UGI Surgery

Question 1

Best evaluation of oesophageal LN

Answer 1

PET CT and endoscopic US

Question 2

What is the minimum number of lymph nodes that need to be resected in a potentially curative D2 gastrectomy?

Answer 2

Removal of less than 16 nodes constitutes understaging and potentially under treatment.

Question 3

Histology in oesophageal achalasia

Answer 3

The situation in achalasia is best considered as the reverse of Hirschprungs disease. Ganglion cells are absent or reduced in the dilated segment and it is Auerbachs plexus that the changes occur.

Question 4

Placement of pH probe for pH study

Answer 4

5cm above the lower sphincter

Question 5

Gastric lymphomas

Answer 5

Most comman are due to lymphomas not arising from the stomach (eg systemic)

The endoscopic appearances of gastric lymphoma are vague and non specific. Mucosal thickening is the earliest sign.

Question 6

Treatment for proximal SCC

Answer 6

Early, localised, proximal tumours should be treated with chemoradiotherapy

Mid and distal oesophageal tumours can be treated with either surgery or chemo radiotherapy

More advanced proximal tumours without disseminated disease can be considered for McKeown type oesophagectomy

Question 7

Reflux with gastric atrium involvement

Answer 7

Suggests H pylori infection

Question 8

foveolar hyperplasia (gland tortuosity and dilatation - seen in gastritis

Answer 8

Usually due to chronic insult such as bile salt reflux

Question 9

Endoscopic frequency for Barrett’s

Answer 9

Every 2-5yrs

Biopsy’s taken quadrantic every 1-2cm

Up to 40% of people with EMR upstaged from high grade dysplasia to invasive cancer

Question 10

Mass encountered inoesphagus and cannot pass

Answer 10

Take bisopsys and withdraw

Order staging investigations

Distal extend not needed

DO NOT PERFORATE THE TUMOUR

Question 11

Chyle leak

Answer 11

Chyle leaks are more common following transhiatal procedures and may cause considerable nutritional compromise. Significant fluid collections should be drained but repeated thoracocintesis may result in the development of infection. Lipid rich TPN is helpful as these patients may lose lipid. Lipid laden diets may worsen the condition. Refractory cases may require surgery.

Question 12

How many biopsy’s should be taken in UGI cancer

Answer 12

6

Question 13

Lymph nodes affected in gastric cardia

Answer 13

Station 1 &2 node sdrain the cardia

Question 14

Most comman oesophageal problem in patients with CREST

Answer 14

Reflex - 70% of cases

Oesophageal involvement is therefore very common. Early features include atrophy of the oesophageal smooth muscle resulting a patulous and ineffective lower oesophageal sphincter. This results in reflux (occurs in 70% of cases). Over time this can result in ulceration, strictures, Barretts oeosphagus and adenocarcinoma.

Question 15

Most sensitive test for staging oesophageal cancer

Answer 15

Endoscopic ultrasound

Question 16

Schatzki rings

Answer 16

Most Schatzki are located at the OG junction. Characteristically the rings have esophageal mucosa above and gastric type columnar epithelium below.

Schatzki rings are an intrinsic occlusion of the lumen of either the distal esophagus or OG junction. They are seldom malignant but may cause symptoms of dysphagia. They are fairly common and may be identified in up to 14% of barium swallows. In patients with symptoms attributable to the ring, benefit may be gained from endoscopic dilation.

Question 17

Type A Gastritis

Answer 17

Autoimmune
Circulating antibodies to parietal cells, causes reduction in cell mass and hypochlorhydria
Loss of parietal cells = loss of intrinsic factor = B12 malabsorption
Absence of antral involvement
Hypoclorhydria causes elevated gastrin levels- these stimulate enterochromaffin cells and these may form adenomas

Question 18

Type B gastritis

Answer 18

Antral gastritis
Associated with infection with helicobacter pylori infection
Intestinal metaplasia may occur in stomach and require surveillance endoscopy
Peptic ulceration may occur

Question 19

Reflux gastritis

Answer 19

Bile refluxes into stomach, either post surgical or due to failure of pyloric function
Histologically evidence of chronic inflammation, and foveolar hyperplasia
May respond to therapy with prokinetics

Question 20

Erosive gastritis

Answer 20

Agents disrupt the gastric mucosal barrier
Most commonly due to NSAIDs and alcohol
With NSAIDs the effects occur secondary to COX 1 inhibition

Question 21

Stress ulceration

Answer 21

This occurs as a result of mucosal ischaemia during hypotension or hypovolaemia
The stomach is the most sensitive organ in the GI tract to ischaemia following hypovolaemia
Diffuse ulceration may occur
Prophylaxis with acid lowering therapy and sucralfate may minimise complications

Question 22

Menetriers disease

Answer 22

Gross hypertrophy of the gastric mucosal folds, excessive mucous production and hypochlorhydria
Pre malignant condition

Menetriers disease is a rare form of acquired gastropathy characterised by giant rugal folds in the gastric body, foveolar hyperplasia and markedly decreased or absent oxyntic glands with antral sparing. It typically presents with abdominal pain, vomting and peripheral oedema. Serum albumin is often low and hypochlorhydria is often present.
At endoscopy rugal hypertrophy is present. However, antral sparing of the disease is often seen. An enlarged gastric fold is defined as one which measures greater than 1cm endoscopically, that persists after air insufflation. Deep full thickness biopsies are needed for histological diagnosis as the pit to gland ratio cannot be determined on superficial biopsies.
The risk of malignancy in association with this condition is 10% during a 12 month period. Treatments include cetuximab and/ or gastrectomy

Question 23

Arteria lusoria

Answer 23

An aberrant right subclavian artery is the most classic cause of dysphagia lusoria. The more common situation is compression by vascular ring such as double aortic arch

Question 24

Sideropenic dysphagia

Answer 24

Iron deficiency anaemia may result in the development of Plummer Vinson syndrome. Some patients may also have oropharyngeal leukoplakia and this is reported to carry an increased risk of malignancy

Question 25

Schatzki rings

Answer 25

Schatzki rings are an intrinsic occlusion of the lumen of either the distal oesophagus or OG junction. They are seldom malignant but may cause symptoms of dysphagia. They are fairly common and may be identified in up to 14% of barium swallows. In patients with symptoms attributable to the ring, benefit may be gained from endoscopic dilation.

They are usually located at the squamo-columner junction, the z line.

Question 26

Optimal length of limb in Roux en Y

Answer 26

Short limbs increase the risk of reflux. Long limbs compromise absorptive function. A length of 40-60 cm is optimal.

Question 27

Malignancy linked to achalasia

Answer 27

The risk of SCC of the oesophagus increases up to 30 fold after 15 years of symptoms. It is unclear whether surgery reduces this risk. The condition usually has a poor prognosis.

Question 28

Types of gastric ulcer