Upper GI Surgery Flashcards
Case selection for bariatric surgery
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.
Pre-requisite to bariatric surgery
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
What to consider whilst awaiting bariatric surgery if there is a long waiting list
orlistat
Adjustable gastric band
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
Complications of adjustable gastric band
Band erosion (rare), slippage or loss of efficacy may require re-intervention
What is a gastric bypass
Combines changes to reservoir size with malabsorptive procedure for more enduring weight loss.
Technically more challenging
difference between gastric bypass and adjustable gastric band
Adjustable gastric band is reversible, while gastric bypass is not reversible
Risks of gastric bypass
Risks related to anastomoses (2% leak rate)
Irreversible
Up to 50% may become B12 deficient
Sleeve gastrectomy
Resection of stomach using stapling devices
Less popular now as initial promising results not sustained
What is barrett’s oesophagus
Metaplastic transformation of squamous oesophageal epithelium to columnar gastric type epithelium
what are the three types of metaplastic process recognised in barretts
b) which 2 types may cause difficulties in diagnosis
intestinal (high risk), cardiac and fundic
the latter 2 may cause difficulties in diagnosis
what allows for the most concrete diagnosis of barretts
Endoscopic features of Barretts oesophagus are present together with a deep biopsy that demonstrates not just goblet cell metaplasia but also oesophageal glands
length of barretts
short <3cm and long >3cm
why do patients need endoscopic surveillance
as a proportion of patients with metaplasia will progress to having dysplasia
how often should patients have endoscopic surveillance
b) how should the biopsies be done
every 2-5 years
b) they should be quadrantic and taken at 2-3 cm intervals
what do you do if there is a mass lesion
endoscopic sub mucosal resection - allowing for patients to be upstaged from high grade dysplasia to invasive malignancy
tx for barretts
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
what is the stomach innervated by
vagus nerve
what are the effects of a vagotomy
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.
What are the effects of surgical bypass
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.
