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by a screen. Yeah, I assume that that's the case. Okay, so, um so, yeah. Welcome, everyone to update your surgical secrets about two. This is a continuation off the session on Monday. So for diversity, who attended a section on Monday, you should know that we've done this stuff so previously a rapid your secret to have got the tail off the tree goose and a duck. If you guys remember things that you have to be worried about, Whatever you are thinking about surgery in removing the esophagus in the subject to me. So the tree goose goes for you. Want to remove the esophagus? You do not want today damage to vagus nerve. You have to divide the Zytiga's vein on you want to stay away? Still play from the traffic. That's you. Remember the Golden alarms 55. That is the most important. Nice guidelines criteria in managing or investigating Really? For dysphagia. So if any of the patients have all of these along symptoms on their above 55 years old, then you want to go for the golden the gold standard investigation, which is upper GI and not to be, which is highlighted under right here that being the most important investigation in the whole upper GI series? Basically. Okay, so, um, just a quick recap. So what do up with the eye surgeons do? There's quite a lot of things on, uh, fixing anatomy on bypassing blockages because that could be, as a result, off cancers that could be as a result of strictures. But Upper GI I said it's mostly deal with, um, problems that arise from the suffer goes all the way down to duodenum onda, small bowel on disk, good involved. Things like symptomatically relief. If you've got a continuous acid reflux, if you've got continuous God peptic also which we will talk about in detail today on also, we'll focus on the little bit on bariatric surgery on them. How do surgery can help people to lose weight on especially the increasingly more obese population finally thinks about anatomically reconstructions. What happens if you have a perforated viscous? What happens if you have a nap? A. G I bleeding, for example, so we will talk about that in today section. So this this starts off to wake everyone up on them to get everyone into the thinking cap. There is a case here, but this case is a bit different. It's not an SBA. It's just a quick fire question that hopefully would get you up to speed with what we talked about earlier on Drip a rescue to what we're going to talk about this time. So feel free to meet yourself type of cancers in the trap. But I'll read out the case So we've got MS is sign up here. So it's actually a real patient off mine, a definite a couple of months ago, obviously not being not having the same name, but this is a 47 year old lady who presented with epigastric pain that woke her up in the early hours in the morning. This pain is worse during Ramadan, when she normally is fasting. On is noted that the pain is done shortly after she breaks a fast After referring her for the gold standard investigation, meaning in mind gold standard, the doctor explained. This disease is commonly caused by a particular bacteria which would respond to a particular treatment regime. Mrs. I know, however, it's allergic to penicillin. So for the first question of the day, please feel free to type your answer in the chat or shell them out. What would be the gold standard of investigation for Mrs I know. So somebody directed message me Feel free to put the India to everyone in the meeting so that everyone knows what what? What? You're what you're putting down know where it is. No blame and shame in this section. So yeah, acts. And what? Who said A pretty endoscopy. Eight. So, yeah, that's absolutely right. So this is a symptom off, at least on acid reflux. Or you could even think about practical situation in this case and get your pulses and all that. So we do need to think of what happened. Your endoscopy and excels have said whatever bacteria so doctor referring to is HPI Laurie Helicobacter pylori, which is the most common cause off peptic ulcer. But to make it more interesting, what type of bet Syria is HPI Laurie Bonus points for anyone can even say so. You could split things up. It's a gram. Positive gram negative. What type of on? How does it look like that? What kind of for features that you have two normal invention in order sued identify a bacteria. So the spiral shape run. I'll give you a spiral. Um, I'll give you a rod, someone says Gram. Negative yet So the whole full marks for this answer is gram negative. Flagellating spiral bacillus. So that's a pylori. And finally, what selection of drugs would be suitable for treatment for Ms is, I know in this case, someone else these under in debt on the okay, Um, Lian says collection like amoxicillin omeprazole boom. He just didn't never event there because she's allergic to penicillin. So except metronidazole thirds of my insulin omeprazole. Excellent. That's the triple therapy for dose who cannot have a monster. Still, it or penicillin. They can have metronidazole instead, and we'll talk about that in detail. It's wrong. Okay, so moving on. So Mrs I know is they diagnosed it a posteriorly side. Do a little ulcer with ongoing pain every two weeks. There's actually quite bad. Even though you give her the triple therapy is still, it's still causing a quite a lot of discomfort. She has returned to you to discuss adoptions, including surgery abroad in Turkey, actually is worried of a particular complication that she read online that if you leave this for way too long. You'll cost yourself some issues and discomfort. You explain to her that surgical options are really done. Any race nowaday but mainly focus is on removal of particular nerve to reduce the acid secretion. You close the concentrated by giving a long term PPI. So therefore, therapy doesn't work. You give for long term PPI in order to in order to help her prevent this from from going any further. So the question is that in the event of a perforated do the ulcer, which blood vessel would likely be affected so that that's some questions with dolls? Okay, um, are shot. Says gastroduodenal last three. Um, why is that? And is it common? Is it common? For if a do dinner also ruptures? This is always affect the dust or duodenal ulcer it or or could it could it have a different sick? Well, it would it have a different after effect? Well, what part of the question tells you that it's gonna be the gets renewed in the lottery? And in the meantime, I think about number five, What nerve is being referred to in the surgical treatment? Yeah, So accent Archerd said. It's a posterior duty ulcer. Therefore, get studio artery. Yes, that's correct. So they get renewed. It actually actually loosed. It's right behind thie. Duodenum. Hence, if you have a possible really, sites do the the ulcer. If that goes through the whole length on, dropped hers or PERFORATES than that, it's likely to go on to the Get the dude in the country. Okay? And finally, what nerve is being to refer is being referred to in all this surgical treatment. What? What is this magic nerve that you can do something about to to reduce the symptoms. I did mention the name of this nerve about three or four times in the last session. Sympathectomy Think again. Which one gives you acid secretion? Is it the sympathetic nervous system? Or if it's your parasympathetic nervous of is parasympathetic nervous system, which is a vagus nerve? Excellent. Okay, fine. So that's the answer. The bathroom, you know, actually, dissolution sits behind the duodenum. For your information, the relationship tip off the first part of the duodenum where normally first, right in front of it. So anteriorly, you've got the quadrant lobe of the liver, and you've got a gold bladder as well on behind it in fairly. You've got the gas for doing our tree on. You've got the head and neck for the pancreas around it as well. So you couldn't have some sequela off bacteria tactics off race amylase light base as a result of a perforated do it posteriorly Adina also, um, Wes on the other side, if you have a anteriorly cited duty an ulcer that would just literally free flow leak into the abdomen into the abdominal cavity and course parents of accidents, which we'll talk about later. Okay, um, for dose of you who just who just joined us. Welcome back to part two of the upper GI I Surgical secrets will continue, but some what we did last time on day tuned for our next section's on a possibility. Surgery lowers your surgery, surgical emergencies and especially these that cardiac arrest. Six. Okay, so a little bit of peptic ulcer a shin. So what it is It's basically a break in the lining of the gastric. Decide Ultram. It's all the way to the muscle layer. So all the way to the muscularity, MacOS a. So in order to call it a peptic ulcer, a gastric doing. Also, it has to break through that layer if you have an erosion of the mucosa, but it's something because a layer, then that's not practical. So that's no. And also you can you can call that gastritis. You can call that gastric erosion or erosive gastritis and all that. But it's no and also that sometimes asking exams what kind of layers it need to bridge for it to be an ulcer. So it's most commonly found in the duodenum. Unlike what most people think the most people thing always. Stomach ulcer is skeptical, so but no. 80% is finally the duodenum on. But again, if you're a male, you have an increased risk factor off this the same in this office, your cancer. But you know, the female counterparts, you already have an increase risk off uh, Goldstone's and you know, other diseases Well, so I think it's quite is kind of fair from this point of view. So what actually happens? What causes peptic ulcer? Is it just if you didn't curry at night? If you lie down straight away afterwards, you just leave it after you eat a lot of cheese. You know you have a bit of hiatus. Hernia is that the only thing that causes peptic ulcer is, well, not necessarily. The actual pathology is basically an imbalance between the acid, perhaps in system to the pepsin is on enzyme that's released by the stomach to induce acid secretion versus the mucosal resistance. The digestion. We already know that the stomach uses this columnar epithelium in order to make it resistant to acid. But over time, if you have loss of off this because of defensive strategy you have, you may develop peptic ulcer. It can be divided into acute or chronic, also based on how long it takes and whether there's any presents the fibrosis when you're doing the gold standard investigation. So if you can see some fibrosis in there, it's a chronic peptic ulcer. Or if it's lasted for over three months, then you can call it a chronic ulceration on. There is a gold standard local here, therefore, first line on the most important investigation and you need to do in order to listen. A CDL sir is an opportunity endoscopy without seeing the outside. Also, you almost can't make a proper diagnosis that this is an ulcer of some sort. Now etiology The most common cause of practical Saray Shin is actually HPI. Laurie, we've talked about a little by helicopter, uh, calico back to pylori, right at the start with the S P s. And we do know that this bacteria takes it, takes into account in 60% off most spectacles, is the next chief causes and sets so and said they blocks the prostaglandin d two by inhibiting the cyclooxygenase on their four court this PDT to helps in the defense layer in protecting the gastric mucosa in order to prevent a little sore. A shin 5% happens from gastric cancer, which we'll talk about. Let's rotten as well. On the other notable causes such as chronic disease, is a linger Ellison syndrome and also stress those are under Allison syndrome. It's a rare gesterone secreting tumor. What we call a gastrinoma. There's normally find found other and the pancreas of the duodenum it is. It could be linked with a bigger hole. Wider picture of what we call multiple endocrine neoplasia. Yes, I want you. You may have heard of it when you prepare for your final exam or if you do quite a little bit of past medicine. They didn't mention it quite a lot. And that's one of the notable causes off the peptic ulcer. A shin that could sometimes be on medical management is a mainstay of treatment. You had more in most times. You, you know, have to say this patient with the attorney. But the surgical treatment is reserved for very chronic treatment resistant cases or, if you have complications that require surgery such as bleeding perforation and guess tree out but obstruction. Okay, moving on. So talk about it's bile or E is a grand, negative, flagellating spiral, but still it's with a fecal oral transmission. Because it's thicker or Aleve. You would know that in the UK is not as bad, but whereas in the rest of the world you can think there's a lot more of these transmission due to poor sanitation. I'm clean water and they accept that. Therefore, it's more, um, prominent in other parts of the world, no prevailing. So how does it work? It works by produced the your ES by making an alkaline environment, therefore initially blocking these acid to work properly and then acid acid for space mixed with a little bit of your areas will have, uh would result in ammonium production and therefore DeSimone and stops it to the particular cells. Of course, is gastritis on, But eventually this infection and gastritis, the soon even mawr acid secretion. In order to counteract this some inflammation which eventually results in matter place here and eventually ulceration. There are a lot of diagnostic tools that you can use. You can use a stool culture, but this is usually not great, because if you start your therapy with a mattress, all you have to wait for at least a month or two weeks for this. From the moment you stop on my preservative, you can do it again. The serology. The antibody test against it is not great as well, because even if you have cleared out, this infection you're sturdy will be positive because you still go activate it towards it. The common urea breath test is a good way to do it. It detects the presence of ammonia and then urea. Therefore, if you've got that, then you're likely to have get a final re just nothing else in the stomach would have normally produce that histology is a good one is well, you can see the effect of gastritis and all that. But maybe stay off the chest of the common your area breath. So the treatment is triple therapy of what it is. It's a three drugs like ex Onda. Uh um, our shop, mentioned earlier, is basically repeat DPI into antibiotics. It's normally amoxicillin and Claritin for myself. If your patient is allergic to amoxicillin and you can give them matter, night is all. You take them twice a day and you continue it for a week, and all of this have 90% effective. C is actually pretty good. That's why I'm pretty. I surgeons don't really don't really deal with simple gastric ulcers anymore because the medical treatment is just marvelous. Now the big question is, or maybe what you guys have been waiting for. Um, it's like, when do you have to, um, you know, take them to their So what in what kind of way do you have to refer them to surgery s. So this is mainly this slide mainly, focus is on telling you the differences between the gastric and duodenum also, so the most common site for against it also to occur. It's under the lesser cure, but your approximate stomach, Where is it doing? Enough. Also, it is in the anterior wall of the first part of the duodenum. So if you remember the SBA, so the question at the beginning off the off the talk missus, I'm not had a posterior. Also, so this is free is not the most common site. But why is it important? Because if you go off posteriorly excited duty also and it ruptures, then you're you're at risk of causing trouble to to get your duty in answering. Causing a major bleed is well, so the presentation of this is what the normally question on exams. It's basically how they present this different. So with the gastric ulcer, you got pain after eating or what they call post friendly, and it's really by vomiting. So what happens if you have start teaching your faces of digestion? Starts the conflict face as soon as you start to see the food or smell the food you that's produced 20% of this sketch like acid assume is the bolus of food comes down from the from the esophagus and answers the stomach. You're you're released them 60% of the rest of the exit in your, uh, in the next phase, and therefore that triggers the old that causes irritation of the ulcer, and you get pain where it's a duty of ulcer. You get pain when you're hungry, because what happens is when you're hungry. The duodenum isn't necessarily free of any acidic condition on. Therefore, you would have pain on is usually relief by eating food, because when you eat food, even though the gastric acid goes freely in the stomach, if you remember talk from from Park one, the pyloric sphincter acts to control to tighten up on DeLauro. Only small amounts of food and digestion kind to go into the duodenum when to do it be that was ready and why you may ask Anthony why in doing it. Also, you get relief when you're just eating some food. Well, that's because the bicarbonate production in the duodenum kicks in, and that's what released. It relieves the pain as the pH gets higher and you've got less acid. So in a gastric, also, perforation is less common. The gastric mucosa is much thicker. It's got lots of rugae that makes it a having more surface area, and the rules are generally take your duodenum onda in duodenal ulcer perforation. It's more common with talk about which vessels it would affect. If you don't take anything else than you think about that as well. There's a question from Lila's check. Is the medical treatments for both triple therapy? Yes, that's correct. With some minor differences in what you do next. Um, so get ulcer is more likely to be malignant. We talk about gastric carcinoma being 5% of the causes of gastric off. But they also therefore in every single cases of gastric, also that you've taken two industrially. You do have to take on Upper GI I. And just to be biopsy, you do have to take a biopsy of the all set. So from that you you taken it and then you send them to histology in order for them to make sure it is not cancerous. On been terms of surgical treatment for gastric ulcer. You cannot take the ulcer out, or you can take a little bit of the stomach that has, um, the ulcer on you can or rejoin it to other places is where in which we're gonna talk about soon. Um, where's and do it Also, you rarely requires stages of treatment. Triple therapy works quite well, But if you do ever require surgical treatment, then it would be removal on the vagus nerve. So you it's a trunk of a cough to me. So you remove the vagus nerve through the trunk on, or you re sect a little bit of their off this stomach, a swell, which will be important while it's run. Why you need to do that? Okay, So before we get on for surgical and you know, I start telling you about what is Bill Roth? One. What is folly? A what? It's very good to me. That's about complications off the ulceration that would actually, you know, make you go knocking to the surgeon store and say, please think this patient, that theater well, perforation is a big one. We know what perforation already in doing the the ulcer. You know that the most common site off off the occurrence is the anterior wall of the duodenum. Hence, if you're up to that actually a wall, what's in front of it, the quantitate local deliver and the gold bladder. Therefore, it's just gonna listen to leak out and then causes peritonitis. For those of you who have not heard of Claritin access before or are still under a war spirits and artists, that's literally why you call general surgeons. That's the only reason why you can't send a patient home. Say, for example, if you're not sure, because you need to rule itself. So peritonitis is basically a nymphomaniac in slash infection off the whole peritoneal cavity and normally, as a result, off a perforated viscous. So imagine you've got stomach. You've got duodenum. If you rupture, does what will happen all of the digestive food over the monthly stuff. You know, all of the stuff that we eat is partially digested, mixed with acid, mixed with stuff, partially honest way being digested in, transported to deliver and all that imagine that just leaks out in in the abdominal cavity. It's basically these food is halfway turning into poop, and therefore, if you have that leaking in the abdominal cavity, you would realistically be in trouble. You would have a lot of trouble because that triggers a sepsis, a septic shock reaction because your body will basically try and fight off this infection. Your body would freak out and just basically started to cause you to go into shock. So your BP would be quite low. Your heart rate is going to go up, You're gonna have a fever. You will start to get quite dehydrated. You have severe pain and most notably, what? Your fireplace. That on examination you will find signs of parents in is, um, by the description off a very tender guarding abdomen. And some people might say, is there's rebound tenderness saying appendicitis and things like that. But basically, if you see a patient with very, very tender abdomen and when you upon very, very gentle palpating the patient just basically, you know within a lot of pain, then you have to suspect pertinence of. In this case, no shoulder tip may be why. Why shoulder to paint? So the shoulder to pain happens because you get irritations off the phrenic nerve. See tree 45, which is along the shore, the tip on, but the friend in effect because you can tell supplies the diaphragm. If you have perforation, perforated viscous, some of these might may irritate the diaphragm and therefore causes shoulder pain. How would you investigated? You do any direct STX rate? So that's an extra one. The patients standing right up and you would see something got new, more peritoneum or air under the diaphragm. So why is there air in an Afrin? Because there's a perforated discuss all the air leaks out, and therefore because off the position of it, the air moves upwards and you cannot go any more any higher up them, um, die from because the diaphragm covers the whole abdominal. And it's a thing between the abdominal and the thoracic cavity. So there's a question of the group that, um, m s would be hematemesis be bright red or coffee ground. Well, um, it depends on how long the blood has been there. Bright red bloods means that it's more likely to be a very acute face. So later on, we'll talk about the courses of Upper GI bleeding things like a suffragette viruses that would be more bright red, Um, or it's something, you know. It could be a mix between the two, but if you go more acute bleeding, that hasn't got time for it to be processed in the stomach on be partially that adjusted to cause it to be coffee ground. There would be more bright red, but also think about bright red. About Pathology is higher up in the esophagus, compared to lower down in the stomach for duty. That, but it's a question from Dallas. Is there any indication to start your medication therapy? An asymptomatic patient tested positive for H. Pylori. Well, here's the thing. Why would you do in a vial? Retested the patient asymptomatic? Unless you're in a different country in which you have privatized health care for your information in the UK, they don't they don't regularly test for is Valerie unless it's necessary? The answer is no. It's finery comprises of a common bacterial. Well, the gut flora, anyway, So most of us would probably have a little bit of a child or e. It's normally when a battery goes, you know, over what it's normally do, you know to maintain home your Stasis, but in the stomach or the duodenum, that's when you start. It's that's causing problems with the quick answer, but I know if they're know asymptomatic, they're not showing any symptoms and do not treat them for for registration. So that shoulder depend always suggest Parents Night is the answer is no. You can have multiple irritations off the phrenic nerve based on any any other course it all if you have a ruptured or very insist, for example, that's a different topic for a different day. But if you've got guided pathologies, you would normally see and hear a lot more of this shoulder tip any you got. Got any pathology? So that works in the exactly the same way. If you get erupted, um, cysts in the patients lying down, the fluid moves over every now and then, and that causes irritation off the area surrounding a diaphragm. And that would cause you to have shoulder tipping. But not necessarily that's a night is the exact wording for peritonitis should be on Bab normally tender abdomen with rebound idea, rebound tenderness or a scientific tennis, um, secondary to guarding. So if the patient is guarding means that whenever you press the stomach, they just go, you know, it's really it really hurt. The stomach goes really intense as the muscle tracks to protect the organs on the insides. And that is equal to parent Parent in is, um, but we'll talk about that more on the managing surgical emergency session. So stay tuned. We'll go through a whole session and how you're going to treat all of the surgical emergencies in an Oscar style manner and also giving you, you know, step by step, approach how you can manage to. Anyway, How would you treat parents and is, um, well, you resuscitated patient, you manage them in a recess station bay. You make sure you assess the airway. First of all, give them oxygen. You make sure you have got you check the breathing. You're gonna do a test that tracks part of your investigation as well. You're going to get a line cannula. So you administer IV fluids. Make sure they're not hypertensive. Actually, you give broad spectrum antibiotics if you think that they have perforated is always safe to stay local guidelines instead of just going into a mg amoxicillin. Metronidazole gentamicin. It depends. Different hospitals used different things. Sometimes you can put in energy to bit a nasogastric tube in order to prevent all of this leakage to go elsewhere. So if you've got a decompressed stomach. All of the stomach contents go back up, then you will. You will make it less likely for for for it to look out to the whole abdominal cavity. Um, you wouldn't think about input output. You would think about putting in a urinary catheter, making sure the discretion is adequately hydrated on be obviously keeping them near by mouth because, um, if they would need surgery that day, they don't need it. They can't eat. But if they have got no peritus, um, that means you don't think the theater. Then that means you treat them conservatively. You treat them, you can't. You go back to your triple therapy and there's no discussion about. You need to rush. You know I need to do things. So So what happens if you actually have a perforated fiscus, either a gastric ulcer or a duodenal also? Well, if something's perforated, you can either close it or you can. You can put another structure to put a patch on it. It's like a repairing a pump, too tired, basically, or if it's in a place where you know that no matter how good you are fixing it. If it's really big that it will leak because it and leak in a couple of days, then, you know, unfortunately to resect the section about that, that is there basically. So how do you do it? You can either do it under one suture. So it's literally like this picture. So you start off on the right side, you go into the left side, and then you go back and you go back on. Then you use it to them off. Or like in the bottom picture here, you would patch it with a mental. So part of the omentum would just basically get stuck on to the part of routine, um, debt perforates on. But we'll talk about that perforation in the posterior posteriorly sected Do you, like, three times? Basically. So you should notice by by the end of the session. Okay, So how do you do? Three pd you guys were talking about, You know, Remicade in therapy, what else can be off for them and obviously having to cover medical things as well? This has already been discussing part. While there's conservative management in which you stopped all of your caffeine alcohol, you know, and then smoking they stop eating burgers? Fries, You know, hot, hot food. Chilly. You stopped having tease, let at night and then just go to sleep straight away. Or you even conservative measures would include putting in more pillows. You know, this kind of stuff would would help the patient up to a certain way with any need to help them with some more medical treatments as well. Things to control gastric acid Renese Brunetti That's our age too. Receptor antagonist metoclopramide might help in order to help to get you emptying and promotes relaxation of the lower esophageal sphincter. Not relaxing, tightening iradicate hpai Laurie with the triple therapy and obviously your respiratory. That's the biggest one. No. So how do you treat but the also disease? Well, in gastric ulcer, you get any ulcer off. You can basically scrape it off either laparoscopically or open. People would probably do it laparoscopically. Read an opening if it's just a spray bottle of an ulcer. And this this this thing called a Bill Roth gastrectomy. So if you guys can see the picture here, Bill drop procedure is basically you take off the distal part of the stomach, chop off a stomach and half basically removed a pilot department park on you anastomosis to the duodenum. By doing this, you would help the movement off the whole gastric content you would help in healing those doses because of the acid. Doesn't look, there's a last that long in the stomach on deviously you if you have a vagus nerve problem and that would be death within the duty and also as well. So you try not to damage your vagus nerve when you do these procedures, Bill. Right time to it's quite different. So you re sect the distal part of the stomach, but he joined them to the duodenum. You joined them to the duodenum as an effort leg, and you live up the duodenum that you have resected. And the duodenum carries through all the pancreatic and hepatic secretions, the all of the pancreas, the Jews, all of the bile that comes to the liver and that acts as an Afrin limb that continues to the judges. Him a swell. And then there's also a poly a time resection, which is basically a Bill Roth type two. But instead of off anastomose in on the half of it to the effort. Limb? Um, that's the most the whole stomach to the gym, and you leave to do the them to do it's bit That's your surgical management off gastric ulcer on dinner. On the other hand, for duodenal ulcers like we mentioned before we would miss is I know you can do a Trunkal or a selective vagotomy. So you would basically divide the vagus nerve as the vagus nerve, um, stimulates acid production on did it. But also you need to think about what else is the vagus? Never do, so the vagus never keeps d keeps the pyloric sphincter in action. So if you don't have to go, if you don't have to take a snuff, the pyloric sphincter will have no control. It wouldn't know, then went to release the stomach contents into the duodenum will just basically go rogue and then, you know, activism. So in order to, in order to save your patients are having lots and lots of other problems. Things like extra. All that obstruction thinks like gastroparesis where things that move, because this pylori spincter is just behaving on on his own. Then you have to do that. You have to do a pyloroplasty as well. That means making a cup in the pylori sphincter and just basically opening it up. Just basically letting things go free. Flow from the stomach to wherever he goes next. Okay, moving off back to Mrs. I'm a mouth. So she isn't any. So Mrs I names in any. She went to Turkey. She had a really got to me and the pyloroplasty because they know that she wouldn't so that she wouldn't have complications on then. Now she came back to you with epigastric pain with crampy, um, with sweating with palpitations and dizziness following having a nice meal out with her friends. So what would be the most likely diagnosis then? We have to pull up. Please take your time. Okay, I'll give you 15 more seconds. Somebody said I can't see the whole Well, the poll is there, so because I can see people are voting in it. So if you press Paul into the honors, um, parts hopefully should be able to see people. Okay, Make your decision guys on answer the pool if you can. Yeah, keep going. We want to get answers. Don't worry. There's no There's no naming machine me. I don't know who you are, who answered which, you know, you get it wrong, but it right. Okay. We will stop it there, Onda. Yeah. So most of you go go to Right. So most of you are aware of a big syndrome, So yeah, basically, you know, enough said you've got it right, you know? You know what? The biggest indoor. So But what happened is you've got they got to me. Therefore the stomach has no control of the calories. You've got my little plastic to resolve that. But that means the pylorus is just basically like another segment of the stomach. But just food would just go free flow from there to the duodenum. So what happens is carbohydrate rich food will enter the duodenum. And that would, of course, you to have this rebound effect where you have insulin inducing hypoglycemia and you have this crampy pain where the stomach is going to absorb things this fast. Can sweating and palpitations because you're you're trying to get really success high carbs on glucose meal that is just loaded into the duodenum. So that the best of big syndrome in short. So you went off about more about this. It's basically it's a basal motor symptoms, so light headedness, tachycardia, flashing sweats and palpitation you can split it into mainly into two types of I don't really dumping syndrome or what they call a proper dumping syndrome or a late that case, Enbrel. So the early dumping syndrome, as the name says, happens pretty quickly, about 15 to 30 minutes after you eat some food. What happens is you got a lot of carbs. Gastric contents that goes into the small bowels on Do all of all of the small bowel do is retained a lot of fluid, and it goes from the spotting Grady in into the into the bowel. Lumen on it increases. The first house is, so we'll have. That's a result of this. You've got all the symptoms above, and because of the parents start since you've got a crampy abdominal pain, how do you manage this? Well is literally. You just have to reduce the amount of food did you take? Eat less carbohydrates and don't drink plenty of water. If you drink too much water while you eat, it's just gonna make it worse. Where's the late visit, which is less common. It's a reactive hypoglycemia, so we know that there's a rapid influx off Alba hydrants into the small intestine. I'm there for the body, you know, in order to maintain home your Stasis. It's just say, all right, then let me take all of that glucose in. Let's release all the insurance that you need And now guess what happens then your body overshoots it, and it causes hypoglycemia. That's why you feel tired and you have you have you can, Yeah, you have sweats and all that. And you can even have hunger and confusion because your body says, Actually, there's no more sugar. There's no more carbs I need more on. But as a result, you treat this by giving them carbohydrates. So bear in mind that the ace, you know, make sure you know which one you're dealing with because one issue eat less carbs and the other one the treatment is you give them cops. Okay, it's another XPA. Then, just to keep yourself awake. If we can release the pool again, don't be great. Thank you. Okay. 30 more seconds. Great. Then seconds one guys. It's a short question. Click on the ball. Why can't it be dumping syndrome? Oh, yes, is least likely to occur high. Read the question. That's the most important That you read the question. Okay, so under fall, so most of you, which is be, actually got it wrong. So you acid bile reflux is less likely to occur. Okay, Why? Why? Because if you imagine, if you look at that picture, you've removed the stomach. Therefore, you have to join the esophagus on duty them together or join the esophagus and order proximal Better stomach, whatever remaining to the digestion. Like like how we talk about it in the building. Type two and a poly eight procedures. So you can have reflux because it's basically that there's less. Um, there's less of a space for for bile to go to. There's now two ways that the bottom go up was before you got a pyloric sphincter. So it can happen. It is pretty common, actually. So this question just basically asks you on two. What kind of stuff did you are messing up with versus where are things adult? That's basically the whole point of the question. So metabolic bone disease is quite common occurrence because What happens is you take a stomach off, everything goes to the dude. Didn't do any nose of Well, I eat them dumping syndrome and all that. You're upset the whole pick agents whole balance off homeostasis in the duodenum. It doesn't. It doesn't function properly. So therefore, you can have metabolic bone disease because I calcium. I am, uh what else is there? Did Oh, all of the stuff that has to do with your bones and calcium part of spaces is all absorbing a duty. Um, so if you do it in office, upset, you know, when I have asthma, calcium and magnesium and all that, therefore you increase your risk off developing metabolic bone disease. They're basing room and talk about Well, it could happen now, B 12. Where's be to have absorbed you have seen it here with your away serviced, you is absorbed in the ileum. So But then, if you if you if you If you ask the question how it's absorbing the Eylea, then why then why? Why is it more likely to occur? Remember, the stomach releases intrinsic factor. That buying's, um, well, interesting factor helps in the digestion and absorption of B 12. So we don't intrinsic factor. You cannot absorb B 12. So even though it's absorbing the Eylea, um, if you drop off the stomach, no intrinsic factor, you're happy to a deficiency, eso think Where is think absorbed? It's an agenda item digitalis to fire. You don't actually do anything wrong with the General. You take off your stomach. So that's why it's least likely to occur because off anatomical relationship where things are okay. Next, we're going into a more fun a cute problems. Now it's now the man who's vomiting blood. So please gonna have to pull up. Please. Oops. I may have press their own one. Let me re long Stop. All Okay? The ball is in. Okay. 30 more seconds. Okay. 10 seconds. Oh, okay. I was in the poll on share the results, so most of you got it wrong. It's a little high portal. Gastropathy, uh, is not so much of a thing, because if you remember the section before, um, most of the stuff. So if you have portal hypertension, where is it? Most commonly occur, so it can't call. It can cause a district called gastric issues, but it's not up to the point where you can have from it and blood vessels that would have would have bleed, and it wouldn't be the most likely explanation. Um, we have mentioned about why a soft agio varicies occur because the lower part of the esophagus drains into thie veins that eventually goes into the portal venous system. But in this case, in a 72 year old gentleman, hey has got a prominent blood vessel that tells you the answer straight away. If you hear the name prominent blood vessel that straight away, do you live for a lesion? So what it is, it's quite rare, but examiners love it because it's on it is there and then it happens. Just this one person in clinic you don't know what's happening is not a spy. Lawry's know whatever. He's not selling Alison. You send them for on a pretty endoscopy boom. You see, a prominent vessel are okay. You know, if I was in so what it is, you know, for a lesion is basically a prominent sub mucosal vessels. So the vessels is running into something closer layers. In the absence of any ulcers, you got no ulcers. It all you know, ulcers there. It's not a spinal problem. Your education therapy is not gonna do anything. Um, this prominent vessel usually lives five centimeters from thie. Get yourself into a junction. So is it lives in a lesser curvature. You can see the confusion that this causes because you're the most common side off. I guess we also is in the less uncomfortable this summer, So yeah, this is why. And even though this is quite a rare, this accounts to 2% off your opportunity bleeding and examine, it's just love it. So I just put it in there for you, too, to be aware about. Okay, um, upper GI bleeding that So what It is. It's a human tennis is I eat more meeting blood, plus or minus Molina saying, passing up dark or blood in the stool with signs of shop and substantial blood loss. And sometimes you can observe signs of liver disease as well, because you need to know what's causing the upper terribly basically the main, the biggest causes a peptic ulcer either in the gastric region or the Judean region. It could also be secondary to suffer too. Embarrasses on D is important because the two the two these two causes have different management. If you have average a bleed second, Richard, probably also you treat them completely differently from a Barris is Well, you still get the blood gift, you know, fluids and do resuscitation and all that. But the mainstay of treatments. What what you do and what medications you give before you take them to industrial. Is that so? In order to remind you all we used to scoring system for this we've got the rocal score, which basically stratifying the risk. Sorry, they're Rachael score, which measures to severity. I always get this mixed up and don't get it mixed up price. The rocal score measures the severity off the Apidra bleed. Where is the glass? Go Blatchford score. Remember, some people say Oh, you have the glass score scored as a lot of gas Go score in. Pancreatitis is which you were here later on in HB the glass go. Every score is use, but people shortened up to Glasko score as well. So what? It is it basically stratifies the risk off death, the risk of bleeding. So if you have a glass go Blatchford score of six or more. That means you need a surgeon Endoscopy. That means you can be on the phone with the endoscopy test or the, uh, yeah structural issue consultant saying that we need to know. Didn't ask a be on it with a glass go Blackfoot of six. If you have a glass stove left for school zero, that means you probably can send the patient home. It's probably know a substantial opportunity of bleeding is probably a little bit of a Mallory Weiss tear. Because remember, we talked about that in the first session, which is just a laceration off the because of Layer so used to scoring system mentioned them in your exams. Sometimes if you have SBS, they will ask you about this questions. If you sit interviews over and prepare for MRCS about two and things that I mentioned them, I was stressed. If I the risk by using Rachael and Vascular blessed for score on, then proceed to the definitive investigation and measurement using on dust to be if the If the GBS scores more than six eso industrial, be access, both investigation and treatment. In this case you heard in the urgently needs endoscopy If all the following See if the patients losing consciousness if they have court hypertension, they're hemodynamically and stable BP less than 90/60. If you've been transfusing four years of blood and I will tell you that's a long time and, you know, you just basically have to sit by with the patient. I had the experience of dealing with patient for a procedure bleed when I was doing surgery. And the patient is actually under medicine because they've got they've been diagnosed with with doing the holster and all that. But the patient actually turned into a full blown opportunity bleeding when I was doing night shift back. But what am in the morning so well, I have to do is just basically sit in the desk, examined the patient every now and then do arterial blood. Guess is to see their hemoglobin to see their oxygenation. If they're tiring out as a result, the firm anemia see if the lactate is going up. See if if what we're giving him is enough to maintain his BP because he's all night. It just basically passing Molina and transfusion of four red blood cells actually quite a lot within 12 hours. Because if you think about it one red blood cell you normally run them about three hours, therefore or two. Or if you want to, faster. But yeah, for red blood cells are more. You need a nostril. He's very way elderly patients because they're less robust and they're more likely to the compensate and end up into shock or go into cardiac arrest that they've got people hypothalamic or circulatory shop on people with multiple comorbidities things with them. Uh, renal disease, advanced cardiac disease because all in all, you're basically removing blood. You've got less cardiac output. You've got less for future, and you don't want these people to suffer. How do you treat this? Obviously you go on. Always said things like an A B C D. Approach. I would assess a patient's airway and making sure your blood, blood, blood Thean Porton things is give your blood really make sure you mention things like cross matched group and safe on the start. The patient on oh, recess negative blood. Whenever you're waiting for that on them, you be thinking about the treatment for various, you know, versus non Barrasso bleed on them. This we will cover in detail on the managing surgical emergency session. That would be a fun session. You'll be. You'll be looking at pictures. You look. You'll be literally be the doctor who is on call on down. You have to deal with this, and we will go through things of Este the camel. Oh, but basically mainstay of treatment average. I'm bleeding. You know longer give tranexamic acid because that's not indicated. You replace blood products. You sometimes can give platelets, depending on what their place to start. You need to discuss with the mentality. With that, with various your bleed, you can give medications to reduce the pressure that it's for a panel on. You can give something called IV terribly pressing, so that's basically within the same class off. Best present, which is an, uh, add a diuretic hormone that would reduce the whole pressure within the esophagus on reduce the risk of, well, the continue of bleeding from the varicies. When we have an ulcer, you would get the patient to end up just to be a set. Eventually, you would want to give them things like IV omeprazole because that would reduce the acid secretion, making sure it's less likely for it to bleed again. When you go into industrial eat, the picture of the hospital left is how is the difficult picture that you will see that there would be a lot of blood around the area. Sometimes you can see squirting blood from a vessel like that, and that's actually if it's a major vessel that you can see and you can't stop with. Thumb your options. Either you can give adrenaline, you can do embolism. Patient. You could put clips. You can use your probes and do even doing angiography while you're doing the endoscopy to identify the bleeding vessel. One of the indication for surgery. So this is where not to be school. Actually, I can't get the bleeding stopped, and you please come on, open the patient. Uh, this is when you have to think about that. If you've got a proper blood vessel of bleeding from a major artery, 50% of the stretching will require surgery on the 30% of the spaces happen. Also, I would have a will have a vessel visible at the ulcer base, which means that you probably may know, You know, just inject adrenaline or cauterizes. This also, because you will then cause the country, too. So, yeah, afterwards you do a little bit of a washout, you suck everything out. And then if it's a duty, and also they may require for the surgery later on, Okay, that's upper GI bleeding. That's that's this. That's a scary stuff out of the way. That's the life threatening emergency is out of the way. Now. We talk about the more chronic things, the more complicated things. So these are gastric cancers and neoplasms or new Pleasant could be split it two benign cancerous. These are benign stuff. Is that the best that you may need to know? But no, definitely need to know It arises from the epithelial cells are the most comfortable. Issues don't adenomatous. Polyps are the most common, so things like familiar adenomatous polyp OSIs. But it was cool. I lynch syndrome and thinks that at the's are these are only and our, you know, our be nice that that could eventually progress into, um, cancer stuff. It's a question on the group can do ambulance the first on a bleeder. Then there's one. Spacing is stable things. Well, yeah, You could do whatever you need to stabilize the patient. You can't just say Oh, yeah. Patients leading called a surgeon. Let's just wait here and let the patient empty half of their blood Vessel out. You You need to You can do You can try and do embolization, but if it's a major artery is a maximum, you don't want to embolize the whole pig because then you lose. You give you induce a skinny and then so you rather put in a something to block it. In the meantime, um, or go off. So coming back in to go through New Pleasant they're two most common ones the polyps and just so GST. It's a guest room in the spinal stromal tumors. So if you remember, the stomach and the doing them in the whole GI Tract have their own pace maker cells. And these pacemaker cells is for it's called Interstitial cell of Cow. See a J. A. L. I hope that's the right way to say it. But basically, if this pace maker cells becomes countries, um, you get just that, that's all. And he can become this big if you If you see them on industrial, he's so treatment is common sense. If it's small, just leave them alone. If it's large, you keep an eye on it. And if it's bleeding or causing pain or causing a lot of obstruction, the volvulus and all that, then you need to take it up. Okay, yesterday. Cancer, um, is very difficult to diagnose. It will go very vague. Symptoms is all non specific. It could start off with dyspepsia, which is why sometimes if they're not responsive to BBI, you need to remember your alarm symptoms. Are your patients slowly changing from this? Your simple dyspepsia to, you know, having anorexia to having Molina's having weight loss? Teo know progressing after you give a PPI. Do they eventually have dysphagia? Did they find it difficult to swallow things? Remember the five G questions you need to ask some dysphagia. Remember the whole algorithm that we talked about in part one due to visit them, and then it could be as obvious as the red red flag symptoms. So you're you're progressive, not intentional weight loss of you. Ask everyone on your medical history. It could be a problem. Acid. It's massive. You can listen. Pop it in on examination. It could be the sign of Detroit. See inside or palpable for coast notes. So if you remember your clinical examination, you normally know that on the left side you have to participate that supraclavicular lymph nodes because that's that's the first thing that gastric cancers will with testis size, too. And it's usually quite big and quite obvious if you spot there and things like your acanthosis nigricans where you've got discoloration, this pigmentation off your armpits, one of the things that you grill through again and again when you do your own skis. But that is a sign of metastatic disease alongside with things like a better megaly ascites George. This so I guess your carcinoma. What? Why, the respect is what can we do to prevent getting cancer as well? If you're a male, unfortunately, you have to twice the chance of developing. Guess your cancer, then your femur counterparts. If you're getting older between a 60 to 80 if your diet is pretty craft on, this is what this is pretty much being pretty crap on. It's literally honest on on his definition. So if you are Mom, if you have malnutrition, then you probably are evident. Increased risk of, um, having gastric carcinoma. If you have diet to this high and nitrates or natural, say me so some some soil in some parts of the world. A rich in nitrates, you can develop gastro carcinoma. It's by Lorrie again. Having gastric polyps and having chronic obstructive will give you uncreative, but what can you do to protect yourself? Certain studies did say that um, high vitamin intake could prevent gastric acid oma, a diet rich and carrot e. So go in either carrots on vitamin C and vitamin E reduces the incidents of gastric carcinoma. So that's one thing that you could do. Maybe people were buying your parents after this talk. But most commonly, the most common type of get through carcinoma is adeno. Constable. Well, that's up to 90%. It's more common in the developed world, and it could be earlier advanced, but usually they're advance on. That's when they have spread to sub mucosal layer, so they breathe t one staging to the mucosa layer and then lift gone beyond that on, but has gone to do something. Other types that are beyond this throat lymphomas, carcinoid with all of which the incidences are going on a downward trend. So you have to worry about that. Too much investigation of choice. You do it. It does to be. Remember, whenever you you think about gastric carcinoma, whether it was an ulcer, you always always, always do. A biopsy on the rest of the investigation is quite similar to when you're diagnosing your esophageal cancer. So you do a CT Tarek supplement perfect to assess for metastases. You do a pet scan to do the same thing. You do an endoscopic ultrasound to properly state the the staging, as that's the most sensitive investigation for that, and you do it stating, like Proscar be. If you suspect that there is a wide spread, a cold personal disease moving on, the prognosis is death dependent. It depends on how far that gastric acid, um, well has gone into thie layers. So if it's confined to the sub mucosa without any live notes or metastases elsewhere, the five year survival is actually pretty good. It's 95 to 100%. That means in five years you probably almost definitely still be alive where a soon as it goes to 82 on and one as it goes to the nearby live notes. Your five year prognosis gone straight away half to 45 to 50% exactly the same as your suffered jail cancer counterparts. You always always, always want to involve the MBT, which is the multidisciplinary team. I remember that this time on them the way that you want to think about whether you want to cure it or whether you want to palliate the patient. All of which depends on quite a number of factors with the patient is suitable for surgery. Whether the patient has a lot of core mobilities what A s a great they're on with the illness. It is even put them under general anesthesia. Would they survive the operation? Or what kind of things are you going to do to maintain their nutrition? What kind of feeding options have you going? Are you going to give them which we'll talk about later on? So the options remain the same. Chemotherapy, radiotherapy, Spence, nutritional support. DPM did enough to me on get shot to me too, And the surgical reception. So how does it look like? Well, um, hopes this is This is how you make the diagnosis of gastric cancer. That's how it looks like, and this image just should be moving. But for somebody that is not so, I'll have a look at that later on. But it's a CT scan that shows a slice off. Forget to us so your treatment options. You can split them into curative or palliative. In 10 curative intent, you can have to do surgery alone. You could do it. This still or subtotaled detail gastrectomy. So what? What does d to mean? It's basically the first deer off the paragard live notes and the second year of notes alongside your gastric arteries. You remember the first bottle talk you do reconstruction by something called roux and why to prevent by Reflux, which basically just means you connect to effort lives in a Y shaped direction to the judge in them today, from the duodenum as well to prevent anybody reflux on. But But the preferable options is to do a distal gastrectomy because it gives you a better quality of life if you do it this leg out straight to me to have to worry about other things as well But all of this is, um it's quite advance, so yeah. So in order to to do that, you can do a comp Teo help before the surgery. Or you could do surgery long, but recent met This suggested that perioperative chemo is better before surgery. Compared to surgery alone, you can give radiotherapy, but it's not usually s s good because of all of the organs around. And you don't want to risk damaging all of this. Run in the structures. Hence chemotherapy. Small relevant. That's the answer. I hope that question palliative. And then this is more medical. This is more mg. You give them supportive care. You prevent them from having nausea and vomiting. Gift A relevant cyclizine. A message on you. Give him steroids to help them. With the appetite, you'll give plenty of opioids or patient controlled and easier for pain. You support the patient for a diabetic point of view of their diabetic. You give him a syringe driver for end of life on Desyrel draw the chemo, radiotherapy, standing and permitted surgery. Okay, moving on a little bit of an after me under duodenum. So the duty in himself is suspected to four parts the first, but it's intraperitoneal within their on Virginia cavity, and the rest of it are retroperitoneal. We'll talk about that right at the end when we talk about embryology. The first part as well remember, is the most common site for ulcers a second, but houses the ambulance vata, which is where the common bile duct just the 3rd and 4th parts are just a boring. It's basically just past behind transferred me to call in, and you forget about this as well. I written gastroduodenal actually here, because that's really water and branches from this superior mesenteric artery, which is the inferior pancreaticoduodenal artery. Don't worry too much about that. The catcher do. The answer is more important. Um, the veins. Thank God they're called the same thing. They drain into the portal venous system, which is why all of your partially digested food goes straight away to to be in the system, and the lymphatics follows the same. That's right as well. Onda sympathetic parasympathetic nervous system come from the celiac and disappear message very classes. So whenever we talk about the duodenum, there's this thing called Trans Final replaced. It's basically they will ask you this on surgical interviews on the ward in theater is basically an imaginary plain midway between the sternal angle, which is some dangle of Louis here on the symphysis pubis. So what it is, it's on the level of L1 unit complains, is an imaginary line. Is complaints pretty much every important structure it contains. The pilot Pylorus is stomach. It contains the left kidney, the neck of the pancreas to find it's a gold bladder and all of the above on there's a picture here that gives you a demonic to try and remember this. But try and know a couple of important ones like second part of duodenum that's imported the neck of the pancreas That's there. The hilum left kidney, the fungus of the goal bladder on. But that's about pretty much four things that I am the spleen. A few if you worry about bleeding. Okay, we're moving on down to the last part of it all, which is about very actually a weight loss surgery. And we have to pull please, with methadone. Yep. Pull back, please. It should be any a simple one. So past your votes on, press on it. Okay, then what's a good okay? And the cold. So most of you answered a bm I off 70 for COPD plus type two diabetes, so Okay, right. Uh, unfortunately, guys know that's not the answer. So if you think about it, if you give someone a beer, if someone is BMY of 70 what kind of practical problems there is if you just decide? Yeah, let's take them to be a little less than put them in our in our bad and then try and operate under what kind of problems have you face practical problems? Well, for a start, your payment might break. Be, um I have 70 means that they're probably more than 250 kg, which is eyes the maximum way off the the surgical tables don't normally carry. They have COPD. You want to operate on someone with a massive restrictive lung disease? Well, a combination of obstructive and restrictive lung disease are they? Are they gonna be fit for surgery? Probably. No. And the diabetic? You removal that all that? Um well, obesity, you know, to make it more educationally appropriate, they will lose their diabetes. But they will also have some sequela that comes along with that. So all of this is based on a nice guideline. So the answer for this is BMY morning of 35 back to diabetes, and we'll talk about that after the second SBA. That's that's another experience. Um, with the following criteria is no indication for bariatric surgery. Basically nice. That's real low. Stop. Okay, 15 seconds more second. Okay. Right. Today I'll share the results. So most of the answer, which is a B m I off 35 on hypertension. That is no indication. Okay, but the guy who has has a bm i off 35 diabetic, you send him for operation. Okay, so this is the answer for this is patient. Stop smoking in the in the last year. So in order to be considered for Barrett surgery, you do not have to stop smoking. So it said you should be, um, following all of the rest of the off the off the following options. So you need to try conservative methods. First, you need to attend to lose weight first in the first six months and fail. You need to commit to a long term follow up because there's no point just referring you for the attorney. And then if you don't want to be followed up, you'll have from a continuous problem. And then the surgery needs to be performing, especially his unit. And finally, that the last option is there, So we'll talk about that in detail. So, uh, bariatric surgeon. First of all, in order to do this, we will need it off about what obesity is. So obesity is when someone has a BM. I'm over that, too. You call them morbidly obese if they have a being like 1 38 and this is linked with a significantly reduced life expectancy. You normally referred him for conservative management first. But if they're morbidly obese, then they might fit the criteria for bad for back surgery on and it depression. Need to undergo careful assessment according to these nice guidelines and the immunity approach on then you. There's two ways you can do bariatric surgery, either by a response, Restrictive? Um, A or a male absorptive pain so restrictive aimed just basically means that you want to decrease the food intake by making the person full really fast. So if you get full after eating three pieces of crispy. Is that meeting to bags of scripts? Then you will be. You won't be as fact because you don't eat as much. Um, if you What happens if you continue to operate? You have you have stomach pains and you'll you'll eventually vomit. Theater option is the absorptive state, which basically alters. In addition, in a way where you would basically course, the patient, too know, absorb food very well on dissolute minute them in in the Feces. The problem with overeating is that turn things into diarrhea and then it causes a lot of bloating and flatulence. So who gets very, very surgery day? So but the nice part serious states that if you have a bm I off more than or equal to 40 or between 35 40 with other significant disease such a stack two diabetes and hypertension, or COPD, that could be improved with weight loss, so that would improve if you lose weight on, um, having a B m. I. R. 40 to 45 at the age of 25 literally significantly reduces your life xx expectancy of up to 10 years. So that's why it is quite important to refer to for Barrett's surgery, So the prerequisites wondered I have to do all non surgical measures will have to fail all of this. Reduce your eating. Try some medications that if all this fat or things that would make you a form and if you eat too much weight would need to have failed before they will need to receive intensive specialist management in in a in a specialist center. You can't just refer them to ah Countryside Hospital in which they won't be able to manage, because the consequences complicating the surgery condition itself have to be fit to have surgery. They can't have, you know, multiple calm abilities. You know, a a message abdominal aortic aneurysm that that wouldn't you wouldn't get them anywhere near the operative table. You need to be committed because bariatric surgery is expensive. And if you if you just go back to your own ways and continue eating, then you just go back to square one. And that's the first line options. Now there are a couple of options off bariatric surgery. You can you can give someone a band. You can give him a gap past, which is basically your bypasses the stomach on, then or you could do a sleep, Get strep to me. So, you know, to explain to you in a back to position, I'll show you these images. So the easiest one is gastric banding. So I guess the banding is basically you put a band alongside of this stomach just below the get yourself a job juncture, and you have a this pouch off stomach on the top. So what happens? This this ring is inflatable. You've got, like, a pump that goes out subcutaneous, and you can actually control it. So what happens is, when you want to be, you start to pump this bank. So basically during tightens, So you got a little bit of space there in which, as soon as you eat something small, you before that's it, you're fearful you don't want to eat anymore, and then that's it. And then it takes longer for this food to basically go from a small part of the stomach to the rest of the stomach, and then you go to buy Laurie Spincter goes to the duty that little that so it affects you in a feeling of society ways. Gastric bypass on the other hand, is basically you. It's a second picture. You cut off the rest of the stomach, staple the stomach, close to be loaded, gastroesophageal junction. And then you basically take the top in the proximal end. And and that's the most, um, to a small bowel, that is just wait, They still from the stomach itself? Sometimes you can do ruin Why? Which is just basically connecting that to the judge. It in where it's you. And obviously the the wildest the duodenum comes along and the proximal part of stomach comes along with the Y. Live on. Both of them was connected to digest it and all that. So these are the options that you now you can think about. You could put Staples. You can. You could put a Band Aid to do contract to me, and I know. Okay, So another respirator. Uh, I've already given you the answer for this. I've already recorded talk about this, actually, so it should be pretty easy. Only one person haven't sex. Okay, five seconds left. Well, we go, but boat worry. Yeah, on. I will stop it there. Okay. So most of the got it right So most of you says do dinner. Yeah, because we talked about this, right. It's a gastrinoma. Diagnosis is something your Alison syndrome, which is quite rare. But it is a gastrinoma. It's increase gastric causes more and more. I said it's mostly comedy. Looking isn't a duodenum, which is why, as a common cause of Judea also, but also, it can also be the pancreas. So that's why the bankers options there. That's it. So, um, feeling up since that before we finish off, Um, then rest Be a please medical. Um, Well, while you guys are doing just someone clarify that defeat back for works because somebody said feedback phone doesn't work, and you resend, please. So if someone asked David, can you please double check your feet back homers? Thank you. Yes, it was amazing. Thank you. This is quite interesting. Question, actually. Give give us some thought, guys, because this is almost the last one anyway, uh, give you I'll give you, like, a good a minute and a half of it's like, give it some thought before you before your answer. Well, actually, I forgot after This is a good of embryology, isn't it? Yeah. It's okay. It's this. Stop the whole. Okay, So most of you relaxing common sense would be fair enough. Um, you said I'm surgically in such a picture. That would have normally be correct. But remember, this man has recovered from a stroke. He's got previous that some project to me. So what happened? If you have in a self injected me jump from the esophagus, then what happen? Who feels the get the stomach, right? Stomach's have to be pulled all the way out there. So your stomach will be from here all the way down there. So in a surgically inserted bank to you wouldn't It's in the back, too, because this stomach and activity is absolutely started. In order to put it in the proper stomach, you need to open the chest on, uh, general surgeons don't play around with the change. Is that acid increased risk of everything. So therefore is in surgically inserted feeding jejunostomy to because the biggest already had a subject. Okay. Feeding options. Basically parents oral and antral. You can give them feeding options with an anti to effectively where stroke, we can give them an energy to That decreases the risk of aspiration, pneumonia and all that. If you have problem to the esophagus that has a distal tumor, you can give a guest right to me by using that. Trust me to If they got problems with the stomach, you can give them and get enough for me to that will have a decreased risk off reflux and all that. You can also given NJ to a nasal judge. It'll tube, but he just put them through the nose, right and surgically inserted. All. If everything else is working, you can give them intravenous therapy. Intravenous, uh, nutrition, TPN or our breath for life. So this is the last SBA is about embryology. Um, so let's give us another Paul. These okay? Give us about 35 to 40 seconds. This There's a question on the on the group, if all is not possible. Canada Rigby. Next option, please. Radiology clean inserted. Get stressed to me. Could be possible. But still, once you've done a self injected me, the anatomy of the stomach is just actually all go on like the stomach was like, pulled into this long, too, so you probably wouldn't want to mess around with it. Things that are on a topically distorted. And if you put feeding their you increase the risk off aspiration as well. You don't you don't. You know that defeats the purpose. So that's where you put them. You know, you put a digital a story. Okay, Paul, most of you often for ligament off trades, which is the suspensory muscles. A duodenum, which is, unfortunately, the wrong answer. Yes, there is a major dude in a popular eso. Zapeta of our data is basically distal to the pylorus. It's located in the second part of the duodenum. It's basically where the opening off the pancreatic ducts and the CB in the common bile duct. The ambulance vata go to to do it in a so that marks the transition between to forget in the middle. So what a little bit of, um Realogy. This is when it all goes full circle. You know, we've talked about everything on day now we come back to the beginning of time so you can develop. You can divide the gut. The fellow missing three types so forgot make a hunger and these are supplied by their subsequent blood supply. So forgot by the Syria trump got by the superior with the artery and find out by the inferior mesenteric artery. So the four got extends old away from the esophagus all the way down to the entry of mild up to the duodenum. So that's your second part of duodenum your major do the pillar on or where you're bill of batteries. So how does it all begin? So it starts the forgot start dividing into the esophagus and larynx. By the fourth week they go together. So if you have a failure and this you can have what we call a suffragette act revia where the esophagus just, you know, just ends up with a Z, a blind and two. Or you can have a truck you suffer. GL fistula are tough. So what? What that means is that between the trachea, the windpipe and the esophagus, you go a whole your connection between the Children. So your patients or pediatric patients will have symptoms like shortness of breath whenever day feed they will have from You don't have this near they will. They will. They cause you a lot of discomfort where it's a big cry, which means that they open up all of the all of the connections in between and they shut their on their airway. They usually know we'll have no problem, because the one is luminess shut. Yeah, and the forget that dilates the stomach rotates the vagus never takes minute on gas, stomach replace to the left to do you need, um, strings to the right. And everyone lives happily ever after. If you don't have this irritation properly, then you have, uh you have something called mild irritation of the stomach, which is a very specific physical pediatric surgery talk for another day. Okay, so what we covered today will be covered so far. For those of you attended both sessions. So we've talked about this pager, which is difficulty in swallowing the steps here after abdominal pain. Or talk about vomiting and vomiting blood we've covered. About what? Um, upper gi X, urgent. Do. And we talk a lot about SPS and you know how to solve problems and related to opportunity surgery. So I'm finished. Thank you very much for for all for attending. Please, please, please do a fill in the feet back for me before you leave. I would really appreciate your feedback based on what we well, what we could do better. You know, if there's anything that you feel like would benefit, you know everyone from recession and feel free to write them in the feedback link, which will be helpful for all of us. So again, I would be We have a pattern. Billion recessions coming up that B two sections would have to suction lower GI eye surgery. We have a managing surgical emergency session coming up, which is would be quite fun interactive on day, Uh, you know, focused at you with your skin and things like that as well. And also, we might have a cardio thoracic surgery right at the end of Well, so if there is any questions at all, please feel free. Write them in a chat. I need yourself on. Do you can have a discussion?