surgery exam 2 Flashcards
indications for esophagectomy
cancer - SCC (upper and middle third), AdenoCa (usually lower third), high grade dysplasia (barrett’s)
esophagectomy surgical options
transhiatal esophagectomy (upper abdomen and cervical incision)
transthoracic esophagectomy (right thoracotomy ad upper abdominal incision)
tri-incisional esophagectomy (Thoracotomy + laparotomy + cervical)
post-esophagectomy complications
- anastomotic stricture –> -dysphagia
- leak
- ischemia (avoid Hypotn & vasopressors!)
post-esophagectomy diet
no stomach reservoir- small, frequent meals
achalasia
motility disorder, loss of peristalsis in distal 2/3 of esophagus and impaired relaxation of LES
-gradual, progressive dysphagia for solids and liquids, regurgitation of food, weight loss
treatment for achalasia
medical - CCB, nitrates, Botulinum injection to LES
Balloon dilation – stretch LES
***(Heller) Myotomy +/- Fundoplication– highest success rate
Hiatal Hernia repair
Reduce stomach herniation, close defect, +/- gastropexy
Anti-reflux Procedures (GERD):
Nissen Fundoplication
(360⁰ wrap)
Partial Fundoplication
(Toupet, Dor, etc.)
post-op diet for GERD and PEH surgery
full liquids for 1-2 weeks, slowly transition to soft diet
what is a subtotal distal gastrectomy?
distal 2/3 of stomach (Gastroduodenostomy (Billroth I)
Gastrojejunostomy (Billroth II)
what is a total gastrectomy?
proximal disease (fundus, cardia) - esophagojejunostomy
reasons for gastrectomy
pailliative resection for cancer (reduce risk of bleeding, obstruction), peptic or duodenal ulcer, GIST
Post-gastrectomy syndromes
Early: leak, retention, hemorrhage Postvagotomy diarrhea Dumping syndrome Alkaline reflux gastritis Gastroparesis Anemia – Iron/B12 Deficiency Early satiety Recurrent ulcer Fistula (Gastrojejunocolic & Gastrocolic) Afferent loop syndrome
gastric volvulus
stomach rotates on its long axis or mesenteroaxial axis
secere abd pain, emesis, retching, inability to vomit, inability pass NGT
gastric infarction = surgical emergency for resection
Borchardt triad=acute epigastric pain, violent retching, inability to pass NGT
small bowel obstruction causes
ABC
adhesions (70%)
bulges (incarcerated hernias)
carcinoma
SBO treatment
conservative:
IVF, NGT decompression
+/- foley
serial abdominal exams and await clinical improvement
surgery- exploratory laparotomy (“ex lap”), lysis of adhesions, possible bowel resection, possible ostomy
Small Bowel Resection
SBO Intussusception Ischemia Hemorrhage Crohn’s Disease Fistula Congenital anomalies Bezoar Neoplasm Adenoma=Most common SB benign AdenoCA=most common SB primary malignant Malignant tumors of SB=2% of all GI cancers GIST
presence of stone(s) in GB
cholelithiasis
stone(s) in the CBD
choledocholithiasis
inflammatory state of GB, acute or chronic
cholecystitis
inflammation/infection of biliary tree
cholangitis
acute cholecystitis in absence of gallstones
Acalculous cholecystitis
indications for cholecystectomy
symptomatic gallstones (biliary colic, acute or chronic cholecystitis, gallstone ileus)
gallstone pancreatitis
acalculous cholecystitis
large gallbladder polyps (>10mm)
whipple resection or bile duct resection (as part of hepatectomy)
malignancy
Relative CONTRAINDICATIONs for cholecystecomy
Cirrhosis and Portal HTN
intra-op and post-op complications of cholecystectomy
Intra-op Bile duct injury Bleeding – cystic artery or right hepatic artery Post-op Bile leak – small vs. large Jaundice – major duct obstruction/excision Subphrenic fluid collection Diarrhea
Courvoisier law
palpable, painless gallbladder + jaundice, indicative of obstruction unlikely to be due to gallstone
when is pancreatic cancer unresectable?
Extensive peripancreatic lymphatic involvement, nodal involvement beyond the peripancreatic tissues, and/or distant metastases.
Direct involvement of SMA, IVC, aorta, celiac axis, or hepatic artery, as defined by the absence of a fat plane between the tumor and these structures on CT scan
what is a “whipple” procedure
Distal gastrectomy (antrectomy), removal of pancreatic head, duodenum, part of jejunum, CBD, GB
Pancreaticoduodenectomy
whipple complications
Delayed gastric emptying Bile leak Pancreatic fistula Dumping, steatorrhea Bile reflux gastritis
most common age for appendicitis
10-30
operation for right sided colon cancer
right hemicolectomy
skip lesions are associated with what?
chron’s disease
continuous lesions are associated with what?
ulcerative colitis
indication to operate for IBD
- Intractability to medical therapy
- Intra-abdominal abscess
- Intractable fistula
- Massive bleeding
- Intestinal obstruction, perforation
- Cancer
- Symptomatic, refractory internal or perianal fistulas (in Crohn’s
definitive treatment (cure) for UC
colectomy
treatment for cecal volvulus
emergent surgery
viable: cecopexy
compromised: right hemicolectomy with primary anastomosis OR ileostomy and mucus fistula
management for diverticular disease
NPO, antibiotics
sx management: sigmoidectomy, diverting ostomy (hartmann’s procedure)
Post dz diet: low fiber, transition to high fiber usually 4-6 weeks out
three different types of hernias
reducible - contents can be replaced within surrounding musculature
irreducible/incarcerated - cannot be reduced
strangulated - compromised blood supply, potentially serious
Large hernias through small orifice
Highest rate of strangulation = femoral
spigelian ventral hernia
at lateral border of rectus at the linea semicircularis
rectus diastasis
separation of 2 rectus abdominus muscles when linea alba becomes stretched, appears as midline ridge. NO FASCIAL DEFECT, no risk of incarceration or strangulation
