264 Section II / General Surgery
TYPES OF SURGERIES
Define the following terms:
Graham patch For treatment of duodenal perforation in poor operative candidates/unstable patients
Place viable omentum over perforation and tack into place with sutures
Truncal vagotomy |
Resection of a 1- to 2-cm segment of |
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each vagal trunk as it enters the |
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abdomen on the distal esophagus, |
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decreasing gastric acid secretion |
What other procedure must be performed along with a truncal vagotomy?
“Drainage procedure” (pyloroplasty, antrectomy, or gastrojejunostomy), because vagal fibers provide relaxation of the pylorus, and, if you cut them, the pylorus will not open
Define the following terms:
Vagotomy and pyloroplasty Pyloroplasty performed with vagotomy to compensate for decreased gastric emptying
Chapter 40 / Upper GI Bleeding 265
Vagotomy and antrectomy Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II
What is the goal of duodenal Decrease gastric acid secretion (and fix ulcer surgery? IHOP)
What is the advantage of No drainage procedure is needed; vagal proximal gastric vagotomy fibers to the pylorus are preserved; rate (highly selective of dumping syndrome is low vagotomy)?
What is a Billroth I (BI)?
Truncal vagotomy, antrectomy, and gastroduodenostomy (Think: BI ONE limb off of the stomach remnant)
What are the contraindica- |
Gastric cancer or suspicion of gastric |
tions for a Billroth I? |
cancer |
266 Section II / General Surgery |
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What is a Billroth II (BII)? |
Truncal vagotomy, antrectomy, and |
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gastrojejunostomy (Think: BII TWO |
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limbs off of the stomach remnant) |
What is the Kocher |
Dissect the left lateral peritoneal |
maneuver? |
attachments to the duodenum to allow |
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visualization of posterior duodenum |
STRESS GASTRITIS |
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What is it? |
Superficial mucosal erosions in the |
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stressed patient |
What are the risk factors? |
Sepsis, intubation, trauma, shock, burn, |
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brain injury |
What is the prophylactic |
H2 blockers, PPIs, antacids, sucralfate |
treatment? |
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What are the signs/symptoms? |
NGT blood (usually), painless (usually) |
How is it diagnosed? |
EGD, if bleeding is significant |
What is the treatment for |
LAVAGE out blood clots, give a maximum |
gastritis? |
dose of PPI in a 24-hour IV drip |
MALLORY-WEISS SYNDROME |
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What is it? |
Post-retching, postemesis longitudinal |
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tear (submucosa and mucosa) of the |
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stomach near the GE junction; approxi- |
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mately three fourths are in the stomach |
Chapter 40 / Upper GI Bleeding 267
For what percentage of all |
10% |
upper GI bleeds does this syndrome account?
What are the causes of a tear?
What are the risk factors?
What are the symptoms?
What percentage of patients will have hematemesis?
How is the diagnosis made?
What is the “classic” history?
Increased gastric pressure, often aggravated by hiatal hernia
Retching, alcoholism (50%), 50% of patients have hiatal hernia
Epigastric pain, thoracic substernal pain, emesis, hematemesis
85%
EGD
Alcoholic patient after binge drinking— first, vomit food and gastric contents, followed by forceful retching and bloody vomitus
What is the treatment?
When is surgery indicated?
Can the SengstakenBlakemore tamponade balloon be used for treatment of Mallory-Weiss tear bleeding?
Room temperature water lavage (90% of patients stop bleeding), electrocautery, arterial embolization, or surgery for refractory bleeding
When medical/endoscopic treatment fails ( 6 u PRBCs infused)
No, it makes bleeding worse
Use the balloon only for bleeding from esophageal varices
ESOPHAGEAL VARICEAL BLEEDING
What is it? |
Bleeding from formation of esophageal |
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varices from back up of portal pressure |
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via the coronary vein to the submucosal |
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esophageal venous plexuses secondary to |
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portal hypertension from liver cirrhosis |
268 Section II / General Surgery
What is the “rule of two thirds” of esophageal variceal hemorrhage?
What are the signs/ symptoms?
How is the diagnosis made?
What is the acute medical treatment?
In the patient with CAD, what must you give in addition to the vasopressin?
What are the treatment options?
What is the SengstakenBlakemore balloon?
Two thirds of patients with portal hypertension develop esophageal varices
Two thirds of patients with esophageal varices bleed
Liver disease, portal hypertension, hematemesis, caput medusa, ascites
EGD (very important because only 50% of UGI bleeding in patients with known esophageal varices are bleeding from the varices; the other 50% have bleeding from ulcers, etc.)
Lower portal pressure with somatostatin and vasopressin
Nitroglycerin—to prevent coronary artery vasoconstriction that may result in an MI
Sclerotherapy or band ligation via endoscope, TIPS, liver transplant
Tamponades with an esophageal balloon and a gastric balloon