SESAP ALIMENTARY II Flashcards
Mirizzi syndrome
obstructive jaundice due to extrinsic compression of the common hepatic duct (CHD) caused by a stone impacted in the neck of the gallbladder or cystic duct.
Up to 25% of patients have an increased risk of gallbladder cancer.
Because the stone is characteristically in either the neck of the gallbladder or the cystic duct, previous cholecystectomy does not rule it out as a possible diagnosis
Four factors contribute to development of Mirizzi syndrome:
(1) The cystic duct must be anatomically parallel to the CHD
(2) a stone must become impacted in the cystic duct or gallbladder neck,
(3) the CHD must be obstructed by the stone or by the secondary inflammatory response,
(4) the longstanding obstruction must cause intermittent or constant jaundice with occasional cholangitis.
treatment of Mirizzi syndrome
One study suggested that laparoscopic cholecystectomy can be successful with type 1 Mirizzi syndrome
or
external compression of the CHD by a stone impacted in the cystic duct or Hartmann pouch,
but the authors cautioned that open cholecystectomy is the method of choice for type 2 Mirizzi syndrome, a fistula between the gallbladder and common duct from inflammation and erosion.
Another retrospective study indicated that of 14 patients who underwent laparoscopic surgery, 11 required conversion to an open procedure.
Gastrin is a hormone secreted by
G cells in the gastric antrum.
the action of gastrin
It acts on parietal cells to stimulate hydrochloric acid after ingestion of food.
Patients who have a gastrinoma as their source of uninhibited gastrin secretion usually present with
peptic ulcers secondary to acid hypersecretion.
unopposed gastrin secretion in response to achlorhydria typically occurs in patients with
atrophic gastritis or who take proton pump inhibitors.
Hypergastrinemia occurring with gastritis related to Helicobacter pylori infection is caused by
the decreased somatostatin release by D cells due to increased pH and circulating cytokines around D cells.
Gastric carcinoid tumors also termed
neuroendocrine tumors (NETs),
gastric carcinoid tumors subclassified into 3 distinct groups:
type 1
associated with chronic atrophic gastritis/pernicious anemia (; 70–80%),
type 2
associated with multiple endocrine neoplasia type I (MEN I) Zollinger-Ellison syndrome (ZES; ; 5%),
type 3
sporadic NETs of the stomach ( 15–20%).
treatment of gastric carcinoid tumors
Because type 1 and 2 NETs of the stomach generally pursue an indolent course, tumors smaller than 2 cm (up to 6 in number) should be resected endoscopically, with subsequent interval follow-up.
require more aggressive management, and local surgical resection is recommended:
when greater than 2 cm,
or those with recurrent tumors,
or those with more than 6 tumors generally
type 1 NETs of the stomach arising in the setting of chronic atrophic gastritis, antrectomy may be performed to eliminate the source of gastric production.
Antrectomy results in tumor regression in such cases.
treatment of gastric carcinoid tumors In patients with type 2 NETs of the stomach secondary to ZES/MEN I syndrome,
treatment with somatostatin analogs may be initiated and result in tumor regression.
treatment of sporadic (type III) gastric carcinoid tumors
type 3 isolated sporadic NETs of the stomach requires more aggressive surgery,
partial gastrectomy and lymph node dissection.
associated findings with gastric carcinoid tumor
anemia, hypergastrinemia, and atrophic gastritis consistent with type 1 gastric carcinoid.
5% of patients with pernicious anemia, an autoimmune condition in which antibodies are directed against parietal cells.
The destruction of parietal cell mass results in atrophic gastritis, a loss of acid production, hypergastrinemia, and macrocytic anemia from the loss of intrinsic factor and Vitamin B12 absorption.
Roux-en-Y gastric bypass effects on hormones
ghrelin, glucagon-like peptide-1, and peptide YY that influence eating behaviors and body weight.
Roux-en-Y gastric bypass physiologic effects
fat malabsorption:
After RYGB, the secretion of bile and lipolytic enzymes is reduced, because lipids never pass through the duodenum.
Undigested fat passes into the colon, producing fat malabsorption and steatorrhea.
protein intolerance:
Intolerance of protein-rich foods, such as meat and dairy products, is common. For this reason, many patients fail to meet the daily recommended protein intake, which should average 60–120 g/day.
CCK stimulation and effects
Under physiologic conditions, fat passes into the duodenum and stimulates cholecystokinin (CCK).
CCK stimulates the gallbladder and pancreas to release bile and lipolytic enzymes.
Vitamin deficiencies of Roux-en-Y
iron, Vitamin B12, calcium, Vitamin D, folate (Vitamin B9), and thiamine (Vitamin B1) is recommended.
In addition, iron, calcium, and thiamine are absorbed primarily in the duodenum, which is precluded with RYGB.
Iron stores decline after gastric bypass procedure, making iron-deficient microcytic anemia very common.
Vitamin C supplementation should also be added to increase iron absorption and ferritin levels.
Oral iron supplements can decrease absorption of calcium, magnesium, and zinc, so these should be taken at different times of the day.
RYGB procedure alters the absorption of Vitamin B12 by isolating the source of intrinsic factor, the distal stomach, from the alimentary stream.
However, substantial deficiencies in Vitamin B12 do not occur until at least 1 year after the surgery. Deficiency can result in macrocytic anemia and neuropathy.
calcium deficiency and bone loss.
The loss of fat absorption is believed to contribute to Vitamin D deficiency because it is a fat-soluble vitamin.
This is believed to increase bone turnover and to decrease bone mass. However, calcium deficiency and loss of bone density can occur in the presence of normal Vitamin D and parathyroid hormone (PTH) levels.
An increase in serum PTH levels is indicative of negative calcium balance or Vitamin D deficiency. If deficient, Vitamin D can be supplemented with ergocalciferol or cholecalciferol.
When performing LAR resections for cancer, division of the inferior mesenteric artery (IMA) at its origin from the aorta (high ligation) is often performed to
remove the lymph node basin at risk for metastasis and provide adequate mobilization of the proximal bowel for a tension-free anastomosis.
arterial flow occurs through collateral vessels.
Sudeck point
junction of the colon and rectum
when the LIMA was divided at its origin at the aorta how it is perfusion maintained with descending colon rectal anastomosis
The arc of Riolan
The arc of Riolan
is an inconstant artery
connects the proximal SMA or 1 of its primary branches to the proximal IMA or 1 of its primary branches.
It is classically described as connecting the middle colic branch of the SMA with the left colic branch of the IMA.
It forms a short loop that runs close to the root of the mesentery.
It is an important connection between the SMA and IMA in the setting of arterial occlusion or significant stenosis such as proximal SMA occlusion.
The marginal artery of Drummond is the anastomoses
The marginal artery of Drummond is the anastomoses of the SMA:
the terminal branches of the ileocolic,
right colic,
middle colic arteries
and of the IMA:
left colic
sigmoid branches
These form a continuous arterial circle or arcade along the inner border of the colon known as the marginal artery of Drummond.
The marginal artery is an important connection between the SMA and IMA and provides collateral flow in the event of occlusion or significant stenosis.
The junction of the SMA and IMA territories is at the splenic flexure.
where is the marginal artery of Drummond the weakest
the splenic flexure, hence “the marginal artery” at this point,
known as the Griffiths point
management of esophageal high-grade dysplasia
Observation with proton pump inhibitor therapy is an accepted management strategy.
This requires endoscopy with biopsies every 3–6 months.
This strategy is clearly inferior to radiofrequency ablation.
Antireflux operations, although good for treating the symptoms of gastroesophageal reflux disease, have not been conclusively demonstrated to reduce the cancer risk.
Photodynamic therapy, usually with a light-sensitizing agent such as porfimer sodium, has fallen out of favor due to issues related to buried glands (i.e., islands of Barrett epithelium under a layer of seemingly normal squamous epithelium) and stricture formation.
Esophagectomy was considered an acceptable option because of the high rate of occult carcinoma with high-grade dysplasia. However, given the efficacy of radiofrequency ablation, esophagectomy is reserved for patients in whom the high-grade dysplasia cannot be completely eradicated or in whom other signs increase the suspicion of carcinoma presence. A randomized, sham-controlled trial showed that endoscopic radiofrequency ablation can eradicate Barrett metaplasia and dysplasia and reduce the progression to carcinoma (table 1). It is now considered the primary treatment for Barrett esophagus with high-grade dysplasia in patients without other signs of carcinoma, such as ulceration or nodularity!!!
Small bowel diverticula are categorized by location and type. Location categories include
Location categories include duodenal and jejunoileal.
small bowel diverticuli that are true diverticula how common compared to false diverticula
most common
Duodenal
Meckel diverticula
periampullary diverticula
periampullary
asymptomatic
occasionally they can cause biliary obstruction.
Diverticula of the jejunum and ileum
pulsion diverticula similar to that of the colon.
Although the exact incidence of ileojejunal diverticulosis is unknown, because most of these patients are asymptomatic, it is generally considered far less common than colonic diverticulosis. Most autopsy series place the prevalence of jejunoileal diverticula at approximately 2% or less. The jejunum is a more common site of diverticula than the ileum. The diverticula occur on the mesenteric side of the bowel where the blood vessels enter the bowel from the mesentery. Perforation, bleeding, and obstruction are the most common urgent presentations. Perforation accounts for more than 20% of emergency surgical interventions for jejunoileal diverticula compared with hemorrhage, which accounts for less than 2%. Recurrent abdominal pain is rarely associated with jejunoileal diverticulosis, and weight loss is not likely related to jejunal diverticula.
Bleeding as the presenting sign in colon cancer does what to prognosis
is not associated with worse prognosis,
association between duration of symptoms and colon cancer and survival
none
and there is no association between duration of symptoms and survival in patients with colon cancer.
Patients with intestinal obstruction as their presenting sign of colon cancer
short duration of symptoms with a poorer prognosis.
Peutz–Jeghers syndrome have what present risk of developing colon cancer
how to her overall survival compared to sporadic colon cancer patient’s
pproximately 40% of patients with Peutz–Jeghers syndrome developing colon cancer.
However, these patients are subjected to increased screening compared with the general population. Thus, their cancer is often detected at an earlier stage, resulting in a good prognosis and improved survival rates. at
defect and survival using neoadjuvant chemotherapy versus adjuvant chemotherapy and unresectable pancreatic adenocarcinoma
essentially the same, whether they were given neoadjuvant chemotherapy or were resected followed by adjuvant chemotherapy.
is barely a 2 chemotherapy and radiation therapy improves progression free survival and in unresectable pancreatic adenocarcinoma
yes
A 2009 meta-analysis of chemotherapy for locally advanced and metastatic pancreatic cancer showed improved progression-free survival in patients receiving gemcitabine-based combination therapy, but that improvement was offset by greater toxicity in those patients.
hepatocellular carcinoma Surgical resection is reserved for:
noncirrhotic patients or those with well-preserved liver function and relatively limited tumor burden (ideally a single lesion).
what precludes attempt of primary resection for hepatocellular carcinoma
poor liver function:
Bilirubin values greater than 1.1 mg/dL
cirrhosis:
evidence of portal hypertension (esophageal varices, ascites, thrombocytopenia, portal vein pressure gradient ≥10 mm Hg)
are predictors of postoperative hepatic failure and thus preclude resection.
hepatocellular carcinoma Radiofrequency ablation and alcohol injection are therapies usually reserved for patients who
are not primary surgical resection candidates due to the number or distribution of lesions.
Both of these ablative options are most effective for masses less than 3 cm.
hepatocellular carcinoma chemoembolization
Transarterial embolization (TACE) involves injection of a chemotherapeutic agent, such as doxorubicin or cisplatin, in conjunction with occlusion of the hepatic artery supplying the liver lobe containing the tumor.
This approach is generally used in patients with sufficiently high tumor burden or more advanced cirrhosis to obviate either resection or ablation.
criteria for transplantation with hepatocellular carcinoma
University of California, San Francisco, criteria in 2001 expanded the original 1996 Milan criteria to:
single tumor 6.5 cm or less
or
2–3 lesions 4.5 cm or less,
totaling 8 cm or less,
original Malan criteria:
Less than 5 cm single lesion
3 or fewer lesions less than 3 cm
what can be used to bridge or temporize patient with hepatocellular carcinoma and awaiting transplantation
may benefit from bridging radiofrequency ablation or chemoembolization
recurrence rate with multicentric hepatocellular carcinoma primary resection
Despite the high risk of multicentric recurrence (70% at 5 years),
8 cm hepatocellular carcinoma associated survival rate 5 years with primary resection
primary resection offers the best therapeutic option for this patient, with the potential for a 50% survival rate at 5 years.
octreotide used with a pancreatic leak/fistula
Although somatostatin analogues such as octreotide do decrease fistula output,
Cochrane review does not affect the development of perioperative pancreatitis, postoperative mortality, reoperation rates, or the intensive care unit length of stay.
the
Preoperative intravenous antibiotic therapy before excision of a chronic sinus pilonidal disease
has not been shown to decrease wound complications, improve healing, or affect recurrence!!
pilonidal disease surgical management and relative success rates
Surgical options include complete sinus excision with primary closure or healing by secondary intention, with or without marsupialization of the wound edges. Success of primary closure requires a narrow field of excision and care to avoid sitting in the immediate postoperative period
Sinus recurrence, however, is more frequent after primary closure compared with healing by secondary intension.
previously SESAP question indicated primary closure probably better than advancement flap
serum albumin and serum transferrin predictive of an increased risk of morbidity and mortality at the time of esophageal resection
serum albumin less than 3.0 mg/dL and a serum transferrin less than 18 g/dL are predictive of an increased risk of morbidity and mortality at the time of esophageal resection.
rate of radiation induced esophagitis with neoadjuvant radiochemotherapy
Radiation-induced esophagitis develops in 15–28% of treated patients, further worsening dysphagia.
For esophageal cancer patients with dysphagia receiving neoadjuvant therapy how should nutritional deficit be treated
Preoperative esophageal stenting has emerged as an alternative approach to promote nutritional repletion in patients undergoing neoadjuvant chemoradiotherapy before esophageal resection. The options available for stenting include uncovered bare metal stents or covered silicone stents. Uncovered metal stents are best suited for palliation of patients with inoperable esophageal cancer, because they become incorporated into the wall of the esophagus and are not removable. Covered silicone stents offer more effective relief of dysphagia and can be removed later, either endoscopically or at the time of surgery.
Several recent studies have compared these various forms of nutritional support in patients undergoing neoadjuvant therapy before esophageal resection. Compared with enteral feeding, oral alimentation after placement of a covered silicone stent results in better relief of dysphagia, higher performance status, better tolerance of chemoradiotherapy, and a better quality of life. Patients receiving silicone stents have a mean weight gain of 6 kg and a greater mean improvement in albumin levels. Oral alimentation after silicone stenting reduced the incidence of major operative complications by more than 50% compared with enteral feeding. The incidences of stent related complications are less than 5%. No difficulties with stent removal or intraoperative dissection at the time of surgery are reported. Oral alimentation after placement of a covered silicone stent is a safe and effective means to relieve dysphagia and promote nutritional repletion in patients undergoing neoadjuvant chemoradiotherapy followed by surgical resection for esophageal cancer.
Percutaneous endoscopic gastrostomy tube placement should be avoided because of its potential to render the stomach unusable as a replacement conduit for the esophagus.
Nasojejunal feeding tubes frequently become dislodged, resulting in an interruption of nutritional support or more serious complications, including aspiration pneumonia.
The complications of feeding tube placement can be especially devastating in esophageal cancer patients because of their malnourished state and ongoing malignancy.
The acute onset of chest and upper abdominal pain after an episode of vomiting strongly suggests
Spontaneous perforation of the esophagus, also known as Boerhaave syndrome or barogenic rupture (figure 2),
Boerhaave syndrome
FULL -thickness
LONGITUDINAL tear
in the esophageal wall as a result of vomiting.
typically occurs in the intrathoracic esophagus just above the gastroesophageal junction.
Boerhaave syndrome typically presents and what timeframe after episode of retching
A significant delay in diagnosis and continued oral intake resulting in mediastinal contamination are common.
Of the factors that critically influence prognosis in these patients with Boerhaave syndrome
the most significant is delay in diagnosis.
including pre-existing comorbidities and esophageal disease,
first studies to obtain a patient suspected a Boerhaave syndrome
chest x-ray
Gastrografin swallow
management of Boerhaave syndrome
endoluminal stent placement to nonoperative management has emerged as a feasible “AND SAFE” alternative for the treatment of esophageal perforation.
Stent placement closes the site of esophageal perforation, stops ongoing contamination of the mediastinum, preserves esophagogastric continuity, avoids the potential morbidity and mortality of open surgery, and allows for earlier oral intake and a decrease in hospital stay.
Plastic stents are mainly used for the treatment of leaks and strictures of benign disease because of their ability to be removed more easily with less damage to the esophageal wall.
Stent placement occlusion rate of 94%.
Stent migration occurs in fewer than 5% of cases.
Stent removal is typically performed 4–6 weeks after implantation.
mortality rates of Boerhaave’s syndrome based on time to presentation
When treatment is performed within the first 24 hours, mortality rates are between 16% and 24%.
When treatment is delayed and performed after more than 24 hours, mortality rates increase rapidly up to 50%.
Because of these high mortality rates of Esophageal perforations some surgeons have advocated
nonoperative management, with cessation of oral intake and intravenous antibiotics until healing is confirmed. This approach is also associated with a long hospital stay in many patients, and it often requires enteral or parenteral nutritional support.
At 48 hours after spontaneous esophageal perforation weighted management
both direct esophageal repair
AND esophageal exclusion
are associated with mortality rates approaching 50%.
Under these circumstances, endoscopic covered stent placement is a less invasive approach that seals the site of esophageal perforation is a safer option.
Gastrointestinal stromal tumors (GISTs) are most commonly found where
They are most commonly found in the
stomach (60%)
small bowel (35%).
treatment of GIST
Complete surgical resection to grossly negative margins is the treatment of choice for gastric GISTs.
lymphadenectomy is not required for GISTs because these tumors spread hematogenously.
Surgical options include laparoscopic versus open resection, depending on tumor size, location, and extent of local invasion.
Adjuvant therapy with imatinib is a recommended for:
intermediate- to high-risk GISTs and has been shown to improve recurrence-free and overall survival.
Neoadjuvant imatinib NOT indicated in resectable disease but may have a role in cytoreduction and organ-preserving surgery
prognosis of GIST
Although resection offers the potential for cure,
recurs in 40–90% of surgically treated patients.
Prognostic indicators include tumor size, mitotic index, tumor location, and tumor rupture during surgery.
achalasia diagnosis
barium swallow,
endoscopy,
manometry.
Endoscopy is used to exclude malignancy, because patients with achalasia are at increased risk for both squamous cell and adenocarcinoma of the esophagus.
manometry findings of achalasia
pathognomonic is failure of LES relaxation
other findings:
elevated resting LES pressure
aperistalsis of the body with secondary and tertiary contractions.
Treatment of achalasia using botulinum
Botulinum toxin inhibits the release of acetylcholine, resulting in a reduction in LES pressure.
It has been shown to be efficacious in reducing chest pain and dysphagia in patients with achalasia; however, its effects are time limited, with relapse of symptoms in more than 50% of patients after 3 months.
Repeated injections in initial responders may confer some long-term benefit up to 2 years.
first line treatment and achalasia
Endoscopic pneumatic dilation is considered a good first-line option for the treatment of achalasia.
Compared with botulinum toxin, pneumatic dilation has much higher long-term response rates (75–90% at 5 years), with low complication rates.
Age and successful disruption of the LES fibers, as measured manometrically, are predictors of symptom relief with pneumatic dilation.
Patients older than 50 years are less likely to require retreatment than younger people are.
surgical treatment of achalasia
Surgical myotomy results in complete disruption of the LES fibers from the stomach to the esophagus, thus reducing resting LES pressure.
A partial fundoplication may be performed with the myotomy, depending on the presence of reflux symptoms preoperatively.
best predictor of successful surgical treatment of achalasia
The most consistent preoperative predictor of successful surgical myotomy:
elevated resting LES pressure greater than 30 mm Hg.
predictor of failure of Heller myotomy for achalasia
Failure of surgical myotomy is associated with:
megaesophagus
lengthy high-amplitude esophageal contractions.
Prior pneumatic dilation and treatment with botulinum toxin have not been shown to significantly affect surgical outcomes in patients with achalasia.
( but Botox does make it more difficult…)
management of gallstone ileus
cholecystectomy and fistula management are not mandatory.
Because the cholecystenteric fistula is usually large, recurrent symptoms are rare and Abdominal exploration will involve an enterotomy proximal to the site of obstruction to remove the stone. T
Operative intervention should include manual examination of the entire small intestines, because a second stone may be present.
Drainage of the gallbladder has occurred by means of the fistula, thus cholecystostomy is unnecessary.
Enteroscopy is not recommended in this setting.
Choledochal cyst disease may present as
dilation in a variety of locations within the biliary tree.
The classical triad of
jaundice,
right upper-quadrant pain,
abdominal mass,
treatment of choledochal cysts
surgically resected when possible to avoid the long-term consequences of cholangitis, liver cirrhosis, pancreatitis, and malignant transformation.
workup of choledochal cysts
Magnetic resonance cholangiopancreatography provides a noninvasive test to image the biliary tree and assess feasibility of surgical resection.
Such imaging should supersede endoscopic retrograde cholangiopancreatography, brushings, tumor markers, or fine needle aspiration.
types of choledochal cysts
#1 Fusiform dilation and extrahepatic duct #2 diverticulum of the extrahepatic duct #3 intraduodenal (choledochocele) #4a intrahepatic and extrahepatic ducts #4b multiple dilations of the extrahepatic duct #5 multiple intrahepatic biliary cysts (Caroli disease)
compare stapled hemorrhoidectomy outcome
stapling device for hemorrhoidectomy:
Less pain results in a quicker return to normal activities in controlled studies.
higher recurrence rate.
Infection rates are similar
satisfaction is similar
rates of bowel obstruction would be decreased in laparoscopic gastric bypass compared with the open procedure.
overall rate of bowel obstruction remains approximately equal between the 2 approaches and is possibly even higher with the laparoscopic approach - because of increased internal hernia revealed laparoscopic procedure
3 potential causes of internal hernia laparoscopic Roux-en-Y gastric bypass
Three potential spaces of internal herniation are created during the procedure.
first is known as the Petersen defect between the Roux limb mesentery and the mesocolon.
second is the jejunojejunostomy mesenteric defect.
third is the space created by passing the Roux limb through the transverse mesocolon. Occurs only in the retrocolic Roux-en-Y gastric bypass
draw Roux-en-Y
-
type of obstruction based on time of onset of symptoms
Early obstructions (within 30 days) are more likely caused by technical error causing obstruction at the jejunojejunostomy.
Late obstruction is more likely due to internal hernia or adhesive disease.
Internal hernia is thought to be a late complication because the patient’s weight loss causes a decrease in intraperitoneal fat and subsequent enlarging of mesenteric defects.
valuable diagnostic tool to diagnose obstruction after Roux-en-Y
As a result, a is laparoscopic reexploration, and many bowel obstructions after laparoscopic Roux-en-Y gastric bypass can be treated laparoscopically.
treatment of sigmoid diverticulitis
No matter what the approach, colonoscopy, or, alternatively a barium enema, is recommended after nonoperative treatment and before operative treatment of sigmoid diverticulitis in patients of all ages.
Studies based on decision analysis models suggest that life expectancy will be optimized if elective surgery is performed after the third or fourth attack of uncomplicated diverticulitis. This finding is particularly relevant, because elective diverticular disease resection has a significant rate of morbidity and mortality—higher than that of elective colorectal carcinoma resection!!
Hartmann operation is commonly considered for Hinchey stage III and IV (table 1).
clinically stable patients with favorable anatomy, it is possible, and perhaps better, to perform resection with colorectal anastomosis with or without diverting loop ileostomy.
Subsequent ileostomy takedown is substantially easier for both patient and surgeon than the colostomy takedown required with the traditional approach.
Other approaches for Hinchey III and IV include damage control sigmoid resection with a delayed anastomosis as well as irrigation and drainage alone.
The American Society of Colon and Rectal Surgery now recommends, “The number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in defining the appropriateness of surgery.”
Polyps of the gallbladder
Polyps less than 0.5 cm are usually benign and most frequently represent cholesterolosis.
Asymptomatic patients with cholesterol polyps do not need treatment.
However, a repeat ultrasound examination at 6 and 12 months may be appropriate.
Follow-up examinations are not necessary if the polyp is unchanged.
Polyps at least 1 cm in diameter may represent cholesterol polyps, adenomas, or carcinomas.
Multiple polyps, pedunculated polyps, and those that are hyperechoic compared with the liver are usually cholesterol polyps,
whereas solitary and sessile polyps that are isoechoic with the liver are more likely to be neoplastic and a laparoscopic cholecystectomy should be performed.
Lesions greater than 1.8 cm are usually malignant!
Because these lesions may represent advanced cancer, patients should undergo preoperative staging with CT scan and endoscopic ultrasound.
If malignancy is proven, an extended cholecystectomy with lymph node dissection and partial hepatic resection of the gallbladder bed is required.
most coming Meckel diverticulum
carcinoid is most commonly seen. In a population-based epidemiological study, 77% of Meckel diverticulum neoplasms were carcinoids.
Meckel diverticulum true or false
true
A hernia containing a Meckel diverticulum is referred to as a
Littre hernia.
Inguinal (50% in 1 series), umbilical, or femoral.
In the elective settingstudy of choice to detect heterotopic tissue within a Meckel diverticulum.
a technetium-99 pertechnetate
Capsule endoscopy is often used in the workup for small intestinal bleeds, but it is not the preferred study if a Meckel diverticulum is suspected.
A Grynfeltt-Lesshaft hernia refers to
a hernia of abdominal contents through the superior lumbar triangle.
This lumbar triangle is formed by
quadratus lumborum, the 12th rib, and the internal oblique muscle.
sigmoid resection recommended for patient’s with diverticulitis
overall:
It is currently recommended that the decision to proceed with elective sigmoid colectomy after recovery from uncomplicated acute diverticulitis should be made on a case-by-case basis and that the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in determining the appropriateness of surgery.
For patients who experience diverticulitis complicated by abscess formation requiring percutaneous drainage, a sigmoid resection is recommended even if otherwise full recovery from the episode of diverticulitis with conservative management is achieved!
technical anatomic guidelines for what bowel should be resected for elective sigmoid colectomy for diverticular disease
not all of the diverticula-bearing colon must be removed.
The distal margin of resection should extend to where the taenia coli diverge onto the upper rectum, because diverticulum formation below this level is very uncommon.
The proximal margin should be an area of pliable colon without hypertrophy or inflammation.
Anastomotic leaks after pancreaticoduodenectomy occur in what percent
15–25% of cases.
For a patient with newly diagnosed resectable adenocarcinoma of the colon, preoperative workup should include
full inspection of the colonic mucosa, preferably by colonoscopy; complete blood count; chemistry profile; carcinoembryonic antigen; and CT scan of the chest, abdomen, and pelvis.
NOT routine to do Positron emission tomography-CT (PET-CT) as part of the preoperative workup.
appropriate for For a patient with newly diagnosed resectable adenocarcinoma of the colon, preoperative workup
If CT scan examination demonstrates potentially curable metastatic disease, further evaluation with PET-CT is warranted.
Under such circumstances, the purpose of the PET-CT scan is to evaluate unrecognized metastatic disease that would prevent the possibility of surgical cure.
Patients with clearly unresectable metastatic disease (such as >5 metastatic lesions within the liver) should not have a baseline PET-CT scan, because the results will not affect the clinical management.
PET scan false negative and positive situations and adenocarcinoma of the colon
PET-CT scans should not be used to assess the response to chemotherapy, because these PET scans can provide a transient falsely negative result after the use of chemotherapeutic agents.
False-positive PET scans can occur in the presence of tissue inflammation or infection. A PET-CT scan in a patient with active inflammation from ulcerative colitis would not be of value.
The rectoanal inhibitory reflex (RAIR)
is a normal reflex that occurs in response to distention of the distal rectum.
causes relaxation of the internal anal sphincter.
allows the rectal contents to be “sampled” by the sensory area of the proximal anal canal, thus providing a means to determine stool from gas.
best measured with anal manometry.
transient contraction of the external sphincter is often seen with the reflex.
Hirschsprung disease is
a functional obstruction that results from aperistalsis due to congenital loss of ganglion cells within the distal colon and rectum.
Adult Hirschsprung disease
same entity as Hirschsprung disease in the pediatric age group,
differing only pediatric age group in its degree of severity and timing of diagnosis.
The clinical course of patients with adult Hirschsprung disease is characterized by
chronic debilitating constipation since birth.
Most patients with adult Hirschsprung disease are diagnosed before the age of 40 years.
Adult Hirschsprung disease almost always involves a very short segment of the distal rectum and thus gives rise to less severe symptoms.
The diagnosis of adult Hirschsprung disease is suggested by the absence of the rectoanal inhibitory reflex as measured by anal manometry.
The rectoanal inhibitory reflex is a normal reflexive response where distention of the distal rectum results in a decrease in the internal anal sphincter tone. Appropriate treatment of adult Hirschsprung disease consists of proctectomy with removal of the aganglionic segment and anal mucosectomy with coloanal anastomosis. Anorectal myomectomy provides varying success. Simple anal dilatation is not likely to affect the clinical course of Hirschsprung disease.
Primary sclerosing cholangitis (PSC)
s characterized by inflammation and fibrosis of the intrahepatic and extrahepatic bile ducts.
immune-mediated progressive disorder that can progress to the development of cirrhosis, portal hypertension, and hepatic decompensation.
5% of patients with ulcerative colitis.
Colectomy for ulcerative colitis does not appear to improve or prevent PSC. In fact, PSC may develop several years after colectomy.
all patients suffering from ulcerative colitis should undergo what survellance
annual surveillance colonoscopy, with multiple biopsies beginning 8–10 years after the diagnosis of colitis. Patients who suffer from both ulcerative colitis and PSC are known to be at increased risk for development of dysplasia and colorectal cancer compared with other patients with ulcerative colitis. Given this increased risk, ulcerative colitis patients with PSC should undergo annual surveillance colonoscopies beginning at the time of diagnosis of the PSC.
timing of gallstone source control with cholecystectomy
early cholecystectomy after endoscopic choledocholithotomy decreased the risk of mortality by 78% compared with a “wait-and-see approach.” !!
Early removal of the gallbladder after clinical presentation with choledocholithiasis decreases the risk of death and complications, and this improvement is seen even in patients at high operative risk.
In patients classified into American Society of Anesthesiologists IV or V groups, the mortality was decreased from 13% in the wait-and-see patients to 7% in the early cholecystectomy patients. T
in patients managed by wait and see, 5.4% developed recurrent jaundice or cholangitis, but only 0.9% developed pancreatitis.
In a prospective randomized trial, 47% of patients managed nonoperatively developed greater than 1 biliary-related event during 2 years of follow-up compared with 2% of patients who underwent laparoscopic cholecystectomies after initial endoscopic choledocholithotomies.
That study found a significant increase in conversion to open procedures in the wait-and-see patients who underwent cholecystectomies after symptomatic recurrence (55%) compared with the early cholecystectomy patients (20%).
Compared with urgent operation for acute, left-sided colon obstruction due to a potentially curable colon cancer, the use of self-expanding metal stents as a bridge to elective operation has
lower risk of stoma being required
patient’s managed who presented with left-sided obstructing colon cancer
must include decompression to avoid subsequent perforation.
either a palliative stoma or Hartmann procedure in 25% of patients.
However, up to 40% of Hartmann procedures are never reversed.
The morbidity of operation for acute obstructing colorectal cancer is high, and mortality rates are 9–27%.
Self-expandable metal stents are advocated as an alternative to operation. For patients with metastatic disease, self-expandable metal stents may allow palliation without operation or stoma formation.
For patients with potentially curable colorectal cancer, these stents may serve as a “bridge to surgery” by allowing for decompression and subsequent 1-stage surgery without stoma formation.
Approximately 50–60% of patients with acute obstructing colorectal cancer are candidates for self-expandable metal stents.
technical success rate and using expandable metal stent for starting colon cancer
and possible advantages However, adult intussusception has a pathologic lead in up to 90% of patients.
The technical success rate, defined as the ability to deploy stent and relieve obstruction, is high (88–100%).
This results in a shortened hospital stay by up to 5–8 days, as well as a decreased need for intensive care unit admission.
With relief of obstruction, the need for emergency operation and stoma formation at any point in treatment is reduced (odds ratio = 0.02).
The use of stents as a bridge to subsequent resection in colon cancer is not associated with worse oncologic outcome or higher mortality, although better long-term data are needed.
Patients with short segment obstruction and distal obstructions are the best candidates for self-expandable metal stents. The overall complication rate is approximately 20%, with migration being the most common problem (10%). Perforation from stent placement occurs in up to 4%. The most important risk factor for perforation is the use of balloon dilation.
what percent of adult intussusception to is malignant
Approximately 65% of colonic intussusception has a malignant lead point.
In the small bowel, up to 30% of these lead points are malignant.
Thus, up to 90% of adult intussusception cases require definitive treatment with surgical resection.
best test to diagnosed adult intussusception
Abdominal CT scan is considered to be the best diagnostic imaging modality, with an accuracy of 60–100%.
The classic finding is the “target sign,” which is caused by bowel within bowel.
Mesenteric vessels within a bowel lumen may be seen as well.
cecal volvulus
Cecal volvulus occurs in 2 types: axial ileocolic volvulus (90%) and cecal bascule (10%).
In axial ileocolic volvulus, the cecum and terminal ileum rotate up and over to the left upper quadrant.
Cecal bascule occurs when the cecum flips upward and anterior in a horizontal plane.
Both types require a highly mobile cecum, which is thought to occur from failure of the mesentery to fuse to the posterior parietal peritoneum in the right paracolic gutter.
The preferred treatment right hemicolectomy. N
nonviable bowel should be resected without detorsion, because this may lead to septic shock.
The majority of patients can be reanastomosed after resection even with gangrene and obstruction.
However, ileostomy, with or without a mucous fistula, remains an option if there is peritonitis or severe bowel distention.
highest rate of adhesion related obstruction admissions.
Open adnexal operations have the highest rate of adhesion-related readmission (23%) to the hospital, mostly due to SBO,
ileal pouch–anal anastomosis (19%),
total abdominal hysterectomy (15%),
colectomy (9%).
percentage of adhesion caused a small bowel obstruction that require operative intervention
only 3–8% required operative intervention when presenting for adhesion-related small bowel obstruction
percentage of small bowel obstruction after lap route a mean
Postoperative adhesions are frequent after abdominal and pelvic surgery and occur in 50–95% of patients who undergo subsequent laparotomy.
(SBO) occurs in nearly 5% of patients who have undergone prior abdominal operation of
open versus laparoscopic risk for developing small bowel obstruction after operation
OPEN cholecystectomy and hysterectomy are associated with higher rates of SBO compared with laparoscopy
NO difference arthroscopic versus open appendectomy
effect of closing peritoneum in separate layers to prevent adhesion readmissions and small bowel obstruction
closing peritoneum in separate layers is WORSE
Closure of the peritoneum as a separate layer appears to increase adhesion-related readmissions and SBO. or
patient characteristics the increased risk of small bowel obstruction after operative intervention
NOT affected by:
Age, gender, and presence of cancer do not appear to affect postoperative adhesion formation, readmission, or SBO.
stigmata of recent upper gastrointestinal bleeding
active bleeding or
visible vessel in an ulcer bed).
endoscopic treatment indicated for all lesions with high risk stigmata of recent bleeding
upper endoscopy: clips, thermocoagulation, or sclerosant injection
Epinephrine injection alone is NOT sufficient.
low-risk stigmata upper gastrointestinal bleeding
clean-based ulcer
or
CLOT in an ulcer bed ( CAREFUL - visible vessel is high risk)
recommended treatment for low risk stigmata and upper GI bleed
hemostatic therapy is NOT indicated,
patients can be fed within 24 hours and discharged early with oral proton pump inhibitor (PPI) therapy.
management of patient’s with findings of high risk stigmata of upper GI bleed
hospitalized for more than 72 hours
receive intravenous PPI therapy.
Percutaneous embolization or surgery can be considered when endoscopic therapy has failed.
The incidence of cancer in patients with ulcerative colitis
corresponds to cumulative probabilities of
2% by 10 years,
8% by 20 years,
18% by 30 years
There is consensus that colorectal cancer risk is highest in those patients with long duration of disease (adult compared with child) and extent of disease.
what decreasesthe risk of developing colon cancer and ulcerative colitis
use of 5-aminosalicylate was associated with a lower risk of colorectal cancer.
mucosectomy does not confer benefit in terms of disease control, and there is no significant improvement in cancer risk with mucosectomy.
Transanal endoscopic microsurgery (TEMS) is approved now for
amenable to TEMS resection:
polyps greater than 8 cm in diameter,
polyps occupying greater than 50% of the rectal circumference
Polyps above the peritoneal reflection of the rectum (>15 cm),
does not allow for visualization of the anal canal. Its use is limited to lesions located above the anal canal.
Other benign rectal and extrarectal masses, such as carcinoids, and some retrorectal cysts, can also be excised with TEMS.
both full-thickness and partial-thickness excisions.
