- ability to provide 'full' nutrition without gut - can tailor the formulation as needed - inability to use the gut - inability to get full nutritional needs via enteral feeds

Common Gen Surgery Issues Flashcards by Stacy Stojakovic

What do general surgeons do? (13 organs)

stomach
pancreas
gallbladder
intestine
appendix
adrenals
spleen
adipose
thyroid
breast
lymphatics
soft tissue
carcinoma

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Serum proteins & nutritional profile indicates_____

degree of illness & perioperative morbidity

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Half life of:
Albumin
Pre-albumin
Transferrin
Retinol Binding Protein

Albumin: 21 days

Pre-Albumin: 2-3 days

Transferrin: 8 days

Retinol Binding Protein: 12 hours

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Ebb Phase: when does it occur, what is it, energy supply/demand, metabolism, hormones

first 24-72 hours

non-stressed starvation

basal energy requirements are decreased
& supplied by LIVER & MUSCLE GLYCOGEN STORES
then switch to fatty acids and ketones for energy & stop burning muscle protein as much

↓metabolism

catecholamine release
norepinephrine release

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Flow phase: when does it occur, characteristics

Catabolic & Anabolic-peaks 3-5 dyas
HYPERMETABOLIC, HYPERGLYCEMIC
subsides 7-10 days & merges with anabolic phase
high cardiac output, restoration of oxygen delivery & metabolic sustrate

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Blood glucose level post surgery

it is common for people to have hyperglycemia post-surgery

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Hypermetabolic phase:
net result (3)
control what to what range, why?

net result: negative nitrogen balance, ↓adipose stores, hyperglycemia

control of hyperglycemia [at least below 150 (80-150mg/dl)] is important to limit complication & ↓morbidity and mortality

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Normal caloric needs, protein needs

‘stressed’ patient needs

Kcal/gram in: protein, carbs, fat

normal:
25-30 kcal/kg/day
0.8-1g protein/kg/day

‘stressed’:
50 kcal/kg/day
2.5 protein/kg/day

Protein: 4 Kcal/gm
Carbs: 3.4 Kcal/gm
Fat: 9 Kcal/gm

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Enteral nutrition is done via

"if the gut works, use it"
feeding tubes (NG, nasojejunal, duotube, gastrostomy, jejunostomy)

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Parenteral Nutrition: 2 types

Peripheral Parenteral Nutrition

Total Parenteral Nutrition (TPN)

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Enteral nutrition advantages (7)

↓ gut hyperpermability/ translocation
↑ gut blood flow
gut immunity
↓ infectious complications
↓ mortality
GB emptying/avoid hepatic chloestasis

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Enteral Nutrition Sites

Oral
NGT-nasogastric
G-tube: gastrostomy tube, PEG
J-tube: feeding jejunsotomy

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Enteral Nutrition contraindications (5)

& relative contraindications (3)

bowel obstruction
peritonitis
ileus
massive GI hemorrhage
ischemic gut

relative contraindications

pancreatitis
IBD
high output fistula

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Enteral nutrition complications (4)

perforation
aspiration
dislodgement
diarrhea

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TPN advantages (4)

ability to provide ‘full’ nutrition without gut
can tailor the formulation as needed
inability to use the gut
inability to get full nutritional needs via enteral feeds

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TPN disadvantages (7)

cholestasis & hepatic dysfunction
need for vascular access
INFECTION-line & other
electrolyte abnormalities
hyperglycemia
hyper-triglyceridemia
costly

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Anti-reflux procedure

Nissen fundoplication (laprascopic or open)

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Peptic Ulcer Surgery: elective 3 types

Vagotomy & Antrectomy-Bilroth 1
Vagotomy & Pyloroplasty
Highly Selective Vagotomy

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Bariatric Surgery Patient Selection

BMI>40
BMI>35 with comorbidity
failure of nonsurgical weight loss efforts
well-informed, compliant, motivated patients

Restrictive types of bariatric procedures (3)

vertical banded gastroplasty
laparoscopic adjustable gastric band
sleeve gastrectomy

Malabsorptive types of bariatric procedures (3)

jejunoileal bypass
biliopancreatic diversion
biliopancreatic diversion with duodenal switch

Combination of restrictive & malabsorptive bariactric procedure

Roux-en-Y gastric bypass

What is the most common bariatric surgery performed in the US currently?

Route-En-Y Gastric Bypass

restrictive & malabsorptive
procedure 30mL gastric pouch

Gastric banding

silicone band lined with inflatable balloon
Band connected to subcutaneous reservoir
Restrictive

Vertical Banded Gatroplasty

Restrictive Stapled 30mL pouch off the lesser curvature RARELY performed now

Sleeve Gastrectomy

Restrictive majority of greater curvature of stomach (w/small capacity) is created problem: stomach tends to dilate over years

Gastric CA: 4 points to remember

1. lots of structures nearby: pancreas, liver, omentum, duodenum 2. lymph node staging, levels & Tiers 3. Neoadjuvant Therapy: chemo preop and/or post-op 4. Resectability & morbidity associated with it

Nutritional Effects of Total Gastrectomy (3)

1) Macrocytic Anemia (b/c of B12 deficiency, loss of intrinsic factor, folate deficiency) 2) Microcytic Anemia (b/c of decreased iron absorption) 3) Calcium & Vitamin D deficiency (achlorhydria)

Small intestine: beginning, end, 3 functions

pylorus to the ileocecal valve - Absorption - Secretion - Digestion

Meckel's Diverticulum: describe

``` True Diverticulum ANTIMESENTERIC border of ileum "Rule of 2s": 2% 2:1 (male:female) 2 years 2 feet from ileocecal valve 2 inches 2 types of mucosa: GASTRIC or small intestine ```

Meckel's Diverticulum presentation

``` can be asymptomatic abdominal pain bleeding intestinal obstruction Meckel Diverticulitis ```

Meckel's Diverticulum dx & tx

dx: Meckel's Scan Mesenteric Arteriograph Abdominal Exploration tx: resection

Colon and Rectum dz (8)

terminal portion alimentary tract-dz is common - diverticulosis - polyps - adenocarcinoma - ulcerative colitis - hemorrhoids - fissures - volvulus - Crohn's

Colonic Anastomosis

connection between two tubular organs (ie. colonic: end to side, side to side, end to end)

Colostomy

colon divided, proximal end brought through abdominal wall

Hartmann's procedure

Colostomy with distal end oversewn and placed in peritoneal cavity as blind limb

Loop colostomy

loop of Colon up to abdominal wall | [might be used to study distal area in emergency situation, when you want to divert feces from moving into it]

Ileostomy

end | loop of ileum up to abdominal wall

Stoma

temporary or permanent divert stool the stoma is the part outside: imp to look at stoma after the operation to determine the health of the intestine

Proctocolectomy

removal of entire colon and rectum

Abdominoperineal Resection (APR)

VERY LOW RECTAL CANCERS removal of lower sigmoid colon, entire rectum and anus

Low Anterior Resection (LAR)

Cancers of MIDDLE & UPPER SECTIONS OF RECTUM removal of distal sigmoid colon and 1/2 of rectum proximal sigmoid-distal rectum anastamosis

Pectinate (dentate) line importance

below is sensate | above is insensate

Internal Hemorrhoid

above dentate line may bleed & prolapse non-painful

External Hemorrhoid

below dentate line do not bleed, may thrombose Pain, itching, scarring (tag)

Most common cause of rectal bleeding?

Internal hemorrhoids

Hemorrhoid Diagnosis procedures

``` physical examination visual inspection DRE Anoscopy other endoscopic procedures ```