Enquiry 6, Upper GI Surgery

Question 1

How many organs and cell types involved in the digestive system?

Answer 1

comprised of 10 organs covering 9 meters, and over 20 specialised cell types.

Question 2

What are the four main components of the digestive system?

Answer 2

1. Gastrointestinal tract
   - twisting channel that transports food
   - has an internal surgace area between 30 and 40 square meters
2. Pancreas, gallbladder and liver
   - trio of organs that breakdown food using an array of special juices
3. Bodies enzymes, hormones, nerves and blood
   - work together to breakdown food
   - modulate the digestive process
   - deliver its final products
4. Mesentery
   - a large strectch of tissue that supports and positions all of the digestive organs in the abdomen enabling them to do their jobs

Question 3

What beings the digestive process?

Answer 3

• before food even touches your mouth
• anticipating the food causes gland in your mouth to pump out saliva (1.5l a day)
• in the mouth, food is turned into bolus (moist lump) through chewing and mixing with saliva
• enzymes in saliva break down starch
• then swollowed

Question 4

where does food go after mouth?

Answer 4

• goes down a 25cm tube, esophagus
• nerves in the surrounding esophageal tissue sense the bolus’s presence and trigger peristalsis (series of defined muscular contractions) towards the stomach

Question 5

• in the stomach the bolus is bound and broken into chunks by the muscles of stomach wall
• hormone, secreted by cells in the lining trigger the release of acids and enzyme-rich juices from the stomach wall, which starts dissolving the food and break down its proteins
• These hormones also alerty the prancreas, liver and gallbladder to…
• while the pran, live and gall breakdown fats - inside the stomach (after three hours) the bolus is now turned into a frothy liquid called chyme and is ready to move into the small intestine.

Question 6

What happens in the pancreas, liver and gallblader during digestion?

Answer 6

• The enzymes in the stomach alert the pancr, liv, and gallbladder to produce digestive juices and transfer bile, a yellow-green liquid, that digests fat in prep for next stage

Question 7

how is the small intestine involved in digestion?

Answer 7

• Firslty the liver sends bile to the gallbladder, which secretes it into the duodenum, first portion of the small intestine.
• here it dissolves the fats floating in the slurry of chyme so can be easily digested by the pancreatic snd intestinal juices that have leahced into the duod.
• these enzymes rich juices break the fat molecules down into fatty acids and glycerol for easier absorption into body
• The enzymes also carry out final deconstruction of proteins into amino acids and carbohydrates into glucose.
• This happens in the lower regions of the small intestines, the jejunum and ileum, which are coated in lillions of tiny projections, villi. These create huge surface area to maximise molecule absorption and transference into the blood stream.

Question 8

the blood involved in digestion

Answer 8

• once transfered into the blood stream, by villi in the jujunum and ilium, the blood takes the molecules on the final le of their journey to feed the body’s organs and tissures.

Question 9

large intestine

Answer 9

• left over fibre, water and dead cells discarded during digesrtion make it into the large intestine, known as the colon.
• the body drainsout most of theremaining fluid through the intestinal wall.
• whats left is a soft mass, stool.
• the colon squeezes this byproduction into a puch, called rectum, where nerves sense the rectum expanding to tell bodty when time to expel the waste
• the byproducts of digestion exit through the anus

Question 10

how long does digestion last?

Answer 10

30-40 hours

Question 11

What organs are involved in the upper GI for upper gI surgery

Answer 11

●Oesophagus

●Stomach

●Liver

●Spleen

●Pancreas

●Biliary tract

●Duodenum

Question 12

What is AUGIS?

Answer 12

Association of Upper Gastrointestinal Surgery of Great Britain and Ireland

Oesophagogastric (OG)

• Stomach
• Oesophagus

Hepatopancreatobiliary (HPB)

●Liver

●Spleen

●Pancreas

●Biliary tract

●Duodenum

Question 13

What are some Upper GI cancer statistics

Answer 13

●Pancreatic cancer - lower incidence than other types of cancer.

○Increasing with aging population - most patients diagnosed in 70s / 80s.

○80-85% of tumours deemed unresectable

○6% global 5 year survival

○27% in patients who are deemed curable with surgery

○Research is tricky due to small patient numbers

●Oesophagogastric (oesophagus and stomach) cancer

○13 000 patients diagnosed in England & Wales annually

○Oesophageal survival is around 15% at 5 years

○Gastric survival around 19% at 5 years

○Oesophageal cancer - 2 main types

■Squamous cell (smoking and drinking)

■Adenocarcinoma - chronic reflux and obesity. Now more prevalent in Western countries.

Question 14

What are the surgical approaches for an oesophagectomy?

Answer 14

There are 4 main approaches for an oesophagectomy. (multiple incision sites)

1. Ivor Lewis (transthoracic approach) * most common approach in UK
2. Thoracoabdominal approach (quite common at OUH)
3. Transhiatal approach
4. Minimally invasive approach

Please see the additional powerpoint resource on moodle for more details and the link. - hard o cough and shoulder pain

Question 15

Go through the cancer treatment journey and what different words mean

Question 16

ERAS pathway

Answer 16

• most parients for through the eras path
• the guidlines (blue diagram) go through it
• dont walk for first few days just need to get them out of bed
• remenerber will have alot of chords attached so need to think about wheres the aline and what parts need to move
• arterial pressure - measrued by an aline sits in an aerter avergae mean arterial pressure map. necy to blood pressure on monitrue. used to no if its safe to mobilise. minimal 60-65 but normal is 70-100. aline transfuser needds to bw in line wit hheart. blood pressure drops is due to fluid baalnce so you dont wn tto give them too much, as makes lnungs heavy. so it links to lung volume.

Question 17

David:

52,

fairly active but thin

ex smoker

subjective history:environmental factors, personal factors, medi history. so ex smoker - how frequent and how much, how long ago did he give up

objective

moving him is part of the objective assessment. TILEO - task (get out of bed or sit over side of bed) Individual (who is with you, PT, PTA, HCA or NS), Load, environment (catheter chst drains etc) Organisation (explained clearer to patient how the process with carry ot and the other MDT know what their role is in mobilising patient.

then carry out and do it.

what the prioritiees are

who needs to help. three people. 2 physios and then someone else to check where the catheter is and etc and help with making them all more comfortable. fluids drips can be paiful

easier to roll, move legs to side the nroll and sit up.

pcea patient controlled epidural anthesia

pca pat contro an

so who is the rpiority who needs to get out of bed

Review patients on Day 1 post

ventilstor and drug stands are next to the bed

subjective how he is feeling. chest drain and epidural and be painful

objective bp fluids, pain,

get him sitting standing, wlaking on spot or try move

Answer 17

Review patients on Day 1 post

*easier to roll, move legs to side the nroll and sit up.

• Sujective
• Patient goal setting – motivation!
• how he is feeling. chest drain and epidural and be painful objective bp fluids, pain,
• Objective
• get him sitting standing, wlaking on spot or try move
• Respiratory assessment and ACT’s
• environment for mobilisations - where are the tubes and drains? non slip socks so for environment snd organisation (TILEO)
• Mobility assessment – early mobilisation is key:
• lying to sit
• sitting on edge of bed - MAKES IT EASIER TO REACH them
• stretcher chair - get them sitting up gradually, also think of the equipment you have around you to make this task easier and them main point of just istting up is to recruit the lungs and are part the progressional steps of recovery.
• moiter teh minimal map, can challenge is as long as it is not lower that 60/65
• so as you do this have to htink of wat the safety perameters are.
• also think of the affects of chemo on his muscles so although hemo patients are incurredge to exercise slowly it can affect his mobility
• sit to stsn d
• walking on spot
• if thats ok then walk him
• shoulder range of motion exercises particularly on side of incision
• mtion to help bp stats and improve ventilation thorugh larger deeper breaths so breathing control which will help with pulling body up and out of bed.
• Provide with d/c advice regarding increasing activity/pacing/things to avoid
• diaries
• day 3 normally post op complications, lowest dip on lung volume as it tends to dip then compared to day 1 and 2.
• fluid balance, needs to be moitered but david due to his type of surgery cant drink orally only by a tube,
• to help bp and urine output is to give them orinin? so need to moniter fluid balance to prevent renal failure in oseophageal patients. you can hydrate their mouth by allowin them to suck on a damp sponge.

Question 18

Pateint prehab in order:

• what are their baselines? - maximal or sub maximal test (6 min walk test also look on moodel, allow you yo predict 02 and relates to environment and patient). to know their level of fitness. what are their preferences when it comes to exercise (gym or outside or walking or cycling?)
• pick an outcome measure that will give you a clear change and result.
• their goals
• hobbie and lifestyles
• what will their surgery be on? do we need to strengthen the upper or lower limbs more?
• young or old?