1
Q
What are the five types of gastric ulcers?
A
- I: along the lesser curve (mucosal protection)
- II: lesser curve and with a duodenal ulcer (acid)
- III: pre-pyloric (acid)
- IV: cardia (mucosal protection)
- V: diffuse (NSAIDs)
2
Q
What is the most common type of gastric volvulus?
A
organoaxial
3
Q
What are the three types of gastric volvulus?
A
- organoaxial
- mesoaxial
- combined
4
Q
What is the gold standard operation for those with gastric volvulus?
A
emergent reduction, hernia repair, and gastropexy
5
Q
What would be an alternative operative intervention for frail patients with gastric volvulus?
A
endoscopic decompression with double PEG fixation
6
Q
What are alarm symptoms for those with GERD? What should be the next step?
A
- dysphagia, odynophagia, weight loss, anemia, GI bleeding, no response to PPI
- require upper endoscopy to rule out malignancy
7
Q
What are the indications for surgical treatment of GERD?
A
- failure of medical management
- desire to avoid lifelong PPI
- extra-esophageal manifestations (e.g. asthma, cough, aspiration)
8
Q
How is the Demeester score interpretted?
A
a score > 14.72 is consistent with reflux
9
Q
What are the components of the Demeester score?
A
- percent total time, upright time, and supine time with pH < 4
- number of reflux episodes
- number of episodes > 5 min
- longest reflux episode
10
Q
How much intra-abdominal esophagus is needed during hiatal hernia repair?
A
at least 3 cm
11
Q
What are the following kinds of fundoplication:
- Dor
- Nissen
- Toupet
- Thal
- Belsey
A
- anterior 180
- 360
- posterior 270
- anterior 270
- transthoracic anterior 270
12
Q
How should you manage an intra-op capnothorax during hiatal hernia repair?
A
- make the pleural tear larger to avoid tension
- place RRC through tear to equalize pressure
- bring RRC out at end and palce to water seal, then valsalva
13
Q
What does an esophageal diet avoid?
A
- meat
- raw vegetables
- bread
- carbonated beverages
14
Q
How should you evaluate a patient with signifciant dysphagia after hiatal hernia repair with fundoplication?
A
get an esophagram to look for an overly tight wrap or a recurrent hernia/slipped wrap
15
Q
Which hiatal hernias require repair?
A
- type II-IV should all be repaired in an reasonable surgical candidate
- type I only need to be repair if symptomatic (use same indications as for GERD)
16
Q
How often is H. pylori found in gastric and duodenal ulcers?
A
- 75% of gastric
- 95% of duodenal
17
Q
What is the treatment for H. pylori?
A
- PPI
- clarithromycin
- amoxicillin or flagyl
18
Q
What ar ethe risk factors for gastric stress ulcer?
A
- prolonged ventilation > 48hrs
- coagulopathy
- head trauma
- burns
- history of PUD
19
Q
Are gastric or duodenal ulcers more often associated with malignancy?
A
gastric (should biopsy all)
20
Q
What endoscopic findings are indicative of re-bleeding risk after intervention?
A
- actively bleeding vessel: 80%
- visible vessel: 50%
- adherent clot: 15-25%
- clean base: < 5%
21
Q
What operation can be used to stop a bleeding gastric ulcer?
A
- laparotomy
- anterior gastrotomy
- oversew ulcer
- close gastrotomy
22
Q
What is the operative approach to a bleeding duodenal ulcer?
A
- longitudinal anterior duodenotomy at bulb
- control bleed with three-point U stitch technique (superior and inferior bites to control feeding vessel, medial to control transverse pancreatic artery)
- can ligate GDA above duodenum if unable to control
- transverse closure
23
Q
What open stitch configuration is used to control a duodenal ulcer bleed?
A
- superior
- inferior
- medial
24
Q
What are the two most cmmon cuases of bleeding gastric ulcer?
A
H. pylori and NSAIDs
25
How should you approach large duodenal ulcers differently than smaller ones?
large ones > 3cm may benefit from jejunal serosal patch rather than omental patch
26
When should you consider an acid reducing procedure for PUD?
patients undergoing operation for complication of PUD with a history of treatment with PPI and/or eradication of H. pylori
27
How does a highly selective vagotomy differ from a truncal vagotomy?
highly selective does not dennervate the pylorus and so there is no need for a drainage procedure
28
Which hyperplastic gastric polyps require endoscopic resection?
those > 5mm
29
What is the most common mesenchymal tumor of the GI tract?
GIST
30
GISTs arise from what type of cell?
interstitial cells of Cajal
31
Describe the path (including stains) for a GIST.
- spindle and/or epitheloid cells
- CD117 positive
32
What tumors are CD117 positive?
GIST tumors are c-kit positive
33
The malignant potential of GISTs is based on what?
size and mitotic index
34
How do GISTs tend to metastasize? Where does it usually metastasize?
- hematogenously, which is why lymph node disease makes it stage IV
- most common distant met is to the liver and peritoneal surfaces
35
What features of a GIST are poor prognostic indicators?
- location in esophagus, colon, or rectum
- size > 10cm
- high mitotic index (> 10/HPF)
- local invasion
- distant mets
36
Describe the management of an initial GISTs.
- neoadjuvant therapy with imatinib for large and/or locally advanced tumors
- resection to negative margins (do not need lymphadenectomy)
- adjuvant imatinib for those are moderate-to-high riks of recurrence
37
What is the management of recurrent, locally advanced, or metastatic GISTs?
imatinib
38
What is imatinib?
a tyrosine kinase inhibitor used to treat GISTs
39
What is the treatment for imatinib-resistant GISTs?
sunitinib
40
What are the two types of gastric cancer?
intestinal and diffuse
41
What is the mutation that leads to hereditary diffuse gastric cancer?
an autosomal dominant mutation in CDH1
42
How do intestinal and diffuse types of gastric cancer spread?
intestinal via hematogenous, diffuse via lymphatics
43
What is the recommendation for managing hereditary diffuse gastric cancer?
- those with this CDH1 mutation should have prophylactic gastrectomy between age 18-40
44
What is the appropriate staging workup for someone with a new diagnosis of gastric adenocarcinoma?
- routine labs
- CT C/A/P
- EUS with FNA
- PET
- diagnostic lap with peritoneal washing for stage T1b or greater
45
How is gatric cancer staged.
T1a: invades muscularis mucosa
T1b: invades submucosa
T2: invades muscularis popria
T3: invades subserosa
T4: invades through serosa
N1: 1-2 nodes
N2: 3-6nodes
N3: 7+ nodes
similar to esophageal but stomach has serosa
46
What features make gastric cancer unresectable?
- peritoneal involvement
- distant mets
- involvement of root of mesentery or para-aortic nodal disease
- encasement of major vasculature
47
What are the surgical principles for an oncologic stomach resection?
- need 6cm margins (or 2cm past pylorus)
- and 16 lymph nodes
48
Are GEJ tumors treated as gastric or esophageal cancers?
esophageal
49
What degree of lymph node dissection is recommend in the US for gastric cancer?
recommend R0 resection with at least a D1 lymphadenectomy (along lesser and greater curve, stations 1-6)
50
How do D1 and D2 gatric lymphadenectomies compare?
D2 without splenectomy has been shown to have a disease free survival benefit and a trend towards overall survival benefit
51
Which gastric cancer patients get adjuvant therapy?
- no real role for neoadjuvant
- adjuvant for T3-T3 or node positive disease
- use 5-FU based therapy
52
What is retained antrum syndrome? How is it treated?
- retained antral tissue within duodenal stump after gastric resection leads to G cells bathed in alikaline fluid and continuously release gastrin
- check gastrin levels to rule out functional neoplasm
- treat with PPI, vagotomy or resection
53
Describe dumping syndrome. What are the two types?
- tachycardia, diaphoresis, dizziness, and flushing
- early occurs due to abrupt hyperosmolar load to small intestine
- late occurs due to rapid carbohydrate load and the subsequent insulin surge
- treat with small meals, no sugary drinks, and octreotide
54
How is bile reflux gastritis treated?
with prokinetic agents, bile acid binding resins, and conversion to RXY
55
How long should a roux limb be to avoid recurrent bile reflux?
at least 50cm
56
Describe a Bilroth 1 v 2.
- 1 is a duodenal anastomosis to the gastric staple line
- 2 is a duodenal stump with loop GJ anastomosis
57
Describe the pathophysiology and treatment of afferent limb syndrome.
- obstrction leads to bacterial overgrowth, deconjgated bile acids, steatorrhea, malnutritoin, and vitamin B12 deficiency with megaloblastic anemia
- start with antibiotics but treat with conversion to roux-en-y or bilrth 1
58
What happens to gastrin levels with gastric outlet obstruction?
increase because it is driven by gastric distension
59
What GIST mutation confers resistance to imatinib?
PDGFRA
60
Gastric mass with biopsy showing expansion of marginal zone compartment with development of sheets of neoplastic small lymphoid cells?
MALToma, treated with antibiotics for H. pylori
61
How is a MALToma treated?
with antibiotics for H. pylori (typically regresses with treatment)
62
