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Year 3 - Met3a > Gastrointestinal operations > Flashcards

Gastrointestinal operations Flashcards

1
Q

What are the complications from major abdominal surgery

A
  • adhesions
  • bleeding
  • infection
  • paralytic ileus
  • preoperative mortality
  • shock
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2
Q

What are the indications of oesophagectomy

A
  • oesophageal cancer
  • severe oesophageal stricture
  • pre-malignant disease (e.g. high grade dysplasia in Barrett’s oesophagus)
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3
Q

What is the procedure for an oesophagectomy

A
  • performed under GA and single-lung ventilation
  • may be complete, sub-total/partial +/- resection of regional lymph noeds

Open surgical procedures include:

  • Ivor Lewis (two-stage) vs three-stage
  • transhiatial vs transthoracic

Usually performed through two incisions

  • 1 thoracotomy - to mobilise the oesophagus
  • right lung is usually collapsed using a double-lumen bronchial tube and carbon dioxide is blown into the right pleural cavity to compress the lung
  • 1 laparotomy - to dissect and prepare the stomach/intestine for oesophageal reconstruction
  • the new oesophagus or gastric tube is then drawn up the chest and connected to the remaining healthy oesophageal stump, usually via and incision in the neck
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4
Q

What are the major complications for oesophagectomy

A
  • anastomotic leak
  • pneumonia
  • vocal cord palsy
  • delayed gastric emptying
  • acute respiratory disease
  • pancreatitis
  • DVT/PE
  • tracheal tear
  • renal failure
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5
Q

What are the minor complications for oesophagectomy

A
  • AF
  • pleural effusion
  • atelectasis
  • wound infection
  • minor tracheal perforation
  • C.diff colitis
  • Jejunostomy-tube infection
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6
Q

What are the indications for a laparoscopic cholecystectomy

A
  • Biliary colic (repeated attacks)
  • Acute cholecystitis
  • Chronic cholecystitis
  • Cholangitis and gallstone pancreatitis (both can occur when gallstones become stuck in common bile duct)
  • Gallbladder cancer
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7
Q

What is the procedure for laparoscopic cholecystectomy

A
  • Several (usually 4) small incisions made to allow insertion of operating ports
  • Cystic duct and cystic artery identified and dissected, then ligated with clips and cut
  • Removal of gallbladder through one of the ports
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8
Q

What are the complications of a laparoscopic cholecystectomy

A
  • Biliary injury or damage to the bile ducts
  • leakage from stump of cystic duct
  • wound infection
  • urinary retention
  • bleeding
  • retained stone in common bile duct
  • respiratory complications
  • cardiac complications
  • intra-abdominal abscess
  • hernia
  • bowel injury
  • sepsis
  • pancreatitis
  • DVT/PE
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9
Q

What happens in biliary injury and what symptoms do they have

A
  • can cause bile leak leading to abdominal pain, fever and sepsis several days following surgery
  • increase in serum bilirubin
  • increase in serum ALP
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10
Q

What are the indications of right hemicolectomy

A
  • adneocaricnoma of the right colon
  • adenocarcinoma of the caecum and appendix
  • adenomatous polyps that cannot be removed endoscopically
  • carcinoids
  • inflammatory bowel disease
  • caecal volvulus
  • severe appendicitis with involvement of the caecum
  • colonic diverticulitis and diverticular disease
  • Trauma
  • Bowel infarction
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11
Q

what is the procedure of the right hemicolectomy

A
  • Right paramedian incision

Determine extent of resection

  • Take right colic and ileocolic vessels at their origins to ensure proper lymph node harvesting
  • Take care to preserve the main branch of the middle colic vessels
  • Omental attachments to the right colon are generally removed with the specimen

Mobilise the colon
- Separate terminal ileum and caecum from retroperitoneal structures – most importantly ureter and gonadal vessels

Create anastomosis

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12
Q

What are the complications of the right hemicolectomy

A
  • postoperative ileus
  • anastomotic leak
  • wound infection
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13
Q

What are the indications for a lower anterior resection

A
  • rectal carcinoma in upper 2/3 of the rectum

- diverticulitis

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14
Q

What is the procedure of the lower anterior resection

A
  • Rectum is excised
  • Proximal stump of descending colon is anastomosed to rectal stump
  • Integrity of completed anastomosis tested by air insufflation of the rectum
  • If there is concern about the anastomosis or it is low (<7cm from the anal verge) it is wise to defunction with a temporary loop ileostomy
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15
Q

What are the complications of the lower anterior resection

A
  • low anterior resection syndrome
  • anastomotic dehiscence/leak
  • ED in males
  • local tumour recurrence
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16
Q

What are the symptoms of lower anterior resection syndrome

A
  • faecal incontinence (stool and flatus)
  • faecal urgency
  • frequent bowel movements
  • bowel fragmentation
  • some only experience constipation and tenesmus
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17
Q

what is the cause of lower anterior resection syndrome

A
  • cause unclear - could be nerve damage or loss of rectoanal inhibitory reflex
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18
Q

What are the indications for an abdominoperineal excision of the rectum

A
  • rectal carcinoma - in distal 1/3 of rectum

- recurrent or residual anal (squamous cell) carcinoma

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19
Q

What is the procedure of abdominoperineal excision of rectum

A
  • Removal of the anus, rectum and part of the sigmoid colon along with regional lymph nodes
  • Incisions made in the abdomen and perineum
  • End of remaining sigmoid colon is brought out permanently as a colostomy
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20
Q

What are the complications of abdominoperineal excision of the rectum

A
  • infection of surgical wound
  • bowel leakage inside the abdomen
  • UTI
  • loss of blood supply to the stoma after colostomy
  • urinary incontinence
  • bowel obstruction
  • hernia around colostomy
  • ED in males
  • adhesion
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21
Q

What are the indications for Hartmann’s operation

A

→ Initially developed for distal colon adenocarcinoma
- Complicated diverticulitis (stage III or IV)

Rectosigmoid cancer in:

  • Emergency – obstruction, perforation or haemorrhage
  • Elective – cure, palliation, anticipation of impending obstruction
  • Ischaemia
  • Volvulus
  • Iatrogenic perforation of colon during colonoscopy or by foreign body
  • Lymphoma
  • Metastatic cancer to the pelvis
  • Crohn’s disease
  • Trauma
  • Anastomotic dehiscence/leak
  • Pseudomembranous colitis
  • Rectal prolapse
  • Leiomyosarcoma
  • Ulcerative colitis
  • Radiation injuries
  • Retroperitoneal bleeding
  • Pneumatosis cystoides
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22
Q

What is the procedure for Hartmann’s operation

A
  • resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy or ileostomy
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23
Q

What are the complications for Hartmann’s operation

A
  • wound infection (most common)
  • rectal stump leak
  • abscesses around the rectal stump
  • fistulae from rectal stump to bowel
  • retraction of colostomy
  • parastomal hernia
  • skin irritation around colostomy
  • paralytic ileus
  • wound dehiscence
  • ureteral injury
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24
Q

Where is a Colostomie (stoma) usually

A
  • usually in the left iliac fossa and flush with the skin
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25
Q

Name the types of colostomies

A
  • loop colostomy
  • end colostomy
  • Paul-mikulicz colostomy
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26
Q

Describe how a loop colostomy works

A
  • Loop of colon is exteriorised and partially divided, forming two stomas that are joined together (proximal end passes stool, distal end passes mucus)
  • Rod under the loop prevents retraction and may be removed after 7d
  • Often temporary and performed to protect a distal anastomosis, eg after anterior resection
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27
Q

Describe how an end colostomy works

A
  • Bowel is divided and the proximal end is Brough out as a stoma

Distal end may be

  • resected e.g. abdominoperineal resection
  • closed and left in the abdomen e.g. Hartmann’s operation
  • exteriorised forming a mucous fistula
28
Q

Describe the Paul-mikulicx colostomy works

A
  • Double barrelled colostomy in which the colon is divided completely (e.g. to excise a section of bowel)
  • each end is exteriorised as two separate stomas
29
Q

What is the output of a colosotmy

A
  • colostomies ideally pass 1-2 formed motions/day in to an adherent plastic pouch
  • some can be managed with irrigation thus avoiding a pouch
30
Q

Where is an ileostomies

A

usually right iliac fossa

31
Q

What are the two types of ileostomies

A
  • loop ileostomies

- end ileostomy

32
Q

what does an ileostomy look like

A
  • protrudes from the skin and emit frequent fluid motions which contain active enzymes (so skin needs protecting)
33
Q

Describe a loop ileostomy

A
  • can be formed to definition the colon as a temporary measure e.g. during control of difficult perianal Crohn’s disease
34
Q

Describe a end ileostomy

A
  • follows total or subtotal colectomy, e.g. for UC - subsequent ideal pouch-anal anastomosis can allow for stoma reversal
35
Q

what is an alternative (non-stoma forming) surgery

A
  • Low/ultralow anterior resection – part of the rectum is excised and proximal colon anastomosed to the top of the anal canal; the lower the level of anastomosis, the higher the risk of complications
  • Transanal endoscopic microsurgery – allows excision of small tumours within the rectum with preservation of sphincter function
36
Q

What is urostomies

A
  • fashioned after total cystectomy, brining urine from the ureters to the abdominal wall via an ideal conduit that is usually incontinent
  • formation of a catheterizable valvular mechanism which may retain continence
37
Q

What should you avoid when choosing stoma site

A
  • bony prominences
  • umbilicus
  • old wounds/scars
  • skin folds and creases
  • waistline
38
Q

What are the early complications of stoma

A
  • haemorrhage at stoma site
  • stoma ischameia - colour progresses from dusky grey to black
  • high output (can lead to lowering potassium) - consider loperamide +/- codeine to thicken output
  • obstruction secondary to adhesions
  • stoma retraction
39
Q

What are the delayed complications of stoma

A
  • obstruction (failure at operation to close lateral space around stoma)
  • dermatitis around stoma site (worse with ileostomy)
  • stoma prolapse
  • stomal intussusception
  • stenosis
  • parastomal hernia (risk increases with time)
  • fistulae
  • psychological problems
40
Q

What are the indications of splenectomy

A
  • splenic trauma
  • hypersplenism
  • autoimmune haemolysis
  • ITP
  • warm autoimmune haemolytic anaemia
  • congenital haemolytic anaemia
41
Q

What is the procedure of splenectomy

A
  1. mobilise early post-splenectomy as transient increase platelets predisposes to thrombi
  2. characteristic blood film seen post-splenectomy: Howell-Jolly bodies, Pappenheimer bodies, target cells
42
Q

What are complications of splenectomy

A
  • Lifelong increased susceptibility for infection
  • infection commonly caused by encapsulated organisms - streptococcus pneumonia, haemophilia influenzae, neisseria meningitis
43
Q

How do you reduce the risk of infection after a splenectomy

A

Immunisations

  • pneumococcal vaccine at least 2 week pre-op; re-immunise every 5-10 years, avoid in pregnancy
  • Hib vaccine
  • meningococcal vaccination course
  • annual influenza vaccine

Life long prophylactic oral antibodies - penicillin V

  • pendants, bracelets or patient held cards to alert medical staff
  • advice to seek urgent medical attention if any signs of infection
44
Q

How are haemorrhoids attached

A
  • attached by smooth muscle and elastic tissue but prone to displacement and disruption either singly or together
45
Q

What can cause haemorrhoids to form piles

A
  • gravity
  • increased anal tone
  • effects of straining

these can cause them to protrude to form piles

46
Q

are haemorrhoids painful

A
  • there are no sensory fibres above the dentate line so haemorrhoids are not painful
  • they do become painful if they thrombus when they protrude and are gripped by the anal sphincter which blocks the venous return
47
Q

How do you classify haemorrhoids

A
  • 1st degree - remain in the rectum
  • 2nd degree - prolapse through the anus on defecation but spontaneously reduce
  • 3rd degree - as for 2nd degree but require digital reduction
  • 4th degree - remain persistently prolapsed
48
Q

What is the differential diagnosis for haemorrhoids

A
  • perianal haematoma
  • anal fissure
  • anorectal abscess
  • anorectal tumour
  • proctalgia fugax
49
Q

What are the causes of haemorrhoids

A
  • Constipation with prolonged straining; although in many bowel habits may be normal
  • In minority of cases – congestion from a pelvic tumour, pregnancy, CCF or portal hypertension
50
Q

describe the pathogenesis of haemorrhoids

A
  • Vicious cycle: vascular cushions protrude through a tight anus, becomes more congested and hypertrophy to protrude again more readily
  • protrusions may then strangulate
51
Q

What are the symptoms of haemorrhoids

A
  • bright red PR bleeding - often coating stools, on the tissue, dripping into the pan after defecation
  • may be mucus discharge and pruritus ani
  • severe anaemia may occur
52
Q

What is the investigations for haemorrhoids

A
  • abdo exam
  • DRE
  • colonoscopy/flexi sigmoidoscope to exclude proximal pathology if >50 years old
53
Q

what is the 1st degree of medical management of haemorrhoids

A
  • increasing fluid and fibre +/- topical analgesics and stool softener
  • topical steroids for short periods only
54
Q

what are the 2nd and 3rd line medical therapy for haemorrhoids

A
  • Rubber band ligation
  • sclerosants
  • infra-red coagulation
  • bipolar diathermy and direct current electrotherapy
55
Q

what does rubber band ligation do to haemorrhoids

A
  • banding produces an ulcer to anchor the mucosa
56
Q

What are the side effects of band ligation

A
  • bleeding
  • infection
  • pain
57
Q

What is a sclerosants

A
  • 2ml of 5% phenol in oil is injected into the haemorrhoid above the dentate line, including fibrotic reaction
58
Q

what are the side effects of sclerosants

A
  • impotence

- prostatitis

59
Q

How does bipolar diathermy and direct current electrotherapy work

A

Causes coagulation and fibrosis after local application of heat

60
Q

How does infra-red coagulation work

A

Applied to localised areas of haemorrhoids, it works by coagulating vessels and tethering mucosa to SC tissue

61
Q

What are the two surgery procedures used in haemorrhoids

A
  • excisions haemorrhoidectomy

- stapled haemorrhoidectomy

62
Q

How does excision of haehmorrhoidectomy

A
  • most effective treatment - excision of haemorrhoid +/- ligation of vascular pedicles as day case surgery
  • needs 2 weeks off work
63
Q

when is stapled haemorrhoidectomy used

A
  • procedure for collapsing haemorrhoids
  • may result in less pain, shorter hospital stay and quicker return to normal activity than conventional surgery
  • used when here is a large international component
64
Q

What are the complications of surgery used in haemorrhoids

A
  • constipation
  • infection
  • stricture
  • bleeding
65
Q

How do you treat prolapsed, thromboses haemorrhoids

A
  • analgesia, ice packs and stool softeners
  • pain usually resolves in 2-3 weeks
  • some advocate surgery

Year 3 - Met3a (43 decks)

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