280 Section II / General Surgery
Why is it thought that the postoperative survival is so much higher in Japan?
Aggressive screening and capturing early cancers
GIST
What is it? |
GastroIntestinal Stromal Tumor |
What was it previously |
Leiomyosarcoma |
known as? |
|
What is the cell of origin? |
CAJAL, interstitial cells of Cajal |
Where is it found? |
GI tract—“esophagus to rectum”—most |
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commonly found in stomach (60%), |
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small bowel (30%), duodenum (5%), |
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rectum (3%), colon (2%), esophagus (1%) |
What are the symptoms? |
GI bleed, occult GI bleed, abdominal |
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pain, abdominal mass, nausea, |
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distention |
How is it diagnosed?
How are distant metastases diagnosed?
What is the tumor marker?
What is the prognosis?
What is the treatment?
Is there a need for lymph node dissection?
What is the chemotherapy for metastatic or advanced disease?
CT scan, EGD, colonoscopy
PET scan
C-KIT (CD117 antigen)
Local spread, distant metastases Poor long-term prognosis: size 5cm,
mitotic rate 5 per 50 HPF (high power field)
Resect with negative margins, / chemotherapy
NO
Imatinib—tyrosine kinase inhibitor
|
Chapter 42 / Bariatric Surgery 281 |
MALTOMA |
|
|
|
What is it? |
Mucosal-Associated Lymphoproliferative |
|
Tissue |
What is the most common |
Stomach (70%) |
site? |
|
What is the causative agent? |
H. pylori |
What is the medical |
Nonsurgical—treat for H. pylori with |
treatment? |
triple therapy and chemotherapy/XRT in |
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refractory cases |
GASTRIC VOLVULUS |
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|
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What is it? |
Twisting of the stomach |
What are the symptoms? |
Borchardt’s triad: |
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1. Distention of epigastrium |
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2. Cannot pass an NGT |
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3. Emesis followed by inability to |
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vomit |
What is the treatment? |
Exploratory laparotomy to untwist, and |
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gastropexy |
C h a p t e r 42 |
Bariatric Surgery |
What is it? |
Weight reduction surgery for the |
|
morbidly obese |
Define morbid obesity. 1. BMI 40 (basically, 100 pounds above ideal body weight) or
2.BMI 35 with a medical problem related to morbid obesity
What is the BMI? |
Body Mass Index |
What is the formula for BMI? Body weight in kg divided by height in meters squared
282 Section II / General Surgery
What is a formula for a rough estimate of BMI without using metric measures?
What medical conditions are associated with morbid obesity?
What are the current options for surgery?
Define gastric bypass.
Wt (pounds) 703
(Ht in inches)2
Sleep apnea, coronary artery disease, pulmonary disease, diabetes mellitus, venous stasis ulcers, arthritis, infections, sexhormone abnormalities, HTN, breast cancer, colon cancer
Gastric bypass (malabsorptive)
Vertical-banded gastroplasty
Stapling off of small gastric pouch (restrictive)
Roux-en-Y limb to gastric pouch (bypass)
How does gastric bypass |
1. |
Creates a small gastric reservoir |
work? |
2. |
Causes dumping symptoms when a |
|
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patient eats too much food or high- |
|
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calorie foods; the food is “dumped” |
|
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into the Roux-en-Y limb |
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3. |
Bypass of small bowel by Roux-en-Y |
|
|
limb |
Which operation works best overall?
What are the possible postoperative complications after weight reduction surgery?
What is the most common sign of an anastomotic leak after a gastric bypass?
What is the incidence of anastomotic leak?
What is the mortality rate of an anastomotic leak?
What is a lap-band?
Chapter 42 / Bariatric Surgery 283
Gastric bypass (mean weight loss 50% of excess weight)
Gallstones (if gallbladder in situ), anastomotic leak, marginal ulcer, stenosis of pouch/anastomosis, malnutrition, incisional hernia, spleen injury, iron deficiency, B12 deficiency
Tachycardia
3% (1%–5%)
10%
Laparoscopically placed band around stomach with a subcutaneous port to adjust constriction; results in smaller gastric reservoir
What is a Petersen’s hernia? Seen after bariatric gastric bypass— internal herniation of small bowel through the mesenteric defect from the Roux-en-Y limb
284 Section II / General Surgery
C h a p t e r 43 |
Ostomies |
Define the following terms: |
|
Ostomy |
Operation that connects the GI tract to |
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abdominal wall skin or the lumen of |
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another hollow organ; a man-made fistula |
Stoma |
Opening of the ostomy (Gr. “mouth”) |
Gastrostomy |
G-tube through the abdominal wall to |
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the stomach for drainage or feeding |
Jejunostomy |
J-tube through the abdominal wall to the |
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jejunum for feeding |
Kock pouch |
“Continent ileostomy” |
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Pouch is made of several ileal loops |
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Patient must access the pouch with a |
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tube intermittently |
Colostomy |
Connection of colon mucosa to the |
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abdominal wall skin for stool drainage |
End colostomy |
Proximal end of colon brought to the skin |
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for stool drainage |
Mucous fistula |
Distal end of transected colon brought to |
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the skin for decompression; the mucosa pro- |
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duces mucus, an ostomy is a fistula, and, |
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hence, the term mucous fistula (proximal |
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colon brought up as a colostomy or, if the |
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proximal colon is removed, an ileostomy) |
Hartmann’s pouch |
Distal end of transected colon stapled |
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and dropped back into the peritoneal |
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cavity, resulting in a blind pouch; mucus |
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is decompressed through the anus |
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(proximal colon is brought up as an end |
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colostomy or, if proximal colon is |
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removed, an end ileostomy) |
Double-barrel colostomy |
End colostomy and a mucous fistula |
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(i.e., two barrels brought up to the skin) |
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Chapter 43 / Ostomies 285 |
Loop colostomy |
Loop of large bowel is brought up to the |
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abdominal wall skin and a plastic rod is |
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placed underneath the loop; the colon is |
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then opened and sewn to the abdominal |
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wall skin as a colostomy |
Ileal conduit |
Loops of stapled-off ileum made into a |
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pouch, anastomosed to the ureters, and |
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then brought to the abdominal wall skin |
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to allow drainage of urine in patients |
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who undergo removal of the bladder |
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(cystectomy) |
Brooke ileostomy |
Ileostomy folded over itself to provide |
|
clearance from skin |