Upper GI surgery

Question 1

What are the main differences between the types of oesophageal cancer?

Answer 1

Adenocarcinomas:

• Distal oesophagus
• Related to obesity more strongly
• Can be caused by Gastro-oesophageal reflux (barrett’s metaplasia)

Squamous cell carcinomas:

• Proximal & middle third of oesophagus
• Smoking, alcohol are more strongly associated
• Low socioeconomic status

Question 2

What are the symptoms of oeophageal cancer?

Answer 2

Progressive Dysphagia

Dyspepsia / acid reflux

Frequent hiccups/burping/belching

Weight loss

Pain between shoulder blades

Question 3

How is oesophageal cancer investigated?

Answer 3

Upper GI endoscopy

Can also do barium contrast swallow study

Question 4

How is oesophageal cancer staged?

Answer 4

CT chest/abdomen

(if unfit for surgery then discontinue. If fit then do:)

EUS (T/N staging)

PET CT (M staging)

Question 5

How are patients with oesophageal cancer who are unfit for surgery treated?

Answer 5

Stenting

Palliative radiotherapy

Palliative chemotherapy

Question 6

If a patient with oesophageal cancer is fit for surgery, how are they treated?

Answer 6

Oesophagectomy + Chemotherapy

• 5 year survival 45%

Question 7

If a patient has oesophageal cancer which hasnt spread, but there are concerns over their fitness/suitability for surgery; how are they treated?

Answer 7

Chemotherapy + radiotherapy

• 5 year survival ~30%

Question 8

What are the different approaches to oesophagectomy?

Answer 8

Ivor Lewis

Trans-hiatal

Left thoraco-abdominal

Question 9

How does an oesophagectomy work?

Answer 9

Cancerous section of oeophagus removed

Stomach pulled up into the chest and then reattached

(Either the stomach or colon can be used as a conduit)

Question 10

What are the modifiable risk factors for stomach cancer?

Answer 10

H.pylori infection

Smoking

Alcohol

Excess of Salted fish, pickled vegetables and cured meat

Question 11

What are the ALARMS symptoms for stomach cancer?

Answer 11

Anaemia

Loss of weight

Anorexia

Recent onset of progressive symptoms

Masses & Melaena/Haemotemesis

Swallowing difficulty (dysphagia)

Dyspepsia is the most common symptom

ALARMS or >55 = Upper GI endoscopy

Question 12

How is gastric cancer investigated and staged?

Answer 12

Upper GI endoscopy

Contrast meal

Staging:

CT chest/abdo and Laparoscopy

Question 13

What are the types of gastric surgery?

Answer 13

Subtotal gastrectomy

Total Gastrectomy and Roux en Y reconstruction

Question 14

Is a gastrectomy done as an open procedure or laparoscopically?

Answer 14

Can be both

Question 15

What is a typical presentation for GORD?

Answer 15

• Reflux obviously
• Heartburn
• Dysphagia / swallowing pain (especially with hot/alcoholic drink)
• Relieved by antacids

Question 16

What anatomical problem causes GORD?

Answer 16

Hiatus hernia of stomach

Question 17

What two types of hernias can cause GORD?

Answer 17

Sliding hiatus hernia

Paraoesophageal hiatus hernia

Question 18

How is GORD investigated?

Answer 18

Endoscopy

Oesophageal ph Studies & Manometry

It is worth noting that the Clinical diagnosis of GORD can be made without investigation (unless there are alarm signs)

Question 19

What is meant by ‘oesophageal pH studies and Manometry’?

Answer 19

Manometry - measurement of strength of muscle contractions in oesophagus

pH studies - measures acidity of whats coming up

Question 20

Why is endoscopy used to investigate GORD?

Answer 20

• Can identify hernia
• Assess any oesophagitis
• Can identify Barrett’s oesophagus/metaplasia etc

Question 21

How is GORD treated?

Answer 21

50% of patients are treated only in primary care (drugs & advice) and dont get surgery

Surgical treatment:

• Laproscopic hiatus hernia repair & fundoplication

Question 22

What happens in Fundoplication?

Answer 22

1. Herniated section of stomach pulled back through the hiatus
2. This flappy ass bit of stomach is then wrapped round the oesophagus like a coat
3. Flappy bit of stomach is attached to other part of stomach once round the oespohagus

Question 23

What are side effects of laparoscopic hiatus hernia repair and fundoplication (GORD surgery)?

Answer 23

• Dysphagia
• Difficulty to belch and vomit
• Gas bloating
• Excess flatulence
• Diarrhoea

Question 24

What are the Overweight groups on the BMI scale?

Answer 24

Overweight: 25.0-29.9

Obesity I: 30.0-34.9

Obesity II: 35.0-39.9

Obesity III: 40.0+ (morbidly obese)

Question 25

What BMI groups is bariatric surgery indicated for?

Answer 25

Obesity groups II & III

BMI of 35+

Question 26

50% of patients with GORD dont get surgery, how are they treated?

Answer 26

Antacids

Weight loss

Sleep more upright (extra pillows)