ABDOMIN III Flashcards
neuroendocrine tumor in pancrease - what do they include
Gastroenteropancreatic-neuroendocrine tumor (GEP-NET) is a unifying concept of related tumors including carcinoid tumors, functional endocrine tumors (e.g., insulinoma, gastrinoma), and nonfunctioning neuroendocrine tumors (e.g., islet cell tumors).
one-half are malignant, the neuroendocrine carcinomas can behave in an indolent fashion.
Resection is potentially curative, even in the face of metastatic disease.
Functional GEP-NETs should be resected, if possible, to palliate symptoms from hormonal production.
If surgical treatment is being considered, nonfunctional tumors with metastases should undergo resection of both the primary and metastatic lesions and can lead to significant long-term survival.
In this patient who was an otherwise excellent surgical candidate, a combination of a Whipple pancreaticoduodenectomy with resection of the liver lesion with concurrently or staged resection of the liver lesion is the best treatment option.
enucleation is an acceptable treatment for isolated small tumors involving the body and tail, a large tumor involving the head of the pancreas is not amenable to enucleation.
Patients with multiple hepatic lesions not amenable to resection can undergo liver-directed treatment with chemoembolization, radiofrequency ablation, cryotherapy, or other regional therapies.
Gastroenteropancreatic-neuroendocrine tumor
(GEP-NET) is a unifying concept of related tumors including carcinoid tumors, functional endocrine tumors (e.g., insulinoma, gastrinoma), and nonfunctioning neuroendocrine tumors (e.g., islet cell tumors). These tumors have a broad range of clinical presentations and behaviors. Although approximately one-half are malignant, the neuroendocrine carcinomas can behave in an indolent fashion.
Resection is potentially curative, even in the face of metastatic disease. Functional GEP-NETs should be resected, if possible, to palliate symptoms from hormonal production. If surgical treatment is being considered, nonfunctional tumors with metastases should undergo resection of both the primary and metastatic lesions and can lead to significant long-term survival.
In this patient who was an otherwise excellent surgical candidate, a combination of a Whipple pancreaticoduodenectomy with resection of the liver lesion with concurrently or staged resection of the liver lesion is the best treatment option. Peptide receptor therapy can be used to palliate endocrinopathies for patients with metastatic neuroendocrine tumors but would not be appropriate for treatment of the primary tumor. Octreotide is a valuable treatment in functional neuroendocrine tumors that are otherwise not resectable but does not have a role as a sole therapy for resectable lesions. Primary neuroendocrine tumors do not usually respond to radiation therapy; therefore, radiation plays no role in their treatment. Although enucleation is an acceptable treatment for isolated small tumors involving the body and tail, a large tumor involving the head of the pancreas is not amenable to enucleation. In addition, enucleation does not address the liver metastasis. Patients with multiple hepatic lesions not amenable to resection can undergo liver-directed treatment with chemoembolization, radiofrequency ablation, cryotherapy, or other regional therapies.
Splenic cysts parasitic
usually from Echinococcus
managment of painful umbilical hernia in patient with acsites, mesh? patent umbilical vein?
Safe elective repair comparable to the NON-cirrhotic population can be accomplished,
Preoperative control of ascites significantly decreases hernia recurrence and allows SAFE MESH!
Ascites control may be accomplished through medical diuresis coupled with serial abdominal paracentesis the serial abdominal taps or transjugular intrahepatic portosystemic shunt.
Peritoneal drains may be used to aid postoperative ascites management if a more urgent repair is required.
Herniorrhaphy should be avoided in the presence of a patent umbilical vein, because ligation during herniorrhaphy may alter the portal circulation and lead to acute portal vein thrombosis. The ensuing liver failure may necessitate emergent liver transplantation.
splenic abscesses
The most common etiology of a splenic abscess is hematogenous spread to the spleen from another septic focus, such as endocarditis, diverticulitis, or directly from intravenous drug abuse.
Trauma to the spleen can make the organ more susceptible to infection if there is a devascularized segment of splenic parenchyma. Patients present with fever, elevated white blood cell count, and left upper-quadrant pain. Diagnosis is made by CT scan (figure 1).
Intravenous antibiotics and splenectomy provide the best means of source control. Aspiration or percutaneous drainage may occasionally be successful; they are associated with increased rates of abscess recurrence (50–60%). This is not a cyst, and internal drainage of an abscess is usually not performed. Common organisms include Staphylococcus and Streptococcus species and Gram-negative enteric organisms.
Overwhelming postsplenectomy infection (OPSI) is a highly lethal complication of splenectomy. OPSI is seen more commonly in patients who have either had splenectomy for hematologic reasons, in those who are immunocompromised, or in children. When elective splenectomy is considered, the patient should receive vaccines for the following encapsulated organisms: Streptococcal pneumoniae, Haemophilus influenzae, and Neisseria meningitides.
Splenectomy results in long-term remission with ITP rates in
66–85% of patients
Medical management, including corticosteroids and intravenous immunoglobulin response rates in adults
20–25% remission rate in adult patients.
factors that assist in predicting clinical response to splenectomy.
Age younger than 40 years is the most widely acknowledged predictor of positive response to splenectomy.
NOT Response to corticosteroids, time from diagnosis to surgery, preoperative platelet count, and gender have not been consistently shown to affect response to splenectomy in patients with ITP.
Contrast-enhanced CT scans characteristic imaging for: Hemangiomas
most common benign lesion seen in the liver.
NOT associated with oral contraceptives and carry no malignant risk.
On CT,
peripheral asymmetrical (CAREFUL - “nodular enhancemnt”) enhancement
delayed vascular filling i
risk of rupture is exceedingly
indication for resection is typically pain
Contrast-enhanced CT scans characteristic imaging for: Metastatic neuroendocrine cancer
is hypervascular on the arterial phase
and
hypoattenuating on the venous phase
Contrast-enhanced CT scans characteristic imaging for: Hepatocellular carcinoma
hypervascular enhancement on the arterial phase
characteristic portal venous washout on the venous phase
Contrast-enhanced CT scans characteristic imaging for: Focal nodular hyperplasia
With the exception of its characteristic central scar, FNH enhances homogeneously during the arterial phase
difficult to see on the venous phase.
central scar may also be present for FNH.
typically present in women and are not associated with risk of rupture or malignancy
treatment of infected necrosis
is laparotomy and pancreatic débridement;
however, this approach is being challenged.
Minimally invasive pancreatic necrosectomy is described as endoscopic débridement performed via transgastric, laparoscopic, or retroperitoneal routes.
end-points of major complications or death.
the step-up approach had a significantly lower incidence of multiple organ failure!!
and dcr systemic complications (12% vs. 42%, P = .001)!
but no difference in the rate of death!!
Acute appendicitis in pregnancies managment
SESAP says get the MRI because high false neg rate (lecture says no incr risk of complicaitons with lap expl)
try us first
Because of the difficulties in diagnosis, failure to use preoperative imaging resulted in a negative appendectomy rate of 23–33% in a recent series.
Ultrasound initial imaging test for suspected appendicitis in pregnant patients in most institutions. Unfortunately, sensitivity of ultrasound imaging in the diagnosis of appendicitis is as low as 20% in some series.
Enteral nutrition, compared with total parenteral nutrition, infected necrosis
reduces mortality, multiple organ failure, systemic infections, and the need for operative interventions in patients with acute pancreatitis!
Acute appendicitis in pregnancies
Because of the difficulties in diagnosis, failure to use preoperative imaging resulted in a negative appendectomy rate of 23–33% in a recent series.
Ultrasound initial imaging test for suspected appendicitis in pregnant patients in most institutions. Unfortunately, sensitivity of ultrasound imaging in the diagnosis of appendicitis is as low as 20% in some series.
If the diagnosis cannot be ascertained via ultrasound, MRI avoids ionizing radiation and has a high sensitivity and specificity for appendicitis and alternative diagnoses in pregnant women.
Although the cost of MRI is greater than CT or ultrasound, it is a minor expense compared with that incurred during a negative appendectomy.
Uncomplicated appendicitis results in pregnancy
a 2% rate of fetal loss and 4% rate of early delivery.
Perforated appendicitis can result in fetal loss and early delivery ratesrates
6% - 30%
with an 11% rate of early delivery.
Treatment of mesh infections depends on
the patient’s clinical status.
Patients who may be septic require antibiotics and explantation. Concomitant procedures performed via the same incision as hernia repair, enterotomy, surgical site infection, and enterocutaneous fistulae are associated with higher rates of mesh explantation.
Expanded polytetrafluoroethylene mesh used in open ventral incisional hernia repairs is significantly more likely (4-fold) to need explantation than polypropylene or expanded polytetrafluoroethylene mesh used in laparoscopic repairs.
Well-incorporated mesh does not need to be removed during an explantation procedure.
Spigelian hernias penetrating the
transversus abdominis
and
internal oblique muscles,
but lying posterior to the external oblique aponeurosis.
Spigelian Patients present most frequently whate
fifth and sixth decades of life.
spigelian hernias are located where
anywhere along the Spigelian fascia”
between the lateral edge of the rectus abdominis muscle and the semilunar line.
most frequently develop at or inferior to the arcuate line.
transversus abdominis
and
internal oblique muscles,
but lying posterior to the external oblique aponeurosis.
difference between rates for laparoscopic or open repair of ventral hernias, recurrence, pain,Seroma, infection, enterotomy
no
no difference in pain intensity
no Seroma formation
significant decrease in the incidence of surgical site infections (3% vs. 13%).
Enterotomy was uncommon in both groups (1.6% vs. 0.6%, NS).
step-up approach with initial percutaneous drainage and then advancement to endoscopic drainage
In 1998, the Liverpool pancreas center introduced a minimal access technique for pancreatic necrosectomy. This technique requires the placement of a drain into the retroperitoneal space and then serial dilation of the drain tract until a retroperitoneal endoscopic approach can be undertaken.
The area is then débrided and irrigated, and drainage catheters are left at the completion of the procedure. This technique showed a significant decrease in complications associated with necrotizing pancreatitis. There were decreased rates of postoperative organ failure, intensive care unit support, and complications (e.g., multisystem organ failure, bleeding, visceral perforation, and death) compared with open procedure.
The step-up approach showed a statistically significant decrease in the number of complications. New onset multisystem organ failure also occurred less frequently. There was no difference in the number of deaths in each group. A step-up approach with initial percutaneous drainage and then advancement to endoscopic drainage appears to provide for the best outcome for these complicated patients.
Cholecystectomy is indicated in the asymptomatic patient for what polyp
is larger than 6 mm
sessile,
primary sclerosing cholangitis.
If the patient is asymptomatic, the polyp is pedunculated, and 6 mm or smaller, follow-up ultrasonography is indicated.
If on repeat ultrasonography, the polyp increases to more than 6 mm or begins to develop sessile features, cholecystectomy is indicated.
Prophylactic mesh placement at the time of stoma formation
conclusively been shown to reduce the incidence of parastomal herniation!
NO incr morbidity or mortality with the use of mesh.
This analysis included biologic and synthetic mesh.
best approach to surgical management of parastomal herniation
Mesh placement is used in the repair of established parastomal hernias, because
primary direct suture fascial repair (as done historically) leads to unacceptable recurrence rates of 46–100%.
The type of mesh used may affect the rate of complication for stoma hernia (not initial stoma formation): synthetic mesh repair is associated with a higher rate of complications than biologic mesh, often leading to the need for mesh explantation.
Mesh infection, extrusion or erosion, chronic pain, bowel obstruction, seroma formation, and intestinal fistulization occur more often with synthetic mesh.
Sufficient robust long-term data are not currently available to conclude that laparoscopic mesh placement is superior to open mesh placement.
trial comparing watchful waiting and early surgical repair with open tension-free techniques
0.5%) watchful waiting patients experienced acute incarceration, and none experienced strangulation during the 4.5-year followup.
Twenty-three percent converted from watchful waiting to surgical repair during this time, and hernia-related pain was the most common reason provided.
outcomes after laparoscopic totally extraperitoneal (TEP) or open Lichtenstein inguinal hernia repair,
chronic pain to be 9.4% TEP
versus 18.8% at 5 years in the 2 groups, respectively Lichtenstein
This finding includes patients reporting mild pain, defined as occasional discomfort or pain not limiting daily activities. By contrast, moderate or severe pain, defined as occasional or daily interference with daily activities, was noted in only 1.9% (TEP) and 3.5% (open) of patients after 5 years.
A long-term follow-up of a randomized controlled trial reported that testicular pain was a more common finding in patients who underwent a TEP repair compared with open mesh repair.
Ureter injuries
Ureter injuries are relatively rare, but missed injuries lead to significant morbidity and mortality. Injuries to the ureter are classified and managed based on the degree and location of the injury. The ureter is divided into upper, middle, and lower thirds (table 1). The upper or proximal ureter extends from the ureteropelvic junction to the area where it crosses the sacroiliac joint. The middle ureter courses the bony pelvis to the iliac vessels. The lower portion extends from the iliac vessels to the bladder. The blood supply to the ureter (ureteral artery) is tenuous and runs longitudinally along the ureter without collateral flow in 80% of patients. Reconstruction options for the upper third of the ureter include ureteroureterostomy or ureteropyelostomy. Reconstruction options for the middle third of the ureter include ureteroureterostomy, transureteroureterostomy, or anterior wall bladder flap (Boari). Reconstruction options for the lower third of the ureter include ureteroneocystostomy with direct reimplantation and ureteroneocystostomy with a psoas hitch. Early identification and surgical repair improves overall morbidity; therefore, drainage and delayed operative repair is not a preferred management strategy.
pyogenic liver abscess
This patient presents with a pyogenic liver abscess (PLA). As treatment of appendicitis, diverticulitis, and other intra-abdominal infectious processes has improved, the incidence of PLA has decreased dramatically. Biliary obstruction, stenting, or instrumentation is now a more common primary source for PLA than seeding through portal blood flow. The management of PLA has evolved as radiologic imaging and percutaneous techniques have improved. Treatment of PLA is primarily antibiotics and percutaneous drainage. Needle aspiration of a small (<5 cm), simple abscess may suffice, but large multiloculated abscesses frequently require multiple catheters and interventions to ultimately resolve the abscess. In patients with malignancy, percutaneous drainage remains the treatment of choice; however, the presence of yeast in the abscess or demonstration of communication with the biliary tree may predict failure of the percutaneous treatment strategy. In a retrospective study, 104 patients with PLA were treated with percutaneous or surgical drainage, and percutaneous drainage was found to produce statistically significant improvements in morbidity, length of hospitalization, and hospital costs. Therefore, percutaneous drainage is preferable to either open or laparoscopic drainage or liver resection as a first-line treatment strategy. Hypertonic saline injection has been used for ablation of benign liver masses and cysts but not for pyogenic hepatic abscesses. Thiabendazole is a broad-spectrum anthelmintic used in the treatment of strongyloidiasis, trichinosis, and visceral larva migrans.
tx of splenic cysts
NO Percutaneous aspiration of the cyst contents leads to poor results, with reaccumulation of the cystic fluid being the norm.
BEST The newer technique of partial splenectomy offers the best management option of eliminating the entire cyst wall, thereby minimizing recurrences, yet maximizing the remaining functional splenic parenchyma. This can be done either through an open laparotomy incision or laparoscopically.
tx of splenic cysts
NO Percutaneous aspiration of the cyst contents leads to poor results, with reaccumulation of the cystic fluid being the norm.
BEST The newer technique of partial splenectomy offers the best management option of eliminating the entire cyst wall, thereby minimizing recurrences, yet maximizing the remaining functional splenic parenchyma. This can be done either through an open laparotomy incision or laparoscopically.
Luschka ducts
second most common source of leak
are accessory,
drain subsegmental areas of liver into the extrahepatic bile ducts (not gallbladder itself)
Ducts of Luschka are estimated to to 50%
most common source of bile leak after lap chole
cystic duct leak
can’t blame it on duct of Luschka! (these are second most common source
Treatment of a Luschka duct leak not recognized at the time of cholecystectomy
successfully accomplished by sphincterotomy and transampullary stenting to decrease the pressure in the biliary tree.
statistical improvement of lap vs open ventral hernia repair
surgical site infections
The most consistent finding across all studies was a significant decrease in the incidence of surgical site infections (3% vs. 13%). Enterotomy was uncommon in both groups (1.6% vs. 0.6%, NS).
