Upper GI Surgery

Question 1

What are the types of oesophageal cancer and their key differences?

Answer 1

Adenocarcinoma
- Distal
- Related to obesity
- Can be caused by Gi reflux -> Barrett’s metaplsia -> Dysplasia -> Cancer

Squamous cell:
- Proximal/middle
- Related to smoking & alcohol
- And a low socio-economic status

Question 2

How does oesophageal cancer present?

Answer 2

PROGRESSIVE DYSPHAGIA
Anorexia/weight loss
Odynophagia
Chest pain/heartburn
Haematemesis

Question 3

How do we investigate suspected oesophageal cancer?

Answer 3

Upper GI Endoscopy

Can also do a barium swallow

Question 4

Whats worse about a barium swallow?

Answer 4

Doesnt ive you an opportunity to biopsy or identify what is causing the stricture, just see where it is/that it exists

Question 5

How do we stage oesophageal cancer?

Answer 5

Chest & abdo CT
If unfit for surgery stop staging as theres no point
If resectable you can continue with EUS & PET CT

Question 6

How do we treat oesophageal cancer?

Answer 6

If its metastatic or they’re unfit for surgery:
- Stenting
- Palliative radiotherapy/chemo

If its resectable:
- Oesophagectomy & chemo
- Chemo adjuvantly & neo-adjuvantly

Question 7

How does an oesophactomy work?

Answer 7

Cut out part or all of the oesophagus and pull the stomach into the chest then reattach.
You can also use part of the colon as a transplant.

Question 8

What are the effects of an oesophagectomy on the patient?

Answer 8

Very radical so:
- Mortality is up to 10%
- Takes up to 10 months to return to pre-op QOL
- Often have to adjust to eating small amounts often to prevent reflux
- Must have a feeding jejunostomy for the first few months

Question 9

What is gastric cancer most associated with?

Answer 9

Heliobacter Pylori infection?

Question 10

How does gastric cancer present?

Answer 10

Mostly non-specific symptoms:
- Dyspepsia most common

Alarm features:
- Dysphagia
- Evidence of GI blood loss (melaena etc)
- Weight loss
- Vomiting
- Upper abdominal mass

Question 11

How do investigate/stage a suspected gastric cancer ?

Answer 11

Endoscopy
Contrast meal

Stage with a chest/abdo CT and laparoscopy

Question 12

How do we treat gastric cancer ?

Answer 12

Subtotal or total gastrectomy (if total use a roux en Y reconstruction)

Can be laparascopic or open

Question 13

What is roux en Y reconstruction?

Answer 13

Cut gastropeosophageal junction and duodenum/jejunum junction.
Anastomose the oesophagus to jejunum and duodenum to jejunum.
This way food bypasses stomach and duodenum but bile/gastric juice still gets in

Question 14

How does GORD present?

Answer 14

Heartburn
Waterbrash
Cough

Question 15

What are the risk factors for GORD?

Answer 15

Obesity
Alcohol
Smoking

Question 16

How do we manage GORD?

Answer 16

• Lifestyle modifications
• Proton Pump Inhibitors
• Surgery (if theres somthing anatomical to fix)

Question 17

What is the most common surgery for GORD?

Answer 17

Laparascopic hiatus hernia and fundoplication .

The hernia is pull back throug then the fundos is tied round the oesophagus distally to reinforce the closing of the the LOS.

The oesophageal hiatus is also often stitched tighter to prevent anymore.

Question 18

Complications of Hiatus hernia repair + Fundoplication?

Answer 18

Dysphagia
Bloating
Excess Flatus
Diarrhoea
Difficulty vomiting/burping

Question 19

How do we investigate GORD?

Answer 19

With endoscopy
Also pH and manometry study

Question 20

What is bariatric surgery?

Answer 20

Surgery that leads to weight loss and reduction in co-morbidities

Question 21

What are the types of Bariatric surgery?

Answer 21

Restrictive - Decreases stomach size thereby inducing early satiety

Malabsorptive - Bypassing sections of intestine leading to reduced absorption of nutrients

Combination - Gold standard e.g. Roux en Y gastric bypass

Question 22

Example of restrictive bariatric surgery?

Answer 22

• Synthetic gastric band
• Stomach stapling
• Sleeve Gastrectomy

Question 23

Example of malabsorptive bariatric surgery?

Answer 23

Biliopancreatic diversion (bypasses part of the duodenum to reduce calorie intake).

With or without duodenal switch and ileal interposition

Question 24

How do we decide on bariatric surgery?

Answer 24

• Patients choice
• Experience of available staff
• Patients diet/BMI/co-morbidities

Question 25

How does a laparscopic adjustable gastric banding work?

Answer 25

Hollow silicon band around upper end of stomach creating a pouch and narrow passage into rest of stomach, band is inflated with isotonic fluid,

Question 26

Advantages/disadvantages of laparascopic adjustable gastric banding?

Answer 26

• Relatively minor
• Reversible
• Needs an implanted device
• Can prolapse or slip
• Some need revisional surgery

Question 27

What is a laparascopic sleeve gastrectomy?

Answer 27

Removal of part of the stomach leaving a sleeve or banana shape close with staples
Type of partial gastrectomy.

Question 28

Advantages/disadvantages of laparascopic sleeve gastrectomy?

Answer 28

• No foreign body, dumping syndrome or small bowel manipulation
• Quite invasive
• Risk of bleed/leak

Question 29

What is laparascopic gastric bypass?

Answer 29

Small stomach pouch made and anatomosed to second portion of jejunum.

First portion of jejunum anastomased to 2nd part.

Smaller food intake and avoids duodenum & 1st part of jejunum

Question 30

Advantages/Disadvantages of gastric bypass?

Answer 30

• Quick & Dramatic weight loss
• Invasive
• Requires lifelong supplements due to malabsorptive side
• Can require revision

Question 31

Complications from bariatric surgery?

Answer 31

• Anastomotic leaks
• DVT/PE
• Infection
• Malnutrition
• Vit/Mineral deficiencies
• Hair Loss
• Excess Skin