Short-turnover protein (prealbumin, retinol-binding protein, transferrin) levels should be measured at least weekly to assess the adequacy of protein delivery. An ongoing catabolic state will adversely affect short-turnover protein levels, even with maximal protein delivery.
Failure of an enterocutaneous fistula to close spontaneously is associated with acronym FRIENDS):
the presence of a foreign body within the tract or adjacent to it, previous radiation exposure of the site, ongoing inflammation (most commonly from Crohn disease) or infection that contributes to a catabolic state, epithelialization of the fistula tract (particularly if the fistula tract is less than 2 cm long), neoplasm, distal intestinal obstruction, and pharmacologic doses of steroids.
Fistulas associated with a concurrent pancreatic fistula also have a low rate of spontaneous closure, as do those occurring in the presence of malnutrition or adjacent infection.
In general, anatomic locations that are favorable for closure are the oropharynx, esophagus, duodenal stump, pancreas, biliary tree, and jejunum.
Investigations in lower GI bleed should be specific and less time consuming
Small bowel enteroclysis, which uses a tube to infuse barium, methylcellulose, and air directly into the small bowel, yields better images than simple small bowel follow-through. Because the yield has been reported to be very low and the test is poorly tolerated, it is now rarely used.
Capsule endoscopy uses a small capsule with a video camera. capsule endoscopy is an excellent tool for the patient who is hemodynamically stable but continues to bleed, with reported success rates as high as 90% in identifying a small bowel pathology.
The hemodynamically stable patient should undergo small bowel enteroscopy. Usually performed with a pediatric colonoscope, it is referred to as push endoscopy. It can reach about 50 to 70 cm past the ligament of Treitz in most cases and permits endoscopic management of some lesions. Overall, push enteroscopy is successful in 40% of patients .
Double-balloon endoscopy is another technique gaining in popularity. Although technically difficult, this approach is capable of providing a complete examination of the small bowel. In expert hands, double-balloon enteroscopy can identify a bleeding source in 77% of cases with occult bleeding, with the yield increasing to over 85% if the endoscopy is per-formed within 1 month of an overt bleeding episode.The advantage of this technique is that as well as visualization, biopsies can be performed and therapeutic interventions undertaken.
To conclude investigations in lower GI bleed have to be specific and have high sensitivity also.
Q After esophagectomy ICD draining 800 – 1000ml chyle 5-7 days post operatively. Next management
a) NPO, TPN
b) Enteral feeding with medium chain
c) Re explore and suture the defect
Once the diagnosis is made, one should ensure the pleural space is completely evacuated; if needed, drainage is done by a chest tube or a radiologically directed catheter placement.
Feedings are stopped and total parenteral nutrition (TPN) is started. The amount of chest tube output is then monitored for several days in order to make a decision about the possible need for reoperation. Small leaks can seal with nonoperative therapy. Large initial daily outputs (typically greater than 1 L/day) often fail nonoperative therapy and require reoperation. An absolute amount of drainage for prediction of failure is unknown and one should consider also if there is a gradual reduction in daily output to continue with conservative therapy.
If the drainage is less than 500 mL per day and slowly decreasing, continued conservative therapy is frequently successful. Continued volumes more than 1 L after 2 days of TPN is a good indication of the need for reoperation. In general, it is better to be more rather than less aggressive in returning to the operation theater with a chylothorax. It was more common after THE and was associated with longer intensive care unit (ICU) and hospital stays. There was no difference in mortality between those with and without a chylothorax.
Patients with initial drainage exceeding 2 L within 2 days of starting conservative treatment all required reoperation.
Sacral nerve stimulation is the newest modality in treatment for anal incontinence. In it electrodes are placed via the sacral foramina. The nerve supply of anal sphincter is similar to lower extremity so their stimulation can lead to contraction of various foot muscles.
Nissen fundoplication is complete 360 degree but has high incidence of gas bloat. To counter this modification done to wrap over 52 F tube for 1-2 cm
Belsey - Left thoracotomy, mobilization of distal esophagus and stomach, hiatus opened from above, fundus is brought 270 degrees around distal esophagus. Then the whole assembly is brought down and crura is repaired.
Hill procedure - No fundoplication is done
Toupet is anterior fundoplication either 240 degree or 270 degree.
Sharp objects can be removed over overtubes and not always require surgery. Lead batteries can corrode and decay in the stomach or intestine and should always be removed. Most common impacted foreign bodies are food boluses above a pathological narrowing and require endoscopic break up
Contrast examination is not always required and might complicate things
b) Submucosa is the strongest and most important layer for intestinal anastomosis. It has fibroblasts that will ultimately release collagen and hold the anastomosis together. This layer should be fully incorporated in the anastomosis.
Inverted Vs everted anastomosis of intestine debate has been log going on but now many prefer inverted because mucosa is exposed to mucosa and eventually degrades joining the two submuoca together to cause healing by primary intention.
Question on Duodenal atresia was asked in AIIMS 2017 in April
Q) An infant presents with duodenal atresia. Which of the following is true about this condition?
a) It is the most common GI atresia
b) It presents soon after birth with non bilious vomiting
c) Pre natal detection of duodenal atresia is common
d) Gastro jejunostomy is the procedure of choice to bypass the obstruction
Commonly detected in the pre natal ultrasound
Duodenal atresia is seen in 1:5000 live births and most common atresia is jejunoileal (1in 2000). It is associated with lot of other congenital malformations like Down's, prematurity, biliary atresia etc.
In exams like DNB SS questions on ASD and VSD are common. Most cardiac surgery questions are here
Q) Most common ASD is
a) Ostium Primum
b) Ostium Secundum
C) Sinus Venosus
d) All are equal
ASDs ■ Common defects
Ostium secundum: fossa ovalis defect (approximately 70 per cent of ASDs) Ostium primum: atrioventricular septal defect (approx imately 20 per cent of ASDs)
Sinus venosus defect: often associated with anomalous pulmonary venous drainage (approximately 10 per cent of ASDs) Patent foramen ovale: common in isolation, usually no left-to-right shunt (not strictly an ASD)
Inferior vena cava defects: a low sinus venosus defect and may allow shunting of blood into the left atrium
Coronary sinus septal defect: also known as unroofed coronary sinus with the left superior vena cava draining to the left atrium as part of a more complex lesion