Anatomy
Describe Peterson's Space
mesenteric defect created by the JJ between the mesentery of the roux limb and transverse colon mesentery
Name 2 of the (3) criteria for bariatric surgery ?
GIST originates from what cells
interstitial cell of cajal (pacemaker cells)
90% associated w/ c-kit, CD117 mutation
Name (2) criteria for surgical intervention in GERD patients
- Extra esophageal manifestations: asthma, hoarsness, cough , chest pain, aspiration)
- failed meds
- weight loss
How do you diagnose bile reflux
impedence probe
Branches of the Celiac trunk
- left gastric
- splenic: short gastrics and L gastroepiploic
- common hepatic: GDA and R gastric then becomes proper hepatic artery
% of excess weight loss with RNY gastric Bypass?
60-70%
Gastric maltoma treatment
Generally trt w/ abx (triple therapy)
- first step is to check if the pt is H pylori positive – if pos then do cytogenic analysis to detect t(11;18)
*if t(11;18) negative – trt w/ standard H pylori eradication protocol
*if t(11; 18) positive – then probably won’t respond as well to abx : trt anyway but if persists beyond 12 mon trt w/ radiation
*H pylori neg maltoma trt w/ radiation.
Most common site of a leak following a RNYGB ?
GJ - typically from a technical error
Describe early dumping syndrome?
20-30 min after meal , hyperosmolar load
trt: first line dietary modification ; 6 sm meals, high fiber, sep liquids and solids , avoid simple sugars
What is blind loop syndrome ?
Name (2) presenting symptoms
Limb stasis leading to bacterial overgrowth
steatorrhea , diarrhea, B12 def w/ megaloblastic anemia, Hypocalcemia (calcium binds to unabsorbed fatty acids in the intestinal lumen)
What is a Phi angle ?
Phi angle (4-58deg) : angle created by a line drawn through the spinal column and and a line drawn through the horizontal axis of the gastric band
GIST : when should imatinib be considered?
(Name 2 instances)
- >5 mitoses per 50 hpf
- size > 5 cm
- unresectable tumors
- metastatic
Ideal length of a roux limb in a RNYGB
roux limb should be 100-150 cm
(80-120 for BMI of 40’s and closer to 150 for BMI > 50
Most common metabolic deficiency after a RNYGB
Thiamine !
Describe the course and major branches of the left vagus
becomes the anterior vagus = gives rise to the hepatic branch, celiac branch and anterior gastric branch (including n of laterjet near the pylorus)
Presentation of afferent limb syndrome ?
partial obstruction of limb with accumulation of biliary and panc secretions = epigastric pain until -> biliary emesis w/ relief of symptoms
mc with long (> 30 cm) antecolic reconstructions
*can also present chronically as obstructive jaundice, cholangitis, pancreatitis
Gastric Adenocarcinoma : What is the goal for margins and lymph node harvest ?
15 LN
4-5 cm margins
Gastric Adenocarcimona : When would you consider a total gastrectomy vs a partial gastrectomy
subtotal gastrectomy for distal lesions (need 4 cm margins) vs total gastrectomy (for proximal lesions)
* Body/antrum considered distal
What is H pylori quadruple therapy ?
PPI, bismuth, tetracycline, & metronidazole
List the Johnson Classification for location of Gastric Ulcers (1-5)
1 lesser curve (MC)
2 duodenal and lesser curve
3 pre-pyloric
4 proximal lesser curve (cardia)
5 anywhere /diffuse (mc NSAIDs)
Treatment for Gastric band slippage ?
access the port and remove all the fluid from the band can then proceed to OR to lap adjust band or remove it
Will present with sudden development of food intolerance or reflux
Gastric Adenocarcinoma : What is the difference between a D1 and D2 resection ?
D1 (nodal stations 1-6 along lesser / grtr)
D2 : D1 + stations 7-11(L gastric art, common hepatic art, celiac trunk , splenic hilum, splenic artery)
What procedure for acid reduction gives the best acid suppression and least risk of recurrence?
- vagotomy and antrectomy
What is the mutation associated with Hereditary diffuse gastric cancer - and what is the recommended prophylactic treatment?
CDH1
Trt w/ ppx gastrectomy by 18-40 yo
Also have an increased risk of lobular Breast cancer