ABSITE 2021 Flashcards
Dx of Fibrolamellar HCC
- Labs: normal AFP and elevated neurotensin (vs. FNH)
- Imaging: well circumscribed w/ central scar. Similar to FNH
Hemodyamic parameters:
Septic shock
Neurogenic shock
Cardiogenic shock
Septic: high CI, low SVR, +/- wedge
Neurogenic: high CI, low SVR, low wedge
Cardiogenic: low CI, high SVR, high wedge
Pheo w/up:
- plasma or urine metanephrine (se)
- 24-urine metanephrine (sp)
- CT (> MRI)
- MIBG (if multi-focal)
Mucinous cystic neoplasm dx and tx
- dx: EUS-FNA w/ high CEA (>190), low Amylase
- tx: resect
Tx pelvic fx
- Binder
- Angio OR packing w/ fixation (especially if IR n/a)
- Fixation
- refractory bleed after angio → packing + fixation
STSG vs. FTSG
- STSG: epi + part dermis
- higher survival/less resistant
- more 2’ contxn. (don’t use over joints)
- ideal use: large wounds (trunk, extremities) - FTSG: epi + full dermis
- lower survival/more resistant
- more 1’ contxn
- ideal use: small, cosmesis, functional area (joints)
F5 Leiden Mechanism
- acts w/ Xa to convert prothrombin to thrombin
- protein C/S acts by inhibiting factor 5 and 8
- mutated factor 5 can’t be inactivated by protein C/S
W/up of gastrinoma…
Dx:
- Off PPI: G > 1000 or >200 w/ secretin stimlation
- Can’t get off PPI: SS Scintigraphy
Localize:
- Triphasic CT/MRI
- SS Scintography (Dotatate PET/CT)
- Endoscopic US
- Selective intra arterial Ca
- OR: Intra-Op US, transduodenal palpation, duodenotomy, palpate HOP
Tx pseudocyst/WON
Dx: US or CT
- if can’t r/o cystic neoplasm on imaging must get EUS-FNA
Tx: Only drain if there are persistant sxs. Wait 4-6 weeks for wall to mature
- near stomach/duo, > 6cm: endoscopic cystogastrostomy/duodenostomy
- open cysto-enterostomy
Post trx lymphoproliferative disorder - path, px, and tx
Path- EBV positive B cell proliferation
Px- B sxs (fever, fatigue, weight loss)
- may cause lymphoma
Tx- reduce IS, rituximab
Tx of Thrombosed external HMHD
- w/in 48h- excision
2. after 48h- medically manage
Free water deficit
TBW x [(Na-140)/140]
TBW = weight x .6 (men) or .5 (women)
Order of contents in thoracic outlet
- Subclavian VEIN
- Phrenic NERVE
- Anterior scalene MUSCLE
- Subclavian ARTERY
- Brachial plexus NERVE
- Middle scalene MUSCLE
Corrected Ca
- serum Ca + [ (4 - patient’s albumin) x .8]
- Always falsely low (not high)
Tx of pancreatitis masses
- WON sterile
- WON infected
- Pseudocyst
- Infected pseudocyst
- WON sterile: conservatively
- WON infected: step-up approach
- Pseudocyst: tx if sxs (infxn, obstruction, pain)
- - 4-6w → internal drain → cystenterostomy - Infected pseudocyst: drainage (internal, external, endoscopic)
Indications to tx ICA stenosis
- Asx: > 60%
- Sxs: > 50%
- Sxs: contralateral motor/sensory sxs, ipsi vision sxs
Distal pancreatectomy in a trauma situation
Always do splenectomy unless stable and young (<30)
EBV associated with
- B cell lymphoma (Burkitt)
- n/ph cancer
- PTLD
Medications for hyperthyroidism - MOA and s/e
- PTU: thyroperoxidase and de-iodinase inhibitor
- s/e of aplastic anemia or agranulocytosis. OK for preggo. - Methimazole: thyroperoxidase inhibitor
- s/e of cretinism, aplastic anemia and agranulocytosis
Mechanism:
VWF
Fibrin
- VWF: binds GP1b on PLTs and attaches them to endothelium
- Fibrin: Links Gp2b/3a to form PLT plug
MRSA tx
- Vancomycin, Linezolid (best)
- Clind, bactrim, and doxy have partial coverage
- Ceftaroline (new 5G cephalosporin)
- Muporicin for skin burn
Neostigmine
MOA: AChE inhibitor
Use: reversal of non-depol muscle relaxants
Bethesda criteria for thyroid
**1 cm is cutoff to get an FNA
- Non-diagnostic → repeat FNA
- Benign → follow-up
- Undetermined significance → repeat FNA
- Follicular neoplasm → lobectomy, repeat FNA, or genetic testing (no core needle)
- Suspicious for malignancy → lobectomy vs. thyroidectomy
- Malignant → thyroidectomy
Achalasia - Dx and Tx
Dx:
- no peristalsis
- high LES pressure > 15 (vs. scleroderma, low)
- incomplete relaxation
Tx:
- myotomy (6 eso, 2 stomch) is 1st line (avoid Nissen).
- botox or dilation if high risk.
Ab reactions:
- Non-hemolytic
- Hemolytic
- Urticaria
- TRALI
- Anaphylaxis
- Non-hemolytic: fever; cytokine from donor leukocytes
- Hemolytic: fever + HOTN; recipient Ab attack donor leukocytes
- Urticaria: recipient Ab attack donor plasma
- TRALI: donor Ab attack recipient WBC
- Anaphylaxis: recipient Ab attack donor IgA
Cowden’s mutation and cancers
Mutation: pten
Ca: breast ca + thyroid ca + hamartomas
TLV
TLV = RV + ERV + TV + IRV
FRC = RV + ERV IC = TV + IRV
Umbo ligs remnants:
- Round
- Median
- Medial
- Omph/M
- Round: umbo vein
- Median: urachus
- Medial: umbo artery
- Omph/M: vitelline duct (Meckel’s)
Octreotide
- Somatostatin analogue
- Inhibits exocrine function of pancreas and CCK release
Drainage of gonadal veins
- Right- IVC
2. Left- Left renal vein
Tx Medullary thyroid cancer
- TOTAL thyroidectomy
- Bilateral central/level 6 dissection VI dissect
- Lateral neck dissection on that side if central+
- Start T4 postop. Monitor w/ calcitonin AND CEA
Tx for hyponatermia
- Acute w/ any sx’s: hypertonic saline bolus
2. Chronic and asxatic: free water restriction
Ulcers:
- Marginal
- Cameron
- Marjolin ulcer
- Cushing’s ulcer
- Marginal: REYGB at GJ anastomosis
- Cameron: on lesser curve of large hiatal hernia
- Marjolin ulcer: chronic wound
- Cushing’s ulcer: elevated ICP
Tx facial nerve inj
relative to lateral canthus of eye
- Medial- non op OK (arborization)
- Lateral- OR!
Radial scar- Dx and Tx
- Dx: spiculated mass with central sclerosis
- Tx: excisional bx
preA vs. Albumin
- Prealbumin: >15; t1/2 is 1-2 days
2. Albumin: >3.5; t1/2 is 21 days
Tx pop aneurysm
> 2cm- ligation and bypass
<2cm- observation; avoid stents
Tx for ectopic pregnancy
- Stable– methotrexate or salpingotomy
- MTX: absolute c/i if patient is breast-feeding - Unstable– salpingectomy
Hyperkalemia EKG
Hypokalemia EKG
- hyperK: peaked T wave, prolonged PR, eventual SINE
- hypoK: QT prolongation, ST depression, U waves
HS reactions
1- IgE allergic rxn 2- Ab rxn 3- immune cx; ex- serum sickness 4- delated; t-cell mediated 5- auto-immune
Tx Pap thyroid ca in preggo
- Postpone until 2T if advanced
- If stable, postpone until after delivery
- RAI is c/i
Mastodynia tx
- OCP/NSAIDS
- non-cyc + >30 OR cyclic + mass
- mammo
Tx Mucinous neoplasm of appendix
- Confined to appendix: appe only
- Involving the base or ruptured: usually R hemicolectomy
- Peritoneal disseimation: can dx with perc bx
- if no appendicitis can postpone appe until cytoreductive surgery
GCS eye opening
4- spon
3- to voice
2- to pain
1- none
Torsades
“polymorphic ventricular tachycardia”
2/2 hypoK, hypoCa, hypoMg
all cause qt prolongation
Normal values: CVP, WP, SVR, CI
CVP 2-6
WP 4-12
SVR 700-1500
CI 2.5-4
When to excise burns
- < 72 hours but not until after appropriate fluid resuscitation
- Used for deep 2nd-, 3rd-, and some 4th-degree burns
- Viability is based on punctate bleeding (#1), color, and texture after removal (use dermatome)
- Wait 1 week for face, palms, genitals, soles
TTP - Path, Px, Tx
Path- def in ADAMtS13
Px- TCP purpura, neuro sx, kidney dz, hemo anemia, fever
Tx- plasmapheresis → splenectomy if failed
LE angio
AT comes off first and goes lateral
TP trunk- PT behind tibia, peroneal behind fibula
Liver lesions on arterial phase: HCC Mets Adenoma Hemangioma FNH
HCC- Homogeneous enhancement. Rapid w/out.
Mets- Hypoattenuation
Adenoma- Heterogeneous enhancement
Hemangioma- Periph enhancing
FNH- Centrifugal enhancing
**If unclear, MRI can distinguish benign from malig
Methanol and Ethylene glycol toxicity - Px and Tx
Px: profound AG metabolic acidosis
- metabolized in the liver
- oxalate stones → renal failure
Tx: NaB + fomipazole (ADH inhibitor)
- consider iHD
Ureter anatomy
Runs under the vas/uterine arteries
Runs over the iliacs
Elective surgery after stent
ASA lifelong Plavix - BMS: 6w - DES: 6m Post pone elective surgery until these times
If surgery is needed (i.e. cancer) wait at least 1m for DES
UE Injuries:
- supracondylar humerus
- DRF
- Mid shaft
- ant shoulder disloc
- post shoulder disloc
supracondylar humerus- brachial artery DRF- median nerve Mid shaft- radial nerve ant shoulder disloc- ax. nerve post shoulder disloc- ax. artery
Teg interpretation: R time K time a angle MA LY 30
R time- FFP K time- cryo a angle- cryo MA- PLTs LY 30- TXA
Rule of 6's: R > 6 minutes alpha angle > 60 degrees MA < 60 mm LY30 > 6%
DeMeester score and indications
pH <4 , changes in position, duration, # of episodes
> 14.7 is positive
Indications:
- Scope negative but has sxs
- Max medical therapy by has sxs
- Post op but has sxs
SD
1, 2, and 3 SD = 67%, 95%, and 99.7% of the data
s/e of ileal conduit
Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)
Angiodysplasia of the colon - Dx and Tx
Dx: usually found in cecum and ascending colon
-2nd MC CO gi bleed (vs. div’s)
Tx: if bleeding or iron deficiency
- Endoscopic
- Surgery if refractory
Stewart-Treves syndrome
Post mastectomy lymphangiosarcoma
- rare and highly malignant
Tx- wide local excision w/ 3-6 cm margin
Tx for gallstone ileus
Stable and healthy- stone removal and take down fistula
Unstable, old/frail- stone removal only!
Sorafenib
TK inhibitor
Tx of HCC
Stricturoplasties
- Heineke s’plasty
- Finney s’plasty
- Side2Side isoperistaltic s’plasty
Heineke s’plasty: <10cm; open long and close transversely
Finney s’plasty: > 10cm; segment folded on itself and common wall created
Side2Side isoperistaltic (MIchellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together
**These can’t be performed in proximal duo. If stricture is in the proximal-duo perform a G-J bypass
Best test to dx gastroparesis
Scintigraphic gastric emptying
Burn degrees
1D: epidermis
2D superficial: pap dermis, painful, blebs and blisters; hair follicles intact; blanches
2D deep: retic dermis, decreased sensation; loss of hair follicles, need skin grafts
3D burn: subcutaneous fat, leathery
4D: fat/muscle/bone; surg
Tx of ARDS
TV at 4-6 ml/kg Permissive hypercapnia Survival benefit: prone, pralayze -P/F < 100 = severe **Must get echo to r/o cardiogenic edema
Interleukins 1, 2, 4, 6
IL1: fever
IL2: T cell prolif and Ig production
IL4: T/B cell maturation
IL6: hepatic acute phase reactant
Glucagonoma - loc, px, dx, tx
Loc: distal (a cells)
Px: dermatitis, DRH, DM, nec mig erythema
- most malignant
Dx: gluc > 1000
Tx: distal panc + splenectomy + LADN’y + CC’y
Aminocaproic acid
Plasmin inhibitor
Use: DIC, excess tpa
s/e of carb, protein, and lipid
carb- immunosuppression, resp failure
lipid- pro inflammatory
protein- false neurotransmitters, rise in ammonia/urea
Bx and Tx actinic keratosis
- Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
- Tx: topic 5FU. Photodynamics, imiquimod, cautery
no margin
Hirschsprung surgeries
- Duhamel
- Soave
- Swenson
Duhamel: agang stump in place/gang colon pulled behind; neo-rectum; less dissection/stricture
Soave: pull-through; “reverse alte”; remove M/SM; pull bowel within an aganglionic cuff; least dissection
Swenson: original; aganglionic segment resected to sigmoid colon; oblique anastomosis- colon x rectum.
z11 trial implications
If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK
Hard signs of vascular injury
shock expanding hematoma pulsatile bleed thrill/bruit absent pulse ischemia
If negative –> ABI – if positive –> CTA (to localize)
Polyps that require surgery instead of endoscopic resection
Submucosal invasion > 1mm Poorly differentiated <1 mm margin LV invasion Tumor budding Taken piecemeal
Iron def sxs
anemia, glossitis, brittle nails, cardiomegaly
T staging indications for neoadjuvant
- eso
- stomach
- colon
- rectal
- lung
- eso: select t1b (SM) or T2 (MP)
- stomach: t2 (MP)
- colon: t4b (adjacent organs)
- rectal: t3 (through MP)
- lung: n2 nodes
Atlanta classification pancreatits
- Interstitial:
<4w- acute peripanc collection
>4w pseudocyst - Necrotic:
<4w- acute necrotic collection
>4w- walled of necrosis
Fuel for SB and LB
SB- glutamine
LB- SCFA (acetate, butyrate)
Motilin
Motilin – released by intestinal cells of gut; ↑ intestinal motility (erythromycin acts on this receptor)
Screening in IBD patients
Start 8 years after sx onset
2-4 random bx every 10 cm throughout the colon + suspicious areas
Repeat schedule:
- normal: q1-3 years
- PSC, stricture, or dysplasia w/out colectomy: q1 year
Any dysplasia usually gets a colectomy
- if resectable with negative can consider endoscopic resection with close surveillance
NEC
Bloody stools after 1st feed
tx- resuscitation, abx
W/up of thyroid nodule found on exam or incidental imaging
- U/S and TSH
a. Nodule + Low TSH ➡ RAI uptake scan
- hot/functioning: thyrotoxicosis (no cancer)
- cold: FNA
b. Nodule + Normal/High TSH ➡ FNA
c. Any nodule > 1 cm gets an FNA
Tx male breast ca
Tx: simple mastectomy w/ SLNBx
- BCT usually can’t be done b/c not enough tissue
- if ER+: can use tamoxifen (Her2+ is rare). consider orchiectomy if metastatic.
- Prognosis similar to W but delay in presentation is common
Nutcracker eso manometery
high amplitude/long peristalsis
normal LES pressure
normal relaxation
Tx- (identical to DES)
- PPI, CCB, TCA
- Long segment myotomy if refractory
MC etiology of ESRD leading to kidney trx
- DM, 2. HTN, 3. PCKD
Repair of Bile Duct Injury
- Intro-op:
- convert to open, intra-op cholangio, repair OR
- widely drain and send to specialty center - Post-op:
- Perc cholangiography to define the anatomy
- Control spillage: external drain +/- stent +/- PTC
c. Repair in 6-8 weeks
Treatment approach base on Strasburg class:
A- CD stump leak:
- Intraop: clip/ligate and leave drain
- Postop: perc drain + ERCP plasty/stent
B- Aberrant right hepatic ligation:
Asx and < 3mm- ntd
Sxs (cholangitis from occluded seg)- REYHJ
C- Transect aberrant right hepatic:
- External drain if post op
- Sxs: REY-HJ
D- Lateral injury to CHD/CBD:
- No devascularization and small: 1’ T-tube closure
- Devascularized: REY-HJ
E- full transection of CHD/CBD
- < 1cm or distal w/out tension: 1’ T-tube closure
- > 1cm OR proximal injury: REY-HJ
e1- > 2cm e2- <2cm e3- at confluence (confluence intact) e4- at confluence (confluence separated) e5- abbarent RH duct injury w/ CBD stricture
Eso dysplasia tx
- LGD- scope q6-12m lifetime (even if fundoplication)
- HGD- ablation + Q3m scope
- T1a- ablation
- t1b- esophagectomy
*Fundoplication does not decrease cancer risk
Superior epigastrics
Inferior epigastrics
SE: runs between rectus and posterior rectus sheath; branch of int mammary
IE: runs between transversalis fascia and parietal perit; branch of EI
When to intubate burn patients:
- hypoxia, hypercarbia, severe upper airway edema
- If stable and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling
Tx hemobilia after trauma
- EGD → CTA (if stable)
- angio embolization (no surgery)
- catheterize the celiac artery first ➡ R/L hepatic ➡ SMA
Paget Von Schroetter syndrome - path, px, tx
path- narrowing of SC/Ax vein 2/2 mech compression
px- acute swelling
Tx- catheter directed thrombolysis before anything else (NOT open thrombectomy)
Tx of AT3 def
Tx- recombinant at3 or FFP followed by heparin then warfarin
Vitamin C mechanism
hydroxylation of lysine and proline
type 3 collagen cross-linking
Inidications for neoadjuvant chemotherapy for rectal cancer
Stage 2 and above
Stage 2: at least t3 (crossing musc prop) or any n (stage 3)
Periop anticoagulation
- High risk pt: afib, MHV, recent TE event (3m)
- High risk surgery: nsurg, optho, cards
- Med risk surgery: abdominal operations
- Low risk surgery: dental
- bridge for high risk patients
- stop warfarin 5 days before surgery if not bridging, resume on day of surgery
- Hold Noac 2 days before surgery and resume 1 day after
- continue aspirin for low/moderate risk surg
- stop Plavix 5 days before
What is not suppressed by high dose dexa
Adrenal mass Ectopic mass (small cell cancer)
Metabolic alkalosis - chloride responsiveness
- Cl responsive (Ur Cl < 20)
- temporary loss, replaceable
- vomiting - Cl resistant (Ur Cl > 20)
- hormonal, continuous loss
- conn’s, steroids, hyperaldosterone
Heller myotomy margins
6 cm proximal, 2 cm distal
Eso- vertical fibers first (outside), then circular (inside)
Margin for invasives cancer vs. dcis
Invasive cancer- no tumor on ink
dcis- 2 mm
**if both in specimen, margin is no tumor on ink
Tx hypertrophic cardiomyopathy
beta blockers
avoid inotropes
use neo if needed
ITP- dx and tx
dx- of exclusion
tx-steroids → IVIG 2nd line → splenectomy
do not tx unless PLT < 30k or 20k in low risk
Staph species
G+/aerobe/clusters; coag+ → aureus
coag- → epidermidis
Cryptorchidism tx
- wait until 6m old
- if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma
- risk of ca higher in both testes.
Sarcoma stage and grade
- Grade ~ differentiation, mitotic count, and necrosis
- - more important than size, nodal/distal mets for prognosis
2. Stage Stage 1- G1 w/ any T stage Stage 2- G2/3 and T1 Stage 3- G2/3 and T2+ Stage 4- N+
Neuroblastoma dx and tx
dx
- CT: displacement of renal parencyma (vs. Wilm’s).
tx:
- S1-2 (low risk) → surg alone
- S3+ (high risk) → surg + chemo/XRT
Gastrin MOA
G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ HCl
Stimulated by ACh, beta ago, AA
Innervation to internal and external anal sphincter
- Internal: SNS/PSNS fibers from superior rectal and hypogastric plexus
- External: Internal pudendal nerve from 4th sacral nerve
Esophagus blood supply
Cervical- inf thyroid
Thoracic- aortic branches
Abd- left gastric/inferior phrenic
CBD and PD on ERCP
CBD at 11’
BD at 1’ to 3’
Tx Urethral injury
Grade:
1/2- contusion/stretch ➡ cath
3- part disruption ➡ OR
4/5-complete disruption ➡ cystostomy + OR
TEF - MC types - dx and tx
- Type C – most common type (85%)
- Proximal esophageal atresia (blind pouch) and distal TE fistula
- dx: AXR: distended, gas-filled stomach - Type A – second most common type (5%)
- Esophageal atresia and no fistula
- dx: XR: gasless abdomen
Tx:
- Resuscitate w/ repogle tube
- G-tube placement to decompress and feed
- Delayed right extra-pleural thoracotomy
Tx of Ogilvie’s
- supportive, dc narcotics, ng tube, neostigmine
- if > 10cm ➡ scope decompression and neostimgine
- failure ➡ OR
**scope or enema before giving neo to r/u obstruction
Tx of prolactinoma
- Bromocriptine or carbegoline (both dopa agonists)
- bromo is safe in pregnancy - Surgery if failure
Pros/Cons:
- Sevoflurane
- Isoflurane
- Halothane
- NO
- Sevo: rapid induction, less pungent. Good for kids.
- Isoflurance: good for neurosurgery; no increase in ICP
- Halothane: slow onset/offset, cards depression, hepatitis.
- NO: least cardiac depression b/c sympathomimetic (don’t use in cardiac failure). c/i in SBO. Highest MAC.
Atropine MOA
competitive inhibitor of ACh at muscarinic receptor liver metabolism
Tx FMD
angio + balloon (no stent)
MEN1/MEN2 genes
MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene
Birads score
0- redo imaging OR require U/S 1- negative, NTD 2- benign, NTD 3- benign, repeat q6m 4- suspicious, bx 5- highly suspicious, bx 6- confirmed, excise
MOA and use of antifungals:
Azoles
Micafungin
Amphotericin
Azoles: ergosterol synth inhibitor
- non systemic candida (yeast infection)
Micafungin: echinocandin; inhibit glucan production
- dissemintated candiasis
Amphotericin: binds ergosterol and inhibits
- invasive mucor or cryptococcal meningitis
Recurrent laryngeal nerve
motor to larynx except circothryoid
injury: hoarsness, airway compromise, cord paralysis (permanent ADduction)
- If bilateral may need a trach
PFTs for lung resection
- Preop FEV1 and DLCO predicted > 80% ➡ no further testing
- >.8L wedge, >1.5L lobe, >2L pneumo
- < 80% ➡ lung scan for PPO FEV1, DLCO - PPO FEV1, DLCO > 60% ➡ no further testing
- < 60% ➡ exercise test - VO2 > 10 ml/min/kg ➡ OK for surgery
- < 10 ➡ high risk for surgery
Origins of medullary thyroid cancer
- 4th pharyngeal arch releases NCC which form parafollicular C cells
Gastrinoma - loc, px, dx, tx
Loc: gastrinoma triangle (CBD, panc neck, 3D)
Px: refractory PUD
- Mostly malignant
Dx: G > 1000 (off PPI) or >200 w/ secretin (off PPI)
- SS Scintigraphy (dotatate scan) if can’t get off PPI
Tx: Screen for MEN1
- <2 cm: enucleate w/ LADN’y
- > 2cm: resect w/ LADN’y
qSOFA score
- AMS (<15)
- RR > 22
- SBP < 100
MC Benign and Malignant H/N tumors - tx
- Benign: Pleomorphic adenoma
- Tx: superficial parotidectomy even if asx - Malignant: mucoepidermoid carcinoma tx
- Tx: total parotidectomy (facial nerve preservation) + MRND + XRT
Tx frostbite
Frostnip: rapid re-warming
2d: clear/milky blister- drain
3d: HMHG blister- leave intact
4d: bone- prostacyclin/TPA, amputate
Tx of Pilonidal cyst
- ASx: NTD
- Acute abscess: drain only
- Chronic cyst: offer surgery if effecting QOL
- - marsupialization and leave open: lower recurrence
- - primary closure: faster healing. Off midline- less comps (preferred)
MCCO Cancer
Male- prostate, lung, CRC
- death: lung, prostate, CRC
Women- breast, lung , CRC
- death: lung, breast, CRC
Tx TCPenia
<10k if asx
<20k if septic, chemo/rads, RF’s
<50K if elective surgery
Tx Annular pancreas
neonates- duododuodenostomy (mobile duo)
adults- duodenojejunostomy
TNFa
produced by macrophages
causes cachexia
W/up of pancreatic cystic neoplasms: Pseudocyst Serous cystadenoma MCN IPMN
- MRI 2. EUS w/ FNA (If unclear):
- High CEA > 190
Pseudocyst- high Am, low CEA
Serous cystadenoma- low Am, low CEA
MCN- low Am, high CEA (>200)
IPMN- high Am, high CEA (>200)
Propofol - pros and cons
Pros
- rapid distribution and on/off
- decreases ICP
Cons
- s/e: hypotension, resp depression, meta acid
- no analgesia
- metabolism: liver
Enterohepatic circulation
Liver → P BSalts → hepatocytes → conjugated BS:
- 80% active ileum absorbed
- 20% deconjugated by bacteria → passive colon absorbed
- 5% out in stool
Tx CO poison
- 100% O2 w/ facemask or intubation (not hi flo)
- Hyperbaric O2 is controversial - intubate if comatose, severe acidosis
Indication for APR
- Rigid proctoscopy: w/ in 2cm of anal verge (levators)
- PE: baseline sphincter dysfxn
- Recurrent SqCC (s/p Nigro)
Cancer associations: CEA AFP CA 19-9 CA 125 Beta-HCG PSA NSE BRCA I and II Chromogranin A Ret oncogene
CEA – colon CA AFP – liver CA CA 19-9 – pancreatic CA CA 125 – ovarian CA Beta-HCG – testicular CA, choriocarcinoma PSA – prostate CA NSE – small cell lung CA, neuroblastoma BRCA I and II – breast CA Chromogranin A – carcinoid tumor Ret oncogene – medullary thyroid CA
Types of esophagectomy compared
- Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy
- anastomosis: thoracic
- theoretically more thorough oncologic resection
- may be better in more fit patients - Transhiatal: abdominal + L neck
- anastomosis: cervical
- theoretically less chance of mediastinal leak, shorter operation
- may be better if old/frail and distal esophagus tumors - McKeown: abdominal + L neck
- anastomosis: cervical
***Gastric conduit supply- R gastroepiploic (off GDA/CHA)
Somatostatinoma - loc, px, dx, tx
Loc: head Px: DM, GALLSTONES (> glucagonoma), steatorrhea, block exo/endo pancreas - most malignant Dx: sx's + high fast SS Tx: resect + LADN'y + CC'y
Specific to UC
Crypt abscess
Psuedopolyps
Etomidate - Pros and Cons
Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e
Cons- adrenocortical suppression
W/up and Tx testicular ca:
- Seminoma
- Non-seminomatous
- AFP, HCG, LDH
- U/S
- Inguinal orchiectomy : based on path/markers decide on RPND
- Seminoma: XRT
- Non-seminomatous: retroperitoneal node dissection
**ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection
Liver collection dx and tx:
Pyo
Amoebic
Echino
Pyogenic- after div’s;
- drain and abx (+mica if fungal)
Amoebic- after mexico trip
- metronidazole (no drain)
Echinococcal- wall Ca+ and sub-cysts
- albendazole and resect/PAIR
Maneuvers
- Kocher- lateral peritoneal attachment of D2
- Maddox- white line from sigmoid to splenic flex
- abdominal aorta, left renals, celiac, SMA, left iliac - Cattell- continuation of kocher; from D2 to sigmoid
- IVC, right renals, right iliac
EVAR specs
Proximal landing: > 1.5 cm - diameter < 3cm Common iliac (distal landing): > 1 cm - diameter > 8 mm Neck angulation < 60 degrees
EI diameter> 7mm
Tx of anal fissure
- Sitz bath, fiber, topical nifedipine/nitroglycerin
- Good sphincter tone: LATERAL, INTERNAL sphincterotomy
- If poor sphincter tone: botox injection
**If 2/2 crohn’s dz: optimize medical management
Lynch genes
DNA MM repair gene (MLH1, MSH2, MSH6, PMS2)
EPCAM
Condyloma types
- acuminatum- HPV (6, 11- benign; 16, 18- Ca)
2. lata- syphilis
Tx of liver lesions:
Hemangioma
FNH
Adenoma
Hemangioma: only if sxatic or KM syndrome
FNH: NTD
Adenoma: < 4cm w/out OCP response or > 4cm
REY limbs
Roux- 75 to 150 cm
BP- 15 to 50 cm
Dx and Tx congential DPGM hernia
-Dx: prenatal dx on US
- Tx:
1. intubate (in delivery rm)
2. NGT +/- ECMO
3. delay OR when stable
Indications for neoadjuvant therapy for stomach cancer
Any T2 lesion or LN involvement
T2: growth into the muscularis propria
Stages of empyema formation
- Exudative –> drainage or VATS (1-7 days)
- Fibrinopurulent –> VATS (7-21 days)
- Organizing –> thoracotomy (21+)
- *VATS between days 3-7
- Preferred over 2nd CT placement or fibrinolytics.
Vertebral artery occlusion px
posterior circulation
sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia
5Ts of cyanosis
TOF Transposition of GVs Truncus art Tricuspid atresia TAPVC
DES - Manno and Tx
unorganized peristalisis
normal LES pressure
normal relaxation
Tx:
- CCB (+TCA if chest pain)
- Botox injection (endoscopic)
- Last resort: long segment myotomy
Supraceliac aortic control
- HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram
- Stable: left medial visceral rotation is preferred
Mondor disease - px and tx
px- tender, “cord-like” structure
tx- NSAIDs
Dx and Tx Phyllodes
Dx:
-Bx w/ stromal overgrowth, atypia, high MI, “leaf-like”
Tx: WLE w/ 1 cm margin
- can spread hematogenous to lung
Replaced Rand L hepatic
Right- SMA (behind pancreas and CBD)
Left- left gastric (in gastrohepatic ligament)
Effective for enteroccous
Ampicillin/Amoxacillin
Vancomycin
Timentin/Zosyn
(Resistant to all cephalosporins)
Loss in excess weight for each surgery
REYGB- 75%
SG- 60%
Lap band- 50%
Acid/Base of Ng suctioning
HypoCl, HypoK metabolic alk
Loose HCl and fluid
Turn on RAA system
Retain Na/Excrete acid (paradoxic acidurea)
Types of vagotomy
- Truncal vagotomy: transect ant/post @ distal eso
- removes lesser curve and pylorus nerve
- need pyloroplasty. high r/o dumping syndrome - Highly selective: transect @ crow’s ft, preserve laterjet
- removes innervation to lesser curvature
- preserves pylorus → no drainage procedure
Indications for total thyroidectomy (pap and follicular)
Indications for total thyroidectomy:
- Tumor > 4cm
- Tumor 1-4cm and patient preference
- Distant mets or extra-thyroid disease
- Nodal disease
- Poorly differentiated
- Prior radiation
*micro-mets do not count as distant disease
Tx Soft tissue sarcoma
dx:
- < 3cm: excisional bx
- > 3 cm: incisional bx or core needle
tx:
- resect w/ 2 cm marg
- neoadj: rhabdomyo, Ewing, high grade, > 10 cm
- adj XRT: > 5cm, high grade, recurrence, close marg
- adj chemo: never
Step up approach
Infected pancreatic necrosis (WBC + gas on CT)
- IV abxs
- Perc drain OR endo drain (if stomach is close to pancreas)
- 2nd drain
- VARD/DEN
- lap necrosectomy
CN11
spinal accessory nerve
exit jugulars foramen
innervates SCM and trapezius
goes along post triangle
- Central cord syndrome
2. Anterior cord syndrome
- Central cord: loss of pain, temp, motor
- motor UE> LE loss (vs. anterior syndrome)
- hyperextension in the setting of SS - Anterior cord: loss of pain, temp, motor
- below the level of the lesion
- ASA injury or anterior cord compression
Tx SVT
types: af, aflutter, paroxysmal SVT, WPW
1. vagal → adenosine
- may unmask afib/flutter
2. HDS: BB, CCB ➡ sync cardioversion
3. HDUS ➡ sync cardioverison
Von Hippel Lindau - mechanism and surveillance
VHL gene - upreg. of VEGF
- Brain/retinal hemangioblastoma- q2y brain MRI
- Clear cell RCC- q1y US/MRI of abdomen
- Pheochromocytoma- yearly metanephrines
Melanoma w/up and tx
- Punch bx
- Tumor thickness is strongest prognostic indicator:
- - MIS- 5mm margin
- - <1mm- 1cm
- - 1-2mm- 1-2cm
- - >2mm- 2cm - SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
- If SLNBx+ or Cx positive nodes: q4m US surveillance OR completion LN dissection
- LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes
- *In-transit disease: lesions > 2cm from primary but not beyond regional tumor basin
- immunotherapy or BRAF inhibitor
- only excise if feasible (few lesions)
**MOHS can be use for in-situ disease. Need 5 mm margin.
Steps of rapid sequence intubation
c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine
PSC vs. PBC
PSC: Male; intra/extra hepatic; onion fibrosis; chain of lakes
a/w UC, cholangioca
PBC: Female; intra hepatic; granulomas; +AMA;
a/w Sjogren, RA
tx both- trx, cholesty., UDCA
CPP
MAP - ICP
normal CPP > 60
Normal ICP < 20
Draining peri-rectal abscess
- Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles)
- Supralevator abscesses need to be drained trans-rectally
Dx and Tx malrotation
Px: Any child with bilious vomiting needs an emergent UGI to rule out malrotation
Dx: UGI – duodenum does not cross midline
Tx:
1. resect Ladd’s bands
2. widen the mesentery (resect central bands)
3. counterclockwise rotation
4. place cecum in LLQ (cecopexy), duodenum in RUQ
5. appendectomy
Epidural hematoma
Biconvex
MMA
DOES NOT suture lines
MEN syndromes
1- pancreatic (gastrin), pituitary, parathyroid; menin; AD
2a- Parathyroid,MTC, Pheo; ret; AD
2b- Pheo, MTC, marfanoid/neuroma; ret; AD
CRC staging
stage 1- t1 to t2, n0
stage 2- t3 to t4, n0
stage 3- node involvement
stage 4- m1
Nitrogen balance
Protein intake (grams)/6.25 - (UUN + 4 grams) UUN =grams of nitrogen excreted in the urine over a 24 hour period 4 = stool and insensible losses
Recommended protein = 1g/kg/day
Nitrogen = protein intake/6.25
Periop Warfarin
stop 5 days before
Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6
Management of PE
- no RH strain → acoag
- RH strain → IR catheter
- RH strain + HDUS → systemic tPA
Methemoglobinemia - px, dx and tx
Px: from nitrites such as Hurricaine spray, fertilizers
- Fe2+ becomes Fe3+ impairing O2 binding
- can be induced w/ G6PD def or serotonergic drugs
- Dx: blood gas can measure OR pulse ox says 85%
- Tx:
1. G6PD def or serotonergic drugs: vitamin C
2. Otherwise: methylene blue
Layers of colon/rectum
- mucosa
- sub-mucosa (strongest)
- muscularis propria
- serosa
LE vascular trauma
small- patch plasty
large- contralateral GSV
limited time/unstable- shunt
Tx Post dural puncture headache
after epidural
tx with blood patch
Tx for DVT
- unprovoked: malignancy, inherited –> indefinite
- provoked: surgery, travel, preg, OCP, immbility –> 3m
**open thrombectomy –> last resort forthreatened limb loss secondary to extensive (ileofemoral) DVT OR phlegmasia
**IVC filter: if recent intracranial/spine surgery, evidence of ongoing post op bleeding
Loop diuretics vs. Ca sparing diuretics
loop- furosemide
Ca sparing- thiazides
MALT lymphoma tx
associated w/ h. Pylori.
Tx:
- Low grade: triple therapy (eradicate HP)
- High grade: chemo and XRT (CHOP) +/- rituximab
lower extremity bypass graft failure depends on temporal relation to the surgery.
- <30d: technical error
- 1m-2y: intimal hyperplasia, (at the distal anastomosis)
- > 2y: progressive atherosclerotic disease
Tx Parathyroid ca
- Control hypercalcemia:
- IV fluids 1st! Then bisphosphonates
- cinacalcet (sensipar - ca mimetic) - Parathyroidectomy w/ hemithyroidectomy + L6/central neck dissection + XRT
- no chemo
- some don’t perform the L6
Tx infected pseudocyst
aspirate/gram stain to dx → drainage (internal, external, endoscopic)
Tx Melanoma of anal canal
Px- S100+, pigmented. NO chemo-XRT
Tx:
- WLE (1 cm). No SLNBx
- APR if sphincter involved, LADN, or > 4mm
- *5y-S is 20% w/ R0
- *WLE = APR
Kaposi’s sarcoma - cause and px
HSV8
Violet/brown papules
Mechanism and Tx of thyroid dz:
- Graves
- TMN
- Hashimoto’s
- DeQuervains/Subacute
- Reidels
- Graves: IgG stimulates TSHr ➡ hyperT
- BB, PTU ➡ RAI ➡ thyroidectomy - TMN: chronic TSH stimulation ➡ hyperT
- BB ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy - Hashimoto’s: antiTPO/TG Ab ➡ hypoT
- thyroxine ➡ partial thyroidectomy - DeQuervains/Subacute: viral URI
- NSAIDS/ASA ➡ steroids - Reidels: autoimmune inflammation
- steroid, thyroxine ➡ extensive fibrosis often need surgery for compression
Sonograph FNA recs
cystic- no bx
isoech/hyperech- FNA if > 2cm
hypoech (high sus)- FNA if > 1cm
Tx anal incontinence
1st line- fiber/bulking, exercises
refractory- overlapping sphincteroplasty
s/e of silver nitrate, silver sulfadiazene, mafenide, bacitracin
Silver nitrate- eletrolytes disturbace (no sulfa)
Silver sulfadizene- neutropenia, sulfa
Mafenide- met acidosis, sulfa (covers pseudo and eschar)
Bacitracin: G+; nephrotoxic
Triple therapy
PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks
APC gene
chrom5
1st mutn in adenoma to carcinoma
mc mutation in colon ca
a/w FAP.
Contents of post triangle
- CN 11
- subclavian artery
- EJV
- brachial plexus trunks
Gail model
- age
- age 1st period
- age 1st birth
- 1d relative
- previous bx
- race
Associated orthopedic injuries:
- post hip disloc’n
- post knee disloc’n
- DRF
- Supracondylar humerus fx
- Anterior shoulder disloc’n
- post hip disloc’n- sciatic nerve (peroneal branch)
- post knee disloc’n- popliteal atery
- DRF- median nerve
- Supracondylar humerus fx- brachial artery
- Anterior shoulder disloc’n– axillary nerve
Anti-staph Penicillins
Oxacillin
Methicillin
Nafcillin
Dobutamine
B1 at low dose
- inotropy
B2 at high dose
- vasodilation
types of endoleak and tx
- proximal/distal seal- balloon expansion of distal/proximal attachments + stent
- back bleeding- coil embolization
- graft defect (tear or overlap leak)- additional graft coverage
- porosity- resolves on its own
Carcinoid vs. GIST vs. Desmoid
- Carcinoid- Kulchinsky cells (enterochromaffin-like) tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable
- GIST- cajal cells
tx- resection, imantinib - Desmoid- spindle cells
tx- resect if extra-abdominal. NSAID/estrogen if intra
Meckel’s Diverticulum Pathophys
Anti-mesenteric border of SB
2/2 peristant viteline duct
pancreatic and gastric tissue
2 feet from IC valve
VRE (vancomycin-resistant Enterococcus)
Synercid, linezolid
Acetazolamide MOA
Inhbitis carbonic anhydrase
non-AG metabolic acidosis
Milrinone
Midodrine
Milrinine- PD inhibitor, contractility with vasodilation
Midodrine- a1 agonist
Hyperaldosterone w/up
Px: resistant HTN and hypokalemia
- AM plasma aldo AND plasma renin
- A/R < 20: 2nd hyperaldo
- A/R > 20: primary hyperaldo ➡ - Confirmatory test: salt load suppression test
- give salt load ➡ 24h urine aldo remains elevated - Discern laterality: CT scan
A. Unilateral: adenoma, unilateral hyperplasia, carcinoma ➡ offer lap adrenal
B. Bilateral or negative ➡ adrenal vein sampling
- Lateralization: offer lap adrenal
- No lateralization: idiopathic hyperplasia ➡ tx medically
Tx and Dx of SBP
dx- ↑ascitic PMN and + culture;
tx- 3GC abx AND albumin (survival benefits)
HLA test
- Donor organ: carries Ag (on WBC)
- Recipient body: carried Ab
Recipient serum with donor wbc
Tx acute variceal HMHG
octreotide + antibiotics → endoscopic intervention (ligation/sclerotherapy) → TIPS
Tx SVC syndrome tx
- Elevate HOB
- CXR and CTA
- Assess sxs
A. Life-threatening sxs: secure airway ➡ consider AC ➡ venogram ➡ endovascular stenting
B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo
Crystalloid and colloid for trauma kids
Crystalloid: 20cc/kg
PRBC: 10cc/kg
Melanoma characteristics: superficial spreading lentigo nodular acra
superficial spreading- MC
lentigo- sun exposed, best prog
nodular- worst prog
acral- AA
**thickness is most indicative of prognosis
Tx appendicitis
- Uncomplicated: no perforation, abscess, mass
- Septic/Unstable: immediate lap appe
- Stable w/ abscess
- < 3cm: lap appe
- > 3cm: IR drain ➡ interval appe in 6-8 weeks; lap appe if no cx imporvement - Phlegmon:
- ileocecal resection likely: abx trial 1st
- ileocecal resection unlikely: lap appe
**Lap appe a/w higher intra-abdominal abscess and OR time (lower overall complication rate)
Tx MEN2A/B
- urine metanephrine to r/o pheo 1st
- tx pheo 1st w/ adrenalectomy
- Address thyroid
- 2A: total thyroid at 5y
- 2B: total thyroid at 6m
Tx MEN1
- HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
- Asses other lesions
Tx anaplastic thyroid ca
aggressive, undiff
mort ~ 100%; no tx
tx- XRT improves short-term survival +/- surg
Hepatitis seromarkers
Vaccinated: surface Ab+
Resolved Hb infection: surface Ab+ and core Ab+
Active: surface Ag+, surface Ab+, and core Ab+ (IgM)
Chronic: surface Ag+, surface Ab+, and core Ab+ (IgG)
GI Hormone Release and action:
Glucagon
Insulin
Glucagon – alpha cells of pancreas
- glycogenolysis, gluconeogenesis
Insulin – beta cells of the pancreas
- cellular glucose uptake; promotes protein synthesis
TASC classifcation
TASC a and b usually get endovascular repair
A- < 3cm
B- 3-10 cm
Criteria for transanal excision of adenocarcinoma
T0 or T1 (submucosa)
< 3 cm
< 30% circumference
Palpable on DRE (<8cm from anal verge)
**local recurrence rate is higher
Merkel cell ca - dx and tx
Dx:
- rare neuroendocrine tumor of the skin
- looks like BCC w/out rolled edges
Tx:
- highly radiosensitive
- Tx (like melanoma): surgical excision + SLNBx! + XRT
Breast abscess tx
US aspiration BEFORE I/D if refractory
Bx if > 2 weeks to r/o ca
5 steps to LADDS procedure
resect Ladd’s bands widen the mesentery counterclockwise rotation place cecum in LLQ (cecopexy), place duodenum in RUQ appendectomy
Beta lactamase inhibitors
Sulbactam/Tazobactam
Clavulanic acid
Entamoeba vs. echinococcus - dx and tx
- Entamoeba
dx: from mexico; microscopy, antigen testing, or PCR
- CT: rim enhancement
tx: even if asx - MEtronidazole
- Surgery if refractory
- Echinococcus
dx: enzyme-linked immunosorbent assay
- CT: calcification + endocyst
tx: albendazole x2 weeks then PAIR
- ‘pair’ - puncture, aspiration, injection (etoh), re-aspiration
HNPCC screening and treatment
- CRC: scope q1-2y starting at 20-25
- Surgery if:CRC or endoscopically unresectable lesions
- TAC with IRA w/ q1y rectum surveillance - Endometrial ca
- childbearing: endometrial sampling q1y
- completed children: TAH-BSO - Ovarian ca: annual pelvic exam and TVUS
Tx choeldochoal cyst
- fusiform dilation: REY-HJ
- diverticulum: simple excision
- choledococele: transduo excision/sphincteroplasty
4a. intra + extra dilation: hepatic resection + recon
4b. extra only: excision + recon - intra only: transplant
Vit D vs. PTH
Vit D: increase Ca and Ph
PTH: increase Ca and decrease Ph
Arterial content
(1.34 x Hb x Sa02) + (.003 x PaO2)
Px, Dx, and Tx:
Duo atresia TEF Pyloric stenosis Intussusception Malro
Duo atresia: newborn; bilious emesis directly after birth
- a/w down syndrome
- dx: AXR- doube bubble
- tx: duodenoduodenostomy
TEF: newborn, spit ups. can’t place NG. resp sxs
- dx: AXR- gasless (A), gas (C)
- tx: right extra-pleural thoracotomy
Pyloric stenosis: 1-3 months; NB projectile vomiting
- dx: U/S- 4mm thick, 14 mm long
- tx: pyloromyotomy
Intussusception: 3m-3y; currant jelly stool
- dx: U/S w/ bull’s eye
- tx: air contrast enema
Malro: 1y-5y; sudden onset bilious emesis
- dx; UGI- no duo sweep (any child w/ bilious emesis)
- tx: ladd’s procedure
Cori cycle
recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production
provides 40% of glu when starving
Tx of GB cancer
1a: LP only
- lap chole only
1b: muscle inovlved
- lap chole + seg 4b and 5 + LADN
- CD margin positive: REY-HJ
Layers of mucosa
Epithelium
Lamino Propria
Muscularis mucosa
Stage 3 breast cancer and tx
3a- 4 to 9 nodes ➡ +/- neoadj
3b- chest wall (not pec wall) or breast skin ➡ +/- neoadj
3c- supra clavicular nodes ➡ neoadj required
Tx of CBD stone intra-operatively
- Flush ➡ glucagon x 2
- Lap exploration
A. Transcystic: stone < 1 cm, <8 stones, CD > 4 mm, no CHD stones, normal anatomy
B: Lap CBD: stone > 1cm, > 8 stones, CBD > 7 mm, CHD or junction stones, abnormal anatomy - Open exploration: if lap exploration failed
- CBD < 2 cm: trans-duo sphincteroplasty
- multiple stones, CBD > 2 cm: biliary-enteric drainage.
- Leave T-tube- avoid spasm and back pressure that could blow out your stump
W/up Hurthle Cell Cancer
- FNA- hurthle cells
- lobectomy 1st for diagnosis
- If malig: total thyroidectomy +/- L6 nodes
- If palpable nodes: MRND
No RAI
Conduit after esophagectomy
Stomach and Right gastroepiploic
- if you notice this is out then stop the procedure and discuss conduit options at a later time (don’t go for colon or jejunum b/c needs to be prepped)
Cancer Markers: Ca 126 bHCG AFP Inhibin
Ca 125- epithelial
bHCG- choriocarcinoma
AFP- germ cell/endodermal/yolk sac
Inhibin- granulosa/sex-cord
Tx of High grade AIN/bowen’s disease of anal margin
- Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin
- otherwse: cryo, curettage, 5-FU, laser - Lifetime surveillance even if tx!
- Bowen disease = SqCC in situ = high grade AIN
- Actinic keratosis is precursor
Types of rejection - px, path, and tx
- hyper-acute: w/in 1 hour
- path: ABO Ab (t2 HS)
- px: mottled organ
- tx: remove organ - acute cellular: days-weeks; change in organ function
- path: B or T (t4 HS)
- px:
- - kidney: decrease UOP, elevated Cr; tubulitis
- - liver: elevated enzymes; endothelitis, portal triad lymphocytosis
- tx: increase IS, steroids, IVIG - chronic: months-years
- path: B or T (t4 HS)
- px: organ dysfunction after months-years
- - kidney: interstitial fibrosis, tubular atrophy
- - liver: bile duct atrophy
- - heart: vasculopathy and atherosclerosis; 1/2 @ 10y
- - lung: bronchiolitis obliterans; 1/2 @ 5y
- tx: increase IS or re-trx (no good options)
Tx DPGM injury
- All left sided and most right sided should be repaired
- Abdominal approach
- Debride devitlized tissue
- Repair with absorbable or non-abs monofilament
- If too large to close primarily can use mesh or tissue flap (if contamination)
Tx of liver abscess:
- fungal
- hydatid cyst
- amoebic
- pyogenic
- fungal: perc drain + micafungin (ampho is 2nd line)
- hydatid cyst: albendazole qwks then PAIR
- amoebic: metronidazole
- pyogenic: DRAIN! and Abxs (even if multi-loculated)
Periop NOAC
stop 2 days before elective surgery
Strep species
G+/aerobe/chains;
a hemo- pneumo, viridans
b hemo- GAS(pyo)/GBS(aga)
non hemo- enterococci
Hypocalcemia vs. Hypercalcemia - sxs and ekg
- HypoCa: tingling, chvostek/trousseau sign
- EKG: qt prolongation - HyperCa: stones, bones, groans, overtones
- EKG: shortened QT
Calcitonin
Parafollicular C cells
Inhibits osteoclast resorption
Increases Ph excretion
Types of Shunts
- Total: porto-caval, meso-caval
- Relieves bleeding and ascites
- More hepatic encephalopathy - Partial: distal spleno-renal
- Relives bleeding only
Crohn’s drugs MOA:
Azathioprine/6-MP
Sulfasalazine/5-ASA
Infliximab
Azathioprine/6-MP: inhibit DNA synthesis
Sulfasalazine/5-ASA: COX/LOX inhibitor
Infliximab: monoclonal Ab to TNF; moderate crohns, recurrent perianal fistula!
GI Hormone Release and action: Gastrin Somatostatin CCK Secretin VIP
- Gastrin - G cells in antrum
- ↑ HCl, IF, and pepsinogen - Somatostatin – D cells in antrum
- inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output - CCK – I cells of duodenum
- gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells) - Secretin – S cells of duodenum
- ↑ pancreatic HCO32 release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release - VIP – pancreas and gut
- ↑ intestinal secretion (water and electrolytes) and motility
Anal canal
Dentate line
Anal verge
Anal margin
Anal canal- from levators to verge
Dentate line- w/in the canal; columnar/sq. jxn
Anal verge- sqamous/myoc. jxn
Anal Margin- 5-6 cm from the anal verge
Tx Galactocele
dx/tx- aspiration
no tx if asxatic, continue bfeeding
T and N staging for gastric cancer
t1- SM t2- MP t3- xMP/subserosa t4- invade n1: 1-2, n2: 3-6, n3: >7
Stages of graft healing
- imbibition (direct diffusion)
- inosculation (cap beds meet)
- revascularization
Hernia repairs: Bassini McVay Lichtenstein Shouldice
Bassini: conjoint tendon to inguinal ligament (from pubic tubercle medially to internal ring laterally)
- may need relaxing incision in anterior rectus sheath
McVay: open the floor to ➡ conjoint tendon to cooper’s/pectineal ligament.
- transitional stitch from conjoint, cooper’s, and femoral sheath at medial aspect of femoral vein
- re-approximate the rest of the inguinal floor by suturing the conjoint tendon to the inguinal ligament
- may need relaxing incision
Lichtenstein: mesh to inguinal ligament and conjoint tenown
Shouldice: divide the floor ➡ 4-layer tissue closure
EBUS accesible nodes:
2, 3, 4, 7, 10, 11, 12
- innominate seperates level 3, 4
- 4: carinal
- 7: sub-carinal
- 10: R/L hilar
- n2 nodes: 1-9
- n1 nodes: 10-14
- cannot sample 5, 6 (sub-aortic/AP window) ➡ chamberlain procedure (Parasternal mediastinotomy)
- 8 (para-eso), 9 (IPL) ➡ EUS or VATS
Child’s Pugh Score
Billirubin, Albumin, INR, Ascites, Encephalopathy
Order of cells in healing:
- Hemostasis: PMNs (24-48h)
- Inflammatory: macrophages (48-96h)
- Proliferative: lymphocytes (3d)
- Maturation: fibroblasts (10d)
Hemophilia A
f8 deficiency, SLR
MC inherited disorder
tx- DDAVP (mild), f8 concentrate (severe)
Adenoid cystic carcinoma - px and tx
Px: MC minor salivary gland tumor (SM gland)
- Spread along nerves
- Remains quiescent for years then metastasizes
Tx: Total parotidectomy w/ facial nerve preservation + MRND + XRT
- don’t aggressively resect b/c very XRT responsive
Tx for cholangiocarcinoma
- Resectable if:
- contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor
- no distant mets or organ invasion - Consider location
Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
Middle ⅓: hepaticojejunostomy
Lower ⅓: pancreaticoduodenectomy (Whipple) - Consider chemo + transplant if unresectable
acid and alkali burns
- Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis
- Acid burns (battery acid) produce coagulation necrosis
** copious water irrigation as soon as possible
IPMN - dx and tx
dx- MRI then EUS/FNA; high CEA, high amylase
tx-
1. Branched
- resect if >3 cm, sxs, or signs of malig (nodule)
- Otherwise surveillance
2. Main duct
- resect if > 1 cm or sxs (60% chance of Ca)
- 5-9 mm EUS/FNA. Resect if SOMalig
- < 5mm, surveillance MRIs
Tx PDA
to close- indomethacin
to open- PGE1
Airway management - trach vs. crich
- Elective trach: between 2nd and 3rd trach rings
- Crich: CT membrane between thyroid cart and cric
- Thyroid cart ➡ cricoid cart ➡ rings
- Avoid nasotracheal intubation w/ basal skill fractures - hemotympanum, CSF rhinorrhea/otorrhea
Dopamine dosing
low- d1/2 ago (renal dose)
medium- B ago
high- A ago
Parkland formula
4 x weight x TBSA
1st 1/2 in 1st 8h
2nd half next 16
arm = 9, leg = 18, each torso = 18, head = 9, each hand = 1, genitals = 1
UOP: .5-1 cc/hr. 1-2 cc/hr if child < 30 kg
Who needs stress dose steroids and how to dose
> 20 mg of steroids for > 3 weeks
Surgery: continue regular dose the day of surgery +
- Low risk (inguinal hernia): just continue regular dose day of surgery
- Moderate risk: 50 mg HC pre-proc. Then 25q8 x 3
- High risk: 100 mg HC pre-proc. Then 50q8 x 3
Tx of Zenkers
Dx- UGI (don’t do EGD)
<3cm- open myotomy (left neck incision) +/-diverticulectomy
>3cm- rigid scope division of UES (common lumen)
Tx SIADH
Acute – vaptan, demeclocycline
Chronic – fluid restriction, diuresis
Spinal vs. Epidural
Spinal- below l1/l2; SA space; fast; n/m block
Epidural- any level; epidural space; slow; no block
VIPoma - loc, px, dx, tx
Loc: distal Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin - most malignant Dx: high VIP Tx: resct + LADN'y + CC'y
Gastric CA tx
neo-adj chemo for T2+ or N
proximal- total gastrectomy
distal- partial
5cm margin; 15 nodes
DDAVP/Vasopressin
Made in SON of HT. Stored PP.
Cause endothelium to release f8 and vWF
ASD
L to R shunt
Paradoxical emboli
surg if sxs or asx < 5 yo
surg before school
Milan criteria
indications for trx w/ HCC
- Single tumor < 5cm
- No more than 3 tumors each < 3 cm
**Hepatectomy if compensated cirrhosis (no portal HTN), low MELD, and solitary mass < 3 cm is still preferred
**5-year transplant pt survival is 65-90%
Posterior and anterior vagal trunk branches
Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet
Anterior trunk- hepatic branch, ant laterjet
Tx of SqCC of anal margin
tx like SqCC of the skin
half-lifeacoags:
war
hep
noac
war - 36h
noac- 12h
hep- 1.5h
3.5 half lives to ss
Insulinoma - loc, px, dx, tx
Loc: throughout (B cells) Px: whipple's triad. Most benign. Dx: I/G > .4 and high C-pep Tx: < 2cm encucleate, >2cm resect. - Diazoxide if can't tolerate surgery - LADN'y if suspect malignancy
Dx and Tx fat necrosis
dx- oil cyst w/ Ca+ rim
tx
no trauma- bx
trauma- watch
Tx Panc divisum
ERCP sph’otomy of MINOR papilla (Santorini/Superior)
Indications for neoadjuvant therapy eso cancer
high grade t1b or T2 and above OR any nodal involvement
Also get XRT
Marfans vs. Ehlers-Danlos
Marfans- Fibrillin defect (elastin);
- AD; tall, aortic root dilation, lens defect, arachnodactyly
Ehlers Danlos- t1, t3 , t5 collagen defect
- hyper elastic skin, hypermobile joints
Bladder ca dx and tx
dx- CT urogram is 1st step for any bladder, kidney, or ureter cancer suspected
- T1a- no muscle
tx- endoscopic resexn + BCG/mitoM - T2a- muscle/beyond LP
tx- cystectomy + chemo + LND - T3- fat/nodes)
tx- neoadjuvant
Tx tracheal inj
Small ➡ absorbable in 1 LAYER w/ strap
- primary repair up to 5-6 rings
Large → tracheostomy
- avoid below 3rd ring (TI fistula)
Specific to Crohn’s
Creeping fat Skip lesions Transmural Cobblestoning Granulomas Fistulas
Uremic PLT dysfunction
2/2 renal disease
reversible dysfunction
tx- ddavp
Escharotomy indications
- Circumferential deep burns
- Low temperature, weak pulse, ↓ capillary refill, ↓ pain sensation, or ↓ neurologic function in extremity
- Problems ventilating patient with significant chest torso burns
- *Perform within 4–6 hours
- *May need fasciotomy if compartment syndrome suspected after escharotomy
Gastric ulcers: elective classification and management
Dx- EGD and Bx (Bx needed to r/o ca!)
Tx-only tx if refractory to max medical management after 12 weeks.
- lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2
- gastric + duo; high acid ➡ antrectomy + vagotomy
- pre pyloric: high acid ➡ antrectomy + vagotomy
- GE junction: normal acid ➡ sub-total gastrectomy + REY
Emergent vs. Elective UC Tx
Emergent:
- Steroids +/- abxs
- Infliximab, Cyclosporine
- TAC with end-ileostomy
- When stabilized can perform completion proctectomy and IPAA
- Don’t do proctectomy in emergent situations
Elective:
- Indications: dysplasia, cancer, refractory disease
- PC w/ IPAA
- Surgery reduces: erythema nodosum, arthritis
- no effect on PSC or ank spondy
Kasabach-Merritt Syndrome
hemangioma + thrombocytopenia
usually infants
resect!
peri-op anti-PLT therapy in pt with stent/PCI
No CVdz:
- stop ASA 7-10 days before surgery.
- Restart after 24-72h depending on bleeding in surgery
Known CV dz
Elective surgery:
- delay surgery until after optimal time (6w for BMS, 6-12m for DES)
Emergent surgery:
- c/w DAPT unless high bleeding risk
Peutz-Jeghers - px and screening
Px- intestinal hamartomas, pigmented oral mucosa, polyposis, breast/pancreatic ca
- AD, STK11 mutation
Screening
1. Scope @ 25y then q2 years b/c high r/o GI/pancreas ca
Acute hemolytic trx reaction
rapid RBC destruction by host IgM/IgG
+direct coomb’s
Omphalocele
2/2 failure of umbo ring closure 11th week gut returns to abdominal cavity normal bowel (protected) Other congenital defect are more common
Cryo used to treat?
- VWD
- Fibrinogen def
- Hemophilia A
Zone injuries
penetrating:
- zone 1-3 –> explore
blunt:
- zone1 –> explore
- zone 2-3 –> do not explore
TOS tx
neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
Venous- catheter directed thrombolysis → surgical decompression
Arterial- C7/1r resection, subc artery resection/reconstruction
Contents of FFP and Cryo
FFP: all clotting factors
Cryo: VWF, f8, fibrinogen
FAP Dx and Tx
AD; APC mutation
Dx: > 100 adenoma or < 100 w/ fam hx
CA by 40
Tx:
- sigmoidoscopy q1y at 10 (don’t need colonscopy)
- TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen)
- q1y scope post op for duodenal cancer (MC COD)
- polyposis/high grade dysplasia @ stump → proctectomy +/- pouch
BRCA risks and tx
female breast, ovarian, male breast
I- 60, 40, 1
II- 60, 10, 10
Tx:
- pre meno: offer bilateral mastectomy OR q1 MRI starting @ 25
- post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH)
**SOO decrease r/o OVARIAN Ca (80%) for BRCA1/2
AND breast Ca for BRCA2 only (50%)
**No TAH!
When to operate on adrenal mass
OR:
- all functioning tumors
- all > 6 cm –> open resection (no lap)
- if < 6cm with suspicious features - >10HU, <50% @ 10m w/out –> open resection (no lap)
Tx Neck trauma
OR if platysma violation + crepitus, odynophagia, pulsatile bleed, expanding h’oma, bruit, thrill
Non-op w/up: 4V angio, doppler or CTA, UGI (esophagography) or esophagoscopy, bronchoscopy
Adjuvent chemo for breast ca
- Adjuvent chemo: tumor > 1cm, nodal dz, aneuploidy
- echo before for cardiotox - Tamoxifen/Anastrazole: 5y for HR+ tumors
- Tamox for men too - Trastuzumab- 1y for Her2/neu+ tumors
- echo before for cardiotox
FNH
path- CENTRAL STELLATE SCAR!
bright on arterial phase homogenous
tx- resect if sxatic. no malignant potential.
Secretin vs. CCK
Both released by duo
S cells ➡ Secretin- duct cells ➡ bicarb
I cells ➡ CCK- acinar cells ➡ enzymes
Pancreas drainage procedures
- duct > 7mm- Peustow, pancreaticojej (for large duct)
- duct > 7mm and large head- Frey, pancreasticojej + core out head
- duct < 7mm and large head- Berger, pancreatic head resection
Tx papillary/follicar thyroid ca
- Indications for total thyroidectomy:
- Tumor > 4cm
- Tumor 1-4cm and patient preference
- Distant mets or extra-thyroid disease
- Cervical or central nodes
- Poorly differentiated
- Prior radiation - Nodes dissection:
A. Therapeutic lateral neck dissection: of involved compartments if palpable or bx+ nodes
B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes.
- Usually not performed for follicular - Radio iodine indications (6w post op, want TSH high)
- Only after total thyroidectomy to be effective
- Tumor > 1 cm
- Extra-thyroidal disease
Heparin - MOA
accelerates AT3 activity and INDIRECTLY inhibits thrombin
Screening guidelines for breast ca
Mammogram every 2–3 years after age 40
then yearly after 50
High-risk screening
- mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative
Tx SDH
- Nonop- HDS, <10 mm, <5 mm shift
2. Evac- > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP
Central venous O2 vs. mixed venous O2
Mixed venous: from PA
Central venous: from SVC only (estimation of mixed)
Reversals: BB CCB Tylenol Benzos CN/Nitroprusside Vecuronium/Rocuronium Ethylene glycol Methemoglobinemia
BB overdose: fluids/atropine → glucagon CCB: Ca + Insulin + Atropine + Pressor Tylenol: NAC Benzos: flumazenil CN/Nitroprusside: sodium thiosulfate, amyl nitrite Vecuronium/Rocuronium: sugammadex Ethylene glycol: femopizole and bicarb OR ethanol; iHD Methemoglobinemia: methylene blue
Orientation of portal triad
Bile duct lateral
Hepatic artery medial
Portal vein posterior
Cryoptococcus
Coccidiomycosis
Histoplasmosis
Mucormycosis
- Crypto- CNS sxs in AIDs pt
tx- amphotericin - Coccidio- pulm sxs in the southwest
tx-amphotericin - Histo- pulm sxs in ohio river valley
tx- itraconazole → ampho B - Mucormycosis- burns/trauma w/ bloody cough
tx- emergent debride, ampho
Polyps that require surgery instead of endoscopic resection
- Submucosal invasion > 1mm
- Poorly differentiated
- <1 mm margin
- Lymphovascular invasion
- Tumor budding
- Sessile polyp (if you can’t get it all)
LN harvest/margin eso stomach colon rectum
eso- 15/7cm
stomach- 15/5cm
colon-12/5 cm
rectum- 12/5 cm
Succinylcholine
ONLY depolarizing short half life and rapid onset (RSI) Used for "full stomach" degraded by plasma CE s/e: rhabdo, hyperK, M/H c/i: spinal cord injury, renal failure, large burns
tx of M/H: stop drug, dantrolene, Bicarb, cooling, tylenol
Breast nerve: Thoracodorsal Intercosto-brachial Lateral petoral Medial pectoral Long thoracic (medial)
Thoracodorsal (lateral)- LD, ADduct Intercosto-brachial- hypesthesia Lateral petoral- p major Medial pectoral- p major/minor Long thoracic (medial)- SA, wing scap
Cohort study vs. Case control
Cohort: prosepective; exposed vs. non-exposed
RR- [a/a+b]/[c/c+d]
Case control: retrospective; diseased vs. non-diseased
OR- (a/b)/(c/d)
Tx acute limb ischemia
Tx: Rutherford
1- no deficits ➡ hep gtt. imaging. eventual revasc
2a- motor intact ➡ imaging. hep gtt (motor intact, sensation). eventual revasc
2b- any weakness, rest pain ➡ hep gtt and immediate revasc (don’t image if delay in tx)
3- paralysis ➡ amputation
Revasc options:
- Endovascular: short segment, single lesion
- Open: long segment, multiple lesions
Warthin tumor/Papillary cystadenoma
benign tumor of salivary gland
often BILATERAL and 2/2 smoking
Slow growing
Tx- complete resection with uninvolved margins even if ASx
Hemangioma - path and tx
path- PERIPHERAL ENHANCEMENT
tx- if rupture, size change, or KM syndrome
Pancreatic ducts
Wirsung- major, lies inferior
Santorini- minor, lies superior
Gluconeo precursors
lactate , pyruvate, AA
Sirolimus
MOA: mTOR inhibitor Less nephrotoxic s/e - lymphocele (w/ obstruction) - wound complications/poor wound healing: held or switched to tacro before hernia repairs
Tx of rectal prolpase
Not past the verge- biofeedback, fiber
Many comorbidities- Altemeir (perineal rectosigmoid’y)
Prolpase < 50cm- Delorme (plication)
Young/healthy- rectopexy +/- resection
Px and Tx of Hypertrophic scar
Px: 3–4 months after injury secondary to ↑ neovascularity
- More likely to be deep thermal injuries
Tx: steroid injection into lesion (best), silicone, compression; wait 1–2 years before scar modification surgery
Li Fraumeni
p53 mutation - TSG on Ch17
cell cycle regulation and apoptosis
breast ca + soft tissue sarcoma b4 45
Chylothorax dx and tx
- dx: fluid TG > 110
- tx: chest tube and NPO
- < 1L/day: MCT diet, octreotide, TPN → 7d: thoracic duct lig (Open R chest or IR)
- > 1L/day: thoracic duct ligation (Open R chest or IR)
Chemotherapy indications for breast ca
- Tumors >1cm
- Positive nodes
- Triple negative tumors
Tumor lysis syndrome
hyperU, K, Ph w/ hypoCa
CaPh crystal ➡ renal failure + hypoCa
tx: IV hydration ➡ iHD
CRC T and N
t1- SM t2- MP t3- xMP/subserosa t4- invade n1- 1-3, n2- >=4
Rectovaginal fistula tx
wait 3-6m
low- endorectal advancement flap
high- abdominal approach
Schiatzki’s Ring - Tx
Associated with hiatal hernia
Tx- only if sxatic. dilation only and PPI
NNT`
NNT = 1/absolute risk reduction (ARR) ARR = event rate in intervention group - rate in control group AR = event rate in intervention / rate in null group RRR = (rate control - rate experimental) / rate control
Tx childhood GI disease: Pyloric stenosis Intussusception Duo atresia TEF Malro
Pyloric stenosis: pyloromyotomy Intussusception: air contrast enema Duo atresia: DD or DJ TEF: right extrapleural thoracotomy Malro: LADDS proc
Tx Panc fistula
tx- NPO, TPN x 4-6 wks → ERCP w/ stent → surgery
Max dose of lido and bupiv
lido = 5mg/kg (7 w/ epi)
bupiv = 2.5 mg/kg
tx- lipid emulsion
Tx Aspergillosis
MC fungal infxn in IC patients
aspergilloma- resect
aspergillosis- voriconazole!
Dx and Tx of GIST
- Dx- MC GI Sarcoma
- - EGD: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC.
- - Bx: cajal cells. c-KIT+ - Dx/Tx- wedge resection (gross). no bx unless neoadj
- can be R0 or R1 resection - Imatinib (TK inhibitor) - > 5cm or >5 mitosis/50 hpf
Vitamin K
gamma CARBOXYLATION (not decarb) ofGLUTAMATE on 2, 7, 9, 10, c, s Px- coagulopathy, suspect if obstructive jaundice
Rectum:
- Arterial supply
- Venous drainage
- Arterial supply:
- IMA to superior rectal a.
- II to middle rectal a
- II to internal pudendal a. to inferior rectal a. - Venous drainage-
- SRV ➡ IMV ➡ PV (portal)
- MRV/IRV –> internal pudendal –> internal iliac (systemic)
Kcal per macronutrient
protein = 4 kcal/g dextrose = 3 kcal/g lipid = 9kcal/g carb = 4 kcal/g
Hinchey
1- pericolic abscess
2- pelvic abscess
3- purulent
4- feculent
Contents of ant triangle
Carotid sheath, anca cervicalis, CN 12 (hypoglossal)
Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular
Facial vein is the gateway
Tx for Leriche syndrome
aortobifemoral bypass
Benign lesions that require excisional bx
Atypical DH/LH LCIS/DCIS radial scar papillary lesion any atypia
Future Liver Remnant
minimum 20% if normal liver
pre-op chemo/some dysfxn = 30%
cirrhosis = 40%
Cervical neoplasia
CIN1- tx infection, close f/up
CIN2- cryo or leep
CIN3- cryo or leep
type 1 vs. type 2 error
type 1: false positive
- say something is true (reject the null) when it’s not
- minimize by including stat significance
type 2: false negative
- say something is false (do not reject the null) when it’s true
- minimize by increasing sample size
- increases with higher P-value (more likely to make a false negative)
power = 1 - type2
clostridium - px and tx
anaerobic, GPR
MC CO emphysematous cholecystitis
MC CO gas gangrene
tx- PCN, clinda 2nd line
Early excision and graftingf
- Day 1 of burn
- Can be considered in stable patients with limited burns (< 20%) that are clearly 3rd degree
- Saves costs; minimizes pain, suffering, and complications
hepatic adenoma
path- EARLY HETEROGENEOUS enhancement on A phase w/ rapid washout
tx- stop OCP use.
resect if > 5cm or sxatic
DVT tx
ileofemoral- cather directed thrombolysis
other- anticoagulation
Types of mastectomy
- Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin
- MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes
- BCT: partial mastectomy + XRT
Pyoderma gangrenosum
associated w/ IBD
RESOLVES after resection
pre-tibial
tx- steroids
AG
Na - (Cl+Bic)
NaCl = non-AG, metabolic acidosis
Causes of AG MA: Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, LA, Ethanol/Glycol, Salicylates
MOA reglan and erythromcyin
reglan: dopamine antagonist
erythromycin: motlin receptor agonist causing SM contraction
VIPoma
Loc: distal
Px: watery DRH, hypoK, achlorhydria, inhibits gastrin
Tx: resect (distal panc)
Thyroid ima
supplies medial aspect of both lobes of the thyroid
come off the innominate/brachiocephalic
T and N staging eso cancer
t1a- LP and MM t1b- SM (where it spreads) t2- MP t3- adventitia t4a- resectable structures t4b- unresectable structures n1: 1-2 nodes, n2: 3-6 node, sn3: 7+
Tx of burn types: Acid burn Alkalia burn Hydrofluoric acid burns Powder burns Tar burns
Tx of burn types: Acid burn: irrigation Alkalia burn: irrigation Hydrofluoric acid: spread calcium Powder burns: wipe away before irrigation Tar burns: wipe with lipophylic glycerol
Barrett’s eso surveillance
Bx- Goblet cells and columnar cells
No dysplasia- 4 quad every 2 cm q 3-5y
Dysplasia/Nodule- 4 quad every 1 cm q 3-6m
*Fundoplication is only c/i in HGD
HNPCC vs. Lynch S Dx and Screening
HNPCC- fulfill amsterdam criteria
- 3+ relatives with Lynch syndrome-associated cancers (CRC, cancer of the endometrium or small bowel, transitional cell carcinoma of the ureter or renal pelvis),
- 2 generations
- 1 ca dx < 50 yo
Lynch syndrome- refers to mutation in DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) or the EPCAM gene.
Serum osmolarity
Osm = 2xNa + Glu/18 + urea/2.8
Superior laryngeal nerve
motor to cricothyroid
injury: trouble w/ high pitch, voice remins clear
Cord looks normal on laryngoscopy
tx- none
Cause of stones: CaOx Uric Acid Cysteine CaPh MgAmPh
CaOx- diet Uric Acid- protein Cysteine- AA metab. error CaPh- high pH MgAmPh- urease infxn
Location of vagus nerve
LARP
left anterior, right posterior to esophagus
GCS motor
6- obeys commands 5- localized 4- w/draws 3- flexion (decort) - 'flex your core' 2- extension (decErebrate) 1- none
LeFort fxs
I- palate
II- nose and palate
III- entire face
Human bite tx
amox/clavulanate (augmentin)
MC for human bites- eikenella
tx flank wound
HDS- CT w/ triple contrast (oral, IV, rectal)
HDUS- OR
Indics and steps for ED thorac
trauma with witnessed loss of vital but SOL
SOL = ECG activity, reflexes, GCS > 3
- Access thoracic cavity
- Pericardiotomy - staple, suture, clamp
- Thoracic aorta cross clamp
- Cardiac massage +/- defib
TRALI
DONOR Ab attacks recipient WBC
Amphotericin
MOA: binds ergosterol and alters permeability
lipid soluble (CNS)
s/e- nephrotoxic, hypoK
MCCO healthcare infection: HAP central line infection SSI UTI GI infection SBP NSTI ICU infection
HAP: staph aureus (pseudomonas #2) central line infection- coag negative staph (staph epi) SSI- staph aureus UTI- e. Coli GI infection- c. diff SBP- e. coli NSTI- polymicrobial ICU infection- VAP
Tx of trx of great vessels
1st give PGE1 → ballon atrial septostomy
Tx SqCC of anal canal
Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC
Recurrence- APR
SqCC equivalents- large cell ker. (SqCC), transitional zone, LCl non-ker, basaloid, mucoepidermoid
TOF
Most common cyanotic defect 1. VSD 2. Pulmonary outflow obstruction 3. Over-riding aorta 4. RVH tx- beta blocker; surgery at 3-6m
Spigelian hernia
Richter’s hernia
spigelian- found along semilunar line lateral to rectus
richters- protrusion and/or strangulation of part of the intestine’s anti-mesenteric border
Cutoff for low risk lung nodules not requiring follow-up
- 6mm ➡ NTD
- 6-8 mm ➡ q6-12m CT
- > 8mm
- low risk pt- q3m CT
- high risk pt- bx or resection
Light’s criteria
PLprotein/serum Pr >.5
PLLDH/serum LDH > .6
PL LDH > 2/3 ULN
Treatment of colo-cutaenous fistula
- Start with conservative tx
- Quantify output:
- High output: > 500 cc/day ➡ likely OR
- Low Output: < 200 cc/dayt ➡ likely conservative - OR if failed after about 6 weeks
Most abundant bacteria in the colon
Bacteroides fragiles
T staging for esophageal cancer
t1a- muscularis mucosa: endo resection t1b- SM: upfront esophagectomy t2- muscularis propria: neoadjuvant t3- adventitia: neoadjuvant *no serosa. Ca spread through SM lymphatics
Exposing the pancreas
Head: kocherize
Body: incise gastrocolic ligament ➡ lesser sac
Tail: mobilize spleen
Thoracic duct course
- originates at L1-L2 @ c. chyli
- cross from R to L at T4-5
- empties into L SC/IJ jxn
Duo vs. stomach ulcer px
Duo ulcer: pain 2-3h after meal
- 90% H. pylori, 10% NSAIDS/ASA
Stomach ulcer: pain right after meal
- 75% H. pylori, 25% NSAIDS/ASA
**NSAID/ASA: decrease mucosal mucus secretion and bicarb secretion
Effective for Pseudomonas
- Ticarcillin, Zosyn
- 3/4G cephalosporin (ceftriaxone, cefepime)
- Aminoglycodies (genta, tobra)
- Flouroquinolones (cipro)
- Meropenem/Imipenem
**Not linezolid (good for G+/MRSA)
Tx hypertrophic cardiomyopathy
beta blockers
avoid inotropes
use neo if needed
most common organism in burn wound infection
most common viral burn wound infection
Pseudomonas (< 10^5 organisms – not a burn wound infection)
HSV
Tx Infected panc necrosis
stable- wait 4 weeks, IR retroP drain
unstable- debride
Debride: VARD (video-assist retroP)- utilize retoP drain, DEN (endoscope), open necrosectomy
Cuff size for kids
age/4 + 4
Grading and tx of BCVI
1- <25% narrowing ➡ ASA 2- > 25% narrowing ➡ ASA 3- PsA ➡ ASA + IR stent 4- complete occlusion ➡ ASA only 5- transection ➡ OR if accessible. Otherwise IR.
*most are not surgically accessible
Ectopic parathyroids
- Superior parathyroids
- usual location: jxn of RLN and INFERIOR thyroid artery. Posterior to RLN.
- Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath. - Inferior parathyroids
- usual location; along inferior thyroid vein. Anterior to RLN.
- Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass - 4 normal appearing galnds
- supranumary PT in the thymus
**Overall, thymus is MC location or ectopic gland
Trauma to the pancreas
- Head
- main duct: drain w/ staged resection
- no duct: drain - Tail
- main duct (grade 3+): resect w/ splenectomy (unless young and HDS)
- no duct (grade 1-2): drain
S/e and medications of trx meds
- Tacro
- Azathioprine
- Mycophenolate
- Sirolimus
- Cyclosporine
Tacro: calcineurin inhibitor; bind fK –> calcineurin –> block IL2
- 100x more potent than cyclosporine
- neuro sxs (tremor), nephrotox, hepatotoxic, GI sxs
- alopecia
Cyclosporine: calcineurin inhibitor; bind cyclophillin –> calcineurin –> block IL2
- nephrotox, hepatotox, neuro sxs
- gingival hyperplasia, hypertrichosis
Sirolimus: bind fK –> mTor inhibitor (IL2 inhibitor)
- impaired wound healing, interstitial lung disease, hyperlipidemia, thrombocytopenia
- anti neoplastic effects (good for cancer)
MMF: purine (T cell) inhibitor
- GI sxs, myelosuppression, anemia
Basilixamab: il2 inhibitor
- GI sxs
Azathioprine: purine (T cell) inhibitor
- myelosuppression, marrow suppression, pulm fibrosis
Interossei and lumbrical innervation
palmar- ulnar n, adduct
dorsal- ulnar n, abduct
lumbricals- median (1-2)/ulnar (3-4)
S/e of tamoxifen
dvt/pe
uterine cancer
DCIS tx
lumpectomy (2mm) + XRT +/- boost +/- endocrine
- no SLNBx (does not metastesize)
- no chemotherapy
if XRT c/i → mastectomy AND SLNBx (b/c 20% have invasive ca)
DCIS SLNBx
- does not metastasize
- not w/ l’omy unless >4cm, multicentric, palpable, high grade
- required w/ mastectomy b/c 20% have invasive ca
Dx and Tx of Cystadenoma
low CEA, low Amylase
tx- resect if sxs
Post polypectomy screening
- 1-2 tubular adenomas <5mm in size → 5 years
- 3 or more adenomas → 3 years
- Advanced adenomas - >1cm, HGD, or villous elements) → 3 years
- Hyperplastic polyps → 10 years. 3-5 years if > 1cm.
- Piecemeal removal → 2-6 month scope
Encapsulate organisms
Strep pneumo (MC)
Neisseria
Haemophilus
Casues of increased ET CO2
Increased muscle activity (shivering)
Increased metabolism (sepsis, fever, malignany hyperT)
Increased CO
Decreased minute ventilation
tx of Meckels
tx- resection if sxs
base < 2 cm → diverticulectomy
> 2 cm or wide base → seg resection
if appendicits leave Meckel’s alone
- Only consider taking out incidentally found asx Meckel’s in young/healthy pt
- Leave if asx in adults or concern for ca
Products of posterior pituitary
“PAO in the POST”
ADH, Oxytocin2/2 direct stem from neurosecretory cell
Hereditary pancreatitis
PRSS1 trypsinogen mut’n
AD
smoking cessation is important
Cilostazol - MOA and use
MOA- PDi, inhibits PLT aggregation
tx for periph claudication
- c/i in any degree of HF (PDi)
Esophagus and Trachea access
Proximal eso- L cervical
Mid eso/prox thoracic eso- R thoracotomy
Distal eso- L thoractomy
Carina/Either main-stem- R thoracotomy
Aorta- L thoracotomy
Ureter injuries
proximal ⅓ (U/P jxn and above) → primary ureterourostomy
middle ⅓ → primary or tran uretero urosotomy
lower ⅓ → re-implanation +/- hitch
- early: w/in 5 days- stent, explore, or repair
- late: > 10 days- perc nephro and delayed repair
Vitamin D processing
7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3
Tx papillary/follicar thyroid ca
Start with lobectomy
Indications for total thyroidectomy:
- Tumor > 4 cm (1-4 cm, close observation or total)
- Extra-thyroidal disease
- Multi-centric or bilateral lesions
- Previous XRT
Indications for MRND
- extra thyroid extension
Radio iodine indications (6w post op, want TSH high)
- Consider for 1-4 cm, definitely > 4cm
- Extra-thyroidal disease
- Need total thyroidectomy to be effective
Tx for hemobilia
angioembolization
Tx Odontoid fx
1- upper D, stable, non-op
2- base of D, unstable, worst, +/- surg
3- c2 vert, usually no OR
GCS verbal
5- normal 4- confused 3- inappropriate words 2- incomprehensible 1- none
MELD
- Bili
- INR
- Creatinine
- At least 15 for trx
- Pts added for HCC, hilar cholangiocarcinoma
- HCC gets automatic score of 22
Intraductal papilloma dx and tx
MCCO bloody nipple dc
dx- contrast ductogram
tx- resection
Tx Umbo and Inguinal hernia in child
most close by 2
<3cm- primary repair
>3cm- mesh
repair by 5
Inguinal- repair by 2 weeks if reducible
- otherwise, OR then
Gastroschisis
GastRoschisis to the Right of midline
rare defects…EXCEPTION- instestinal atResia
Mineral def:
- Zn
- Sel
- Chromium
- Copper
- B1
- B3
- Zn: wound heal/skin
- Sel: cardiomyopathy
- Chromium: hyperglycemia
- Copper: micro anemia
- B1 (thiamine): wernicke’s encephalopathy, p. Neuropathy
- B3 (niacin): pellagra (DRH, demetnia, dermatitis)
MC aortic infections
aneurysmal- staph
non-aneurysm- salmonella
Effective for VRE
Synercid
Linezolid
Predictors of good outcome after reflux surgery
- Typical sxs
- DeMeester Score > 14.72
- Improvement w/ acid suppression
UES vs LES
UES- cricopharyngeus; higher resting pressure (70)
LES- lower resting pressure (15)
Stiewert-Stein Class and Tx
Relation to GEJ:
- 1-5 cm above; Ivor-lewis
- 1 cm above-2 cm below; esophagectomy and prox gastrectomy
- 2-5 cm below GEJ; total gastrectomy
*Require 5 cm eso margin, 4 cm gastric margin, 15 nodes for eso CA
Esophageal CA tx
HGD, TIS, T1a: endoscopic ablation/resection
T1b: upfront esophagectomy
T2 or N: neoadjuvant then esophagectomy
T4b or M: definitive chemo-XRT
< 5cm from cricoP: definitive chemo-XRT
> 5 cm from cricoP: esophagectomy
Absolute C/I to anti-reflux surgery
- Cancer
2. Barrett’s w/ HGD
Alarm sxs for GERD
- dysphagia
- odynophagia
- bleeding
- weight loss
- anemia
*Require EGD
Tx of Leiomyoma
- sxs or > 4cm- enucleate
- < 4cm- observe
- > 8cm or circumferential- esophagectomy
Approach:
Cervical- L
Mid eso- R
Distal eso- L
W/up for trauma to the esophagus
- CT: para-eso air/fluid, subc air, trajectory
- if negative can trial clear. If +: - Endoscopy:
- if negative can trial clears. If dysphagia w/ clears: - GG esophagography (UGI): if negative:
- Thin barium
Required for staging esophageal CA
- CT of chest, abdomen- M
- Whole-body PET scan- M
- EUS- T and N stage
Caustic injury w/up
- Avoid NGT. No neutralizing agents
- CT scan if stable
- Early endoscopy (AFTER CT)
- OR if unstable. Otherwise, restart orals in 48h.
- alkali- liquefaction necrosis. worse outcome
- acid- coagulation necrosis
Steps of Heller myotomy
- Divide G-H ligament
- ID R crus and posterior vagus
- ID L crus and anterior vagus
- Divid short gastric vessels
- Expose GEJ (excise eso fat pad)
- Myotomy (6 eso, 2 stomach)
- Nissen, dor, or toupet wrap
How to mobilize the stomach for intra-thoracic anastamosis
- Divide G-H ligament
- Transect the L gastric. Keep the R gastric.
- — Lesser Curve Mobilized—- - Transect gastro-colic until prox duo. Avoid R gastro-epiploic!
- Extend gastro-colic to take the L gastro-epiploic, short gastric vessels, and gastrophrenic vessels
- — Grater Curve Mobilized —-
To gain extra length:
- Kocher maneuver
- Divide the R gastric artery
Greater omentum = gastro-colic + gastroc-splenic + gastro-phrenic ligaments
Epiphrenic divertciulum
Loc: distal eso. R > L. Pulsion
Tx: only if sxs.
- L diverticulectomy w/ contra myotomy
Dx and Tx of Eso perf
Dx- XR then contrast esophogography (GG then Ba)
Tx-
- abxs (fungus)
- Cervical: open neck and place drains
- Thoracic: L thoracotomy, extended myotomy, cover w/ 2 layers, buttress, NG, chest tube
- if achalsia: contra myotomy - Very unstable: exclusion and diversion
Selective non-op:
- Contained perf
- Minimal signs of sepsis
Stenting: contained perf or minimal extrav after EGD
Causes of hyperPh and hypoPh
- HyperPh: hypoPTH, renal failure
- HypoPh: hyperPTH, liver resection
FeNa
(Serum Cr x Urine Na) / (Serum Na x Urine Cr) x 10 "USC/UC's" <1% = Pre-renal >1% = Intrinsic >4% = Post-renal
Fluid Production/Absorption:
- Saliva
- Stomach
- Biliary
- Pancreatic
- SB
- LB
Fluid Production:
- Salive: 1500
- Stomach: 1500 ml
- Biliary: 500 ml
- Pancreatic: 1500 ml
- SB: 1500 ml
Absorption:
- SB: 8.5L
- LB: 500 ml
TBW
TBW = 42L
- 2/3 ICF
- 1/3 ECF: 3/4 interstitia, 1/4 blood
LR formula
130 Na 4 K 109 Cl 2.7 Ca 28 Lactate
Refeeding Syndrome
HypoMg, Ph, K
Sxs- paresthesia, confusions, RD, cardiac failure
pH relation to pCO2
10 mmHg increase in pCO2 = .08 decrease in pH
Tx of DI
- Central- DDAVP
2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ
Tx of endometrial CA
Hysterectomy, bilateral BSO, peritoneal w/out, LN sampling
Required for Tx AND staging!
Pregnant lap appe
Left lateral decubitus position
Entry port:
- take into account fundal height (6cm above)
- P/S @ 12 wks, half-way @ 16 weeks, umbo @ 20 weeks
- 2T-3T: supra-umbo if possible otherwise LUQ or RUQ
Px and Tx of ovarian torsion
Sudden pain + adnexal mass w/out bleeding
- vs. ectopic which usually has bleeding
Lap detorsion
Oopherectomy only if- necrosis, CA, recurrent
Monitor and reverse TPA
Fibrinogen level (<100 = r/o bleeding) Reverse: a-CA
Tx of Warfarin skin necrosis
Stop Coumadin
Give vitamin K
Start hep gtt
Intrinsic vs. Extrinsic Pathways
Intrinsic: 8, 9, 11, 12
Extrinsic: 7 (shortest t 1/2), Tissue factor
Common: 1, 2, 5, 10
Reversal of NOACs:
Apixaban
Rivoroxaban
Dabigatran
Apixaban: andexanet
Rivoroxaban: andexanet
Dabigatran: idarucizumab (+iHD)
VWD dx and tx
dx: normal PLTs. Abnormal BT, PTT
- ristocetin test or measure vWF level
tx-
type 1: not enough; ddavp –> cryo
type 2: qualitative; ddavp –> cryo
type 3: none; VWF/f8 concentrate, cryo
Tx of hepatic encephalopathy
- Correct precipitating cause
- Lactulose (goal 2-3 stools/day)
- Rifaximin
- Neomycin
PEP:
- HIV
- HBV
- HCV
- HIV- 4wks of anti-retroviral combo
- HBV- HBIG. +Vaccine if not vaccinated
- HCV- No recommendations.
Segmental liver anatomy
7 - 8 - 4a - 2
6 - 5 - 4b - 3
Dx and Tx of Budd-Chiari Syndrome
Dx: doppler Tx: 1. Lifelong AC 2. < 4 weeks: thrombolytics 3. > 4 weeks: angioplasty/stenting 4. Refractory: TIPS, transplant, surgical shunt
Tx of Isolated Gastric Varices
2/2 chronic pancreatitis induced splenic vein thrombosis
tx- Splenectomy
PPx for variceal bleeding
- Varices < 5 mm. Pugh A - no tx
- Varices < 5 mm. Pugh B/C- b block
- Varices > 5 mm. b-block +/- endo ligation
**TIPS not use for prevention.
Effects of pneumoperitoneum
Increase preload initially, then decrease
Increase afterload. Decrease CO
Increased PCO2. Decrease FRC
Decrease renal function
Steps to Peustow
- Upper midline incision
- Enter the lesser sac
- Kocherize the duodenum
- Split open the duct AT LEAST 7 cm
- Side-to-side REY-PJ in 2 layers
*For main duct > 7 mm
Pancreas blood supply and anatomy
Head- Superior PD (Off GDA, off CHA, off CeT) and Inferior PD (off SMA)
Body/Tail- Branches of the splenic artery
Head- right of SMA (SMV is right of SMA also)
Uncinate- hugs the SMV and SMA
Neck- over the SMA
Body/tail- left of SMA
Indication for ERCP w/ GB dz
- Bili > 4
- CBD stone on U/S
- CBD > 6 mm and Billi > 2
- Ascending cholangitis
Autoimmune pancreatitis
Px: pancreatitis w/ normal Lipase and LFTs
Dx: elevated IgG, biopsy to prove.
- CT: dilated w/ no Calcs
- Brush biliary tree if concern for malignancy
Tx: steroids
W/up of pancreatic cancer
- Pancreatic protocol CT
- EUS: if questionable LN or vessel involvement
- PET/CT: selectively if suspicion for malignancy.
- Staging scope: if suspect disseminated dz
- Bx: Not if resectable. Only if neo-adj chemo
- ERCP: if jaundice or dx uncertainty
Tx of chronic pancreatitis
- Lifestyle changes (EtOH, smoking)
- Oral analgesics
- Endoscopic sphincterotomy
- Surgery
Tx of pancreatic ascites
- NPO, IVF, NGT, TPN, SS (60% resolve)
- Endoscopic sphincterotomy/stent
- Surgery (REY P-enterosotmy or tail resection)
Tx of acute mesenteric ischemia
Thrombotic: at origin of SMA; prox. jejunum to transverse colon
Embolic: distal SMA; jejunal sparring
- no peritonitis- endovascular embolectomy
- peritonitis- ex lap to evaluate bowel, embolectomy/bypass
Dx and Tx of chronic mesenteric ischemia
- Dx:
1. duplex (Celiac > 200, SMA > 275) is 1st line for screening
2. CTA (>70%) for definitive dx - Tx: Sxs + stenosis of > 70%
1. Endovascular plasty/stent is 1st line. 1V stenting is enough (SMA > celiac)
2. Open surgery: if can’t tolerate endovascular - aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation
Tx of renovascular stenosis
- BB
- ACEi: unless 1 kidney or bilateral dz
- efferent dil’n can worsen kidney dz - PTA: perc trans-luminal angio +/- stent
- Nephrectomy
Open SMA embolectomy
- Lift transverse mesocolon
- Trace MCA. Palpate the SMA at root of mesentery along inferior margin of pancreas
- Incise peritoneum and dissect down to the artery (left of the SMV)
- Therapeutic heparinize
- Proximal and distal control
- Transverse arteriotomy at infra-pancreatic segment
- 2 or 3 Fogarty balloon passed proximal and distal
- Close arteriotomy with interrupted proline
Tx of air embolism
- LEFT lateral decubitus and Trendelenburg (trap air in the RV)
- Aspirate central line
Timing of endarterectomy after a stroke
- Non-disabling stroke or TIA: 2d-2w
2. Big stroke: no consensus
Do not cardiovert if
- High likelihood of cardiac emboli
2. Afib > 48 hours
When to consider ppx fasciotomy
6+ hours of warm ischemia
Femoral embolectomy
- Longitudinal incision over the groin
- Expose femoral common, SFA, and profunda
- Control with vessel loops
- Ensure ACT > 250
- 4-5F fogarty proximal, then distal to SFA and profunda (2x clean pass for each)
- Infuse hep saline
- Close arteriotomy w/ interuppted prolene
Exposure of LE arteries:
- Femoral
- AK Pop
- BK Pop
- TP Trunk
- Femoral: vertical incision over the artery from inguinal ligament
- AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus lateralis. Incise deep fascia superior to sartorius muscle. Watch out for GSV.
- BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment.
4, TP trunk: MEDIAL incision below the tibia. Dissect to deep compartment. Divide medial solus origin of the tibia to get to the deep compartment.
Preference for peripheral fistula
Location:
- Rad/Ceph
- Rad/Bas
- Bra/Ceph
- Bra/Bas
- Prosthetic
Rule of 6’s:
- flow > 600/min
- diameter > 3mm before placement. > 6mm after placement
- depth of 6mm
SC Steal syndrome - path and tx
Path- Prox SC stenosis. Reversal of flow through ipsilateral vertebral to SC
Tx: if V/B sxs (diplopia, vertigo, dysphagia, ataxia)
- PTA w/ stent to SC artery
- Carotid to SC bypass
Vertebral/Cervical to COW
R carotid: off innominate ➡ IC ➡ AC/MC ➡ COW
L carotid: off aorta ➡ IC ➡ AC/MC ➡ COW
R vertebral: off R SC ➡ Basilar ➡ PC ➡ COW
L vertebral: off L SC ➡ Basillar ➡ PC ➡ COW
Branches of the external carotid
- superior thyroid artery
- ascending pharyngeal artery
- lingual artery
- facial artery
- occipital artery
- posterior auricular artery
- maxillary artery
- superficial temporal artery
“Some Anatomists Like Freaking Out Poor Medical Students”
major branches of internal carotid
- ophthalmic
- anterior choroidal
- anterior cerebral
- middle cerebral
- posterior communicating artery
**posterior cerebral comes off of the vertebro-basillar system
Tx of type B dissection
- Uncomplicated: b-blocker for impulse control, elective repair
- Then surveillance q3, 6, 12m. TEVAR if progression - Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR
Tx of splenic aneurysm
- > 2cm, sxatic, or fertile age female
- embolize distal AND proximal (back bleeding from short gastric) - Otherwise, monitor
Tx of aneurysms
- splenic
- renal
- iliac
- femoral
- pop
- splenic: > 2cm or sxs ➡ embolize
- renal: > 1.5 cm ➡ covered stent
- iliac: > 3 cm ➡ covered stent
- femoral: > 2.5 cm ➡ covered stent
- pop: > 2 cm ➡ exclusion and bypass
Tx of psuedoaneurysm
tx- compress 20m → thrombin
immediate surg- infxn, HDUS, pulsatile, skin changes, ischemia, AMS
Nerve injuries during CEA:
- Recurrent laryngeal
- Marginal mandibular
- Hypoglossal nerve
- G/Ph nerve
- Superior laryngeal
- Accessory
- Recurrent laryngeal: MC cranial nerve; 2/2 clamping; hoarseness
- Marginal mandibular: excessive retraction and angle of jaw; Ipsilateral lip palsy
- Hypoglossal nerve: ipsilateral tongue deviation
- G/Ph nerve: from high dissection; difficult swallowing
- Superior laryngeal: high-pitch
- Accessory: failure to shrug shoulders
Tx of Type A dissection
- Treat with immediate surgery
- Put patient on bypass
- Median sternotomy
May-Thurner Syndrome
Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine
tx- venogram, thrombolysis and stenting
W/up of non-variceal UGI bleed (M/W tear)
- NGT+ ➡ EGD w/in 24h- clips, coags, banding, sclerose
- NGT-:
- HDUS: IR angio (must be brisk)
- HDS- C’scope/consider RBC scan, surgery
Surgical options for acid reduction surgery
Surgical options:
- Truncal vagotomy and drainage
- Truncal vagotomy and antrectomy
- Proximal gastric vagotomy
Elective indications:
- refractory to medical management
- suspicion of a malignancy within an ulcer
Acute indications: HDS, minimal contamination AND:
- PUD w/ unknown h. pylori status (if known can just be tx medically) OR
- Unable to stop NSAID therapy (NSAID ulcer)
Acute surgical options for duodenal ulcer disease
Indications: bleeding, perforation, obstruction
- Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed
- can tie off the GDA if continues to bleed
- close transversely
- vagotomy not general performed - Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment
- If close to pylorus: pyloroplasty (+/- truncal vagotomy)
- If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy - Obstruction: NGT, resuscitation, anti-secretory ➡ EGD w/ balloon dilation ➡ antrectomy
- Only do acid surgery acutely (vagotomy/drainage) if:
- – HDS, minimal contamination AND
- – PUD w/h. pylori status negative, unknown, refractory OR
- – Unable to stop NSAID therapy (NSAID ulcer)
**EGD does not require bx for duodenal ulcers
Tx of gastric ulcer disease
Indications for surgery: bleeding, perforation, refractory, can’t rule out malignancy
- must have a biopsy of some kind (r/o malig is higher than with duo ulcers)
- GC, antrum, body: wedge resection
- Lesser curve: distal gastrectomy w/ bil 2
- GEJ:
- – bleeding: anterior gastrotomy, over-sew, send biopsy
- – perf: sub-total gastrectomy w/ REY reconstruction
**Can’t wedge lesser curve b/c prominent L gastric arcade and subsequent deformed stomach
Tx of Complications after Billroth 2
- Afferent limb obstruction
- convert Bil 1 or REY - Bacterial overgrowth: 2/2 short ante-colic limb
- try abxs 1st. convert to REY - Duping syndrome: small meals, no sugar –> octreotide
- Alkaline reflux gastritis: prevent w/ 50+ roux limb.
- pro-kinetics, bile-acid binding ➡ convert to REY
How to confirm H. pylori eradication
4-weeks after triple therapy:
- Urea breath test: preferred 1st line
- EGD + Bx: preferred if known gastric ulcer (r/o CA)
- Fecal Ag test
Mesenteric Defects after REYGB
- Mesocolic: from retrocolic roux limb whole in the mesocolon
- J-J defect
- Peterson’s defect: mesentery of roux limb and transverse mesocolon
Primary fuel source in fasting state
- 1st 4 hours: exogenous glucose
- 4h-1d: Liver glycogen
- 1d-1w: gluconeogenesis phase
- brain uses protein from gluconeo (switches to ketone by day 4)
- body uses ketones - 1w+: proteins-sparing phase
- FA/Ketones are used everywhere
- Only RBCs use glucose
Dx and Tx of rectus sheath hematoma
Dx- mass unchanged with contraction Tx- CTA if HDS. OR if unstable: 1. Observation- no active bleed 2. IR- if active bleeding or T3 (pre-vesicle space) 3. OR- if HDUS or skin necrosis
Removal of perc chole tube
- Remain in place for 3-6 weeks for tract to form
- Cholangiogram to assess CD patency
- Clamp tube or elective chole if surgical candidate
Essential fatty acids and immuno-nutrition
- Linoleic acid- omega-6 (Cis, Unsturated)
- α-linolenic acid- omega-3 (Cis, Unsturated)
Immuno-nutrition = arginine, omega-3 FA
- a/w less infections, shorter LOS
Effects of hypomg
Sxs- similar to hypoCa ~ chvostek (tetany), tremor, fasciculations
- PTH resistance: hypoCa and hypoVitD
- NAK ATPase (ROMK) release of K: hypoK
- HypoPh
RQ interpretation (metabolic cart)
CO2/O2
< .7 = underfeeding .7 = pure fat .8 = pure protein .8-.9 = desired 1 = pure carb >1 = overfeeding
BSC vs. SqCC - dx and tx
BSC: most common malignancy in US; pearly, rolled borders, peripheral palisading; MC upper lip ca
SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca
Tx:
- 4 mm for unaggressive
- 8 mm for aggressive tumors
- 1 mm for MOHS
- LADN’y for clinical positive nodes
- Can consider SLNBx for high risk SqCC
- Limited role for chemo/XRT
Tx of paronychia and felon
- Pronychia: non-purulent infection of nail fold
- Non-purulent: clinda only
- Purulent: lateral incision to nail bed - Felon: fingertip pulp abscess
- vertical incision over the pulp
- abxs only if not tense
Dx and Tx of Nac Fac
- LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV
- CT: gas, thick fascia
- abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage
- surgery
SAAG score
Albumin Serum - Albumin in ascites
> 1.1 = portal HTN (cirhosis, HF, budd-chiari, PVT)
< 1.1 = TB, pancreatitis, infection, chylous
- chylous if milky and TG > 200
Dx and Tx of pancoast tumor
- Perc bx- usually sqcc
- Mediastinoscopy (or EBUS)
- Induction chemo-XRT
- Surgical evaluation
- c/i to oncologic resection: extra-thoracic mets, n2 disease, brachial plexus above T1, spinal canal (vessels are not a c/i)
- vascular involvement is not c/i
Dx and Tx of pancreatic leak
Dx: complication of splenectomy - drain collection and send for amylase Tx: 1. ASx: observe 2. Sxs: perc drain, NPO, TPN 3. ERCP, sphincterotomy, internal drain 4. Distal panc
Types of hyperPTH
1- High Ca/Low Ph: over-secretion
2- Low Ca/High Ph: CKD or VitD def (physiologic)
3- High Ca/High Ph: kidney transplant
Dx and Tx of Ewing Sarcoma
Dx- “onion skin” in diaphysis
Tx- chemotherapy (1st line) + surgery or XRT
Pulmonary sequestration
No bronchial commmunication
- Intra-lobar: MC; blood from aorta; pulmonary veins
- Extra-lobar: systemic arteries and veins
Tx- lobectomy or segmentectomy
Lung anatomy: R vs. L
Right:
- oblique/major fissure: separates lower from middle/upper
- horizontal/minor: separates middle from upper
- main bronchus 90-degrees; 2 bronchi
Left:
- oblique/major fissure; 1 bronchus
RF and Tx of T/I fistua
RF- trach below 4th ring OR, high pressure cuff, high innominate cross
- Over-inflate the cuff
- Intubate from above
- Compress against the sternum
- Median sternotomy
- Ligation AND division of innominate artery
- Buttress tracheal hole w/ muscle
Indications for pleurodesis
- Air Leak > 5 days
- Recurrent (even if contra side)
- High risk occupation (scuba, pilot)
- IC (AIDS)
Px, dx and tx Lymphocele
Px- sudden decrease in UOP weaks after trx
—2/2 lymphatic leak from iliac dissection
—Sirolimus is a RF
Dx- US
Tx- perc drain ➡ peritoneal window
Px, Dx, Tx of RAS and thrombosis after kidney transplant
- Thrombosis: sudden cessation of UOP immediately post op
- Dx: U/S
- Tx: nephrectomy unless small branch - Stenosis: refractory HTN and elevated Cr
- Dx: US (vel > 180, 70%)
- Tx: perc angio/stent
**No pain with arterial issue (pain = venous issue)
Causes of low UOP after kidney trx
- Immediate: arterial thrombosis- nephrectomy
- Weeks: lymphocele- open/lap peritoneal window
- Months: polymovirus (BK)- nephrostomy + reconstruction
Px, Dx, Tx of PTLD
Px- LADN, fevers w/in 1 year
- B cells proliferation 2/2 T cell suppression from IS
Dx- PCR+ for EBV
Tx- reduce IS
Inflow and outflow for pancreas transplant
- Inflow: iliac vessels (kidney- left, pancreas- right)
- -donor SMA and splenic artery are connected with donor iliac artery Y graft to be plugged into the right iliiac - Outflow: iliac vessels
- -donor SMV/splenic vein are already connected. Plugged into R iliac vein (or SMV/PV)
**Duo can be connected to SB or bladder
w/up of kidney graft dysfunction
- Elevated Cr. Low UOP.
- US: high RI is a non-specific finding
- Vascular abnormality ➡ angio, stent, or surg
- Lymphocele/Urinoma ➡ perc drain ➡ perit window
- Negative: graft dysfunction ➡ Core needle bx
Post transplant hepatic artery vs. PV thrombosis
- HA thrombosis: MC
- Early: days/weeks- hepatic failure ➡ thrombectomy OR re-trx
- Late: months- abscess, strictures ➡ temporize, re-trx
- Stenosis: angio and stent - PV thrombosis: rare
- Early: days/weeks- FHF ➡ thrombectomy or re-trx
- Late: months- encephalopathy, varices ➡ AC
- Stenosis: angio and stent
GVHD - px, dx, tx
- Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx
- WBC from donor recognize recepient as foreign
- B+T cells
- Dx: bx
- Tx: steroids + IS
Tx of testicular torsion
- Surgical de-torsion of involved testes
- If doubtful viability: <10 keep, >10yo orchiectomy - Exploration and fixation of uninvolved testis as well!
**don’t delay OR for U/S if suspicion is high
Dx and Tx of RCC
Dx: triple phase CT (don’t need tissue bx unless mets)
- do cystoscopy after CT
Tx: Radical nephrectomy + LND +/- chemo +/- XRT
- TK inhibitor is 1st line chemo
Types of hydrocele and Tx
- Communications: children. 2/2 patent processes
- <2yo: conservative; >2yo: surgical excision - Non-communicating: adults. 2/2 secretions not connected to peritoneum
- dont tx if asx. tx w/ excision.
Dx and Tx of LCIS
Dx
- usually incidental. pre-menopausal women. mammo negative
- R/o breast ca is .5% per year
Tx
- Must perform lumpectomy bc 10-20% chance of surrounding DCIS or CA
- Don’t need negative margins as long as dx can be made
- No SLNBx
PPx
- Surgery can be done for prophylaxis
- Can get hormonal therapy
- Surveillance w/ MRI or mammo q6m
Dx and Tx of inflammatory breast ca
Dx: skin punch bx
Tx:
- Neo-adjuvant
- MRM
- XRT
- Endocrine tx
TRAM vs. DIEP flap
TRAM- skin, fat, and rectus; more functional loss
DIEP- skin, fat only; preferred; slightly more flap loss; less morbidity
Fibroadenoma - px, dx, tx
Px- pain w/ periods
Bx- fibro-epithileal lesions (if “aggressive” concern for phyllodes)
Tx- resect if > 3cm, sxs, growth, anxiety, discordance
Tx of breast ca in preg
1T (13w)- mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T
2-3T- lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT
Indications for post-mastectomy radiation
- > 5cm
- 4+ nodes
- margin
- skin involvement
Boundaries of ax dissection
- medial: p. minor
- lateral: lat dorsi
- superior: ax vein
- posterior: subscapularis
Trauma to the chest and abdomen. HDUS.
General start with ex-lap b/c significant cardiac or above DPGM bleed would have killed the patient already
Bolus fluid and blood in children
Fluid: 20cc/kg
Blood: 10cc/kg
Repair aortic trauma
Access usually with Mattox maneuver
If < 50% closure primary with polypropylene suture
If > 50% perform a PTFE patch
Visceral artery trauma
Celiac- Mattox; try to reconstruct; can be ligated
SMA- Mattox of follow root of mesocolon; cannot ligate
IMA- Mattox; try to recontruct; can be ligated
Proximal Control and Access
- Supra-celiac: G-H ligament ➡ lesser sac ➡ R
- Supra-mesocolic: supra-celiac aorta; mattox
- Infra-mesocolic: infra-renal aorta; trans-peritoneal
Small bowel trauma
- Serosal tear: interrupted, non-absorbable
- <50%: 1 or 2 layer closure
- > 50%: resection and anastaoisis
- Multiple short segments: resection and anastamoisis
Access to neck zones
Zone 1: thoracic inlet to cric ➡ median sternotomy with left neck incision
Zone 2: cric to angle of mand ➡ left neck incision
Zone 3: angle of mand to skull base ➡ IR
Causes of R-shift/decrease affinity on Oxy-Hb curve
2,3 DPG
Elevated temp
Higher paCO2
Acidosis
Shock class
- No VS changes
- Tachycardia
- Hypotension and combative
- No UOP and obtunded
Lung cancer staging
T1: <3 cm with no main bronchus
T2: 3-5 cm w/ invasion of main bronchus or pleura
T3: 5-7 cm with chest wall, pericardium
T4: >7cm w/ mediastinum, great vessels, DPGM, trachea, esophagus
n1: ipsi peri-bronchial nodes
- n1 nodes: 10-14
n2: ipsi mediastinal/subcarinal nodes
- n2 nodes: 1-9
n3: contra mediastinal/hilar; any-supraclavicular
* *Need at least least 3x N1 and 3x N2 (6 total) for staging
S1: T1 or T2. No N.
S2: T3 or N1
S3: T3 and N1 or T4 or N2
S4: M1
Ketamine c/i
- MI (b/c increases SNS activtiy and cardiac demand)
2. Space occupying brain lesion
SCIP Quality Measures
- abx 1h prior to incision (for approrpaite pts)
- include G negative coverage for GI procedures - abx dc w/in 24h
- appropriate hair removal
- controlled 6am glucose in cards pts
- dc foley on POD1-2
- normothermia
Insulin peri-op
On morning of surgery:
- Don’t take oral hypo-glycemics
- Don’t take short-acting insulin
- Take 1/2 of long-acting insulin
Indications for pre-op spiromtery
- all lung resections
- smoking > 20 years
- suspected pulmonary disease (COPD, ILD)
- reduced exercise tolerance, unexplained dyspnea
Appendicitis PE maneuvers
- Obturator- pain w/ internal rotation = Pelvic appe
- Psoas- pain w/ extension = retrocecal
- Rovsing- pain on the right with left push
Absolute c/i to PEG
- Uncorrectable coagulopathy
- Unctronolled ascites
- Unable to oppose stomach to abdominal wall (inability to transilluminate is only relative)
- Survival < 4 weeks
Tx of sublgottic stenosis
2/2 to traumatic cric placement
tx- resection with re-anastamosis (dilation doesn’t work)
Frey Syndrome
Gustatory sweating
2/2 auriculotemporal nerve
Dx and Tx:
TG duct cyst
brachial cleft cyst
cystic hygroma
- TG duct: midline through hytoid bone; sistrunk procedure
- if infected tx w/ abxs first - Brachial cleft: anterior SCM; resection
- Cystic hygroma: posterior triangle; resection (avoid infection)
Component separation
- Anterior: EP aponeurosis 2cm lateral to semilunar line from costal margin to inguinal ligament
- Posterior: Cut posterior rectus sheath and mobilize retrorectus plane
Mesh choices
- Heavy weight polyprop: micro-porous; lower recurrence but more infections
- Light weight polyprop: macro-porous; less infections but high risk of adhesions (coat bottom with PTFE)
Based on contamination:
- clean: synthetic
- clean/contaminated: synthetic is preferred! ( even w/ controlled enterotomy w/out gross pillage)
- contaminated: biologic mesh if > 3 cm
- dirty/infected: biologic mesh if > 3 cm
STITCH trial
5 mm bites every 5 mm
Boundaries of femoral canal
floor- cooper’s/pectineal ligament
anterior- inguinal ligament
medial- lacunar ligament
latera- femoral vein
Tx of parastomal hernia
- ASx- can observe
- Sxs- sugarbaker (preferred), or keyhole
- do not relocate
- Only repair for obstruction or strangulation
- LB herniates more than SB
Boundaries of triangle of doom/pain
Doom: Apex- internal ring. Medial- vas. Lateral-spermatic vessels
Pain: (inverted triangle): Base- inguinal ligament. Medial- spermatic vessels. Lateral- reflected peritoneaum
- Nerves (medial to lateral): femoral, FBFG, AFC, LFC
Tx of hiatal hernia
Type 1- asx: NTD; sxatic: PPI; Surgery if refractory
Type 2-4: surgery even if asx
Type of ventral hernia repair
- < 2cm: suture repair +/- mesh
- 2-10 cm: sublay or underlap w/ mesh
- Sublay: retro-rectus aka rives-stoppa (under the peritoneum)
- Underlay: aka IPOM (intra-perionteal only) under the peritoneum - > 10 cm: component seperation w/ mesh
Dx and Tx Ischemic Orchitis
dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5
tx- NSAID and pain meds. Orchiectomy is last resort.
MCCO Cushing syndrome
- Exogenous steroids
- ACTH pituitary adenoma- lap adrenalectomy
- Cortisol secreting adrenal adenoma- trans-sphenoidal resection
- ACC- open adrenalectomy
Tx of ACC
OPEN adrenalectomy + mitotane
Dx and Tx of Addison’s
Cause- AI attack of adrenal cx
Dx- cosyntropin test - cortisol remains low
- deceased cortisol and aldo with high ACTH
Tx- steroids
Relative strength of steroids
- Dex
- M-pred
- Pred
- H-cort
w/up of Hypercortisolism
- Initial tests: choose 1-2
- 24h urine free cortisol (most se)
- late night salivary cortisol
- overnight 1 mg dexa suppression - ACT Level
A. ACTH normal/high - high dose dexa suppresion
- no suppression: small cell lung ca
- supperessed: pituitary adenoma
B. ACTH low
- CT positive: adrenal mass
- CT negative: exogenous
Dx and Distribution of carcinoid tumors
Dx: 24H urine HIAA or serum chromo A
- Octreotide scan if can’t locate
Distribution:
- Rectum
- SI (ileum)
- Appendix
- Colon
Tx of mesenteric vein thrombosis
- AC
- Surgery if peritonitis or failure to improve
- can also consider endovascular thrombolytics - 2nd look operation 24-48 hours
Tx of Grave’s disease
- Beta blocker
- Methimazole. PTU if preggo
- RAI once euthyroid- worsens opthalmopathy and c/i in pregnancy
- Surgery if refractory, opthalmotaphy, compressive sxs, RAI and methimazole/PTU c/i
**Preggo: beta blocker, PTU. Avoid RAI. Surgery if can’t tolerate PTU
W/up of Hashimoto’s disease
- FNA- r/o ca
- Bloodwork- antiTPO/TG Ab
- Tx- thyroxine ➡ partial thyroid
**MCCO hypoT in the US
Tetanus ppx
- Full immunized (>= 3 toxoid doses)
- clean/minor: toxoid vaccine if dose >= 10 years
- dirty or > 1cm: toxoid vaccine if dose >= 5 years - Unknown or not fully immunized
- clean/minor: toxoid vaccine
- dirty or > 1 cm: toxoid vaccine + Ig
Dx and Tx of CMV colitis
Dx
- usual CD4 < 50
- PCR is unreliable b/c does not prove end-organ disease
- must scope and bx to confirm dx
Tx: gancylovir
- initiate HAART
- opthalmic exam to r/o retinitis
Standard w/up for lung ca
- PET/CT
- PFTs
- Bronchoscopy (can be intra-op)
- Mediastinal eval- EBUS or mediastinoscopy
Indications for ICP monitor
- GCS <= 8 AND:
- CT evidence of pathology OR
- 2/3: age > 40, HoTN, abnormal posturing
**IF GCS <= 8 with normal CT of the head, 2/3 (age > 40, HoTN, abnormal posturing) to get an ICP
Bronchiolitis obliterans
MCCO long term lung trx failure
2/2 bronchiole inflammation
Px- serial decline in PFTs. Normal tacro. CT- ILD
Dx- of exclusion
Tx- steroids, IS, reTrx (very poor outcomes)
Endovascular head-induced thrombus tx (after RFA)
- Stop at saph-fem/saph-pop jxn: no tx
- <50% of deep vein occluded: surveillance
- > 50% of deep vein occluded: AC until clot resolves
- Occlusive deep vein: tx as a dvt (3m of AC)
**Prevent by ablating > 2.5 cm from the jxn
Pressor for neurogenic shock
- Above T6: nor-epi (b/c HoTN and brady)
2. Below T6: Phenylephrine (may worsen brady above T6)
Discerning idiopathic constipation:
- Dyssynergic
- Slow transit
Discerning idiopathic constipation:
- Dyssynergic: lack of external relax w/ push
- Slow transit: retained 6+ markers on day 6
Vitamin A
- wound healing especially in steroid patients
- def: night blindness
PPV and NPV
PPV = of those who test + how many have the dz NPV = of those who test - how many do not have the dz
Increasing prevalence = increase PPV and decrease NPV
Pearson’s R Value
Correlation coeff between -1 and 1
1 = very strong positive (direct proportion)
> .7 = strong positive
0 = no correlation
- .7 = strong negative
Do not determine causation
Phases of clinical trail
- Safety in a small group of humans
- How well does the drug work
- RCT compared to standard of care
- Long term safety and monitoring
Chest exposures
- Median sternotomy: ascending aorta, innominate, bilateral carotids, RIGHT subclavian, precordium
- add neck/supraclav extension for distal control - Left Anterolateral thoracotomy: left subclavian (high), trauma/extremis (heart, lung, aorta)
- can extend to clambshell in trauma
- can extend to neck/supraclav for LEFT subclavian - Right Anterolateral: SVC, IVC
- Right Posterolateral:
- airway: distal tracheal, R main bronchus,
- GI: thoracic esophagus
- Vasculature: azygous vein - Left posterolateral:
- airway: L main bronchus
- GI: cervical and distal esophagus
- vascular: descending aorta
Indications for hepatectomy instead of liver trx in HCC patient who meets Milan criteria
Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm
Mucor/Rhizopus vs. Aspergillus - path and tx
- Mucor: DM or IS patients
Path- broad hyphae w/ irregular branching
tx- intubation, ampho, and surgery - Aspergillus
Path- narrow hyphae w/ regularbranching
tx- voriconazole. resect if aspergilloma.
SMA embolus vs. thormbosis
Embolus- lodges after the middle colic. Jejunal sparring
Thrombus- at ostium; pan-bowel
SMA embolectomy steps
- Retract transverse colon cephalad
- Identify SMA
- Arteriotomy proximal to middle colic
- Fogarty cathter
- Close arrteriotomy
Bilateral adrenal trauma
Suspect adrenal crisis
Tx- 4mg IV dexamethasone
Desmoid Tumor - path and tx
A/w FAP (after surgery, 2nd MCCO death)
Path- non calcified, fibrotic, low mit index, spindle cells
Tx- WLE for extra-abd; NSAID, anti-Estrogen if intra!
Pseudomyxoma peritonei - px and tx
Px- mucinous adenoca 2/2 appendix; scalopped liver
Tx- debulk anything > 2mm + HIPEC (@ 41C)
MCCO PD catheter malfunction
- Infection
2. Outflow failure- MC 2/2 constipation
Superior and Inferior epigastric anatomy
Superior Epigatric
- from int thoracic (mammary)
- Between rectus sheath and trans fascia
Inferior Epigastric
- from ext iliac
- Between rectus and transc fascia
Serologic work-up for adrenocortical mass
- Dexa suppression (cortisol)
- Urine androgens (sex hormones)
- Plasma metanephrines (pheo)
- aldo/rennin ratio > 30 (salts)
Dx and Tx endometriosis
Dx- often require laparoscopy
Tx-
1. Medical therapy
2. Surgery if unresponsive. Ablation if young.
Staging laparoscopy
- Perform before neo-adjuvant, before surgery, or high risk for metastatic disease (especially if CT is resectable but patient seems high risk)
- Obtain histo sample, peritoneal lavage, U/S of nodal basins, explore lesser sac
MCCO primary hyper-aldosteronism and tx
- Bilateral adrenal hyperplasia (60%)- medical
- Adrenal adenoma (Conn’s syndrome)- lap adrenal
- Adrenal adenoca- open adrenal + mitotane
* Can use adrenal vein sampling to distinguish
Dx and Tx of chronic mesenteric ischemia
Dx- CT + duplex; SMA > 275 cm/s, Celiac > 200 cm/s
Tx- angio + stent or surgery
Resectability of pancreatic tumor
- Unresctable- distant met, >180 SMA/celiac,
- EUS/FNA for tissue dx for neoadjuvant - Borderline- <180 SMA/celiac
- EUS/FNA for tissue dx for neoadjuvant - Resectable- dx lap + whipple
Tx of horseshoe abscess
Midline drainage incision of deep posterior space
Bilateral lateral counter-incisions for ischiorectal space
Tx of anorectal fistula
<30% sphincter- fistulotomy or cutting seton
>30% sphincter- draining setons + ARAF or LIFT
Tx of Internal HMHDs
G1- bleeding, G2- spontaneous reduce, G3- manual reduce:
-1st line: sitz, stool softener, bowel reg, fiber, fluids
-2nd line: rubber band, sclerotherapy, coag.
G4- cant reduce
-1st line: surgical HMHD’ectomy
Tx of External HMHDS
1st line: sitz, stool softener, bowel reg, fiber, fluids
2nd line: surgical HMHD’ectomy
Thrombosed: incise or excision if w/in 48h
Paget’s disease of the anus (px and tx)
Px- intractable pruritis, eczematoid rash
Tx- colonscopy (r/u malignancy) + WLE + perianal bx
ARAF vs. LIFT
ARAF- elevate flap of M/SM, curette the tract from external opening, cover internal opening w/ flap
LIFT- dissect I/S tract, ligate the tract, curette the tract from external opening, +/- core out the tractanal
Px Tx of Carcinoid of the rectum, appendix, and small bowel
Px:
- GI tract > pulm > GU
- Rectal is now > midgut b/c screening scopes
- Midgut a/w flushing
- Right sided valvular plaques (lung protects the left heart)
Tx:
< 2 cm- local excision (transanal, appendectomy, segmental)
> 2 cm- formal resection (APR, R hemi-colectomy, cancer resection WITH mesentery)
Unresectable cholangiocarcinoma
Criteria
- bilateral HA or PV
- unilateral HA with extensive contra duct
Tx
- no extrahepatic dz ➡ neoadj chemo-XRT + liver trx
- extrahepatic dz ➡ chemo-XRT
Bismuth classification and tx
For hilar cholangioca. Only t4 unresectable.
1: CH duct- REYHJ + LADN +/- lobectomy
2: bifurcation- REYHJ + LADN +/- lobectomy
3: R or L HD- REYHJ + LADN + lobectomy
4: Both ducts- chemo-XRT + liver trx
Lap CBD exploration
- Dissect CD to the level of the duo
- Cholodochotomy distal to the CD/CBD junction
- Fush, basket, or fogarty balloon the stone out
- Close primarily, over a T-tube, or over a stent
Advantage of T-tube closure
- Does not prevent leak better than primary closure
- Allow for future cholangiogram
- Allow for perc stone removal once tract matures
Indications and technique for biliary enteric drainage
- Retained stoned that cannot be cleared with lap CBD exploration
- Transduo sphincteroplasty c/i b/c CBD > 2cm and there are multiple stones
Px and Tx of Chalangitis
Dx: fever, RUQ, and jaundice - stones > malignancy > stricture Tx: - signs of sepsis: resuscitate/abx then urgent ERCP - no sick: US/MRCP
Px and Tx of Sphincter of Oddi dysfunction
Px: Biliary pain with normal RUQ U/S after years lap chole
Dx: mannometry (no MRCP or CT 1st)
Tx: endoscopic sphincterotomy at 11’ (CCB usually ineffective)
- CBD at 11’, PD at 1-3’
- h/o REY: open transduo sphincterotomy
Ideal setting for stone formation
Low bile salts
Low lecithin
High cholestersol
Mirizzi syndrome tx
px- GB neck/CD stone compresses CHD types: 1: no fistula- cholecystectomy 2: < 1/3 circ- CC'ectomy + CBD repair w/ T-T 3: < 2/3 circ- CC'ectomy + REY-HJ 4: full circ- CC'ectomy+ REY-HJ
Types of GB polyp
- Cholesterolosis: MC; CE mphages in LP; benign
- Adenomyomatosis: benign
- Adenoma: malignant; >1cm is RF for CA (resect)
Tx strategy for CBD transections
- Intra-op
- <50%, not cautery: primary repair
- >50%, or cautery: REY-HJ - Late phase
- Place drain
- Define anatomy w/ ERCP, PTC, or MRCP
- Place PTC tube
- CTA to assess for R/L HA injury
- Delayed reconstruction 6-8 weeks once optimized
Open CBD exploration steps
- Begin LATERALLY on the HD ligaments to ID CBD
- Stay sutures at 3’ and 9’. Choledochotomy
- Remove stones (forceps, balloon, milking)
- Cholangiogram
- Close over a T-tube
Conditions for trans-cystic CBD exploration:
- CD > 4 mm, CBD < 7 mm
- < 8 stones, < 10 mm
- No stones in CHD (distal to CD/CBD junction)
- Normal anatomy (no REY-GB)
Conditions for lap or open CBD exploration
- CD < 4 mm, CBD > 7 mm
- > 8 stones, > 10 mm
- CHD stones (proximal to CD/CBD junction)
- Failed trans-cystic or abnormal anatomy (REYGB)
Management of GB polyps
Sx: - sxs, stones, PSC, > 6mm: cc'ectomy For asx: - > 18 mm: tx as GB cancer - > 10 mm: CC'y - 6-10 mm: q6m U/S for 1 year. cc'ectomy if PSC
PSC screening guidelines
Cholangioca: US/MRI/MRCP q6-12m. Annual CA 19-9
GB CA: US q6-12m
CRC: colonscopy q1-2 years (regardless of UC)
HCC: US/MRI/MRCP q6-12m
Steps of intra-op cholangio
- Clip juxn of infun. and CD (prevent reflux)
- Linear incision along CD
- Cathter placed
- Shoot contrast and flouro
* scope can be used to assess masses and remove stones if needed
Tx strategy for major burns
- Resuscitate
- Early excision and coverage (day 3-4)
- Fluid less than before:
- UOP: .5 cc/hr in adult, 1-1.5/hr in children
Airway burn management
Scope if: soot, facial/body burns, singed hairs
Tube if: edema, ulceration, blisters
Dx/Tx hypothermia
Dx- temp < 35C/95F; 1'- environ., 2'- illness/substance Mild: < 94- shivering Moderate: < 89- agitation, afib Severe: <84- comatose, osborne waves Profound: <70- loss of vitals
**moderate = 84-89
Thoracic compartment syndrome
Dx: Respiratory failure 2/2 circumferential chest wall burn
- high peak pressures
Tx: escharotomy
- box incision along ant ax lines connected with sub-xiphoid transverse incision
Dx and Tx of Colovesicular Fistula
- CT w/ oral/rectal (no IV b/c will obscure bladder)
(not cystoscopy or colonoscopy) - Colonoscopy to r/o malignancy
- Cystoscopy if suspect cancer. Retrograde cysto if CT is equivocal or operative planning
Tx- resect sigmoid even if asx; Don’t need to repair the bladder, just drain
Colon cancer and arterial resection
- R hemi- IC, RC, RBMC
- cecum/asc colon - Extended R- IC, RC, MC
- hepatic flex/prox t colon - L hemi- LBMC, LC
- Distal TV, splenic flex, prox descending - Extended L- LBMC, origin of IMA
- splenic flex - Sigmoid- IMA (hi- b4 LC, low- after LC)
- dist desc/sig
Colon CA surveillance after curative resection
- Exam and CEA q3-6m x 3 years
- Colonoscopy @ q1, 3, and 5 years
- No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel) - CT CAP q1y x 3 years
Staging w/up of rectal cancer
- TRUS (avoid if > t2) or MRI- T/N stage
- suspicous nodes on MRI count as clinical stage N (neo-adj) - CT CAP- M stage
- C’Scope- for initial dx and sync lesion. not for T stage
- Rigid Sig’Scope- for distance from anal verge
No need for PET
MRI- circumferential resection margin
Tx of refractory Crohn’s pan-colitis
- Segmental colitis- partial colectomy
- Rectal sparing pan-colitis- TAC w/ IRA
- Pan-colitis w/ rectum- PC w/ end ileostomy
- IPAA whether w/ or w/out loop should NOT be done on Crohn’s b/c r/o pouchitis
Tx of cecal volvulus
Stable- R hemi and primary mosis (no pexy)
Unstable- R hemi with end ileostomy
Tx of radiation proctitis
- Acute: < 6w, no bleeding; alter therapy, supportive, butyrate enema
- Chronic: >6w, bleeding; anti-inf, sucralfate enema, laser coag, hyperbaric O2, surgery
Lynch syndrome dx
AD; MMR gene (MLH, MSH, PMS, EPCAM)
Amsterdam II Criteria - HNPCC/Lynch
- Colon/HNPCC Ca b4 50
- 2+ generations
- 3+ relatives (1 is 1d)
- Exclude FAP
*HNPCC Ca: CRC, ovary, uterus, endometrial, gastric, renal/ureter, SB, brain, skin
Dx of Juvenile polyposis
Dx: 5+ polyps or any polyps w/ family hx
- SMAD4+
Non-adenomatous polyps ~ hamartomas
Tx of Lynch Syndrome
- CRC: q1y C-scope @ 20-25; TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma. q1y scope post op (metachronous CA)
- Endometrial: q1y endometrial sampling @ 30-35; ppx TAH-BSO after children
- Ovarian: q1y TVUS and Ca-125 @ 30-35; ppx TAH-BSO after children
- Stomach: EGD/Bx q2-3y @ 30-35
- Renal: q1y UA and US @ 30-35
Tx of FAP
q1y scope @ 10-12y Tx- TAC w/ IRA or PC w/ IPAA (rectum involved) Colectomy if: - suspected CRC - severe sxs/gi bleeding - HGD or multiple adenomas > 6 mm - marked increase in poylp number - inability to survey colon Surveillance of pouch/rectal cuff post op q1y
APR vs. LAR
Tumors that require APR:
- < 5cm for anal verge
- Tumor at dentate line w/ sphincter involved
- Tumor that can’t get a 1 cm distal margin w/out sphincter
- Poor pre-surgical anorectal function
- Locally recurrent low-lying cancer
Polyposis syndromes:
- Muir-Torre
- Gardner
- Turcot
- P/J
- Cowden
- JuP
- Muir-Torre: MLH/MSH; sebaceous gland tumor
- Gardner: APC; desmoid tumors, osteomas, epidermal cysts/lipomas
- Turcot: APC; Malignant CNS tumors
- P/J: STK; myocutameous pigmentation
- Cowden: PTEN; Hamartoma polyps, endometrial/breast/thyroid CA
- JuP: SMAD4; epistaxis, AVM, telangiectasia
Indications for colonic stent
- Bridge to surgery in acute obstruction
- Palliative measure
* Usually for L-sided lesions
Tx of ureter injury after sigmoidectomy
- <7 days and healthy: re-explore and fix primarily
2. >7 days or poor candidate: perc neph tube, stent; fix in 6-12 wks
Dx/Tx of slow transit constipation
Dx- nuclear medicine colonic transit or radiopaque marker
Tx-
1. Laxative, fiber, pelvic floor exercise
2. TAC w/ IRA (Not TPC w/ IPAA)
Tx of C. diff
- Primary: oral vanco or fidox
- Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus
- 1st-2nd recurrence: tapered vanco or fidox
- Multiple recurrence: consider fecal transplant
- Total colectomy if sepsis or toxic megacolon (colon > 6 cm, cecum > 10 cm)
Dx and Tx of ischemic colitis
Dx- CT first to rule out non-ischemic colitis or infarction; C’scope to confirm
- suspect in low flow state, HoTN
Tx- usually supportive; OR if perf, sepsis
Dx and Sx of PNETs
- Glucagonoma
- Inuslinoma
- Gastrinoma
- VIPoma
- SSoma
- Glucagonoma: glucagona > 1k; NME, DM, DVT
- Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad
- Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1
- VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH)
- SSoma: High fasting SS; DM, stones, steatorrhea
*Do not perform imaging or go to the OR until biochemical diagnosis!
Dx and Tx of Pancreatic cysts:
- Serous cystadenoma
- MCN
- IPMN
- Psuedocyst
- W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA
1. Serous cystadenoma: low M/CEA, low Am; resect if sxs
2. MCN: high M/CEA, low Am; resect
3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm
4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy
Tx of PNETs:
- Glucagonoma
- Inuslinoma
- Gastrinoma
- VIPoma
- SSoma
- Glucagonoma: distal panc w/ splenectomy + cc’y
- Inuslinoma: enucleate
- Gastrinoma: enucleate if < 2 cm; >2 cm, whipple
- VIPoma: distal panc w/ splenectomy + cc’y
- SSoma: resect w/ cc’y
Perform splenectomy for distal panc PNET?
No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm
Steps to Whipple
- Inspect. Frozen any lesions. Abort if +
- Mobilize hepatic flexure. Expose 3D/4D
- Kocherize duo and HOP to LOT
- Palpate the SMA posteriorly from aortic origin
- CC’y. CHD divided above CD entry
- Dissect down the portal vein towards the pancreas developing plane. Ligate R gastric then GDA (branch of common hepatic)
- PV turns into SMV behind the pancreas (where pancreatic vein joins). Create plane between SMV/pancreas
- Divide the stomach at the antrum and duo 2cm past the pylorus
- 2 index fingers are sea-sawed behind the duo and pancreas and in front for PV/SMV, developing a the plane. Transect pancreas using cautery.
- Retract the pancreatic head lateral and PV/SMV medial. Ligate venous tributaries to PV/SMV.
- Perform P-J (2-layer, end to side)
- Perform H-J (1-layer) distal to P-J
- G-J: Billroth 2 (2-layer, end to side)
Arterial anatomy of the celiac trunk
- CHA: gives off GDA then R gastric
- GDA gives of SPDA and R gastroepi - Splenic: gives off short gastrics and L gastroepi
ECG findings of PE
Sinus tach is MC
S1Q3T3 pattern w/ TWI
Dx and Tx of Pulmonary Blastoma
MC primary lung tumor in children
Dx- air/fluid filled cystic lesions. Looks like pneumo.
Tx- Surgical resection +/- chemo-XRT
Length time bias vs. lead time bias
- Length time: screening by its very nature will pick up more indolent disease
- Lead time: asymptomatic disease is caught earlier by screening, “starting the clock” sooner
Brown-Sequard
Ipsi loss of motor
Contra loss of pain/temp
Dx of biliary dyskinesia
Suspect if GB w/ normal US and EGD
Dx- HIDA scan w/ EF < 35%
Px and Tx of epididymitis
Px- scrotal pain and pyuria usually 2/2 STD
Tx- IM CTX and oral azithromycin (STD tx)
Tx of GB perf in acalculous chole
Early CC’y and IV abxs
Avoid perc chole drain even if very sick
Dx and Tx of obturator hernia
Dx- groin pain that improves w/ flexion and bulge
- DO NOT need CT scan for diagnosis
Tx- urgent operative exploration (don’t wait for CT eve if stable)
Emergent ariway in a child
- Try ETT placement with a miller blade
2. Needle cric is preferred over open if < 12
Tx of peptic stricture 2/2 GERD
- Serial dilations
- PPI
- Consider stenting
. Surgery is last resort (in contrast to achalasia)
Exposure to bronchial tree in trauma
Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)
CREST Trial
- Carotid stenting has higher incidence of stroke
- CEA has high incidence of MI
- Composite end-point of stroke, death, MI was the same
Dx and Tx of Bacterial Overgrowth
- px: 2/2 bill2 or REYGB
- – watery stools, bloating, b12 deficiency
- dx: d-Xylose test to
- tx: abxs –> surg 2nd line
Inguinal hernia nerves
- Ilioinguinal: under to EO
- Ilio-hypogastric: supero/medial to the ilio-inguinal. Passes EO superior to the external ring
- GB of GF: runs within the spermatic cord
Types of HRS
Type 1: rapidly progressive RF. May respond to diuretics.
Type 2: slowly progressive renal failure. Ascites refractory to diuretics. Better prognosis.
Treatment of lung ca
- No N2 disease (stage 1-2) –> up-front surgery
- N2 disease or T4 –> chemo-XRT first
n1- ipsi bronchial/hilar nodes
n2- ipsi mediatinal/subcarinal (2-9)
t1- <3cm
t2- >3cm
t3- >5cm OR invading pleura, chest wall, phrenic n, pericardium OR nodule in same lobe
t4- >7cm OR invading DPGM, mediastinum, heart, great vessels, trachea, RLN, esophagus, vert body, carina. OR different ipsi lobe
Lung ca w/up
- < 8mm ➡ surveillance
- > 8 mm ➡ PET-CT
- FDG- ➡ surveillance - FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy)
- nodal disease –> EBUS - No N2 dz –> Segmentectomy or lobectomy
- n2 disease –> chemo
Ingested foreign body w/up
- Abdominal XR!
2. High risk: button batery,
Steps of hiatal hernia repair
- Complete dissection of hernia sac from mediastinum
- avoid vagus nerve
- can divide short gastrics to aid in mobilization - At least 3 cm of esophagus into the abdomen!
- - Colis gastroplasty if insufficient - Close the hiatus with sutures or mesh (posterior and inferior)
- - mesh has better short term outcomes only
Pre-op regiments for aldosteronoma and pheo
- Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic
- Pheo: phenoxybenzamine then BB
Window to the great vssels
innominate vein
Tx of HCC
- Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant
- Consider portal vein embolization if remnant is insufficient
- Consider pre-op TACE to as an adjunct - Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant
- Transplant if candidate: UNOS criteria
- Otherwise: loco-regional therapy or systemic therapy
When to re-implant the IMA in EVAR
- Back-pressure < 40
- Previous colon surgery
- SMA stenosis
- Inadequate left colon flow
Lynch vs FAP Screening
- FAP- chromosomal; APC
- > 100 polyps, including duo
- Surveillance: start at 10 - HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM
- <10 polyps in the colon
- Surveillance: start at 20
Surgical Tx of thyroid/PT cancers
- Papillary/Follicular
- MTC
- Hurthle
- Anaplastic
- PT
- Papillary: lobectomy +/- total + consider ppx L6 for high risk
- Follicular: lobectomy +/- total (criteria)
- no node dissection unless cx+ - MTC: total + bilateral L6
- Hurthle: lobectomy then total + bilateral L6
- Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes
- PT: hemi-thyroid + L6 (usually)
**MRND if L6 is positive
Confirmation of brain death
- Neuro exam:
- absent brain stem reflexes
- no response to stimuli - Apnea test: CO2 > 60
Bleeding during mesh fixation, inguinal hernia
- Open: sewing mesh onto EO –> femoral vein
2. TEP: tacking mesh medially –> corona mortis (obturator branch)
Tx of H/N tumors
- Mucoepidermoid: MC malignant
- total parotid + ppx MRND + XRT - Adenoid cystic: malignant
- total parotid + ppx MRND + XRT - Pleomorphic adenoma: MC benign
- superficial parotidectomy - Warthin/Papillary cystadenoma
- superficial parotidectomy
W/up of UGI bleed/perf:
- Boerhave
- Traumatic esophogeal perf
- UGI bleed
- Boerhave: XR suggestive ➡ UGI (CT controversial)
- Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI
- UGI bleed: +/- NGT ➡ EGD
Tx of Cellular vs. Ab Rejection
- Cellular:
- mild: steroids
- severe: TG - Ab:
- Plasmaphoresis (clear Ab)
- IVIG (so body thinks there are still ab)
- Rituximab (CD20 Ab)
IS for transplant
Induction: choose 1
- Thymoglobulin - polyclonal Ab (potent)
- Basiliximab - IL2 inhibitor (mild)
Maintenance
- Tacrolimus
- MMF
- Prednisone
- Sirolimus
Transplant ABX ppx
- Bactrim- PCP, toxo gondi, listeria, nocardia
- Diflucan- antifungal
- Valganciclovir- CMV
Transplant cross-matching
- ABO Incompatibility
- A, B, O Ab - Cross-match: recipient serum X donor lymphocytes
- preformed HLA Ab (A, B, DR). DR is most important.
- *Livers don’t need a cross-match
- *Can give A2 donors to O recipients
- *Donor: Ags are important (WBC)
- *Recipient: Abs are important
MAC
Low MAC = lipid soluble
High MAC = water soluble
- NO has highest MAC
CDH1
High r/o gastric ca
ppx gastrectomy by age 40
px, dx, and tx of meconium ileus
px- failure to pass meconium
dx- sweat chloride test
tx- GG then NAC enemas
- surgery: ostomy for antegrade enema
Congenital thoracic disorders - px and tx
- Pulm sequestration
- Cystic adenoid malformation
- Congenital lobar emphysema
- CDH
- Pulm sequestration: infection w/ abnormal CXR
- tx: resection - Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree
- tx: lobectomy - Congenital lobar emphysema: XR looks like tension PTX
- tx: lobectomy - CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior
- a/w pulm HTN, NTD, malrotation
- tx: intubate +/- ECMO. Delayed repair.
Ig crosses the placement
IgG
Nutrition requirements per day
- Protein
- Fat
- Carb
Nutritional requirements for average healthy adult male (70 kg)
- 20% protein calories - 1 g protein/kg/day
- burn: 1g/kg/day + 3 g/day x % BURN - 30% fat calories
- 50% carbohydrate calories
Wilcoxon test
Compare PAIRED ordinal variables between two groups
- ex: patient satisfaction before and after an intervention (1-5)
COX proportion hazard modeling
Like a regression model but for survival analysis
Allow you to control for different factors
Changes to VS with preggo
Increased HR
increased SV
Decreased SVR
Decreased BP
Afferent limb syndrome
- AKA bacterial overgrowth
- px: steatorrhea, b12 deficiency
- -MC w/ antecolic Bili2
- Dx: d-xylose breath test
- tx: abxs –> REY/shorten the limb
Medical tx for melanoma
Pd1 inhibitors- pembrozilumab, nivolumab
If Braf+: braf inhibitor remains 2nd line
MC benign/malignant thoracic tumors in adults/children
Adults
- benign: hamartoma
- malignant: sqcc
Children
- benign: hemangioma
- malignant: carcinoid
Tx of Rhabdomyosarcoma
MC soft tissue tumor in children
tx- chemo + XRT + surgery
