Upper GI Surgery

Question 1

Case selection for bariatric surgery

Answer 1

BMI >/= 40 kg/m2 or between 35-40 kg/m2 and other significant disease (for example, type 2 diabetes, hypertension) that could be improved with weight loss.

Question 2

Pre-requisite to bariatric surgery

Answer 2

All non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
Will receive intensive specialist management
They are generally fit for anaesthesia and surgery
They commit to the need for long-term follow-up
First-line option for adults with a BMI > 40 kg/m2 in whom surgical intervention is considered appropriate

Question 3

What to consider whilst awaiting bariatric surgery if there is a long waiting list

Answer 3

orlistat

Question 4

Adjustable gastric band

Answer 4

Laparoscopic placement of adjustable band around proximal stomach.
Contains an adjustable filling port
Effective method for lifestyle control
Reversible
Takes longer to achieve target weight

Question 5

Complications of adjustable gastric band

Answer 5

Band erosion (rare), slippage or loss of efficacy may require re-intervention

Question 6

What is a gastric bypass

Answer 6

Combines changes to reservoir size with malabsorptive procedure for more enduring weight loss.
Technically more challenging

Question 7

difference between gastric bypass and adjustable gastric band

Answer 7

Adjustable gastric band is reversible, while gastric bypass is not reversible

Question 8

Risks of gastric bypass

Answer 8

Risks related to anastomoses (2% leak rate)
Irreversible
Up to 50% may become B12 deficient

Question 9

Sleeve gastrectomy

Answer 9

Resection of stomach using stapling devices
Less popular now as initial promising results not sustained

Question 10

What is barrett’s oesophagus

Answer 10

Metaplastic transformation of squamous oesophageal epithelium to columnar gastric type epithelium

Question 11

what are the three types of metaplastic process recognised in barretts

b) which 2 types may cause difficulties in diagnosis

Answer 11

intestinal (high risk), cardiac and fundic

the latter 2 may cause difficulties in diagnosis

Question 12

what allows for the most concrete diagnosis of barretts

Answer 12

Endoscopic features of Barretts oesophagus are present together with a deep biopsy that demonstrates not just goblet cell metaplasia but also oesophageal glands

Question 13

length of barretts

Answer 13

short <3cm and long >3cm

Question 14

why do patients need endoscopic surveillance

Answer 14

as a proportion of patients with metaplasia will progress to having dysplasia

Question 15

how often should patients have endoscopic surveillance

b) how should the biopsies be done

Answer 15

every 2-5 years

b) they should be quadrantic and taken at 2-3 cm intervals

Question 16

what do you do if there is a mass lesion

Answer 16

endoscopic sub mucosal resection - allowing for patients to be upstaged from high grade dysplasia to invasive malignancy

Question 17

tx for barretts

Answer 17

Long term proton pump inhibitor
Consider pH and manometry studies in younger patients who may prefer to consider an anti reflux procedure
Regular endoscopic monitoring (more frequently if moderate dysplasia). With quadrantic biopsies every 2-3 cm
If severe dysplasia be very wary of small foci of cancer

Question 18

what is the stomach innervated by

Answer 18

vagus nerve

Question 19

what are the effects of a vagotomy

Answer 19

Surgery to the vagus nerves was undertaken prior to the advent of proton pump inhibitors as a means of decreasing gastric acid production.

The operation of truncal vagotomy was effective at reducing gastric acid production. However, it did cause issues with delayed gastric emptying. As a result, surgery to disrupt or bypass the pylorus was often needed. These procedures comprised pyloroplasty and gastro-jejunostomy respectively.

Question 20

What are the effects of surgical bypass

Answer 20

Following gastric surgery it is often necessary to provide some form of gastro-jejunostomy.

The exception to this is where the pylorus is retained intact and the vagus nerves supplying the stomach are not disrupted. The effect of constructing a gastro-jejunostomy is that emptying of the stomach is less co-ordinated. As a result, carbohydrate rich loads enter the proximal small bowel rapidly. In the short term, this results in significant fluid shifts into the small bowel that can increase gut transit times. It also serves as a stimulus for increased insulin release, this can lead to rebound hypoglycaemia which accounts for the symptoms of late dumping syndrome that are sometimes seen.