Surgery Marrow Pg 181-190 (GIT)
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Questions and Answers

What is the most common complication of sleeve gastrectomy?

  • Nutritional deficiency
  • Leak from angle of His
  • Gastro-esophageal reflux
  • Bleeding from staple line (correct)

    • Nutritional deficiencies may arise from sleeve gastrectomy due to a decrease in food consumption.

    True

    What type of surgical technique is used in sleeve gastrectomy?

    Notes procedure

    The procedure known as __________ is a type of primary obesity surgery performed endoscopically.

    <p>Endocinch</p> Signup and view all the answers

    Match the following complications with their descriptions:

    <p>Nutritional deficiency = Deficiency in iron, Vitamin B, and Calcium Bleeding from staple line = Most common post-operative complication Leak from angle of His = Requires revision if persistent DVT/PE = Risk of deep vein thrombosis or pulmonary embolism</p> Signup and view all the answers

    What is the initial investigation for caecal volvulus?

    <p>X-ray abdomen (Erect and supine)</p> Signup and view all the answers

    Caecopexy is performed only in cases with peritonitis.

    <p>False</p> Signup and view all the answers

    List one cause of intestinal strictures.

    <p>Cancer</p> Signup and view all the answers

    In Heineke-mikulicz stricturoplasty, the strictures are handled using ___ approach.

    <p>longitudinal</p> Signup and view all the answers

    Match the type of stricturoplasty with its description:

    <p>Heineke-mikulicz = Longitudinal stricturoplasty Finney's = Transverse stricturoplasty Stricturoplasty (a types) = Side-to-side anastomosis</p> Signup and view all the answers

    Which of the following is a potential complication of laparoscopic gastric banding?

    <p>Band slippage</p> Signup and view all the answers

    The Allurion balloon used in intra-gastric balloon placement is non-dissolving.

    <p>False</p> Signup and view all the answers

    What should patients supplement after gastric banding surgery?

    <p>multivitamin, minerals, and thiamine</p> Signup and view all the answers

    The distance from the GE junction to where the adjustable band is placed during gastric banding is __________ cm.

    <p>6</p> Signup and view all the answers

    Match the following surgical procedures to their order of maximum weight loss:

    <p>Bariatric Bypass (BPD/DS) = 1 Sleeve Gastrectomy = 2 Gastric Bypass = 3 Gastric banding = 4</p> Signup and view all the answers

    What sign may indicate a large bowel obstruction when viewed on an X-ray?

    <p>Coffee bean sign</p> Signup and view all the answers

    In caecal volvulus, the apex of the distended bowel typically points to the right shoulder.

    <p>False</p> Signup and view all the answers

    Which feature is NOT associated with Adynamic Bowel Obstruction?

    <p>Hyperdynamic sounds (+)</p> Signup and view all the answers

    What is the emergency procedure for sigmoid volvulus if there are no signs of peritonitis?

    <p>Emergency sigmoidoscopic decompression</p> Signup and view all the answers

    In cases of perforated caecal volvulus, the procedure involves performing a __________ followed by a colostomy.

    <p>Hartmann's Procedure</p> Signup and view all the answers

    Obstruction in the upper GI tract typically presents with distension first.

    <p>False</p> Signup and view all the answers

    Match the type of volvulus with their respective characteristics:

    <p>Sigmoid volvulus = Apex points to right shoulder; no signs of peritonitis Caecal volvulus = Apex points to left shoulder; small intestine distended Emergency management = Sigmoidoscopy for sigmoid; laparotomy for caecal Definitive surgery = Sigmoidopexy or sigmoidectomy for sigmoid; Hartmann's for caecal</p> Signup and view all the answers

    What is the initial investigation used to diagnose bowel obstruction?

    <p>X-ray abdomen</p> Signup and view all the answers

    In bowel obstruction, > 3 air-fluid levels on an erect X-ray suggest ______.

    <p>obstruction</p> Signup and view all the answers

    Match the type of bowel obstruction with the corresponding characteristic:

    <p>Dynamic Bowel Obstruction = Bowel contraction (+) Adynamic Bowel Obstruction = Silent abdomen (+)</p> Signup and view all the answers

    Which type of anastomosis is performed in a Roux-en-Y mini gastric bypass?

    <p>Both A and B</p> Signup and view all the answers

    The Roux Limb length is fixed at 100 cm for all patients undergoing the procedure.

    <p>False</p> Signup and view all the answers

    What is the most common cause of mortality in the first month after Roux-en-Y mini gastric bypass?

    <p>DVT - Pulmonary Embolism (PE)</p> Signup and view all the answers

    Anastomotic leaks can lead to symptoms such as __________ in the abdomen.

    <p>pain</p> Signup and view all the answers

    Match the following complications with their descriptions:

    <p>DVT - Pulmonary Embolism = High risk in the first month, most common cause of mortality Anastomotic Leak = Pain, peritonitis with rebound tenderness Nutritional Deficiencies = Iron deficiency anemia and neurological symptoms Internal Hernias = Stemmer's and Petersen's hernias</p> Signup and view all the answers

    Which patient group has the longest Roux Limb length?

    <p>Superobese Patients</p> Signup and view all the answers

    Nutritional deficiencies are a potential complication of Roux-en-Y mini gastric bypass.

    <p>True</p> Signup and view all the answers

    What diagnostic tools are mentioned for managing complications like leaks?

    <p>USG and CT Scan</p> Signup and view all the answers

    The __________ is the removed portion of the stomach in the Roux-en-Y mini gastric bypass.

    <p>gastric pouch</p> Signup and view all the answers

    Which of the following is NOT a potential complication of Roux-en-Y mini gastric bypass?

    <p>Hypoglycemia</p> Signup and view all the answers

    What is the initial management step for bowel obstruction?

    <p>Nil per oral</p> Signup and view all the answers

    The jejunum appears featureless when affected by bowel obstruction.

    <p>False</p> Signup and view all the answers

    What is the primary definitive management for bowel obstruction?

    <p>Emergency exploratory laparotomy</p> Signup and view all the answers

    The critical diameter for the small intestine is _____ cm.

    <p>3</p> Signup and view all the answers

    Match the bowel section with its description:

    <p>Jejunum = Feathery appearance Ileum = Featureless loops Large bowel = Peripherally arranged Critical diameter = 3 cm (small intestine)</p> Signup and view all the answers

    What is a common clinical feature of jejunal atresia?

    <p>Bilious vomiting</p> Signup and view all the answers

    Intussusception can occur as a result of hypertrophy of Peyer’s patches in children.

    <p>True</p> Signup and view all the answers

    What is the primary management for jejunal atresia?

    <p>Emergency laparotomy with resection and anastomosis</p> Signup and view all the answers

    Type ___ of intestinal atresia refers to an atretic cord with an intact mesentery.

    <p>II</p> Signup and view all the answers

    Match the type of intussusception to its description:

    <p>Primary = Occurs in children; often related to Peyer’s patches Secondary = Caused by pathological lead points like polyps or cancer</p> Signup and view all the answers

    What is the most common type of duodenal atresia?

    <p>Type I</p> Signup and view all the answers

    The double-bubble sign is primarily indicative of congenital hypertrophic pyloric stenosis (CHPS).

    <p>False</p> Signup and view all the answers

    List one clinical feature of duodenal atresia.

    <p>Vomiting since birth or Bilious vomiting</p> Signup and view all the answers

    In checking for bowel viability, a viable bowel shows a ________ color and may have visible mesenteric artery pulsations.

    <p>dark</p> Signup and view all the answers

    Match the following conditions with their associated imaging findings:

    <p>Duodenal Atresia = Double-bubble sign Congenital Hypertrophic Pyloric Stenosis = Single-bubble sign Both = X-ray or Ultrasound</p> Signup and view all the answers

    Which of the following is NOT a symptom of intussusception in children?

    <p>Fever and chills</p> Signup and view all the answers

    Volvulus can occur due to twisting of a bowel loop around its vessels.

    <p>True</p> Signup and view all the answers

    What imaging technique is considered the investigation of choice (IOC) for adults presenting with intussusception?

    <p>CECT Abdomen</p> Signup and view all the answers

    A diagnostic sign observed in intussusception can be described as the _____ sign, which appears as one bowel loop inside another.

    <p>Target/Donut</p> Signup and view all the answers

    Match the following clinical features or signs to their corresponding conditions:

    <p>Sigmoid Volvulus = Long and narrow mesentery Intussusception = Sausage-shaped mass Bowel Obstruction = Prominent distension</p> Signup and view all the answers

    Study Notes

    Sleeve Gastrectomy

    • Surgical procedure for weight loss
    • Functions by reducing the size of the stomach, leading to early satiety
    • Promotes weight loss by decreasing food consumption
    • Common Complications:
      • Nutritional deficiencies: Iron, Vitamin B, and Calcium
      • Bleeding from staple line
      • Leakage from angle of His: Requires revision surgery
      • Deep vein thrombosis (DVT) and pulmonary embolism (PE)
      • Gastro-esophageal reflux
      • Barrett's esophagus
      • Weight gain due to redisention of the sleeve
    • Procedure Types:
      • ROSE (Restorative Obesity Surgery Endoscopically)
      • Endocinch: Primary obesity surgery endoscopically
      • TOGA (Transoral Gastroplasty)

    Roux en Y Mini Gastric Bypass

    • Types:
      • Gastrojejunostomy
      • Jejunojejunostomy
    • Procedure Description:
      • Creates a gastric pouch
      • Removes a portion of the stomach
      • Connects the small intestine to the pouch
      • Bypasses a portion of the small intestine
      • The length of the Roux limb varies depending on the patient's condition:
        • Peptic ulcer: 50 cm
        • Bariatric surgery patients: 100 cm
        • Superobese patients: 150 cm
    • Complications:
      • DVT/PE: Most common cause of mortality
      • Anastomotic leak: Can cause peritonitis
      • Nutritional deficiencies: Iron, Vitamin B, and Calcium
      • Internal hernias: Stemmer's and Petersen's hernias
      • Anastomotic ulcer/stricture: Narrowing of the connection site

    B. CAECAL VOLVULUS

    • Predisposing Factors:
      • Mobile caecum
      • Caecal bascule (Type of mobile caecum)
    • Investigations:
      • X-ray abdomen (Erect and supine)
      • CECT abdomen: IOC
    • Management:
      • If no peritonitis: Laparotomy - (R) Hemicolectomy
      • If peritonitis: (R) Hemicolectomy
      • Caecopexy: Derotate anti-clockwise

    Intestinal Strictures

    • Causes:
      • Cancer
      • Post radiotherapy
      • TB
      • Crohn's
    • Investigations:
      • X-ray abdomen (Erect & supine): Initial investigation
    • Management:
      • If multiple strictures close together: Resection + Anastomosis
      • If strictures are far apart: Stricturoplasty
        • Side-to-side anastomosis
        • Heineke-mikulicz stricturoplasty
        • Finney's stricturoplasty

    Reversible Surgery: Laparoscopic Gastric Banding

    • Procedure
      • Adjustable band placed 6 cm from the GE junction
      • Port of balloon placed near umbilicus
      • Post-surgery: Balloon inflated with NS
    • Complications
      • Access port infection
      • DVT/PE
      • Band infection
      • Tubing leak
      • Band slippage leading to weight gain
      • Stomach erosion
      • Band intolerance
      • Weight regain
    • Intra-gastric Balloon Placement: Endoscopically placed balloon
      • Allurion: Self-dissolving balloon
    • Nutritional Guidelines:
      • After gastric banding: Multivitamins, minerals, and thiamine
      • After sleeve gastrectomy and gastric bypass: Same as gastric banding, plus selenium, copper, zinc, folic acid, and Vitamins B, A, E, and K

    Bowel Obstruction: Part 1

    • Investigations:
      • X-ray abdomen (Erect and supine)
        • Coffee bean sign/Bent inner tube sign
        • Distended large intestine
        • Apex to (Right) shoulder
      • CECT abdomen: 10C
      • Contrast enema: Bird's beak/Ace of spades appearance
    • Management
      • Sigmoid volvulus:
        • No c/o peritonitis: Emergency sigmoidoscopic decompression + Definitive Sx
          • Sigmoidopexy
          • Sigmoidectomy
      • Caecal volvulus:
        • Apex → (Left) Shoulder tip
        • Small intestine distended
        • Peritonitis
        • Sepsis
        • Emergency Laparotomy + Resection of perforated segment
        • Colostomy
        • Creation of stoma
        • Re-anastomosis (once healed)
        • 6-8 weeks

    BOWEL OBSTRUCTION: PART 1

    • Types
      • Dynamic Bowel Obstruction: Mechanical obstruction, bowel contraction (+), hyperdynamic sounds (+)
      • Adynamic Bowel Obstruction: No mechanical obstruction, bowel contraction (-), no hyperdynamic sounds, silent abdomen (+)
    • CLINICAL FEATURES
      • Abdominal pain
      • Distension
      • Vomiting
      • Obstruction
    • INVESTIGATIONS
      • Initial investigation: X-ray abdomen
        • Adults: CT abdomen
        • Children: USG abdomen
      • Erect X-ray: > 3 air-fluid levels suggest obstruction
      • Supine X-ray: Used to note site of obstruction

    Jejunal Atresia

    • Non-canalization of the jejunum
    • Clinical Features:
      • Cardinal features of bowel obstruction
      • Bilious vomiting
      • X-ray: Triple bubble sign
    • Management: Emergency laparotomy -> Resection and anastomosis

    Note: Types of Intestinal atresia

    Type Description
    Type I Mucosal web or diaphragm
    Type II Atretic cord; intact mesentery
    Type IIIa Blind ends of bowel
    Type IIIb
    Type IV Multiple atresia or string of sausage appearance

    Intussusception

    • Telescoping of one bowel loop into the other
    • Intussuscepiens: Receiving portion
    • Intussusceptum: Telescoping portion
    • Types:
      • Primary: Children (6 months - 2 years), Hypertrophy of Peyer's patches, Ileocolic (Ileum → Colon)
      • Secondary: 2° to a pathological lead point: Polyp, Cancer, Meckel's diverticulum, Colo-colic (Colon → Colon)
    • Clinical FEATURES (both types): Cardinal features of bowel obstruction

    Bowel Obstruction: Part 1

    • Jejunum: Feathery appearance, complete volvulus, concertina/step ladder pattern
    • Ileum: Featureless loops
    • Large bowel: Peripherally arranged, incomplete haustrations
    • Critical diameters:
      • Small intestine: 3 cm
      • Large intestine: 6 cm
      • Caecum: 9 cm
    • MANAGEMENT
      • Initial conservative mx:
        • Nil per oral
        • i/v fluids (Ringer's Lactate)
        • Ryle tube/NG tube → Decompression
        • i/v antibiotics: Aerobic, anaerobic, and gram negative cover
        • i/v painkillers
      • Definitive mx: Emergency exploratory laparotomy
        • Caecum visualized first
        • Collapsed → Small intestinal obstruction
        • Distended → Large intestinal obstruction
        • Viable → Check for viability
        • Retain (if viable)
        • Non-viable → Resection and anastomosis/Stoma

    Viable vs. Non-viable bowel

    Feature Viable Bowel Non-Viable Bowel
    Circulation Dark color, becomes lighter.Visible mesenteric artery pulsations Dark color remains.Mesenteric artery pulsations (−)
    General Appearance Shiny Dull and lustreless
    Intestinal Musculature Firm.Peristalsis (may be observed) Flabby, thin, and friable.No peristalsis

    Duodenal Atresia

    • One of the most common causes of bowel obstruction in neonates
    • Due to non-canalization of the duodenum
    • Associated with Down's syndrome (mothers often have polyhydramnios)
    • Clinical Features:
      • Vomiting since birth
      • Bilious vomiting
    • D/d
      • Congenital hypertrophic pyloric stenosis (CHPS)
    Condition Clinical Picture Associations Imaging Treatment
    CHPS Normal at birth; non-bilious, projectile vomiting after a few weeks First born male child USG Abdomen Ramstedt pyloromyotomy
    Duodenal Atresia Vomiting since birth; bilious vomiting Down's syndrome X-ray (Double-bubble sign) Diamond Duodeno-duodenostomy

    Gastrointestinal and Abdominal Surgery

    Intussusception

    • In Children:
      • Symptoms: Drawing up of legs due to pain, red currant jelly stools, and signs of dance
      • Investigations:
        • USG Abdomen: Target/Donut sign and Pseudokidney sign
        • Contrast Enema: Claw/Pincer sign (diagnostic and therapeutic)
        • Contraindications: Recurrent intussusception, pathological lead point, and strangulation
    • In Adults:
      • Investigations: CECT Abdomen (IOC).
      • Surgery: Reduction of intussusception, Resection and anastomosis if perforation, strangulation, or pathological lead point

    Volvulus

    • Definition: Twisting of a bowel loop around its vessels
    • Sigmoid Volvulus (Predisposing Factors):
      • Long and narrow mesentery
      • Redundant sigmoid
      • Loaded sigmoid
      • Patient on anti-psychotic medications
      • Institutionalized patients
    • Clinical Features: Cardinal features of bowel obstruction, prominent distension, obstipation (constipation), closed loop obstruction with high chances of strangulation

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    Description

    This quiz covers two popular surgical procedures for weight loss: Sleeve Gastrectomy and Roux en Y Mini Gastric Bypass. It will explore their functions, common complications, and various procedure types. Test your knowledge on the intricacies of these weight loss surgeries.

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