- What are the main types of bariatric operations that are performed for obesity?
How do they work?
Bariatric surgery can be classified into 3 different types based on the mechanism of weight loss.
This includes; restricitve, malabsorptive and a combination of the two.
Restrictive surgeries reduce stomach’s reservoir capacity to induce early satiety and decrease intake. This includes adjustable gastric banding and sleeve gastrectomy.
Malabsorption methods decrease nutrients absorbed by shortening functionally active bowel. An example of this is the bilio-pancreatic bypass.
Roux-en-Y gastric bypass is combination of restrictive and malabsorptive. If the bilio-pancreatic bypass involves a gastrectomy it can also be considered a combination.
How each works:
adjustable gastric banding- A tight adjustable silicone band is placed around the cardia/ fundus of the stomach to compartmentalise the stomach and create early satiety)
sleeve gastrectomy- removal of the greater curvature of the stomach creating a tubular stomach. Smaller stomach = early satiety
Bilio-pancreatic bypass- Gastroileostomy (remainder of the stomach anastomosed to the ileum) +/- gastrectomy. Biliary and pancreatic secretions enter the remaining duodenal and jejunal passage to enter the ileum distally. Malabsorption due to reduced action of bile and pancreatic enzymes.
Roux-en-Y Gastric Bypass- Small gastric pouch (~30mL) is separated from the stomach and anastomosed with the jejunum (30 – 50cm distal to the ligament of Treitz) = gastrojejunostomy
The gastric remanent and the bilio-pancreatic limb is then anastomosed distal to the gastrojejunostomy site (75 – 150 cm distal)
- You are asked to organise the staging investigations to help decide the treatment plan for a 65 year-old man who has been found to have an oesophageal cancer (adenocarcinoma) when he had an UGI endoscopy performed to investigate dysphagia. Biopsies taken at that investigation have confirmed that what looked like a cancer, is a cancer.
What tests are needed?
What are they aimed at deciding?
After a histopathological diagnosis is made, staging investigations are required for prognostic and management reasons.
A CT of the chest and abdomen is essential to establish the region and size of the primary tumor and to evaluate the presence of metastases. Adenocarcinomas usually metastasise to intra-abdominal sites. (squamous to thorax). CT, however, has limited value in loco-regional staging due to poor sensitivity for determining nodal involvement and determining depth of invasion.
Investigation of choice for loco-regional staging is an endoscopic USS which is effective in showing the relationship of the tumour to oesophageal wall layers and nodal involvement.
A PET scan has greater sensitivity than CT for detection of distant metastases and can be performed if CT is negative for mets.
Other optional staging options include:
- staging laparoscopy- to Detect intraperitoneal metastases that are difficult to diagnose non-invasively
- Bronchoscopy with biopsy and brush cytology which would be indicated to detect airway invasion in patients with locally advanced non-metastatic tumours above the level of carina
- You are asked to organise the pre operative assessment to help decide whether a 65 year-old man is fit for surgery for a locally confined oesophageal cancer (adenocarcinoma).
He presented with dysphagia. His cancer has been proven, and staging complete. The best chance of cure is surgery.
What issues are most important in this patient’s pre op work up?
Oesophagectomy is the only curative treatment for oesophageal cancer but is associated with an operative mortality of up to 5%.
There are many factors to consider in the pre-op work up. These include:
- the pts age- as increasing age is associated with greater morbidity
- the pts nutritional status- the pt has a history of cancer and dysphagia which can lead to profound loss in appetite and weight loss leading to possible malnourishment which is predictive of post-operative complications. The need for a feeding tube should be considered.
It is essential that the pts cardiopulmonary status is assessed. Are there any heart conditions? Can the patient walk up 2 flights of stairs without becoming breathless? Can the pt tolerate the general anesthetics. ECGs, echocardiography, CXR, spirometry and blood gases should all be done.
The patients smoking and alcohol status should be assessed and if the pt is a smoker, cessation for a min. of 4 weeks before the procedure is essential.
Past Medical Hx should be taken into consideration including medical conditions, previous surgical or anaesthetic complications and allergies.
The patient should also be educated of the disease and the procedure and informed of the risks involved and informed consent from the patient is essential.
- You are a GP. A previously fit 65 year-old woman consults you and gives a history of three months of progressive dysphagia, initially she struggled to swallow large food boluses, eg bread or meat, now she can only swallow fluids. She is losing weight.
What would you like to do to manage this lady?
The main concern for this lady is oesophageal carcinoma.
I’d first want to differentiate oropharyngeal dysphagia or oesophageal dysphagia by asking whether the problem initiating swallowing or the experience of food getting stuck? And I’d get a detailed history of the presenting complaint including duration, associated features and other constitutional features and risk factors for oesophageal cancer (smoke,etoh, gord, FH, obesity, hot liquid consump).
I’d then examine the pt by assessing aspiration risk by asking her to sip water and observe for reproducible dysphagia. I’d examine for lymphadenopathy and mass around the face and neck and inspect the mouth (candida, mucosal lesion, dentition). I’d also perform a neuro exam for stroke and degenerative diseases.
For investigation the pt should undergo a barium swallow test to help see abnormalities in the oesophagus and stomach.
If abnormalities are present then a referral for an endoscopy (OGD- Oesophago-Gastro-Duodenoscopy) may be required.
If the endoscopy is normal then an Esophageal manometry may be required if a motility disorder is suspected to measures the strength and muscle coordination of your esophagus.
This patient will essentially need referral to ENT or an UGI surgeon for further investigation and management.
- You are a GP. An otherwise fit 30 year-old man consults you. He has persistent gastroesophageal reflux disease, he is well maintained on 40 mg omeprazole per day, but gets bad symptoms very quickly if he stops taking the treatment. He is not keen on a lifetime of medication.
He wants to know if there are any other treatments, and what the risks are of them?
The management options for this pt include:
- lifestyle intervention such as weight loss, decreasing meal size, stopping smoking and avoiding certain products and adjusting when and how you sleep.
OR - surgery.
Laparoscopic Nissen fundoplication is the surgical management option and involves:
- wrapping the gastric fundus around the lower end of the oesophagus and stitching it in place. This reinforces the closing function of the lower oesophageal sphincter.
Symptom improveme in 85-90% of patients, however some patients still require some form of anti-secretory medication (PPIs).
There is a risk that complications can arise and these include:
- death (mortality rate=1%)
- haemorrahge
- visceral injury- splenic injury or bowel perforation
- surgical site infection
- vagus nerve injury
- gas bloat syndrome (inability of stomach to vent gas into oesophagus after fundoplication)
- dyspagia
- recurrent heart burn
- the need for revisional surgery
- Refer to Photograph - This patient with dyspepsia is having a gastroscopy.
- What does this show in the duodenum?
- How might this be complicated?
- What is the common cause of this?
- How is this condition treated?
- This image shows duodenal ulceration.
- Complications of this condition include:
- Haemorrhage (bleeding)
- Perforation
- Gastric outlet obstruction- (obs at level of pylorus= stomach outlet)
- Fistulation - Common causes of this are:
- H. Pylori
- excessive NSAIDs use
- smoking
- etoh consumption - Treatment is based on cause.
- If H.pylori triple therapy is used to eradicate H.Pylori. This involves the use of a PPI, amoxicillin and clarithromycin.
-o Cease NSAIDs
o Cease EtOH and smoking
o If significant haemorrhage – endoscopic clipping
o If perforated – laparoscopic surgery with an omental patch
- Q1. What is the name of this investigation?
Q2. What does this test show?
Q3. What investigation should come next?
(Achalasia is a failure or the lower oesophageal sphincter to relax that is caused by degeneration of inhibitory neurons within the oesophageal wall.)
- Barium swallow
- The test shows
- Narrowing at the gastro-oesophageal junction
- bird’s break appearance
- Dilation of the proximal oesophagus
- Failure of food to pass through oesophagus - Oesophageal Manometry should come next. It is
o Required for Dx of Achalasia and it works by the use of a catheter to measure pressure changes throughout the oesophagus in order to assess the strength and muscle coordination of the esophagus.
- Oesophageal Manometry should come next. It is
- This is a laparoscopic view of the upper abdomen.
Q1. What organs can you see?
Q2. What is the normal laparoscopic insufflation pressure and why?
1. Answer can vary. But can see one or more of the following. • Liver • Gallbladder • Spleen • Stomach • Transverse colon • Diaphragm • Greater omentum
- Normal laparoscopic insufflation pressure should be from 8 to 12 mmHg and less than 15 mmHg.
The gas pressure should essentially be kept as low as possible while maintaining a satisfactory view
This is to minimise cardiac and respiratory risks predominantly:
- The cardiovascular effect of increasing IAP is that it decreased venous return, reduces cardiac output, and increases systemic vascular resistance (due to increased catecholamines)
-The Pneumoperitoneum shifts the diaphragm up and decreases the functional residual capacity. This is a further reduction to the reduction caused by general anaesthetics and the supine position and this can lead to airway collapse, atelectasis, V/Q mismatch, potential hypoxia and hypercarbia.
Some other issues cause by high IAP include reduced renal function, aspiration of GI contents, and increased ICP.
Watch this video on laparoscopic anatomy:
https://www.youtube.com/watch?v=h3mUMhtIZ_A&t=1s
- This is the endoscopic photo of a patient with a small sliding hiatus hernia. The photo is taken from just above the gastro-oesophageal junction.
Q1: What does this show.
Q2: What is the severity of the reflux in this case?
Q3: How should this be treated?
Q4: If this is a patient who has failed to respond to medical therapy, what is the next option.
Hiatus hernia is herniation of elements of the abdominal cavity, most commonly the stomach, through the oesophageal hiatus of the diaphragm into the mediastinum. Can be classified into sliding, rolling and mixed.
1. The image may show the lower oesophageal sphincter higher up than usual and part of the stomach will be pulled into the thoracic cavity AND there may be oesophagitis. The image may show: - erythema - erosions - ulcerations
- The Los Angeles classification system of oesophagitis can be used to assess severity.
A= one or more mucosal breaks, no longer than 5mm, that do not extend between two mucosal folds B= one or more mucosal breaks, more than 5mm, that do not extend between two mucosal folds. C= one or more mucosal breaks that are continuous between two or more mucosal folds. But involve less than 75% of circumference. D= One or more mucosal breaks that involve at least 75% of the oesophageal circumference.
- You can initially try to treat it medically with lifestyle interventions and medications such as antacids and acid suppresion medications (PPIs, H2 histamine-antagonist).
- If this fails surgical management is necessary. This would involve a reduction of the hiatus hernia and suturing of the diaphragmatic crus and a Nissen Fundoplication- Fundus is mobilised and wrapped around the oesophagus and secured with non-absorbable sutures
REMEMBER: [Ulcers are characterized by segmental or more extensive loss of the epidermis, including the basement membrane, with exposure of the underlying dermis. Erosion is characterized by the partial loss of the epithelium, with the basement membrane left intact.]
- This is the endoscopic picture of a 65 year-old male with a history of chronic dyspepsia. The bottom two photos show an area of slough in the first part of the duodenum posteriorly.
Q1. What are the likely causes of this?
Q2. What complications can occur with this pathology?
Q3. What is the treatment?
This picture seems to show a duodenal ulcer.
- The likely causes include; excessive or long term NSAID use, H.pylori infection.
Risk factors include smoking, alcohol consumption, stress and increasing age.
- Complications that can occur include:
- haemorrhage (gastroduodenal a. as it is post.)
- perforation
- gastric outlet obstruction - Treatment options include:
- H. Pylori eradication – triple therapy (esomeprazole, amoxicillin, clarithromycin)
- Withdrawal of offending or contributing factors (e.g. NSAIDs or steroids)
- Anti-secretory medications, if not already (e.g. PPI)
- A 52 year-old man presents to his GP with two months of difficulty swallowing.
Q1. What questions are important to ask?
Q2. What is the most important diagnosis to exclude?
Q3. How should he be investigated?
- Some important questions to ask would be:
•where is the issue? Is it difficulty initiating a swallow or the feeling of something getting stuck?
- Is swallowing of both solids and liquids affected?
- Duration and rate of progression of symptoms
- Presence of symptom when not swallowing (globus sensation- sensation of a lump or foreign body in the throat.)
- Presence of regurgitation
- Presence of reflux symptoms
- Risk factors for carcinoma (smoking, alcohol)
- History of allergy (asthma, hay fever, eczema) – eosinophilic oesophagitis
- Medical history (ENT surgery, radiotherapy, connective tissue disorder, cardiovascular and neurological disease)
- Medications (dopamine antagonists, anticholinergics, bisphosphonates)
- Most important diagnosis to exclude is oesophageal carcinoma
If asked for other DDx:
o Achalasia, oesophagitis, neurological dysfunction, strictures/ webs, extrinsic compression, other motility disorders
- This series of photographs shows a gastric tumour that is very close to the gastro-oesopgaheal junction at endoscopy.
Q1. What types of gastric tumours do you know?
Q2. How would you investigate this patient if the biopsy of this lesion proved to be an adenocarcinoma?
Q3. What treatment would be required for a lesion in this location?
- Most gastric tumours are malignant and nearly all are adenocarcinoma. The adenocarcinomas can be further differentiated into intestinal and diffuse type.
The rest are lymphomas (most being non hodgkins lymphoma of B cell origin), carcinoid tumours (neuroendocrine tumors from APUD cells) or Gastro-intestinal Stromal Tumours (GIST) (Rare mesenchymal tumours- originate from intestinal cells of Cajal-‘pacemaker’ of gut)
- Benign include:
o Gastric polyps
o Lipoma
o Leiomyoma (smooth muscle tumor)
- • Staging investigations:
o CT chest/ abdo/ pelvis- Local involvement, nodal spread, metastases
o Endoscopic USS- Highly accurate evaluation of depth of invasion (T- stage)
and can also evaluate spread to local structure (pancreas and liver) and nodal involvement
o Laparoscopy for serosal membrane involvement, omental spread, small liver metastases
o PET scan for Metastases - Treatment would involve surgical management.
o Surgery is complex for proximal gastric tumours
o Gastrectomy and subtotal gastrectomy (removes cancerous part of stomach, nearby lymph nodes, and possibly parts of other organs near the tumor) are options
o Distal oesophageal resection may be needed
o Lower mediastinal lymph nodes may be involved
Chemoradiotherapy – may be neoadjuvant (reduces tumor size first) or adjuvant treatment
- This photo taken at gastroscopy shows the area of the lower oesophagus just above the gastro-oesophageal junction.
Q1. What can you see?
Q2. What is the most likely cause of this process?
Q3. How would this be treated?
- Most likely Barrett’s Oesophagus (could also be hiatus hernia or varices). Can see - Salmon-pink coloured columnar cells extending above gastro-oesophageal junction replacing normal squamous epithelium
- Reflux oesophagitis – stomach acid damages squamous epithelium – this leads to a change in the epithelium of the oesophagus to intestinal type columnar epithelium and goblet cells (i.e. metaplasia).
The physiological transformation zone (“Z-line”) between squamous and columnar epithelium is shift upwards
- Treatment would involve:
- Biopsy because there is potential for dysplasia and development of adenocarcinoma
- Management of reflux – lifestyle, PPI, consider Nissen fundoplication
- Radiofrequency ablation is an option for high grade dysplasia
- Endoscopic mucosal resection is an option for nodular Barrett’s oesophagus
- Endoscopic surveillance for malignant changes
