyloric stenosis often occurs in new­born infants. In this case the muscular ring about the pylorus is thickened and enlarged and obstructs the passageway.

Gastrojejunostomy (stomach-to-jejunum opening) is a shunt around the duodenum. This may be done for obstructive disease of the stomach outlet or of the duo­denum. It is commonly performed in conjunction with vagotomy for duodenal peptic ulcer. In this revised digestive route the stomach con­tents are allowed to pass directly into the jeju­num without passing through the duodenum. The bile and other duodenal digestive juices must be allowed to pass from the duodenum up to the gastrojejunostomy site, however. This union of stomach to jejunum may be made in front of the colon (anterior) or behind it (pos­terior) .

Vagotomy is an operation often of value in the treatment of peptic ulcer. Like all tissues in the body, the movements and secretions of the stomach are controlled by the nerves leading to it. The vagus nerve comes directly off the base of the brain to pass down through the neck and the middle chest to pierce the diaphragm and supply the stomach. Vagotomy entails tran­section (cutting) of this nerve. This may be done in the chest or the upper part of the stomach. The movements and acid secre­tions of the stomach are thereby lessened, expe­diting the ulcer to heal.

Gastrectomy (stomach-out) may be partial or total. The former may be necessary for tumors or peptic ulcers, while total gastrectomy is done for cancer. In peptic ulcers rather wide exci­sion of the stomach is performed to remove much of the acid-secreting area. After gastrec­tomy for any cause, re-establishment of the con­tinuity of the tract is necessary.

Small bowel resection may be necessitated for benign and malignant tumors, intestinal obstructions, ulcerated segments, perforations, abscesses and other infections, fistulae, diverticuli, constrictions, injuries, and congenital abnormali­ties. Reconstruction of the system may be by end-to-end or end-to-side or side-to-side re­union.

Colon resection may be indicated for any of the same lesions as for small bowel removal (see above). Similarly, the large bowel may be rejoined by any of the anastomotic methods.

Ileocolostomy (ileum-to-colon opening) may be a means of re-establishing the continuity of the digestive tract when a portion of the colon, including the cecum, is removed. The resection may involve only a small segment of the right colon or may involve much larger sections, including total colectomy (colon-out) Reconstruction may be by end-to-side or end-to end anastomosis.

Enterostomy (intestine-opening) is the es tablishment of an opening between the abdomi nal wall and a loop of small intestine. This may be at any segment of the small intestine, such as duodenostomy (duodenum-opening), jejunostomy (jejunum-opening), or ileostomy (ileum-opening). Similar to gastrostomy, the jejunostomy may be done for feeding purposes where there is an obstructing lesion at a higher level in the digestive tract. Ileostomy is often performed for termination of the digestive stream when total colectomy has been necessitated; or, ileos­tomy may be a temporary outlet of the tract con­tents as a first stage in preparation for a colon operation.

Colostomy (colon-opening) is the formation of an opening between the abdominal wall and colon. This may be devised at any site along the colon and is usually performed on cases where there is obstruction of the colon or the rectum. This provides the termination of the digestive tract onto the abdominal wall instead of through the rectum. This may be a perma­nent opening if the obstruction is incurable or if the rectum has necessarily been removed. Temporary colostomy may be a primary stage for decompression of the colon preparatory to operation on the colon at a more distal site. Colostomy may be of a single opening or a double loop (“double barrel”).

When colostomy is permanent, a device (co­lostomy bag) is worn by the patient for the collection of the food residue as it is passed. This is compatible with an otherwise normal life as the patient becomes rehabilitated and adjusted to its use. Colostomy, of course, is per­formed only where absolutely necessary and indeed may be a life-saving procedure.

Intestinal shunts are often performed when it is necessary to bypass a diseased section of the tract. This directs the intestinal stream around an inflamed segment, which allows the inflammation to subside; or, provides a short- circuit in the tract to re-establish continuity around an obstructed area. This may be a per­manent shunt when the obstructing lesion can­not be removed, but it may also be just a tem­porary measure in anticipation of definitive op­eration when the patient’s condition warrants.

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