ALIMENTARY III

Question 1

Roux-en-Y gastric bypass

- how common and; what our surgical components; present weight losS; operative mortality

Answer 1

(RYGB)
most commonly performed bariatric procedure in the United States.

A 60-mL proximal gastric pouch
anastomosed to a Roux limb.
Roux limb 150 cm long enhances weight loss by means of malabsorption of ingested foods.

Mean excess weight loss approaches 60% at 1 year and is somewhat less at 3 years.

Thirty-day operative mortality ranges from 0.1% to 0.5% in large series.

Question 2

Biliopancreatic diversion - what our surgical components; present weight losS; operative mortality; Compare dumping symptoms and premorbid metabolic resolution to Roux-en-Y

Answer 2

(BPD)

Mean excess weight loss after BPD exceeds 70% in published series. Reported 30-day operative mortality averages 0.5–1.1%.

For the super obese patient, BPD results in significantly superior sustained weight loss than RYGB at 3 years postoperatively.

sleeve gastrectomy by stapling along a #60 French Bougie placed along the lesser curve of the stomach.

duodenum is divided 2 cm distal to the pylorus, preserving the blood supply and vagal innervation of the antrum.

A Roux limb created by dividing the small intestine 250 cm proximal to the ileocecal valve and anastomosing this to the postpyloric duodenal cuff.

The bypassed biliopancreatic limb is sewn to the Roux limb 100 cm proximal to the ileocecal valve, creating the “common channel.”

technically more challenging than the RYGB.

gastric capacity is significantly larger and there is less dumping syndrome than in those patients undergoing RYGB procedure.

more effective than RYGB in reversing premorbid metabolic abnormalities such as diabetes mellitus, dyslipidemia, and hypertension in super obese patients (BMI 50).

Question 3

Laparoscopic Nissen fundoplication involves Success compared to pay fundoplication

Answer 3

360° wrap of the esophagus

with or without division of the short gastric vessels.

Division of the short gastric vessels is rarely necessary to achieve adequate mobilization of the fundus for either Nissen fundoplication or Toupet procedure -But a recommended step and most textbooks…

Results are the same without dividing the short gastric vessels, and division of the short gastric vessels may actually increase postoperative bloating.

Question 4

Toupet fundoplication requires Success compared to Nissen

Answer 4

Laparoscopic a similar posterior esophageal dissection when compared to Nissen

fundus is sutured to the right diaphragmatic crura, creating a 270° wrap posteriorly

The Toupet procedure is associated with less postoperative dysphagia and markedly less need for esophageal dilation in the early postoperative period.

The Nissen and Toupet procedures are equivalent in terms of symptom resolution at 5- and 10-year follow-up.

In prospective randomized trials, 85% of patients have clinical success at 5 years.

Question 5

use of mesalamine inflammatory bowel disease

Answer 5

good for ulcerative colitis

(not Crohn’s)

Combining oral mesalamine (4 g) with mesalamine enemas (1 g) is better than oral monotherapy for patients with mild-to-moderately active, extensive ulcerative colitis.

This combination is appropriate for initial therapy.

Question 6

Generally, patients are candidates for a weight loss procedure

Answer 6

with a BMI more than 40

or

a BMI of more than 35 with at least 2 major comorbidities (not just one like DM).

Question 7

The 3 major Weight loss procedures today

Answer 7

laparoscopic Roux-en-Y gastric bypass (LRGB),

laparoscopic gastric band (LGB),

laparoscopic sleeve gastrectomy (LSG).

Question 8

comparing the 3 major weight loss procedures in terms of outcome, complications, morbidity

Answer 8

ALL 3 procedures reverse insulin resistance in most patients.

Ghrelin levels are decreased with LSG. This finding has theoretical importance in that lowered levels should decrease appetite.

Thirty-day mortality is low in all 3 procedures, with the highest being in LRGB (0.4%).

The incidence of early reoperation with LRGB is approximately 2%; with the other 2 procedures, early reoperation is approximately 1%.
The 30-day complication rate is highest in the LRGB group (4%), but the 1-year complication rate is the same for all 3 (~8%). At 1 year, the percentage of excess weight loss is 60% for LRGB and LSG and 40% for the LGB.

Question 9

Treatment of choice for ulcerative colitis patient who was on mesalamine who need escalation in therapy

Answer 9

go Straight to infliximab

avoids steroids; 33.9% of patients achieved remission after 8 weeks of therapy with 5 mg/kg infliximab, compared with 5.7% given placebo.

Mesalamine cannot be recommended for patients with Crohn’s disease, because results from meta-analyses are inconsistent. A Cochrane review found no benefit of mesalamine. In a meta-analysis, infliximab maintained remission in more patients than placebo (relative risk: 2.50) and increased response (relative risk: 2.19) and spared patients from corticosteroid therapy (relative risk: 3.13).

Both 6-mercaptopurine and azathioprine are successful in managing disease for patients with either steroid responsive ileal disease or ulcerative colitis.

Question 10

Effective complications using infliximab or other immunosuppressive medications for ulcer of colitis patient’s with ileostomy closure surgery

Answer 10

NOT significantly increased postoperative complications after ileostomy closure in patients who received infliximab or other immunosuppressive medications compared with patients who did not!

Question 11

The classic findings of intussusception in children

Answer 11

—a palpable, sausage-shaped abdominal mass,

currant jelly stools

or

an acute abdominal catastrophe

Question 12

adult presentation with intussusception

Answer 12

Vague abdominal pain

NOT classic presentation of pediatric intussusception

Question 13

Rubber band ligation and stapled hemorrhoidopexy are used in the management of

Answer 13

internal hemorrhoids.

Neither can be used in the treatment of external hemorrhoids.

stapled hemorrhoidopexy does not remove external hemorrhoids.

Question 14

External and mixed internal–external hemorrhoids are covered by Y. tissue

Answer 14

anoderm, a modified squamous epithelium that contains pain fibers.

Question 15

Stapled hemorrhoidopexy

Answer 15

operative procedure,

patient preparation, anesthesia, positioning, and management are identical to excisional hemorrhoidectomy.

A circumferential purse sting suture is placed above the dentate line through a specialized anoscope, and the redundant hemorrhoid tissue excised with a hemorrhoid stapler.

A 1- to 3-cm ring of mucosa and submucosa is thus excised.

Care must be taken not to include sphincter muscle or vagina in the staple line.

Fecal incontinence and rectovaginal fistula may result from inaccurate stapler placement.

Question 16

Pelvic sepsis Associated with hemorrhoidal management - what are signs and symptoms

Answer 16

both rubber band ligation and stapled hemorrhoidopexy.

Pelvic sepsis is usually manifested by pelvic pain, fever, and urinary retention.

Initial management consists of examination under anesthesia, débridement of any compromised tissue, and broad-spectrum antibiotic therapy.

Question 17

so-called “hemorrhoid crisis.”

Answer 17

Figure 1 shows fourth-degree strangulated hemorrhoids with thrombosis, gangrene, and necrosis. Figure 2 shows fourth-degree prolapsing strangulated hemorrhoids with edema only.

present with acute pain and nonreducible prolapse, and they may experience urinary retention with either presentation.

Question 18

absolute indications for an emergency hemorrhoidectomy

Answer 18

Gangrene, necrosis, and ulceration

All devitalized tissue must be débrided.

Wounds should be left open to prevent postoperative sepsis.

Question 19

Viable strangulated prolapsing hemorrhoids are treated with

Answer 19

formal surgical hemorrhoidectomy

or

more conservatively in the office with a perianal block, gentle reduction, and multiple rubber band ligations.

Rubber band ligation can be done either at the time of initial reduction or after the edema is resolved.

The perianal block is obtained with 0.25% bupivacaine with 1:100,000 epinephrine and hyaluronidase. This approach is particularly useful in late pregnancy.

Question 20

most common congenital gastrointestinal malformation

Answer 20

Meckel diverticulum

Question 21

Intestinal transplantation is a viable surgical option for patients with Short gut when

Answer 21

Accepted indications for intestinal transplantation in patients with chronic intestinal failure include:

impending or overt liver failure - MOST common cause

central venous catheter related thrombosis in at least 2 central veins,

or

at least 2 episodes per year of systemic sepsis secondary to line infections.

frequent hospitalizations are required for the management of complications related to intestinal failure, such as episodes of volume depletion or repeated episodes of pseudo obstruction.

CAREFUL absolute length of residual small bowel alone is not an indication for transplantation, except in those situations where ultrashort bowel exists (<20 cm in adults) and where unmanageable complications of volume depletion and electrolyte imbalances are certain to occur.

Question 22

Risk factors associated with anastomotic leak

Answer 22

sphincter-sparing surgeries with low anastomosis for rectal cancers.

Risk factors for leak after low anterior resection are:

 large tumor size (especially >5 cm), 
low serum albumin (<3.5), 
low anastomosis, 
higher American Society of Anesthesiologists score, 
intraoperative soilage. 

Temporary diverting stoma overall is associated with lower leak rate, pelvic sepsis, reoperation - AND remains somewhat controversial given the need for an additional operation with potential morbidity,

Most experts believe that diversion is appropriate for patients who are at high risk for anastomotic leakage, such as the patient with a large and low tumor described here.

**Neoadjuvant chemoradiation does NOT appear to influence rates of anastomotic leakage. the

Question 23

Intussusception in adults may present

Answer 23

in contrast to children, and may occur without symptoms as an incidental finding on CT scans performed for other reasons.

“target” sign (figure 1), is pathognomonic for intussusception.

Question 24

Common cause of adult intussusception

Answer 24

commonly disseminated carcinomatosis.

Question 25

Treatment of adult intussusception

Answer 25

En-bloc resection is recommendedThe

Question 26

Meckel’s diverticulum

Answer 26

incomplete obliteration of the omphalomesenteric duct during gestation.

Only 4–6% of patients develop symptoms.

When discovered incidentally at laparotomy, routine resection is NOT recommended, REGARDLESS of age!!

Question 27

he major clinical finding in children With Meckel’s

Answer 27

Gastrointestinal bleeding occurs in up to 50% of cases.

CAREFUL - Fewer than 50% of patients present with symptoms before 2 years of age.

The cause of gastrointestinal bleeding is associated with ectopic gastric tissue in the diverticulum.

Question 28

Most common presentation a Meckel’s an adult

Answer 28

Symptoms of intestinal obstruction are most commonly seen in adults,

and this presentation is the second most common clinical finding in children.

Question 29

Intestinal rotational anomalies in adults Contrast intestinal imaging may identify

Answer 29

right-sided small bowel,

left-sided cecum,

inverse relationship between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV),

or

aplasia of the uncinate process of the pancreas.

A “whirlpool” sign (figure 2), wrapping of the SMV around the SMA with dilatation of SMV, is a common CT finding.

Cecal volvulus occurs with malrotation, and partial small bowel obstruction is common with both malrotation and intussusception in adults.