ABSITE 2014 Flashcards
treatment of T3 gastric adenocarcinoma
gastric resection only (CAREFUL - esoph might get adjuvant)
The risks of locoregional and distant recurrence are high for all T2 or more or node-positive gastric cancers even with surgical resection, thus providing rationale for the delivery of neoadjuvant and adjuvant therapies.
Cam 2014
Neoadjuvant and adjuvant therapy not proven to increase survival
Sab 20012
initial chemotherapy regimens for gastric cancer provide little benefi
the survival for patients receiving adjuvant therapy was no better than surgery alone.
best biospy approach for anterior medialstinal mass
often amenable to core needle biopsy via a parasternal approach, typically with CT or ultrasound guidance.
If image-guided core needle biopsy expertise is not available, an anterior mediastinotomy (Chamberlain procedure) on the left or the right is appropriate.
Thoracoscopy provides access to all compartments of the mediastinum; however, risk of seeding the pleural space with tumor when this approach is used, as well as the postoperative pain and short hospital admission associated with its use.
NO Cervical mediastinoscopy - does not allow access to the anterior mediastinum but may provide diagnostic tissue should accessible paratracheal precarinal and subcarinal areas appear pathologic in the setting of a mediastinal mass.
Well-circumscribed mass with no evidence of invasion and no associated lymphadenopathy can usually be resected primarily, serving both diagnostic and therapeutic purposes. This includes tumors such as early-stage thymomas, teratomas, mesenchymal tumors, or benign cysts. If lymphoma is suspected, biopsy is mandatory
pulmonary function volumes
functional residual capacity-is a really all functional?
ERV, Expiratory reserve volume;
FRC, functional residual capacity - lung volume at end-expiration;
IC, inspiratory capacity;
RV, residual volume, that is, lung volume after forced expiration from FRC;
TLC, total lung capacity;
VC, vital capacity, that is, the maximal volume of gas inspired from RV;
Vt, tidal volume.
NO includes residual volume
physio changes on induction of pheumoparitoneum
What else besides increased peak airway pressure and decreased pulmonary compliance?
collapse of basal lung tissue ultimately causing decreased functional residual capacity (FRC), ventilation perfusion ratio (V/Q) mismatch, increase intrapulmonary shunting of blood which all lead to hypoxemia and increased alveolar arterial oxygen gradient
The mechanical effect of pneumoperitoneum is compression of the inferior vena-cava, which causes reduction in venous return leading to decrease cardiac output and increase in the central venous pressure, resulting in increased vascular resistance in the arterial circulation.
Another effect is tachycardia, which is secondary to increased sympathetic discharge, hypercarbia and decreased venous return. The hypercarbia, acidosis, sympathetic stimulation from decreased venous return and vagal stimulation by stretching of peritoneum also disturb the cardiac rhythm.
diaphagm cephalic displacement and thereby decreasing venous return (with increased pressure)
The pooling of blood in the lower extremities increases the stasis and predisposes the deep vein thrombosis (DVT).
Acid-base findings
Systemic peripheral resistance finding
a increased venous pressure and return?
ASD physiology and treatment
increase right ventricular pressure?
Incr pulmonary flow output
Larger defects are associated with substantial shunting, which may lead to volume overload of the right atrium, right ventricle, and pulmonary arteries. The magnitude of left-to-right shunting depends on the size of the ASD,
ASD repair is indicated in patients with hemodynamically significant ASD (Qp:Qs > 1.5:1), in the absence of severe and irreversible pulmonary hypertension. Consideration for ASD repair may be given in patients with paradoxical embolism. Surgical repair is the treatment modality of choice. Percutaneous closure is the preferred treatment in patients with ostium secundum ASD and suitable anatomy, in the absence of other cardiac conditions requiring surgical repair.
findings at tetralogy of fallot
overriding aorta right ventricular hypertrophy VSD Pulmonary stenosis (resultant pulmonary htn)
Factors associated with right vs left shift oxygenation hemoglobin curve
Right is right - shift curve to right: INCR temp INCR CO2 INCR 2,3 DPG INCR hydrogen (dcr pH)
The curve shifts leftwards in carbon monoxide poisoning - because of binding capsity of CO and fetal hemoglobin - which is why infants do better if transfued with adult blood if in trouble
effect of blood transfusion?
“The data of this study show a decrease of hemoglobin oxygen affinity as a result of blood transfusion in very early preterm infants prone to O2 toxicity
management of distal gastric 2.5 cm polyp with moderate dysplasia
endoscopic resection
Wedge?
Subtotal gastrectomy?
Gastric dysplasia (synonym: intraepithelial neoplasia) can have a flat, slightly depressed or polypoid growth pattern. In Europe and North America polypoid dysplasia is termed ‘adenoma’
most commonly affects the lesser curve and the antrum. Histologically, dysplasia is characterised by architectural as well as cytological atypia and is stratified into two grades, low and high. Low grade dysplasia progresses to adenocarcinoma in up 23% of cases within 10 months to 4 years, whereas malignant transformation of high grade dysplasia has been reported to occur in 60–80% of cases.
Fundic gland polyps are the most common type of polyps detected at EGD. ASSOCIATED with PPI NOT H pylori. usually multiple, small (1 cm in diameter) should be removed entirely to confirm the diagnosis because fundic gland polyps rarely exceed this size.
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The classic association of gastric hyperplastic polyps has been with mucosal atrophy, whether caused by H pylori infection or autoimmune gastritis. In view of the potential cancer risk, all hyperplastic polyps larger than 1 cm should be excised completely
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Gastric adenomas consist of dysplastic epithelial cells that often arise in a background of atrophy and intestinal metaplasia typically associated with H pylori infection. As in the colon, gastric adenomas can be viewed as part of a sequence leading from dysplasia to carcinoma.
sudden abrupt decrease in end tidal CO2
what else is checked besides the circuit
CO2 embolus - embolism were hypotension, bradycardia, and an abrupt drop in end-tidal CO2.
Vascular air embolism
decreases in
end-tidal carbon dioxide (ETCO2), and both arterial oxygen
saturation (SaO2) and tension (PO2), along with hypercapnia,
may be detected.
Emboli (Air, Fat, Thrombus) Sudden hypotension (blood loss, caval compression)
Cardiac arrest
Esophageal intubation (respiration of the stomach!)
sudden increase in end-tidal CO2
what other diagnosis is considered besides malignant hyperthermia
alveolar hypoventilation is manifested by an increase in end tidal CO2.
Tx: Increasing the tidal volume is the treatment
laboratory findings with hyperaldosterone
hypernatremia, hypokalemia, and metabolic alkalosis resulting from the action of aldosterone on the renal distal convoluted tubule (DCT) (ie, enhancing sodium reabsorption and potassium and hydrogen ion excretion).
renin angiotensin system
where as it Renin secreted from?
The enzyme renin is secreted by the afferent arterioles of the kidney from specialized cells called granular cells of the juxtaglomerular apparatus in response to three stimuli:
A decrease in arterial blood pressure (that could be related to a decrease in blood volume) as detected by baroreceptors (pressure-sensitive cells). This is the most direct causal link between blood pressure and renin secretion (the other two methods operate via longer pathways). A decrease in sodium chloride levels in the ultrafiltrate of the nephron. This flow is measured by the macula densa of the juxtaglomerular apparatus. Sympathetic nervous system activity, which also controls blood pressure, acting through the beta1 adrenergic receptors.
contraindication to laparoscopy
Non-correctable hypocoagulability - ABSOLUTE - need hands on massively bleeding vessels
Ascites - Relative
Pulmonary disease
COPD
CHF
Recent MI
most common organism of bacterial peritonitis and cirrhotic with ascites
Escherichia coli?
b fragilis
Klebsiella
Staph aureus?
One of the early steps in the development of SBP is a disturbance in gut flora with overgrowth and extraintestinal dissemination of a specific organism, most commonly Escherichia coli
Escherichia coli 43 Klebsiella pneumoniae 11 Streptococcus pneumoniae 9 Other streptococcal species 19 Enterobacteriaceae 4 Staphylococcus 3 Pseudomonas
Most common organism infection and lymphedema
Staph?
Group A Strep!?
Pseudomonas?
50% total body surface area burn, hospital date 8, obtunded, hyperglycemia, thrombocytopenia, hyperventilation? what is the cause
Burn wound sepsis?
drug reaction
treatment of 1.8 cm squamous cell carcinoma of the lip
excision alone
proven benefit of dermal substitute for burns
“Integra (dermal regeneration template consisting of bovine collagen, chondroitin-6-sulphate and a silastic membrane.)
® was superior to autograft, allograft or xenograft in terms of wound healing time.[21] However, with regard to wound infection and graft take, Integra® did not produce as good a result.[21,23]”
decreased length of Hospital stay?
Early mobilization?
Decrease infection?
treatment of Cancer found adherent to the Lateral anterior surface of the duodenum
en bloc resection includes the third portion of the duodenum?
En bloc resection wedges out involved duodenum with primary repair
what is typically seen on ultrasound with Klatskin
ultrasound, which may show intrahepatic biliary ductal dilation
confluence of the right and left hepatic
increases end-tidal CO2 during hepatic resection
CO2 air embolus? - this is associated with DECREASED endtital CO2
increase in bilirubin without increase of alkaline phosphatase after hepatic resection
hepatic vein obstruction
Budd-Chiari syndrome?
portal venous obstruction?
bleeding?
management of 72-year-old diabetic male with air in the gallbladder wall white count elevated bilirubin right upper quadrant pain
cholecystostomy?
Lap cholecystectomy?
open cholecystectomy?
management gunshot wound right third intercostal space
950 mL initial chest tube output
3 iron 50 mL over the next 2 hours
2 units of blood 3 L of crystalloid required for pressure support
white out on x-ray
right thoracotomy
endotracheal tube and bronch?
maximum amount of lidocaine 70 kg
70x4.5 equals 315
315 divided by 10 equals 31.5
because there at 10 mg per milliliter
nerve the crosses behind current sternocleidomastoid and runs with the sternal cleidomastoid artery
spinal accessory 11?
Indications for choledocho duodenostomy versus hepatic J
choledochoduodenostomy for injury distal to cystic duct
safest approach in complicated infected gallbladER
lateral retraction of the gallbladder and dissection to visualize direct anterior cystic artery and cystic duct
This is better than dome down?
what is management After ERCP for common duct stone extraction, patient develops right abdominal pain, white count was 10.5, air is seen in the retroperitoneum without free air
IV antibiotics?
Gastrografin upper GI?
Drainage procedure of the right upper quadrant her retroperitoneum
management of sick young IV drug abuser with splenic abscess
splenectomy - these bleed like shit if you poke them with CT
CT-guided drainage versus splenectomy
management of pseudoaneurysm infected and IV drug user at the bifurcation of the femoral artery
extra-anatomic native bypass
PTFE graft?
what was released and component separation just lateral to the rectus abdominis
anterior sheath?
Posterior sheath?
Internal/external obliques transversus abdominis
most important to ensure future relapse in a hernia that was previously done open inguinal
Medial pubic symphysis repair of floor
laparoscopic approach with mesh?
5 cm erythematous umbilical hernia and 72-year-old diabetic male with this management chronic cough and smoker
Laparoscopic exploration repair with mesh?
reduction and elective repair
Reduction and optimize pulmonary status with admission to the hospital
management of cirrhotic with ascites showing skin necrosis at umbilical hernia no leak yet
umbilical resection and repair with biologic mesh?
umbilical resection and primary fascial repair
most common inguinal hernia in layman
indirect?
Direct?
Worst prognosis for metastatic colon cancer to the liver
metachronous liver lesion?
bilateral liver metastases
liver metastasis to hepatic artery node
management 40-year-old on oral contraceptives with a 6 cm hepatic lesion identified a noncontrast CT for renal stones
Start patient to stop oral birth control and follow up in 6 months with repeat CT scan?
repeat CT scan with IV contrast hepatic protocol
management of intractable pain in patient is a former alcoholic multiple bouts of pancreatitis tortuous dilated and creatinine duct
transduodenal sphincteroplasty
Endoscopic sphincterotomy?
Lateral pancreaticoduodenectomy
perforation at the GE junction the esophagus what is the best access
Left thoracotomy?
Thoracoabdominal incision?
x right thoracotomy
Was found the perforation site with endoscopy
aortic arch?
How he is adenocarcinoma at the gastroesophageal junction managed
esophagectomy
with possible gastrectomy..
this is classified as gastric cancer?
most likely cause of diffuse gastritis in a patient being treated for pneumonia
mucosal ischemia?
Antibiotic mucosal irritation?
best test to diagnose 2-day-old neonate found to have cecal dilation of meconium ileus and distal decompressed colon
sweat chloride?
Other choice rectal biopsy
Previous 28 week premie on tube feeds develops pneumatosis intestinalis was management
antibiotics and mass becomes septic?
5 cm proximal to the retropubic loss (sphincter?) 2.5 cm sessile adenocarcinoma what is the next step
colonoscopy?
endoscopic ultrasound?
management of
30-year-old Crohn’s patient maintained and sulfasalazine develops erythematous spontaneously draining perirectal
24 hours after admission on antibiotics patient continues a be febrile
steroids?
exam under anesthesia unroofed abscesses
infliximab?
where is the source with no fluctuance no erythema exquisite tenderness posterior rectal exam
Intersphincteric?
Ileal ischial fossa?
goodsals rule
anterior radial straight
posterior curvilinear
treatment of 5 cm right lobe Hurthle cell cancer of the thyroid
total thyroidectomy
2 peripheral cell cancers of the thyroid get post thyroidectomy iodine 131 residual gland ablation
Hurthle cell is a subset of follicular
