Upper GI surgery Flashcards
what are the two different types of oesophageal cancer
adenocarcinoma
squamous cell carcinoma
what part of the oesophagus does adenocarcinoma usually occur in
distal oesophagus
what can are risk factors for adenocarcinoma
obesity
gastro-oesophageal reflux
what can cause gastro-oesophageal reflux
barrets metaplasia
- change of squamous epithelia to columnar
- can be precursor to caner
what part of the oesophagus does SCC usually occur in
proximal and middle third of the oesophagus
what are risk factors for SCC
smoking
alcohol
low socio-economic status
how does oesophageal cancer present
Progressive dysphagia Anorexia and weight loss Odynophagia Chest pain/heartburn Haematemesis
what investigations can be done for oesophageal cancer
endoscopy
contrast swallow
what investigation can be used to stage oesophageal cancer
CT chest/abdomen for TNM staging
what happens if metastases are found on initial investigations
no further staging
unfit for surgery so palliative/supportive therapy only
- palliative chemotherapy
- palliative radiotherapy
?stenting
what happens if no metastases are found on initial investigations and it is found to be resectable
further staging required:
endoscopic US - T/N stage
PET CT - M stage
what are the treatment options if there is a resectable non-met oesophageal cancer
Oesophagectomy + Chemotherapy
5 year survival approx 30%
*Concerns about resection/fitness and no metastatic disease =
Chemo/Radiotherapy
5 year survival approx 20%
how does an oesophagectomy work
part of oesophagus that includes cancer (as well as good margins on either side) removed
stomach pulled up into the chest and reattached to what is left of the oesophagus
what are complications of oesphagectomy
chest infections, arrhythmias, leakage from anastomoses
how does gastric cancer present
non-specific
dyspepsis
alarm features
- dysphagia
- evidence of GI blood loss
- weight loss
- vomiting
- upper abdominal mass
what investigations can be done for gastric cancer
endoscopy
contrast meal
what investigations can be done to stye gastric cancer
CT chest/abdomen
what are the 2 main surgeries for gastric cancer
subtotal gastrectomy
total gastrectomy and Roux en Y reconstruction
what 2 way can gastric cancer surgeries be performed
laparoscopic distally
open gastrectomy
when would anti-reflux surgery be needed
severe GORD - gastro-oesophgeal reflux disease
what are the symptoms of GORD
heartburn, water brash, cough
5-10% adults experience daily GORD symptoms
what are risk factors for GORD
obesity
smoking
alcohol excess
how can GORD be managed
lifestyle modifications
PPI therapy (proton-pump inhibitors)
surgery
what anatomical change can lead to GORD
hiatus hernia
- sliding
- paraoesophageal
what investigations can be done for GORD
endoscopy
oesophageal pH studies and manometry
what is the surgery for GORD
laparoscopuc hiatus hernia repair
fundoplication
what are the side effects of GORD surgeries
Dysphagia Difficulty to belch and vomit Gas Bloating Excess flatulence Diarrhoea
what is bariatric surgery
weight loss surgery - include a number of different procedures - performed on people who are obese and in critical condition because of it
what are the three types of bariatric surgery
restrictive
malabsorptive
combination
what do restrictive surgeries involve
decrease the size of the stomach either by:
- a synthetic gastric band
- stapling
- size reduction by “sleeve gastrectomy”
leads to satiety with smaller volumes of food - eventually leads to food intolerance and weight loss
what do malabsorptive surgeries involve
consist of bypassing segments of bowel - cause malabsorption of nutrients
e.g. the biliopancreatic diversion with or without duodenal switch and ileal interposition
what do combination surgeries involve
involve both aspects of restriction and malabsorption such as the Roux-en-Y gastric bypass, which is considered as the “gold standard” bariatric operation
what needs to be taken into account before bariatric surgery
patients choice
- peers
- ?celebrities
- safety
surgeons choice
- personal/units experience
- patients - BMI/co-morbidity/diet
what is laparoscopic adjustable gastric binding
a hollow silicon band is placed around the stomach near its upper end
- creates a small pouch and a narrow passage into the larger remainder of the stomach
the band is then inflated with isotonic fluids
- it can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of fluid
what are the advantages of LAGB
Relatively minor surgery
Reversible and adjustable
Low operative complication rate
Mortality 0.1%
what are the disadvantages of LAGB
Requires an implanted medical device
Easier to ‘cheat’
Risk of prolapse or slippage
15% will require revisional surgery
what is a laparoscopic gastric bypass
A small stomach pouch is created to restrict food intake - A Y-shaped section of the small intestine is then attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine)
This bypass reduces the absorption of nutrients and thereby reduces calorie intake
what are the advantages of laparoscopic gastric bypass
Quick and dramatic weight loss
Pedigree
Dumping syndrome
what are the disadvantages of laparoscopic gastric bypass
More invasive surgery
Malabsorptive component requires lifelong supplements
More complex if requires revision
Mortality 0.5%
what is laparoscopic sleeve gastrectomy
a partial gastrectomy that results in removal of most of the stomach, with the remainder resembling a “banana” or “half moon.”
The mechanism of action of this procedure is that the resulting decrease in the stomach size inhibits distentson of the stomach so that it becomes full sooner, thereby increasing the patient’s sensation of fullness and decreasing their appetite
what are the advantages of laparoscopic sleeve gastrectomy
Good medium term outcomes
No ‘dumping’ syndrome
No small bowel manipulation
No foreign body
what are the disadvantages of laparoscopic sleeve gastrectomy
More invasive surgery
Long staple line (bleeding/leak)
Short pedigree
Mortality 0.4%
what are the complications of bariatric surgery
Anastomotic leak
DVT/PE
Infection
Malnutrition
Vitamin and mineral deficiencies
Hair loss
Excess Skin
