Lower GI Flashcards
Describe an operation for Colonic ischemia?
Control contamination Palpation of celiac, SMA, IMA pulses Pattern of ischemia may suggest etiology (complete vs. patchy) Hand-held Doppler Wood’s lamp, warm packs Left colon involvement: resection w/colostomy + mucous fistula or Hartmann’s pouch Right colon involvement: resection with ileostomy and mucous fistula Second look laparotomy
Describe an operation for Acute SB ischemia (embolus)
Prep access to greater saphenous vein in thigh
Expose SMA
confirm SMA embolus palpation, jejunal sparring
Embolectomy through transverse arteriotomy
Heparin post-op
“Second look procedure” within 24 h
Describe an operation for sub-acute SB ischemia (thrombosis)
Prep access to greater saphenous vein in thigh
Expose SMA and perform an embolectomy thru a transverse arteriotomy
Assess flow
If poor, SVG between infrarenal aorta and
SMA
(can use suprarenal aorta and pass graft behind
pancreas to SMA)
Heparin post-op
Resect nonviable segments + “second look procedure”
within 24 h
When do you need to do a cystectomy with colon cancer operation?
Invasion of the trigone
What imaging test to get for colon cancer invading kidney?
Contrast pyelogram to evaluate function of contralateral kidney
What operation for obstructing sigmoid cancer with cecal perforation?
Stable
unstable
stable: subtotal colectomy with primary ileorectal
anastomosis
unstable: ileostomy, cecectomy, mucous fistula if unstable
and then will need second stage to remove tumor
What and when do you order imaging for enterocutaneous fistula?
Get CT with IV and PO contrast at diagnosis to evaluate for abscess/IR drain/ degree of contamination.
Medically stabilize for 1 week (if possible) and repeat imaging as a fistulagram to evaluate for distal obstruction.
What is the formula for TPN?
1 gm/kg/day protein
25 kcal/kg/day CHO
25% glucose, 3–4% amino acids, 10% FFA want
50% of non-protein calories as glucose and 50% as
FFA)
What is staging of Hemorrhoids?
Stages of Internal hemorrhoids (above dentate line and
therefore usually painless)
I Painless rectal bleeding
II Prolapse with defecation, spontaneously reduce
III Prolapse with defecation but reduction only manually
IV Unable to reduce
External hemorrhoids are below the dentate line and
hurt when become thrombosed
Operations for hemorrhoids by stage:
Make sure patient has had a colonoscopy!
acute thrombosis→ elliptical surgical excision
under local anesthesia
Stage I and II internal hemorrhoids→ rubber band ligation
perform banding of only one or two quadrants
No banding if septic concern (prosthetics)
Stage III and IV and recurrent symptomatic external
hemorrhoids treated with Ferguson closed hemorrhoidectomy
(elliptical incision over each hemorrhoid down to
sphincter and closure incorporating some of sphincter
fibers to prevent prolapse)
When do you do a colectomy for a polyp
Can do for any one of the following conditions:
sessile polyp
ambiguous margins
unfavorable histopathology
high grade (3 or 4)
angiolymphatic invasionWhat are non-operative treatments for Ogilvies?
Colonoscopic decompression IV neostigmine (need to be in ICU to monitor for bradycardia)
At what diameter does toxic megacolon start?
6 cm
What is colonoscopic surveilance for UC
First scope 5 years after diagnosis
Then yearly.
When do you consider prophylactic colectomy for UC?
At first evidence of dysplasia.
Usually occurs ~10 years from diagnosis.
What are surgical options for prophylactic colectomy for UC?
- Proctocolectomy with end-ileostomy
- TAC with ileorectal anastomosis (and rectal surveilance)
- Total proctectomy and mucosectomy with IAPP
