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Upper GI Surgical Secrets Part 2 Dr Anthony Wijaya Morriston Hospital SwanseaPreviously on Upper GI Secrets.. What Upper GI Surgeons do..? Bypassing Symptomatic Bariatric (weight Anatomical blockages relief loss) surgery reconstructionCASE – EPIGASTRIC PAIN Mrs Zainab, 47, presented with epigastric pain that woke her up in the early hours of the morning. This pain is worse during Ramadhan when she is fasting, and noted that the pain is gone shortly after she break her fast. After referring her for the gold standard investigation, the doctor explained that this disease is commonly caused by a particular bacteria, which would respond to a particular treatment regime. Mrs Zainab is allergic to penicillin. 1.What is the gold standard of investigation for Mrs Zainab? 2.What type of bacteria is the doctor referring to? 3.What selection of drugs would be a suitable treatment for Mrs Zainab?CASE 8 – EPIGASTRIC PAIN Mrs Zainab was diagnosed with a posteriorly sited duodenal ulcer with ongoing pain every two weeks. She has returned to discuss other options, including surgery abroad in Turkey as she is worried of a particular complication that she read online. You explained to her that surgical options are rarely done nowadays, but mainly focuses on the removal of a particular nerve to reduce acid secretion. You close the consultation by prescribing her long-term PPI. 4. In the event of a perforated duodenal ulcer, which blood vessel would likely be affected? 5. What nerve is being referred to in the surgical treatment?CASE 8 – EPIGASTRIC PAIN Mrs Zainab was diagnosed with a posteriorly sited duodenal ulcer with ongoing pain every two weeks. She has returned to discuss other options, including surgery abroad in Turkey as she is worried of a particular complication that she read online. You explained to her that surgical options are rarely done nowadays, but mainly focuses on the removal of a particular nerve to reduce acid secretion. You close the consultation by prescribing her long-term PPI. 4. In the event of a perforated duodenal ulcer, which blood vessel would likely be affected? 5. What nerve is being referred to in the surgical treatment?PEPTIC ULCERATION Break in the lining of GIT to the muscularis mucosae Most commonly in duodenum (80%), stomach (20%). 3-4:1 M:F Pathology – imbalance between acid-pepsin system & loss of mucosal resistance to digestion Acute vs chronic (usually >3/12 and presence of fibrosis = chronic) Requires gold standard diagnosis (OGD). Aetiology • Crohn’s • ZE syndrome 60% 30% 5% • Stress H Pylori NSAIDs Carcinoma Others Endoscopy (OGD) Medical management as mainstay of tx, surgical to tx complications (bleeding, perforation, gastric outlet obstructionH. PYLORI Gram negative flagellated spiral bacillus with faeco-oral transmission 50% world population colonised; Prevalence 20% in the UK Works by producing urease (creating an alkaline environment), resulting in ammonia (toxic to epithelial cells), → release of gastrin in antral G-cells Diagnostic option → stool culture, serology, carbon-13 urea breath test, urease test, histology; Eradication therapy using triple therapy Triple Therapy (90% efficacy) 3 Drugs: PPI + 2 Antibx (*Amox + Clari) 2 Twice a day 1 WeekPEPTIC ULCER DISEASE Gastric Ulcer Duodenal Ulcer Most common site  lesser curvature of Most common site  anterior wall of first part proximal stomach of duodenum Presentation – pain after eating (post- Presentation – pain when hungry and relieved prandially) and relieved by vomiting by food More likely to be malignant Less risk of malignant transformation Perforation less common Perforation more common.. ‘which vessel?’ Tx  ALL GU needs to be biopsied (exclude Rarely requires surgical treatment (unless gastric malignancy) complications) Surgical treatment involves ulcer resection Surgical treatment involves truncal (Bilroth I, Polya) vagotomy/gastric resectional surgery.COMPLICATIONS REQUIRING SURGICAL INTERVENTION Perforation less common in GU. Assoc. with NSAIDs use. DU - usually perf on the anterior wall of duodenum PERITONITIS Sx) severe, unremitting epigastric pain; signs of shock, peritonism, shoulder tip pain Ix) eCXR - pneumoperitoneum; moderate hyperamylaseaemia in DU Tx) resus, O2, IVI, Abx, NGT, I/O; surg mostly but conservative if no peritonism; Surgical - simple closure of DU  underrun with sutures or plugged with omental patch + peritoneal lavage; 72 hrs IV PPi & H. pylori eradication Perforation of a posteriorly sited DU  erode to gastroduodenal artery resulting in UGI bleed (haematemesis & melaena) More in Surgical Secrets – Managing Surgical Emergencies session*stay tuned*SURGICAL MANAGEMENT OF PUD Conservative Gastric Ulcer Duodenal Ulcer Ulcer resection Bilroth Type 1 & 2 Gastrectomy Truncal/selective vagotomy Medical Polya type resectionCASE EPIGASTRIC PAIN You see Mrs Zainab in A&E a year later, following a recent vagotomy and pyloroplasty done in Turkey. She presented with epigastric pain with crampy abdominal pain, sweating, palpitations, and dizziness following a meal with her friends. 6. What is the most likely diagnosis A. Gastric outlet obstruction B. Dumping syndrome C. Upper GI bleeding D. VTEC gastritis E. Iron deficiency anaemiaCASE – EPIGASTRIC PAIN You see Mrs Zainab in A&E a year later, following a recent vagotomy and pyloroplasty done in Turkey. She presented with epigastric pain with crampy abdominal pain, sweating, palpitations, and dizziness following a meal with her friends. 6. What is the most likely diagnosis A. Gastric outlet obstruction B. Dumping syndrome C. Upper GI bleeding D. VTEC gastritis E. Iron deficiency anaemiaDUMPING SYNDROME Vasomotor symptoms (Light headedness, tachycardia, flushing, sweats + palpitations; D+V) Early dumping (proper) - 15-30 mins post-prandially; rapid emptying of hyperosmolar (carbs) gastric contents into SB → influx of fluid down osmotic gradient into bowel lumen  increased peristalsis; Conservative mgx (smaller, dry frequent meals, less carbs, no liquids) Late dumping (less common) reactive hypoglycemia due to more rapid absorption of glucose from upper SI → hyperglycaemia → rebound hypo; Similar sx to above + hunger & confusion 1-3 hrs post eating; controlled by GIVING CARBS;CASE - POST-GASTRIC SURGERY COMPLICATIONS 2. A 63 year old man undergoes a total gastrectomy for carcinoma of the stomach. Which of the sequelae below is least likely to occur? A. Metabolic bone disease B. Bile reflux C. Dumping syndrome D. Zinc deficiency E. B-12 deficiencyCASE - POST-GASTRIC SURGERY COMPLICATIONS A 63 year old man undergoes a total gastrectomy for carcinoma of the stomach. Which of the sequelae below is least likely to occur? A. Metabolic bone disease B. Bile reflux C. Dumping syndrome D. Zinc deficiency E. B-12 deficiencyCASE - HAEMATEMESIS A 72-year-old gentleman is admitted with an episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the submucosa approximately 6cm from the GOJ on the lesser curve of the stomach. What is the most likely explanation for the bleeding? A. Gastric cancer B. Portal gastropathy C. Dieulafoy lesion D. Linitis plastica E. GastritisCASE - HAEMATEMESIS A 72-year-old gentleman is admitted with an episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the submucosa approximately 6cm from the GOJ on the lesser curve of the stomach. What is the most likely explanation for the bleeding? A. Gastric cancer B. Portal gastropathy C. Dieulafoy lesion D. Linitis plastica E. GastritisUPPER GI BLEEDING Haematemesis +/- Malaena; signs of shock and substantial blood loss, signs of liver disease Cause Peptic ulcer Varices Mucosal lesion (gastritis) Treatment Use 2 scoring system: Rockall (severihttps://www.mdcalc.com/rockall-score-upper-gi-bleeding-complete GBS (stratifies risk)://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs Investigations Bloods (incl. ABG+ Lactate)Endoscopy Endoscopy Both Ix and Tx URGENTLY indicated if: • Syncope (haemodynamically unstable) • Hypotension Variceal vs Non-variceal • Transfusion >4x RBC in 12hrs bleed • Age >60 • Multiple comorbiditiesGASTRIC NEOPLASM Benign - arise from epithelial/mesenchymal tissue; Adenomatous polyps most common GIST - arises from pacemaker cells in the gastric wall (ICC) Endoscopy & EUS; Biopsies rarely helpful as lesions submucosa; GIST (GI Adenomatous Small asymptomatic GISTs - left alone; large stromal ones to be kept under surveillance; Polyps tumours) Symptomatic (bleeding, pain, obstruction) needs resectionCLINICAL PRESENTATION OF GASTRIC CA Dyspepsia (persistent) Vague and non-specific sx Not usually responsive to PPI. Remember your ALARMS? Hence why most are caught very late.. Dysphagia Remember the five key questions to ask? Red flag cancer sx Progressive non-intentional weight loss Epigastric mass Troisier sign (palpable Virchow’s node) Left supraclavicular LN – signs of metastatic abdominal malignancy Signs of metastatic disease Hepatomegaly, ascites, jaundice, acanthosis nigricansGASTRIC CARCINOMA Risk factors: Male (2:1 ratio to F), age (60-80), diet (malnutrition, nitrates), h.pylori, gastric polyps, chronic gastritis Adenocarcinoma Other types Most common type of gastric ca (90%) Lymphoma More common in developed world Carcinoids Could be early or advanced (based on whether it has (incidence on a downgoing trend) spread to the submucosal layer) Investigations Endoscopy + CT-TAP PET-scan Endoscopic US Staging laparoscopy biopsy Prognosis Depth dependent : Confined to submucosa without LN/M → 5 year survival 95-100%; T2N1M0 - 45-50% MANAGEMENT MDT  Curative vs Palliative? SURGICAL RESECTION OESOPHAGEAL NUTRITIONAL GASTROSTOMY CHEMOTHERAPY RADIOTHERAPY STENT SUPPORT TUBEDIAGNOSIS OF GASTRIC CANCERTREATMENT OPTIONS CURATIVE INTENT PALLIATIVE INTENT • Surgery alone • Early gastric ca → distal/subtotal or total Supportive care: N+V (cyclize/ondansetron) D2 gastrectomy • Steroids for poor appetite • Combined Peri-operative chemotherapy and surgery is • Pain - opioids; better than surgery alone; mostly for advanced tumours; • Diabetic support • Syringe driver for EOL • Chemotherapy - epirubicin, cisplatin and 5-FU • Radiotherapy - reduces bleeding from adv gastric ca using external beam radiation • Stenting - gastric outlet obstruction • Palliative surgery - gastric bypass for distal tumours or palliative resection;ANATOMY OF THE DUODENUM Divided into 4 parts: ( 1stpart intraperitoneal, the rest are retroperitoneal) First part (L1) – 5cm, most common site for peptic ulceration Second part – Ampulla of Vater Third & Fourth parts – pass behind transverse mesocolon Blood supply – coeliac axis (gastroduodenal artery) and branches from SMA (inferior pancreaticoduodenal artery) – same veins  portal venous system. Lymphatics follows suit and drains into surrounding nodes. SNS + PSNS from coeliac and superior mesenteric plexusesTRANSPYLORIC PLANE Imaginary plane midway between sternal angle and symphysis pubis; (L1) Contains:  Pylorus stomach  Left kidney hilum (L1- left one!)  Fundus of the gallbladder  Neck of pancreas  Duodenojejunal flexure  Superior mesenteric artery  Portal vein  Left and right colic flexure  Root of the transverse mesocolon  2nd part of the duodenum  Upper part of conus medullaris  SpleenSBA – REFERRAL TO BARIATRIC SURGERY Which of the following patients should be referred for 1st line bariatric surgery? A. BMI 30kg/m2 + HTN B. BMI 28kg/m2 + COPD C. BMI 35kg/m2 + T2DM D. BMI 32kg/m2 + HTN + COPD E. BMI 70kg/m2 + COPD + T2DMSBA – REFERRAL TO BARIATRIC SURGERY Which of the following patients should be referred for 1st line bariatric surgery? A. BMI 30kg/m2 + HTN B. BMI 28kg/m2 + COPD C. BMI 35kg/m2 + T2DM D. BMI 32kg/m2 + HTN + COPD E. BMI 70kg/m2 + COPD + T2DMSBA – REFERRAL TO BARIATRIC SURGERY Which of the following criteria is not an indication for bariatric surgery to be performed in the UK National Institute of Clinical Excellence Guidelines? A. Patient stopped smoking in the last year B. Patient tried conservative methods for 6 months C. Commitment to long term follow up D. Surgery performed in a specialist unit E. BMI 35kg/m2 + HTNSBA – REFERRAL TO BARIATRIC SURGERY Which of the following criteria is not an indication for bariatric surgery to be performed in the UK National Institute of Clinical Excellence Guidelines? A. Patient stopped smoking in the last year B. Patient tried conservative methods for 6 months C. Commitment to long term follow up D. Surgery performed in a specialist unit E. BMI 35kg/m2 + HTNBARIATRIC SURGERY Obesity - BMI >32; morbid - >38; significantly reduced life expectancy Conservative management first but if morbidly obese - bariatric surgery Careful assessment according to NICE guidelines & MDT Surgical options - restrictive and malabsorptive Restrictive - decreases food intake by early satiety from small meals; overeating = upper abdo pain & vomiting Malabsorptive - alters digestion  poor absorption & elimination in stool; overeating = diarrhoea + flatulence; Who gets bariatric surgery? BMI >/= 40 or 35-40 and other significant disease (T2DM, HTN) that could be improved with weight loss.BARIATRIC SURGERY Adjustable •Laparoscopic placement of adjustable band gastric band around proximal stomach. Pre-requisites to surgery (NICE Guidelines) •Contains an adjustable filling port •Effective method for lifestyle control • All non-surgical measures have failed to •Reversible achieve or maintain adequate clinically •Takes longer to achieve target weight •Complications such as band erosion (rare), beneficial weight loss for at least 6 slippage or loss of efficacy may require re- months. intervention • Will receive intensive specialist management Gastric •Combines changes to reservoir size with • Fit for anaesthesia and surgery bypass malabsorptive procedure for more enduring weight loss. • Commit to the need for long-term follow- •Technically more challenging up •Risks related to anastomoses (2% leak rate) •Irreversible • First-line option for adults with a BMI > 40 •Up to 50% may become B12 deficient kg/m2 in whom surgical intervention is considered appropriate; consider orlistat Sleeve •Resection of stomach using stapling devices if there is a long waiting list. gastrectomy •Less popular now as initial promising results not sustainedBARIATRIC SURGERYSBA – RESISTANT GASTRIC ULCERS A 42 year old woman with known multiple gastric ulcers attends the surgical out patient unit. She has not improved despite 2 months of proton pump inhibitor treatment. She is found to have a gastrinoma. Where are these most often located? A. Duodenum B. Pancreatic head C. Pancreatic tail D.Jejunum E. Gastric antrumSBA – RESISTANT GASTRIC ULCERS A 42 year old woman with known multiple gastric ulcers attends the surgical out patient unit. She has not improved despite 2 months of proton pump inhibitor treatment. She is found to have a gastrinoma. Where are these most often located? A.Duodenum B. Pancreatic head C. Pancreatic tail D.Jejunum E. Gastric antrumSBA – FEEDING OPTIONS A 73 year old man is recovering from a stroke but is deemed to have an unsafe swallow. Apart from his CVA his past medical history includes rate controlled atrial fibrillation and a previous oesophagectomy. What is the best option for long term feeding? A. Endoscopically inserted PEG-tube B. Surgically inserted PEG-tube C. Surgically inserted feeding-jejunostomy tube D. TPN via central line E. TPN via large bore peripheral venous accessSBA – FEEDING OPTIONS A 73 year old man is recovering from a stroke but is deemed to have an unsafe swallow. Apart from his CVA his past medical history includes rate controlled atrial fibrillation and a previous oesophagectomy. What is the best option for long term feeding? A. Endoscopically inserted PEG-tube B. Surgically inserted PEG-tube C. Surgically inserted feeding-jejunostomy tube D. TPN via central line E. TPN via large bore peripheral venous accessFEEDING OPTIONSSBA - EMBRYOLOGY Embryological transition from foregut to midgut occurs in the duodenum, which anatomical landmark demonstrate this embryological transition from foregut to midgut? A. Duodenal cap (ampulla) B. Minor duodenal papilla C. Major duodenal papilla D. Hepato-pancreatic ampulla E. Ligament of Treitz (Suspensory muscles of duodenum)SBA - EMBRYOLOGY Embryological transition from foregut to midgut occurs in the duodenum, which anatomical landmark demonstrate this embryological transition from foregut to midgut? A. Duodenal cap (ampulla) B. Minor duodenal papilla C. Major duodenal papilla D. Hepato-pancreatic ampulla E. Ligament of Treitz (Suspensory muscles of duodenum)EMBRYOLOGY Gut develops from primitive endodermal tube 3 parts: foregut, midgut, hindgut • Foregut – extends to entry of bile duct to duodenum th • Starts dividing into oesophagus and larynx by 4 week  failure to do so  atresia/trachea-oesophageal fistula (TOF). • Foregut then dilates to become stomach, then rotates forming the lesser sac. Vagus nerve rotates with stomach • As stomach rotates to the left, duodenum swings to the right, fusing its mesentery with the peritoneum of posterior abdominal wall. (all except first inch are retroperitoneal) • Malrotation occurs when the sequence described above fails to occur or is incomplete. What we covered today.. Upper Dysphagia Dyspepsia abdominal pain Haematemesis Vomiting Symptomatic Bypassing Bariatric (weight Anatomical relief blockages loss) surgery reconstructionSee you in our next sessions