Upper GI & Foregut Surgery

Chicago Type I (classic aperistalsis) & Type II (panesophageal pressurization): either Laparoscopic Heller Myotomy (LHM, extending ≥6 cm on esophagus and 2–3 cm onto gastric cardia) plus partial fundoplication (180° anterior Dor or 270° Toupet) OR Peroral Endoscopic Myotomy (POEM). Chicago Type III (spastic premature contractions): POEM is preferred to calibrate a longer proximal thoracic myotomy.

Before: Repeated endoscopic botulinum toxin injections in fit surgical candidates, or thoracoscopic myotomy without an anti-reflux procedure.

Now: Chicago Type I (classic aperistalsis) & Type II (panesophageal pressurization): either Laparoscopic Heller Myotomy (LHM, extending ≥6 cm on esophagus and 2–3 cm onto gastric cardia) plus partial fundoplication (180° anterior Dor or 270° Toupet) OR Peroral Endoscopic Myotomy (POEM). Chicago Type III (spastic premature contractions): POEM is preferred to calibrate a longer proximal thoracic myotomy.

Idiopathic esophageal achalasia stratified by Chicago Classification v4.0 (Types I, II, and III).

In Werner et al. (n = 221 randomized 1:1), 2-year clinical success (Eckardt score ≤3) was 83.0% after POEM vs. 81.7% after LHM + Dor (non-inferiority p = 0.007), while 2-year reflux esophagitis was higher after POEM (44% vs. 29%) because POEM omits a fundoplication.

• POEM vs. LHM RCT — Werner YB et al., N Engl J Med 2019 (PMID 31800987; Ref. 89)
• ASGE / SAGES Achalasia Guidelines — as cited in Addendum §9.1

Perioperative FLOT triplet chemotherapy (4 preoperative + 4 postoperative cycles of 5-FU, leucovorin, oxaliplatin, docetaxel) followed by minimally invasive radical esophagectomy (Ivor Lewis or McKeown with 2-field lymphadenectomy) or total gastrectomy per Siewert class; reserve neoadjuvant chemoradiotherapy (CROSS) for esophageal squamous cell carcinoma or patients unfit for FLOT.

Before: Upfront esophagectomy or uniform neoadjuvant CROSS chemoradiotherapy for all resectable esophageal/GEJ adenocarcinomas.

Now: Perioperative FLOT triplet chemotherapy (4 preoperative + 4 postoperative cycles of 5-FU, leucovorin, oxaliplatin, docetaxel) followed by minimally invasive radical esophagectomy (Ivor Lewis or McKeown with 2-field lymphadenectomy) or total gastrectomy per Siewert class; reserve neoadjuvant chemoradiotherapy (CROSS) for esophageal squamous cell carcinoma or patients unfit for FLOT.

Resectable locally advanced esophageal and gastroesophageal junction (GEJ Siewert I–III) adenocarcinoma (cT1N+ or cT2–4aN0/+).

In ESOPEC (n = 438 randomized 1:1 across 25 centers), median overall survival was 66 months with perioperative FLOT vs. 37 months with CROSS chemoradiotherapy, and 3-year OS was 57.4% vs. 50.7% (HR 0.70, 95% CI 0.53–0.92; p = 0.01).

• ESOPEC Phase III Trial — Hoeppner J et al., N Engl J Med 2025 (PMID 39842010; Ref. 88)
• FLOT4 Trial — as cited in Addendum §9.1

Diagnostic staging laparoscopy with peritoneal washings before treatment; universal biomarker testing (MMR/MSI, HER2, PD-L1 CPS, Claudin 18.2); perioperative FLOT chemotherapy (or PD-1 blockade in dMMR/MSI-H disease); and spleen- and pancreas-preserving D2 lymphadenectomy (retrieving ≥16 and ideally ≥25 lymph nodes) with subtotal gastrectomy (≥4–5 cm margin in intestinal type) or total gastrectomy (diffuse/proximal tumors).

Before: Upfront D1 gastrectomy with routine distal pancreatectomy and splenectomy.

Now: Diagnostic staging laparoscopy with peritoneal washings before treatment; universal biomarker testing (MMR/MSI, HER2, PD-L1 CPS, Claudin 18.2); perioperative FLOT chemotherapy (or PD-1 blockade in dMMR/MSI-H disease); and spleen- and pancreas-preserving D2 lymphadenectomy (retrieving ≥16 and ideally ≥25 lymph nodes) with subtotal gastrectomy (≥4–5 cm margin in intestinal type) or total gastrectomy (diffuse/proximal tumors).

Resectable locally advanced gastric adenocarcinoma (cT2+ or cN+) and extent of lymphadenectomy.

Diagnostic laparoscopy identifies occult radiographically silent peritoneal carcinomatosis in 15–25% of cT3–4 gastric cancers; pancreas- and spleen-preserving D2 dissection significantly reduces locoregional recurrence and gastric cancer mortality.

• NCCN / ESMO Gastric Cancer Guidelines — as cited in Addendum §9.1
• Dutch D1D2 15-Year Trial — as cited in Addendum §9.1

Laparoscopic complete hernia sac reduction and excision from the mediastinum, extensive mediastinal esophageal mobilization to achieve ≥3 cm tension-free intra-abdominal esophageal length, primary posterior crural suture approximation (with selective absorbable biosynthetic mesh buttress only for large tensioned defects), and routine fundoplication (or anterior gastropexy in frail high-risk patients).

Before: Routine watchful waiting in symptomatic patients, simple gastropexy alone without sac excision, or permanent synthetic polypropylene mesh on the esophageal hiatus.

Now: Laparoscopic complete hernia sac reduction and excision from the mediastinum, extensive mediastinal esophageal mobilization to achieve ≥3 cm tension-free intra-abdominal esophageal length, primary posterior crural suture approximation (with selective absorbable biosynthetic mesh buttress only for large tensioned defects), and routine fundoplication (or anterior gastropexy in frail high-risk patients).

Symptomatic giant paraesophageal hiatal hernia (Type II–IV, >30–50% intrathoracic stomach).

Preserving the peritoneal sac in the mediastinum or failing to achieve ≥3 cm intra-abdominal esophagus drives >30–40% anatomical recurrence; permanent synthetic mesh at the hiatus risks catastrophic esophageal erosion.

• SAGES Paraesophageal Hernia Guidelines — as cited in Addendum §9.1

GIST: EUS-guided core biopsy and KIT/PDGFRA mutational profiling; laparoscopic/open wedge resection with intact pseudocapsule (R0) and no lymphadenectomy (neoadjuvant imatinib for 6–12 months if locally advanced/organ-threatening KIT-mutant; 3 years adjuvant imatinib for high-risk resected KIT-mutant GIST). Refractory ulcer bleeding failing 2 EGD treatments: urgent transcatheter arterial embolization (TAE) of the gastroduodenal/left gastric artery (or surgical duodenotomy with 3-point U-stitch gastroduodenal artery ligation if unstable).

Before: Enucleation or formal lymphadenectomy for GIST, empiric imatinib without mutational profiling, or upfront emergency gastrectomy after failed endoscopic ulcer hemostasis.

Now: GIST: EUS-guided core biopsy and KIT/PDGFRA mutational profiling; laparoscopic/open wedge resection with intact pseudocapsule (R0) and no lymphadenectomy (neoadjuvant imatinib for 6–12 months if locally advanced/organ-threatening KIT-mutant; 3 years adjuvant imatinib for high-risk resected KIT-mutant GIST). Refractory ulcer bleeding failing 2 EGD treatments: urgent transcatheter arterial embolization (TAE) of the gastroduodenal/left gastric artery (or surgical duodenotomy with 3-point U-stitch gastroduodenal artery ligation if unstable).

Gastric or small bowel Gastrointestinal Stromal Tumor (GIST ≥2 cm) and refractory non-variceal upper GI peptic ulcer bleeding — two scenarios bundled in one printed matrix row, converted as one card (mirrors the Wave 5 Chapter 7 bundled-row handling).

GISTs rarely metastasize to lymph nodes (<1–2%), making lymphadenectomy unnecessary while pseudocapsule rupture causes peritoneal sarcomatosis; TAE achieves hemostasis in ~80–90% of endoscopic-refractory ulcer bleeds with lower mortality than emergency laparotomy.

• NCCN / ESMO Sarcoma & GIST Guidelines — as cited in Addendum §9.1
• SSG XVIII/AIO Trial — as cited in Addendum §9.1
• ESGE/WSES Upper GI Bleeding Guidelines — as cited in Addendum §9.1

Mandatory EGD + high-resolution manometry (HRM) + 24-h pH-impedance (if Los Angeles Grade A/B or NERD). Select 360° floppy Nissen or 270° posterior Toupet fundoplication (Toupet preferred when esophageal peristalsis is weak/ineffective to reduce dysphagia; magnetic sphincter augmentation [LINX] option in small <3 cm hiatal hernia with normal motility). In patients with severe GERD and BMI ≥35 kg/m², Roux-en-Y gastric bypass (RYGB) is the preferred anti-reflux and metabolic operation.

Before: Empiric 360° Nissen fundoplication based on reflux symptoms alone without objective pH-impedance or high-resolution manometry.

Now: Mandatory EGD + high-resolution manometry (HRM) + 24-h pH-impedance (if Los Angeles Grade A/B or NERD). Select 360° floppy Nissen or 270° posterior Toupet fundoplication (Toupet preferred when esophageal peristalsis is weak/ineffective to reduce dysphagia; magnetic sphincter augmentation [LINX] option in small <3 cm hiatal hernia with normal motility). In patients with severe GERD and BMI ≥35 kg/m², Roux-en-Y gastric bypass (RYGB) is the preferred anti-reflux and metabolic operation.

Preoperative workup and procedure selection for medically refractory GERD (normal BMI vs. BMI ≥35 kg/m² or impaired esophageal motility).

Randomized trials show 270° Toupet achieves equivalent long-term reflux control to 360° Nissen with lower postoperative dysphagia and gas-bloat; RYGB resolves both acid and bile reflux while avoiding crural wrap failure in obesity.

Saudi & Gulf frame (§9.0): the 2024 SGA GERD Care Pathway Consensus (PMID 38813746; Ref. 81) mandates objective endoscopic (Los Angeles grade, Hill valve) and physiological testing (24-h pH-impedance and high-resolution manometry) before anti-reflux surgery — the same testing-first rule this card carries.

• SAGES GERD Guidelines — as cited in Addendum §9.1
• 2024 SGA GERD Care Pathway Consensus — Alzahrani MA et al. (PMID 38813746; Ref. 81)