Surg Med - GI and Bariatric Surgery - Exam 2

GERD S/S

Unpleasant substernal burning

Lasts for a few moments to several mins

Relieved by antacids or food

Occurs 30-60 min after meals and at night

Sx improve with PPI

GERD Absolute Surgical Indications

perforation

uncontrolled bleeding

gastric necrosis

malignancy

GERD Relative Surgical Indications

refractory/disabling sx despite meds

ulcerative esophagitis

peptic stricture

chronic aspiration

barrett's esophagus

GERD Surgical CI

Poor surgical candidates d/t comorbidities

Lack of objective evidence of reflux

GERD - Fundoplication

Total wrap = Nissen

Partial wrap = toupet, dor, or belsey 

Goal is intraabdominal esophagus + antireflux valve

Gastric Cancer S/S

Indigestion

Stomach pain

Nausea

Loss of appetite

Weight loss

Black stools

Gastric CA Surgical Indications

Resectable gastric adenocarcinoma

Surgery is the only curative treatment

Gastric CA Surgical CI

Advanced metastatic disease

Inability to obtain negative margins

Poor operative candidate

Gastric CA - Surgical procedure

Partial/subtotal or gastrectomy with negative margins + lymphadenectomy

Often Billroth II or roux-en-Y

All margins should be negative 

Attempt grossly negative margin of at least 5 cm

Parital SBO

some function (may pass a little bit of gas and may have small BM, but will likely still have sx)

Comple SBO

no passage of stool or gas

SBO S/S

Impaired GI function → obstipation, abd distention, vomiting, abd pain

Fluid and electrolyte loss → vomiting, tachycardia, oliguria

Inflammation → fever, tachycardia, shock

SBO Surgical Indications

Immediate surgery if peritonitis

Ischemia/strangulation

Nonreducible hernia

Closed loop obstruction

Perforation

Failure of conservative tx after ~24-48 hr

Complete SBO more likely needs surgery

SBO Surgical CI

Stable partial SBO without ischemia/peritonitis

SBO - Surgical procedure

Most (80%) don’t need surgery

Occasionally immediate surgery is needed – peritonitis, non-reducible hernia 

Give gastrografin to patient and do a small bowel follow thru (SBFT) 

Exploratory laparoscopy/laparotomy

Lysis of adhesions

Hernia repair

Bowel resection if nonviable bowel

Small Bowel Tumor Surgical Indication

Localized lesion

Symptomatic obstruction/bleeding/perforation

Need to confirm malignancy

Small Bowel Tumor - CI

Diffuse unresectable metastases

No palliative benefit

High risk of short bowel syndrome

Small Bowel Tumor - Surgical Procedure

Segmental small bowel resection with margins +/- lymph node eval depending tumor type

terminal ileum

where is a Meckel Diverticulum typically located?

Meckel Diverticulum S/S

Ectopic gastric tissue secretes gastric enzymes that can erode the mucosal wall and lead to bleeding

Asymptomatic unless associate complications arise

Approx 4-6% will have complications

MC presentation - bleeding, intestinal obstruction, diverticulitis

Meckel Diverticulum Surgical Indications

Resectable tumors

Obstruction

Bleeding 

Asymptomatic w/ RFs

Perforation 

Intussusception

Meckel Diverticulum CI

Asymptomatic cases without complications

Meckel Diverticulum Surgical Procedure

Diverticulectomy with removal of bands

If bleeding, segmental ileal resection including adjacent ulcer

Colorectal CA S/S

Rectal bleeding (gross or occult)

Anemia (iron deficiency)

Weight loss

Change in bowel habits or stool caliber

Obstruction

Colorectal CA Surgical Indications

Resectable colon/rectal cancer

Obstruction 

Bleeding

Perforation

Selected metastatic disease with resectable metastases

Colorectal CA CI

Widespread unresectable disease without palliative benefit

Poor operative candidate

Colorectal CA Surgical Procedure

Complex and varies depending on colon vs rectal

Surgical - complete excision remains the only accepted way to cure a pt with colon cancer

Colonic Polyps S/S

Often asymptomatic

Possible rectal bleeding or anemia

Colonic Polyps Surgical Indications

Large/unresectable polyps

High grade dysplasia

Suspicion for invasive malignancy

Incomplete endoscopic removal

Colonic Polyps CI

Small benign polyps removable endoscopically

Colonic Polyps Surgical Procedure

Colonoscopic polypectomy 

Segmental colectomy if invasive or unresectable 

Takes ~10 yrs for a polyp to turn into cancer, we need to ID them before then so we can prevent cancer

Familial Adenomatous Polyposis (FAP) S/S

Multiple colorectal polyps

Abdominal pain

Rectal bleeding

FAP Surgical Indications

Prophylactic colectomy to prevent cancer 

Near 100% lifetime CRC risk

FAP Surgical CI

Severe comorbidities

Temporary delay if medically unstable

FAP Surgical Procedure

Total proctocolectomy

Often ileal pouch-anal anastomosis (J-pouch)

Diverticulitis S/S

LLQ pain

Fever, nausea 

Changes in bowel habits

Simple – colonic inflammation accompanied by systemic signs of fever and leukocytosis

Complicated – diverticulitis with abscess, obstruction, diffuse peritonitis, or fistulas between the colon and adjacent structures

Diverticulitis Surgical Indications

Complicated diverticulitis 

Recurrent episodes affecting QOL

Diverticulitis surgical CI

Simple uncomplicated diverticulitis → antibiotics/medications first

Diverticulitis Surgical Procedure

Segmental colectomy, possibly with temporary colostomy 

Hinchey 1 → managed w/ abx

Hinchey 2 → drained 

Hinchey 3 → emergent sigmoidectomy (hartmann procedure)

Hinchey 4 → same ^

Volvulus S/S

Abd pain, distention, constipation, vomiting

Often pain and progressive injury to the intestinal wall, with accumulation of gas and fluid in the portion of the bowel obstructed

Can result in necrosis of the affected intestinal wall, acidosis, and death

Volvulus Surgical Indications

Failure of endoscopic decompression

Signs of ischemia

Volvulus Surgical CI

Stable pts responding to non-surgical management

Volvulus Surgical Procedure

Options: detorsion, resection of necrotic bowel, possible colostomy

Acute volvulus requires immediate intervention to untwist the affected segment of bowel and possibly resect any unsalvageable portion 

Can also do a decompressive colonoscopy by putting in a colonoscope → can also put a chest tube in the sigmoid to give it time to decompress

Crohn's Dz S/S

Abd pain, diarrhea, weight loss, and fatigue

Skip lesions that occur anywhere between the mouth and anus

Transmural disease (not just the surface, runs the entirety of the bowel wall)

Complications - fistulae (perirectal, cutaneous, enterovaginal, enterovesicular), sepsis, ischemia, gallstones

Crohn's Surgical Indications

Failure of medical management 

Complete or recurrent intestinal obstructions or abscess

Perforation (free air), hemorrhage, failure to thrive, +/- fistula

Toxic megacolon, extensive disease, or cancer

Crohn's Surgical CI

Diffuse without localized complications

Crohn's Surgical Procedure

M/C operation is an ileocecectomy 

Palliative, not curative

Laparoscopic or open

Resect only involved bowel

Ulcerative Colitis S/S

Only occurs in the colon

Typically starts at the distal rectum and moves proximally depending on how severe the disease is

Inflammation extends in a continuous fashion

Blood diarrhea (watery), tenesmus, abd pain, rectal urgency, fecal incontinence, weight loss, arthralgias

Inflammation of colonic mucosa with ulcerations - hyperemic and hemorrhagic

May affect terminal ileum

UC Surgical Indications

Massive hemorrhage

Perforation

Toxic megacolon

Cancer

Dysplasia

Refractory disease

UC Surgical CI

Poor surgical candidates

Medically controlled disease

UC Surgical Procedure

Total colectomy with ileoanal J pouch is curative (same surgery as FAP)

Regular proctoscopic surveillance is required bc colonic mucosa is retained, leaving risk of future cancer development

Hepatic Tumors S/S

Weight loss

RUQ pain

Jaundice

Hepatomegaly

Hepatic Tumor Surgical Indications

Resectable localized malignancy

Symptomatic benign tumor

Prevention of tumor complications

Adequate future liver remnant

Hepatic Tumors CI

Extensive liver metastases

Poor liver function

Hepatic Tumors Surgical Options

Partial hepatectomy 

Tumor ablation 

Liver transplant in select cases

Hepatic Abscess S/S

Pyogenic → liver abscess formed d/t bacterial infection

Amoebic → parasitic infection causing liver abscess d/t entamoeba histolytica

Hepatic Abscess Surgical Indications

Failure of abx or drainage 

Large abscess/multiple abscesses 

Sepsis

Need for source control

Hepatic Abscess Surgical CI

Stable patients with abscesses draining successfully

Aspiration/Drainage

what is the surgical procedure for a hepatic abscess?

Gallbladder CA S/S

RUQ pain

Jaundice

Weight loss

Gallbladder CA Surgical Indications

Early stage disease without metastasis

Gallbladder CA Surgical CI

Metastatic/unresectable disease

Poor surgical candidate

Gallbladder CA Surgical Procedure

Cholecystectomy with wedge resection of an adjacent 3-5 cm of normal liver and dissection of lymph nodes in hepatoduodenal ligament

If diagnosis is picked up on path report from a routine cholecystectomy, patient may need to be reopened for liver resection if tumor is beyond T1a

Cholangiocarcinoma S/S

RUQ pain

Jaundice

Weight loss

resectable tumor

what is the indication for surgery for a cholangiocarcinoma?

Cholangiocarcinoma Surgical CI

Metastatic disease

Inoperable tumors

Cholangiocarcinoma Surgical Procedure

Intrahepatic → hepatectomy 

Perihilar → bile duct resection + hepatectomy 

Distal → pancreaticoduodenectomy (whipple)

Blumer's Shelf

-A palpable mass in the rectovesical pouch (men) or rectouterine pouch/douglas pouch (women) felt on rectal exam

-Indicates metastatic spread to the peritoneum, classically from gastric carcinoma, but may also occur with pancreatic or CRC

-Suggests advanced intra-abdominal malignancy/poor prognosis 

Virchow's Node

-Left supraclavicular lymph node enlargement (troisier’s sign)

-Caused by spread of abdominal malignancy through the thoracic duct

-Strongly associated with gastric cancer, but can occur in pancreatic, esophageal, or other GI cancers

-Concerning for metastatic disease

Sister Mary Joseph Nodule

-Firm periumbilical/umbilical nodule caused by metastatic cancer spread to the umbilicus

-Commonly associated with gastric, pancreatic, ovarian, or CRC

-Indicates advanced intra-abdominal or pelvic malignancy and poor prognosis

Krukenberg Tumor

-Metastatic tumor to the ovaries, usually bilateral, classically from gastric adenocarcinoma (signet ring cell type)

-May also originate from CRC or pancreatic cancer

-Indicates metastatic GI malignancy

Irish Node

-Enlarged left axillary lymph node associated with gastric cancer metastasis

-Less common than virchow’s node but also suggests advanced metastatic disease

Appendectomy

Surgical removal of the appendix, most commonly for acute appendicitis

Appendectomy Surgical Indications

Acute appendicitis (m/c)

Appendiceal perforation

Appendiceal abscess

Suspicion for appendiceal tumor/malignancy

Appendectomy Approach

-Usually laparoscopic appendectomy (“lap appy”)

-Small abd incisions with camera-guided removal of appendix

-Preferred d/t faster recovery, less pain, lower wound infection risk

-Open appendectomy may be used for complicated perforation or extensive infection 

-Rarely treated with abx alone, but recurrence risk is high and malignancy may be missed

Appendectomy Goal

Remove inflamed appendix before perforation or generalized peritonitis develops

Cholecystectomy

Surgical removal of the gallbladder, typically for symptomatic gallbladder disease

Cholecystectomy Surgical Indications

Acute cholecystitis (m/c)

Symptomatic gallstones (biliary colic)

Gallstone complications (choledocholithiasis, gallstone pancreatitis)

Gallbladder dysfunction/polyps suspicious for malignancy

Gallbladder cancer

Laparoscopic Cholecystectomy

Gold standard

Minimally invasive removal using small incisions and camera

Short recovery and less post-op pain

Cholecystectomy Goal

Remove gallbladder to eliminate obstruction/inflammation and prevent recurrent biliary complications

Colostomy

Surgical creation of an opening (stoma) connecting the colon to the skin surface for fecal diversion

Colostomy Indications

Bowel perforation

Obstruction

Distal CRC

Diverticulitis

Trauma

Anastomotic protection/healing

End Colostomy

-Purpose: diverts stool completely through one end of colon brought to the skin 

-Use: often permanent after rectal resection or temporary in emergencies

-Approach: proximal bowel end forms stoma; distal bowel closed or left as hartmann pouch

Loop Colostomy

-Purpose: temporary fecal diversion to protect distal bowel/anastomosis

-Use: used when bowel continuity will likely be restored later

-Approach: a loop of colon is brought to the surface and opened, creating proximal and distal openings in the same stoma

Brooke Ileostomy

Standard end ileostomy where the ileum is everted ("spouted") and sutured to the skin

Brooke Ileostomy Indications

Ulcerative colitis

FAP

Chron's disease

CRC requiring colectomy

Kock Pouch

Continent ileostomy with an internal reservoir made from ileum

Kock Pouch Indications

Patients unable to have ileal pouch-anal anastomosis (J pouch)

Alternative to standard ileostomy

Kock Pouch Approach

Internal pouch created from small bowel with valve mechanism

Patient periodically inserts catheter to empty stool

Hartmann's Pouch

Distal blind rectal/sigmoid stump left after resection with end colostomy

Hartmann's Pouch Indications

Complicated diverticulitis

Perforation

Obstruction

Emergency colorectal surgery

Hartmann's Pouch Approach

Disease colon removed → proximal colon becomes end colostomy → distal rectal stump is closed (hartmann pouch)

Mucus Fistula

Opening of distal bowel segment to skin allowing mucus and gas drainage

Purpose: prevents buildup of secretions and distal perforation

Mucus Fistula Indication

Temporary bowel diversion

Distal bowel left in place after ostomy creation

Ileal Conduit (urostomy)

Urinary diversion using a segment of ileum to carry urine from ureters to abdominal wall stoma

Purpose: permanent urinary drainage after bladder removal or dysfunction

Ileal Conduit Indications

Bladder cancer (m/c)

Severe bladder dysfunction

Trauma/congenital abnormalities

Fistula

An abnormal connection (tract) between two epithelialized surfaces

Fistula Significance

Can lead to:

Fluid/electrolyte losses

Malnutrition

Sepsis/infection

Skin breakdown (esp high output fistulas)

Fistula - Post Op Causes

Anastomotic leak

Surgical injury to bowel

Poor wound healing

Infection/abscess formation

Tissue ischemia

Radiation injury

Foreign bodies/drains

Fistula Inflammatory Causes

Crohn's

Recurrent abscesses

Diverticulitis

Chronic pancreatitis/pancreatic pseudocysts