Oesophagogastric and bariatric surgery

Question 1

Answer 1

Previously distal stomach but now proximal stomach is more common.

If cancer distal to inshira can do subtotal gastrectomy.

If cancer in body will end up doing total gastrectomy but if more distal can to subtotal

Cannot join a to b because b is retroperitoneal organ which is stuck down.

Question 2

What surgery do we do now?

Answer 2

Question 3

Stomach has rich blood supply, it’s supplied by coeliac trunk which divides into common hepatic-(then divides into right gastric), splenic artery and left gastric artery which supplies lesser curve

There are lots of lymph nodes around these vessels so when remove just stomach without any lymph nodes you’ve done a D1 lymphadenectomy, but in cacer op you need to do a D2 gastrectomy

Answer 3

Question 4

Post-operative care in the community:

Answer 4

Dumping syndrome-divided into early and late dumping. early dumping is vasomotor response to fluid shifts, fluid shits out of intravascular compartment causing hypotensive symptoms. Late dumping-food rich in sugar in intestine tells brain that sugar is coming, brain then tells pancreas to secrete insulin and that removes gluocse form blood causing hypoglycaemia. So manage by saying small frequent meals without liquids, have these before or after meals, and avoid sugary foods.

Dumping occurs with almost all gastro operations

Question 5

Oesophageal cancer

Answer 5

Increased adenocarcinoma

Question 6

GEJ tumours:

Answer 6

C word classification:

If more gastric-type 3

If more oesophageal-type 1

If in middle-type 2

Question 7

2 stage oesophagectomy

Answer 7

Free stomach and use surgical staples to convert it into thin tube. Divide gastrics so it can move up.

Close abdomen, turn patient left side down right side up and do a right sided posterolacteral thoracotomy and pull tube up with remaining oesophagus.

Start abdomen and finish in chest

Question 8

3 stage oesophagectomy (if cancer is higher up)

Answer 8

START with freeing up of thoracic oesophagus left down then put supine and do abdomen then do neck at same time.

In abdo osce look at patient’s back for scars and look for neck scars to determine 3 stage oesophagectomy.

Question 9

Post op care in the community:

Answer 9

As stomach is in chest they will all need regular PPIs since they will get GOR since GOJ is removed.

Question 10

Why so many adenocarcinomas?

Answer 10

=Due to parallel increase in GORD

Maybe due to rising obesity and H pylori eradication

oesophagitis secondary to acid

Question 11

GERD epidemiology:

Answer 11

Question 12

Answer 12

People with acid reflux get hiatus hernia and stomach slips into chest as GOJ is in chest and there is neg pressure in chest so GOJ stays open and keep getting acid. Fundus is bought behind the lower end of oesphagus and stapled to tighten junction.

PPIs are really effective too

Surgery-laproscopic fundoplication

Question 13

Eat slowly, don’t lie down after eating, small frequent meals, light meal at night, sleep propped up, chew slowly, lose weight, less alcohol, avoid triggers eg avoid acidic foods

Answer 13

Question 14

Persistent painful reflux-should undergo endoscopy

If been on reflux for many years then have endoscopy

Answer 14

Short segment barrets don’t even need to survey those people as very low yield,

Make sure you use 4 quadrant biopsy at every 4cm in barrett’s

If LGD switch to every 6 months.

HGD-use resection and radiofrequency ablation so it heals with squamous epithelium.

Question 15

Answer 15

• Roux en Y gastric bypass
• Sleeve gastrectomy
• We operate due to the comorbidities associated with obesity
• Resolution of diabetes, hypertension, sleep apnea and high cholesterol

Question 16

Laparoscopic bariatric procedures

Answer 16

• Laparoscopic adjustable gastric band-once pouch fills up they feel full and stop eating. It requires intense follow up and patients don’t lose that much weight. So doesn’t work well in NHS. Band can slip up and down and cause GORD
• Roux-en-Y gastric bypass-leave stomach behind and transect stomach converting into small pouch. This works as taken 1m away from digestive process. GLP-1 is secreted in distal ileum and colon and ecause food hits here quicker that food stimulates GLP-1 quicker and so satiety quicker and increases insulin too so diabetes improves
• Sleeve gastrectomy-cut away stomach and convert from big bag to narrow tube. Patient’s have to have small frequent meals. Can be leakages and bleeding and can get ulcers, gall stones occur in about 30%, also as moving intestine it can twist causing bowel obstruction.
• Even though people lose weight they have to take vitamins as may get deficiencies