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Upper gastrointestinal surgery

Major Clinical Specialty Areas · 35 questions · 1 free to try

Oesophageal and gastric cancer staging and treatment pathways, Barrett's oesophagus, achalasia and reflux surgery, hiatus hernia, peptic ulcer bleeding and perforation, upper gastrointestinal bleeding including varices, oesophageal perforation and caustic injury, and gastrointestinal stromal tumours.

Every question in this topic is a single best answer item in the style of the exam, followed by an explanation that gives the reasoning for the correct option, why each distractor is wrong, a key point to carry into the exam and, where one applies, the guideline or trial it rests on. Practice mode lets you work through the topic on its own or mixed with others; exam mode draws it into timed papers.

Sample question from this topic

A 63-year-old man is referred with six weeks of progressive dysphagia, initially to solids and now to soft foods, with 5 kg of weight loss. He has a long history of reflux. Gastroscopy shows an ulcerating tumour at 34 to 38 cm from the incisors, partially obstructing the lumen; biopsies confirm adenocarcinoma. Observations and examination are unremarkable; he is independent and walks two miles daily. Bloods: haemoglobin 118 g/L, albumin 36 g/L, normal renal and liver function. What is the most appropriate next step in his management?

  1. AEndoscopic ultrasound of the tumour
  2. BPET-CT
  3. CStaging laparoscopy
  4. DStaging CT of the chest, abdomen and pelvis with intravenous contrast
  5. EDirect referral for oesophagectomy based on the endoscopic findings alone
Show answer and explanation

Correct answer: D

After histological confirmation of oesophageal cancer, the first staging investigation is contrast-enhanced CT of the chest, abdomen and pelvis. Its job is to detect unequivocal metastatic disease and gross local invasion, because finding either changes intent from curative to palliative and makes further invasive or expensive staging unnecessary. Only if CT shows no incurable disease does the patient proceed along the staging pathway — PET-CT to detect occult metastases in those being considered for radical treatment, endoscopic ultrasound where finer T and N staging will alter the plan, and staging laparoscopy for junctional tumours with a gastric component to exclude peritoneal disease.

Why the others are wrong: A — endoscopic ultrasound refines locoregional staging but is pointless if CT has already shown metastases; it comes later, selectively. B — PET-CT is reserved for patients confirmed by CT as potentially curable; it is not the first test. C — staging laparoscopy applies to tumours involving the cardia or stomach after non-invasive staging is complete. E — committing to major resection without any staging risks futile surgery in the roughly half of patients who present with incurable disease.

Key point: Staging of oesophageal cancer is sequential and begins with CT of the chest, abdomen and pelvis; PET-CT, endoscopic ultrasound and laparoscopy follow selectively only when CT shows potentially curable disease.

Guidelines: NICE oesophago-gastric cancer (NG83): staging CT of chest, abdomen and pelvis first, then PET-CT and EUS on the curative pathway.

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