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ABS > STOMACH > Flashcards

STOMACH Flashcards

1
Q

Type 1 ulcer location

A

Lesser curve

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2
Q

Type 2 ulcer location

A

lesser curve + duodenal (2 ulcers)

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3
Q

Type 3 ulcer location

A

Pre pyloric

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4
Q

Type 4 ulcer location

A

Proximal lesser curve (cardia)

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5
Q

Type 5 ulcer location

A

Diffuse

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6
Q

Type 1 EGJ tumor

A

distal part of esophagus located between 1-5 cm above anatomic EGJ

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7
Q

Type II EGJ tumor

A

cardia within 1 cm above and 2 cm below EGJ

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8
Q

Type III EGJ tumor

A

subcardial stomach (2-5 cm below EGJ)

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9
Q

Distal gastrectomy - the remnant is supplied by?

A

Short gastrics

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10
Q

Overall surgical goals in surgical mgmt of GERD

A

-restoration of normal anatomic position of stomach and GEJ
-recreation of anti reflux valve
-any hiatal hernia must be completely reduced which requires mediastinal dissection to ensure adequate esophageal mobilization
-any defect in crura must be closed
-complete mobilization of fundus
-2 cm long floppy fundoplication performed over large 54F bougie

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11
Q

Dor fundoplication

A

anterior 180-200

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12
Q

Toupet fundoplication

A

posterior 270

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13
Q

Thal fundoplication

A

270 anterior

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14
Q

Belsey fundoplication

A

270 anterior transthoracic

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15
Q

Lind fundoplication

A

300 posterior

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16
Q

Capnothorax - what do you do?

A

Enlarge tear to avoid tension capnothorax
Place red rubber catheter with one end into pleural tear and other end into abdomen to equalize pressures
At end of procedure bring one end outside of abdomen and place to waterseal while valsalva administered

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17
Q

Repair of hiatal hernia - what is the key step that decreases early recurrence?

A

mobilization adn excision of hernia sac

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18
Q

What kind of suture to close the diaphragmatic crura

A

Permanent

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19
Q

Tx of H pylori

A

PPI, clarithromycin and amoxicillin vs flagyl for 2 weeks OR bismuth, flagyl, tetracycline and PPI (esp if PCN allergy!!!)

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20
Q

Risk of rebleeding in visible vessel

A

up to 50%

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21
Q

risk of rebleeding when adherent clot

A

15-25%

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22
Q

risk of rebleeding when ulcer iwth clean base

A

<5%

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23
Q

Benefit of highly selective vagotomy

A

Preserves motor innervation to pylorus and eliminates need for drainage procwedure

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24
Q

When to consider vagotomy and antrectomy?

A

Higher morbidity than vagotomy and pyloroplasty or HSV secondary to need for billroth recon, but reserved for stable pts with anatomic indications like large antral ulcers, pyloric scarring

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25
Q

Genetics behind hereditary diffuse gastric ca

A

AD disorder 2/2 germline mutation in CDH1 (cell adhesion molecular E-cadherin)

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26
Q

CDH1 carriers - how do you treat?

A

Prophylactic gastrectomy recommended between 18-40 y.o.
*note women with CDH1 are at increased risk of breast CA similar to BRCA pts

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27
Q

Hereditary syndromes with increased risk of gastric CA

A

Lynch syndrome (DNA mismatch genes)
Juvenile polyposis syndrome (SMAD4)
Peutz Jehgers
FAP (APC gene on 5q21)

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28
Q

NCCN recommends laparoscopic staging with peritoneal washing in gastric CA at what T stage

A

Stage >T1b

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29
Q

T1a gastric CA

A

invades lamina propria or muscularis mucosa

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30
Q

T1b gastric CA

A

submucosa

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31
Q

T2 gastric CA

A

muscularis propria

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32
Q

T3 gastric CA

A

subserosa

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33
Q

T4 gastric CA

A

serosa or into adjacent structures

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34
Q

N1 gastric CA

A

1-2 nodes

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35
Q

N2 gastric CA

A

3-6 nodes

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36
Q

N3 gastric CA

A

7 or > nodes

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37
Q

Wahat is unresectable disease in gastric CA?

A

Peritoneal involvement, distal mets, root of mesentery involvement or para aortic nodal disease confirmed by bx, encasement of major vascular structure excluding splenic vessels

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38
Q

Who gets neoadjuvant therapy in gastric CA

A

cT2 or higher and any N (similar to esophageal and rectal CA!)

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39
Q

Margins and LN goals in gastric CA surgery

A

> 4 cm and LN at least 15

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40
Q

D1 dissection

A

removal of N1 nodes (perigastric nodes along greater/lesser curve stations 1-6)

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41
Q

D2 dissection

A

removal of N1 and N2 nodes (nodes along left gastric, common hepatic, celiac and splenic arteries, stations 7-11)

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42
Q

When is adjuvant therapy recommended for gastric CA

A

Adjuvant 5-FU for T3, T4 or node positive disease following R0 resection

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43
Q

What is retained antrum syndrome

A

retained antral tissue within duodenal stump after gastric resection. G cells bathed in alkaline fluid –> continuous gastrin release –> acid production in proximal stomach remnant and ulceration

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44
Q

Tx of retained antrum syndrome

A

PPI, vagotomy and resection of retained antrum

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45
Q

Early dumping syndrome

A

abrupt hyperosmolar load to small intestine and release of serotonin, neurotensin, bradykinins, and enteroglucagon

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46
Q

Late dumping syndrome

A

rapid carb load to small intestine resulting in large insulin surge and rebound hypoglycemia

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47
Q

refractory dumping syndrome

A

octreotide (or Roux en y esp if late dumping)

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48
Q

alkaline reflux gastritis

A

typically with billroth II anatomy, can be dx with impedance studies

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49
Q

Tx of alkaline reflux gastritiis

A

medical: pro kinetics, bile acid binding resins
Surgical: conversion to RNY

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50
Q

How long of a roux limb to avoid recurrent bile reflux

A

50 cm

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51
Q

What is afferent limb syndrome

A

acute or chronic obstruction of afferent jejunal limb following bilroth 2 recon. Increased luminal pressure of afferent limb can lead to obstructive jaundice, cholanigtis, peancreatitis from back pressure up biliopancreatic system, duodeanal stump blow out, bacterial overgrowth in afferent limb

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52
Q

Tx of afferent limb syndrome

A

conversion to roux en y or bilroth 1 OR braun (enteroentero from afferent limb to efferent)– bacterial overgrowth can be managed first with antibiotics

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53
Q

the anterior vagal trunk divides into?

A

hepatic division and anterior gastric nerve (anterior nerve of latarjet)

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54
Q

Criminal nerve of grassi arises from whic hvagal trunk?

A

Posterior

55
Q

post vagotomy diarrhea

A

dietary adjustment and cholestyramine. usually self resolves. usually not correlated with meals unlike dumping syndrome!

56
Q

Refractory post vagotomy diarrhea

A

Interposition of an antiperstalitc 10 cm segment of jejunum 100 cm from LoT

57
Q

efferent loop syndrome

A

Usually after B2 GJ. GOO caused by kinking of efferent jejunal limb, often because of herniation of limb posterior to anastomosis. Operative correctino usually by reducing efferent loop then closing the retroanastomotic space to prevent recurrence

58
Q

type 1 gastric carcinoid

A

a/w chronic atrophic gastritis, small <1 cm and often multiple polypoid. Grow slowly and only rarely mets to regional nodes or distant sites

59
Q

Type II gastric carcinoid tumors

A

a/w ZES and MEN type 1. Also grow slowly but more likely to metastatsize to regional LN

60
Q

Type III gastric carcinoid

A

Sporadic and most biologicall y aggressive. Often large >1 cm and not assoc with hypergastrinemia. Type III lesions freuquently mets to regional nodes or liver.

61
Q

what are the nerves involved in highly selective vagotomy

A

they innervate parietal cells which are located within the serosa of the stomach

62
Q

selective vagoatomy

A

anterior and posterior gastric nn of Latarjet are ligated (DISTAL to hepatic/celiac branches) the pylorus is denervated and therefore pyloric drainage procedure is needed

63
Q

truncal vagotomy

A

main trunk of vagus including celiac and hepatic branches is ligated and pylorus is denervated as a result. therefore a pyloric drainage porceudre or pyloric bypass procedure is needed

64
Q

most common deficiency after RYGBP

A

iron deficiency anemia
Creation of a small gastric pouch also decreases production of IF leading to B12 deficiency
Rarely thiamine deficiency from excessive vomiting

Bypass of the duodenum leads to hypocalcemia

65
Q

motilin receptors are located

A

in the smooth muscle cells of GI tract

66
Q

parietal cells secrete

A

HCl, IF

67
Q

Enterochromaffin like cells aid in gastric acid secretion via?

A

histamine release

68
Q

MALT lymphoma

A

2:1 male to female ratio, lesions of B cell origin and stain positive for CD19, CD20 and CD22 and negative for CD5

69
Q

First step after Dx of malatoma

A

EUs, lymphoma staging workup

70
Q

High grade maltoma - treatment?

A

chemoXRT + surgery

71
Q

Low grade maltoma - after h pylori eradication therapy. If minimal residuals?

A

Watch and wait - EGD with biopsy q3-6mo x 5 years

72
Q

Failure of H pylori eradication or no regression of maltoma?

A

chemoXRT

73
Q

surveillance after complete remission of maltoma

A

EGD + biopsy every 3-6mo x 1-2 years then every 6 mos 3-5 years then eyarly therafter

74
Q

sserum gastrin levels are elevated in which gastric carcinoid

A

Type I and II

75
Q

Type II carcinoid (gastric) what else should you check for

A

pituitary or parathyroid tumors (MEN 1 syndrome)

76
Q

If fwer than 6 small (<1 cm) nodules and type I or II gastric carcinoids

A

endoscopic removal. If >6 can consider observation and surveillance every 1-2 yuears

77
Q

MC gastric lymphoma

A

large b cell > MALT > Burkitt > mantle cell > follicular

78
Q

Tx of gastric lymphoma

A

multimodality - mostly chemo with CHOP (cyclophosphamide, doxorubicin, oncovin.vincristine, prednisone)

79
Q

pars flaccida technique with lap adjustable gastric band

A

dissection through fatty tissue posterior to GEJ to create a tunnel in which the band sits. This reduces chances that the posterior stomach which is relatively mobile will slip past the band.

80
Q

What size is high risk GIST

A

> 3 cm

81
Q

What margins desired in GIST?

A

Grossly negative

82
Q

Steps of total gastrectomy

A

Examine for mets
Separate omentum from colon
R gastroepiploic and short gastrics are ligated in process of dsisecting ometntum from colon.
Proximal duodenum divided
Right gastric a ligated
Let gastric artery divided at origin
Esophagus divided

83
Q

ideal length of roux limb in RNYGB

A

100-150 cm (100 for smaller 150 for fatter)

84
Q

key steps of LRYGB

A

Small bowel run 30-50 cm distal to LoT and transected
Proximal bowel becomes biliopancreatic limb, distal bowel the roux limb
roux limb is measured up to 150 cm distally
Roux limb is aligned with biliopancreatic limb and jejunojejnostomy is created
Roux limb brought up retrocolic or anteocolic
10-15 mL gastric pouch created by entering the lesser sac 3-4 cm below GEJ
GJ is created

85
Q

When do you usually do a toupet fundoplication?

A

Pts with abnormal esophageal motility and a BMI <35

86
Q

When do you typically use a Dor fundoplication

A

Used after heller myotomy in mgmt of achalasia

87
Q

Advantages of lap sleeve gastrectomy

A

technical simplicity
preservation of pylorus, preventing dumping syndrome
reduction of ghrelin levels
prevention of internal hernias and malabsorption
preserves ability to modigy to LRYGB or duod switch as revisional procedure

88
Q

Where is the band placed in laparoscopic agjustable gastric banding?

A

Usually around the cardia close to the GEJ with approximate 45 degree angle (2-8:00 axis) towards L shoulder

89
Q

Basics of duodenal switch

A

Create gastric pouch 200 mL, preserving pylorus (like a sleeve)
Transect distal ileum approximately 250 cm from ileocecal valve and anastomose to gastric pouch (ALIMENTARY limb)
BP limb anastomosed to ileum between 50-100 cm from ileocecal valve

90
Q

Copper deficiency

A

skeletal demineralization, impaired glucose tolerance, pancytopenia

91
Q

most common nutritional deficiency after BPD

A

protein malnutrition

92
Q

selenium deficiency

A

cardiomyopathy and weakness

93
Q

deficiency of vitamin E

A

hemolytic anemia, neurologic abnormalities

94
Q

The surgeon must be aware of what 2 structures when dissecting the gastrohepatic ligament

A

aberrant left hepatic artery of Hyrtl
Hepatic branch of the vagus nerve

95
Q

Remission of gastric MALToma typically takes how long

A

1-3 years

96
Q

Which translocation for MALToma shows decreased response rate to H pylori

A

t(11;18) translocation
May need XRT or rituximab

97
Q

Where in the stomach is gastrin produced

A

Antrum
Antral G cells act on parietal cells to produce Hal and chief cells to produce pepsinogen

98
Q

Which hormones does pancreas secrete

A

Somatostatin (D cells)
Insulin (beta cells)
Glucagon (alpha cells)

99
Q

Where is CCK secreted

A

duo and jejunum
from I cells

100
Q

Where is secretin produced

A

duo and jejunum (K cells)

101
Q

Risk of internal hernia is significantly higher in which approach to RYGB

A

retrocolic

102
Q

MOA of sibutramine

A

Blocks presynaptic uptake of serotonin thereby potentiating anorexic effects n CNS

103
Q

Mechanism of Orlistat

A

Pancreatic lipase is inhibited which lowers dietary fat absorption

104
Q

Causes of hypergastrinemia WITH increased acid production

A

Gastrinoma
G cell hyperplasia
Retained antrum after distal gastrectomy
Renal failure
Gastric outlet obstruction

105
Q

Hypergastrinemia with normal or low acid production causes

A

pernicious anemia
post vagotomy
use of acid suppressive medication
Chronic gastritis

106
Q

Hypothyroidism is assoc with what gastrin level

A

LOW

107
Q

Best test to confirm eradication of H pylori

A

Urea breath test

Pt given radio labeled urea PO
If H pylori present, urea –> ammonia and radio labeled bicarbonate –> exhaled as CO2

108
Q

MC functional NE tumor in MEN type 1

A

gastrinoma

109
Q

MC functional neuroenndocrine tumor

A

insulinoma

110
Q

MC gastric volvulus

A

organoaxial
Twisting around xis between GEJ and pylorus

111
Q

Best ulcer option to perform in the emergent setting

A

Truncal vagotomy + pyloroplasty

112
Q

Lowest risk of re-bleeding

A

clean visible ulcer base

113
Q

Which types of gastric polyps do not harbor malignancy risk

A

Hamartomatous
Inf;lammatory
Heterotopic
Usually fund

114
Q

Risk of malignancy in typical hyperplastic polyp

A

2%

115
Q

Dieulafoy lesion

A

congenital malformation in stomach, typically on lesser curvature, characterized by a submucosa artery that is abnormally large and tortuous

May erode through mucosa and become exposed to gastric secretions

116
Q

Most sensitive and specific dx test for gastrinoma

A

Secretin stimulation test

increase in gastrin of 120 pg/mL or greater

117
Q

Complication of truncal vagotomy

A

Loss of PS innervation not pylorus which prevents gastric emptying, primarily to solid foods

118
Q

Complication of selective vagotomy

A

Lower rate of delayed gastric emptying but higher rate of recurrent ulcer disease

119
Q

Complication of pyloroplasty

A

Can least rapid gastric emptying

120
Q

How to treat SIBO

A

Labs for B12 deficiency, microcytic anemia
Confirm with lactulose breath test
Treat with abs like rifaximin

121
Q

H pylori and gastric CA

A

PROTECTIVe against proximal gastric CA
Increased risk of DISTAL gastric CA

122
Q

Which gastric CA rising the fastest

A

Proximal due to obesity and reflux

123
Q

proximal gastric CA is 2x more common in

A

men
whites

124
Q

In pts needing tx for H pylori but are PCN allergic what can you sub amoxicillin with

A

metronidazole

125
Q

persistent non healing peptic ulcer

A

obtain 8 or more bx from base of ulcer

126
Q

Giant duo perforation

A

Jejunal serosal patch
Pyloric exclusion
Feeding j

127
Q

Petersen hernia

A

mesentery of Roux (Alimentary) limb and transverse mesocolon

128
Q

What are the 3 types of internal hernias

A

Hernia through Petersen (space between Roux limb mesentery and transverse mesocolon)
Hernia through mesenteric opening at BP limb
Hernia through defect in transverse mesentery that is created to perform a retrocolic GJ

129
Q

Recurrent reflux and weight re-gain after RYGB should make you think of

A

gastrogastric fistula

130
Q

branches of anterior vagal trunk

A

hepatic division
anterior gastric division (anterior nerve of Latarjet)

131
Q

Celiac division arises from which vagal trunk

A

POSTERIOR

132
Q

PErsistent reflux after sleeve not treated with antacids

A

lap magnetic sphincter augmentation band

133
Q

Best bariatric procedures to achieve DM remissio

A

BPD
RYGB

ABS (23 decks)

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