Ch 37 Surgical Alteration of the GI Tract

Question 1

As result of transection of vagus nerve during gastrectomy along w/ increased osmolarity of intestinal contents, patients may experience what?

Answer 1

Watery diarrhea in which an antimotility agent such as loperamide may be helpful

Question 2

Management of an ECF includes what?

Answer 2

Resuscitation, source control, wound care, and nutrition support

Initially most patients with ECF should be kept NPO and PN may be considered

Question 3

• For ileostomies, output should be less than waht per 24 hours?

Answer 3

< 1 L per 24 hours

Question 4

What are some dietary/nutrition considerations for a patient s/p esophagogastrecomy?

Answer 4

Requires patients to limit themselves to softer foods and eat smaller, more frequent meals; many patients will experience inadequate nutrition and require simultaneous jejunostomy tube placement at the time of esophagogastrectomy for prolonged EN

Question 5

What is the role of immonutrition in elective GI surgery?

Answer 5

Immunonutrition in patients undergoing elective GI surgeries may decrease complications and use is recommended by some surgical societies to improve post op outcomes

Question 6

Management of delayed gastric emptying after Whipple includes what?

Answer 6

Prokinetic agents together w/ dietary changes (small meals and avoidance of foods that cause constipation or abd pain)

Question 7

Gastrotomies are mostly done using _____ technique whereas jejunostomies are often done using the _____ technique

Answer 7

Stamm; Witzel

Stammed tubes allow for easier replacement at bedside, and Witzeled tubes allow for greater freedom of movement of the target organ (stomach, jejunum) which can prevent rotation around a fixed point and subsequent obstruction and ischemia

Stamm approach can result in ischemia around gastrostomy/jejunostomy b/c of mucosal compression by intervisceral portion of the tube; Witzel approach can result in visceral narrowing, leading to stenosis or obstruction

Question 8

Which vitamin deficiencies are common in gastrectomy surgery?

Answer 8

B12, C, and D (due to lack of gastric tissue)

Deficiencies may result in delayed wound healing, anemia, and osteopenia/osteoporosis

Question 9

what is the treatment for high output ostomies in hemodynamically stable patients?

Answer 9

Fiber supplementation to thicken output and antimotility agents such as loperamide (Immodium) or diphenoxylate/atropine (Lomotil) to decrease GI transit time and increase water absorption

Question 10

What is considered a high output fistula?

Answer 10

> 500 mL/day

Question 11

Which deficiencies are common in patients with gastric resections?

Answer 11

B12, folate, iron deficiency is common in patients w/ gastric resections; baseline and periodic monitoring of anemia related lab data are important.

Question 12

Surgery in form of a total proctocolectomy (removal of entire colon and rectum) offers UC patients what?

Answer 12

Definitive treatment

Question 13

Inability to achieve good seal around ostomy pouch can result in skin irritation and breakdown. Why is this?

Answer 13

Because of high concentration of active digestive enzymes and acidic pH of ileal contents

More common w/ ileostomies than colostomies

Question 14

What is the difference between a Chylorhorax and Chylous Ascites?

Answer 14

Chylothorax is presence of chyle (composed of lymphatic fluids and chylomicrons) within pleural space

Chylous ascites is presence of chyle w/in peritoneal cavity

Question 15

What is the key anatomical difference between a Low Anterior Resection and Abdominoperineal Resection?

Answer 15

Most significant difference between the 2 lies in preservation of anal sphincter complex with LAR with preservation of continence

Question 16

True or false–a jejunosotmy tube can be used for decompression?

Answer 16

False; Jejunostomy tubes allow for direct feeding of small bowel, but are not used for decompression

Question 17

What is the role of EN in a surgically “open” abdomen?

Answer 17

EN has been found to be safe and potentially reduce time to definitive abd closure, enterocutaneous fistula rates, and infectious complications

EN can be delivered within the first 24-48 hours following resuscitation through either nasoenteric access or surgically placed access points

Question 18

What is an enterocutaneous fistula?

Answer 18

Defined as communications between any 2 epithelial surfaces and described with the higher-pressure component listed first

Question 19

For patients w/ colotis or proctitis after colon resection and proximal diversion of fecal stream, what represents an effective first line treatment?

Answer 19

SCFA enemas

Question 20

Stomas of small bowel and colonic variety can be constructed in which two variations?

Answer 20

End vs Loop

End ostomy provides complete GI content diversion at level of abd wall w/ no downstream intestinal or colonic continuity or flow

Loop ostomy maintains continuity of GI tract from stomach to anus and diverts most, but not all, GI contents from flowing downstream

Question 21

Patients with tumors in head of pancreas undergo what type of procedure?

Answer 21

A pancreaticoduodenectomy, referred to as a Whipple procedure; involves resection of head of pancreas, duodenum, and part of the stomach

Question 22

What should NOT be used to break down a gastric beazor?

Answer 22

Meat tenderizer that contains papain.

Cellulase and cola have been effectively used to help break down the bezoar. Treatment with papain should be avoided because it breaks down normal tissue and is associated with peptic ulcer disease, esophagitis and gastritis. Surgery can also be used.