Vishal Garg, MS

Provides answers to the most frequent question from patients who have undergone GI surgery: “What can I eat from now?”   Pathophysiologic   Implications   Left colostomy: left (distal) colostomy has minimal implication on the pathophysiology of nutrition in these patients, since the only organ bypassed is the rectum which normally is devoted to storage of the feces, minor effects on the final dehydration of the stools, and control of the defecation.  Nevertheless, the nutritionists should be aware of the profound changes in the microbiota induced by the mechanical bowel preparation and prolonged antibiotic therapy which normally occur in patients undergoing colorectal surgery and suggest pre/probiotic treatments.  The output through the stoma is formed stools, and the frequency of the bowel movement and consistency of the feces strongly depends on the preoperative bowel habit (patients with slow transit constipation remain constipated) and type of diet and drinking.  Coecostom

Enhanced recovery after surgery protocol Hepatectomy Pancreatectomy No NGT inserted Inserted for major hepatectomy only, remove on POD 1 regardless of output Inserted only for pancreatoduodenectomy, removed on POD 1 regardless of output Surgical drains Always one drain for major hepatectomies, no drains for minor Single drain after distal pancreatectomy, two drains (anterior and posterior to pancreatojejunostomy) after pancreatoduodenectomy Drain management Drain fluid bilirubin on PODs 1 and 3, remove on POD 3 if levels less than three times that of serum Drain fluid for amylase on PODs 1 and 3, remove on POD 3 if clinically well and amylase level < 1000 Urinary catheter Remove on POD 1 Remove on POD 1 POD 1 diet Clears with daily limit 1000 cc Clears with daily limit 1000 cc (distal resections) Clears with daily limit 500 cc (pancreatoduodenectomy) POD 2 diet Unrestricted clears Unrestricted clears for distal resections, 1000 cc limit per day in pancreatoduodenectomy patients POD

Alkali-induced injury  – Ingestion of alkali (eg, ammonia or sodium hydroxide) acutely results in a penetrating injury called liquefactive necrosis. The injury extends rapidly (within seconds) through the mucosa and wall of the esophagus towards the mediastinum until tissue fluids buffer the alkali. Extensive transmural damage may result in esophageal perforation, mediastinitis, and death. In the stomach, partial neutralization of the ingested alkali by gastric acid may result in more limited injur. Among patients with alkaline ingestions, gastric injury is most common in those who ingest relatively large volumes (200 to 300 mL). Duodenal injury is much less common as compared with the stomach and esophagus, occurring in 30 percent in one series, in contrast to 94 and 100 percent respectively. The process of liquefactive necrosis usually lasts three to four days and is associated with vascular thrombosis and mucosal inflammation, resulting in focal or extensive sloughing and ulceration

  Possible Mechanism of IFALD Intestinal failure associated liver disease (IFALD) is probably the most important complication affecting children with IF on long-term PN. The prevalence of the disorder is unknown because there is no established definition of liver disease in this setting and it is unclear as to whether IFALD should be diagnosed on the basis of clinical, biological, or histological criteria. Indeed, there are insufficient data on the degree and type of liver involvement in patients with long-term PN (Goulet  2015 ; Kaufman et al.  2010 ). The main factors contributing to liver injury in these patients are recurrent catheter-related sepsis ,  p rematurity and low birth weight, lack of enteral feeding, disruption of entero-hepatic biliary acid cycle   (proximal stoma, ileal resection),  intestinal stasis, and bacterial overgrowth  (obstruction, dysmotility, lack of ileo-caecal valve, over-tube feeding…). Factors affecting the onset and the expression of IFALD that are spec

Intestinal failure (IF) was first described in 1981 by Fleming and Remington as the “reduction in gut mass resulting in the loss of the ability of digestion and absorption of food molecules   Functional Classification Basis of onset, metabolic, and expected outcome criteria. Type 1 transient intestinal failure  Type 2 long-term intestinal failure Type 3 chronic intestinal failure    Type 1. Transient, frequent, usually self-limiting, lasting less than 28 days but may need treatment, supplementation or nutritional support. Ileus, by far the most frequently encountered version of IF, may be minimized, but there is no widely accepted single treatment for this commonly seen phenomenon amongst general surgeons.  ex:  post-operative ileus Type 2. This type is severe, often complex and longer-term and requires nutritional support during expectant or conservative management. This type may arise from acute episodes of medical illness but increasingly from surgery or surgical complications. T