Live book 7

Practice Shift — Achalasia: Myotomy Tailored to the Chicago v4.0 Type (Addendum §9.1, Row 3)Tailor myotomy to the Chicago v4.0 type: Laparoscopic Heller Myotomy + partial fundoplication or POEM for Types I–II, POEM preferred for spastic Type III — and stop repeating botulinum toxin injections in fit surgical candidates.Practice Shift — Esophageal/GEJ Adenocarcinoma: Perioperative FLOT Replaces Uniform CROSS (Addendum §9.1, Row 4)Treat resectable locally advanced esophageal/GEJ adenocarcinoma with perioperative FLOT (4 preoperative + 4 postoperative cycles) plus radical resection — not upfront esophagectomy and not uniform CROSS chemoradiotherapy.Practice Shift — Gastric Cancer: Staging Laparoscopy, Biomarkers, FLOT and Preserving D2 (Addendum §9.1, Row 5)Stage and profile before treating gastric cancer: staging laparoscopy with peritoneal washings, universal biomarker testing, perioperative FLOT (PD-1 blockade if dMMR/MSI-H), and spleen- and pancreas-preserving D2 gastrectomy.Practice Shift — Giant Paraesophageal Hernia: Sac Excision, ≥3 cm Esophageal Length, Primary Crural Repair (Addendum §9.1, Row 2)Repair symptomatic giant paraesophageal hernia properly: excise the sac, mobilise the mediastinal esophagus to ≥3 cm tension-free intra-abdominal length, close the crura primarily and add a fundoplication — no watchful waiting, no gastropexy alone, no permanent synthetic mesh on the hiatus.Practice Shift — GIST: Profile Before Treating; Refractory Ulcer Bleeding: Embolize Before Gastrectomy (Addendum §9.1, Row 6)Profile GIST before treating it — EUS core biopsy with KIT/PDGFRA mutation testing, wedge resection with intact pseudocapsule and no lymphadenectomy, imatinib by risk and mutation — and for endoscopy-refractory ulcer bleeding go to transcatheter embolization before emergency gastrectomy.Practice Shift — Refractory GERD: Objective Testing First, Then a Tailored Anti-Reflux Operation (Addendum §9.1, Row 1)Document reflux objectively before any anti-reflux surgery — EGD, high-resolution manometry and 24-h pH-impedance — then tailor the operation: Nissen or Toupet by motility, Roux-en-Y gastric bypass when BMI ≥35 kg/m².Stepwise Clinical Decision Pathway — Upper GI, Esophagogastric & Foregut Surgery (§9.2)Work the foregut pathway in four steps: prove reflux objectively before any anti-reflux operation, tailor the intervention to BMI and achalasia type, stage and biomarker-profile esophagogastric cancer completely, then run perioperative FLOT around a minimally invasive resection.

Memory 6

Rockall score — ABCDERockall score variables (score-as-mnemonic)AIMS65Mortality risk in upper GI bleeding (name-device score)ALARMSAlarm features in dyspepsia / upper GIDiaphragm openings — 8-10-12Vertebral levels of the diaphragmatic openings (numeric device)C3, 4, 5 keep the diaphragm alivePhrenic nerve roots (phrase device)VOMITINGCauses of vomiting