What are the types of oesophageal cancer and their key differences?
- Related to obesity
- Can be caused by Gi reflux -> Barrett’s metaplsia -> Dysplasia -> Cancer
- Related to smoking & alcohol
- And a low socio-economic status
How does oesophageal cancer present?
PROGRESSIVE DYSPHAGIA Anorexia/weight loss Odynophagia Chest pain/heartburn Haematemesis
How do we investigate suspected oesophageal cancer?
Upper GI Endoscopy
Can also do a barium swallow
Whats worse about a barium swallow?
Doesnt ive you an opportunity to biopsy or identify what is causing the stricture, just see where it is/that it exists
How do we stage oesophageal cancer?
Chest & abdo CT
If unfit for surgery stop staging as theres no point
If resectable you can continue with EUS & PET CT
How do we treat oesophageal cancer?
If its metastatic or they’re unfit for surgery:
- Palliative radiotherapy/chemo
If its resectable:
- Oesophagectomy & chemo
- Chemo adjuvantly & neo-adjuvantly
How does an oesophactomy work?
Cut out part or all of the oesophagus and pull the stomach into the chest then reattach.
You can also use part of the colon as a transplant.
What are the effects of an oesophagectomy on the patient?
Very radical so:
- Mortality is up to 10%
- Takes up to 10 months to return to pre-op QOL
- Often have to adjust to eating small amounts often to prevent reflux
- Must have a feeding jejunostomy for the first few months
What is gastric cancer most associated with?
Heliobacter Pylori infection?
How does gastric cancer present?
Mostly non-specific symptoms:
- Dyspepsia most common
- Evidence of GI blood loss (melaena etc)
- Weight loss
- Upper abdominal mass
How do investigate/stage a suspected gastric cancer ?
Stage with a chest/abdo CT and laparoscopy
How do we treat gastric cancer ?
Subtotal or total gastrectomy (if total use a roux en Y reconstruction)
Can be laparascopic or open
What is roux en Y reconstruction?
Cut gastropeosophageal junction and duodenum/jejunum junction.
Anastomose the oesophagus to jejunum and duodenum to jejunum.
This way food bypasses stomach and duodenum but bile/gastric juice still gets in
How does GORD present?
What are the risk factors for GORD?
How do we manage GORD?
- Lifestyle modifications
- Proton Pump Inhibitors
- Surgery (if theres somthing anatomical to fix)
What is the most common surgery for GORD?
Laparascopic hiatus hernia and fundoplication .
The hernia is pull back throug then the fundos is tied round the oesophagus distally to reinforce the closing of the the LOS.
The oesophageal hiatus is also often stitched tighter to prevent anymore.
Complications of Hiatus hernia repair + Fundoplication?
Dysphagia Bloating Excess Flatus Diarrhoea Difficulty vomiting/burping
How do we investigate GORD?
Also pH and manometry study
What is bariatric surgery?
Surgery that leads to weight loss and reduction in co-morbidities
What are the types of Bariatric surgery?
Restrictive - Decreases stomach size thereby inducing early satiety
Malabsorptive - Bypassing sections of intestine leading to reduced absorption of nutrients
Combination - Gold standard e.g. Roux en Y gastric bypass
Example of restrictive bariatric surgery?
- Synthetic gastric band
- Stomach stapling
- Sleeve Gastrectomy
Example of malabsorptive bariatric surgery?
Biliopancreatic diversion (bypasses part of the duodenum to reduce calorie intake).
With or without duodenal switch and ileal interposition
How do we decide on bariatric surgery?
- Patients choice
- Experience of available staff
- Patients diet/BMI/co-morbidities
How does a laparscopic adjustable gastric banding work?
Hollow silicon band around upper end of stomach creating a pouch and narrow passage into rest of stomach, band is inflated with isotonic fluid,
Advantages/disadvantages of laparascopic adjustable gastric banding?
- Relatively minor
- Needs an implanted device
- Can prolapse or slip
- Some need revisional surgery
What is a laparascopic sleeve gastrectomy?
Removal of part of the stomach leaving a sleeve or banana shape close with staples
Type of partial gastrectomy.
Advantages/disadvantages of laparascopic sleeve gastrectomy?
- No foreign body, dumping syndrome or small bowel manipulation
- Quite invasive
- Risk of bleed/leak
What is laparascopic gastric bypass?
Small stomach pouch made and anatomosed to second portion of jejunum.
First portion of jejunum anastomased to 2nd part.
Smaller food intake and avoids duodenum & 1st part of jejunum
Advantages/Disadvantages of gastric bypass?
- Quick & Dramatic weight loss
- Requires lifelong supplements due to malabsorptive side
- Can require revision
Complications from bariatric surgery?
- Anastomotic leaks
- Vit/Mineral deficiencies
- Hair Loss
- Excess Skin