ABSITE

Question 1

neck mass

Answer 1

thyroglossal duct cyst - found in first decade of life, anterior midline, moves with swallowing, remnants of the tract along which the thryoid gland descended

• requires operative removal due to risk of infection
• tx - remove cyst and sinus tract (if tract extends into thyroid lobe, perform lobectomy; if extends through hyoid bone, perform central hyoid resection)
• <1% thyroglossal duct cysts have malignant tissue - if no capsular invasion or mets –> observe
  
  • if invasion –> completion thyroidectomy, nodal dissection, and RIA
• 1-2% of pts who have presumed thyroglossal duct cyst actually have ectopic thyroid - get TSH and US (may need thyroid scan if pt is hypothyroid or no thyroid tissue is visualized)
  
  • if hypothyroid with elevated TSH - give hormonal supplementation, gland might shrink in process
  • if tissue does not regress –> excise

branchial abnormality - aspirate abscesses to prevent disruption of tissue planes (for subsequent excision)

• type 1 cysts - anterior to SCM
• type 4 cysts - deep to carotid sheath (nerves at risk include hypoglossal, vagus, and glossopharyngeal)

features on US c/f malignancy - solid composition, hypoechoic, taller than wide, lobulated or irregular margin (or extrathyroidal extension), punctate echogenic foci (microcalcifications), hypervascularity

Question 2

IBD

Answer 2

IBD in general

• increased risk of CRC and SB cancers - endoscopy w bx q1-3yrs
• extra-intestinal manifestation - erythema nodosum, pyoderma gangrenosum, peripheral arthropathy, episcleritis and uveitis, PSC

UC

fulminant colitis - emergent surgical intervention = total abdominal colectomy with ileostomy (can come back for protectomy and IPAA)

• preserve superior rectal artery - maintains blood supply of rectal stump, aids in healing of rectal staple line
• since rectum is spared - also spare terminal branches of the IMA until proctectomy
• also spare ileocolic artery to allow for collateral blood flow to future J pouch
• divide rectum above peritoneal reflection, above the level of the sacral promontory

IPAA (elective procedure)

• most common complication - 1) obstruction, 2) sepsis (leak, abscess)
• most common side effect is pouchitis (23-59% of pts)
• mild fecal incontinence (17%) - but regardless, pts have 10 BMs/day
• stricture (11%) - if it is not fibrotic, stricture responds well to transanal or endoscopic dilation

PSC - higher risk of malignancy in pts with UC and PSC

• if pt is found to have incidental GB polyp - perform lap chole regardless of polyp size
• 14% of pts with PSC who undergo chole have mass lesions, more than 50% of these are adenocarcinomas

Crohns

pathophys - lymphoid aggregates and granuloma formation

• also transmural inflammation, skip lesions, rectal sparing, cobblestoning, fat creeping, and strictures; anal/peri-anal disease (DONT resect large skin tags)
• increased risk of adenocarcinoma - esp in diseased segments of TI

medical tx - sulfasalazine, loperamide maintenance; steroids for acute flares

• tx of refractory Crohns - resection of involved bowel should be taken to normal margins (palpation)
  
  • after resection of diseased portion of bowel - many extraintestinal manifestation improve/resolve (mucocutaneous issues, occular issues, MSK issues)
    
    • HB manifestations and axial arthropathies dont resolve
• 50% recurrence rate requiring surgery after resection

obstruction secondary to strictures

1. non-operative management, if that fails –>
2. operative management - if resection would sacrifice large amount of normal bowel or would leave pt with < 100cm of bowel in continuity –> strictureplasty (transverse incision, longitudinal closure)
   
   1. stricturoplasties have high rate of complications - increased post-op bleeding rom suture line
   2. so in Crohns it is better to perform resection (2cm from gross disease, dont need clear margins) with p anastomosis - additionally this provides tissue sample to r/o malignancy

pts with diffuse/severe dz of colon - protocolectomy and end ileostomy (no pouches or ilio-anal anastomosis)

anal/perianal - fissures (no lateral internal sphincterotomy), perineal fistula (seton and let heal on its own), anorectovaginal fistulas (rectal advancement flap, possible colostomy)

Other

• vitamin A has been shown to reverse diminished wound healing that occurs with chronic corticosteroid treatment

Question 3

opioid prescribing after surgery

Answer 3

Hill et all - surveyed pts who underwent lumpectomy w/wo SLNBx, lap chole, and lap and open inguinal hernia repair –> found that 72% of prescribed opioids were not taken

codeine - black-box warning agasint use in PACU following tonsillectomy and or adenoidectomy

• converted to morphine by liver (dependent on pts level of metabolism) - respiratory depression can be seen at even normal doses

Question 4

VTE prophylaxis

Answer 4

pediatrics - pharm prevention is indicated when 2(+) RFs are present

• RFs - CVC, hx of VTE, mechanical ventilation, inflammatory disease, malignancy, systemic infection, trauma, prolonged hospital stay (>5d)

Question 5

stats

Answer 5

Type 1 error - pregnant man, false positive

Type 2 error (b) - non-pregnant pregnant lady, false negative

• depends on power of the test - can decrease risk of commiting type 2 erro by increasing sample size

P value - probability that significant relationship was due to chance

odds ratio - describes association, case control studies

bias - cosnider direction and magnitute of effect of bias on results, conservative bias underestimates effect of intervention on outcome

• misclassification bias -
• selection bias
• recall bias
• publication bias
• measurement bias

survival analysis - Cox modeling

multiple linear regression - continuous variables, logistic regression - categorical variables, ANOVA - repeated continuous variables

Question 6

solid organ transplantation

Answer 6

warm ischemia time - time from dividing arterial supply to perfusion with perservation solution

• cold ischemia time - time from cold perfusion to re-implantation

factors negatively affecting post-transplant volume (?) - donor age > 50, female sex of donor, increased heptic steatosis of donor liver, severe donor hypernatremia prior to organ harvest, prolonged cold ischemia time, ABO mismatch between donor and recepient

• liver grafts obtained after DCD are associated with high rates of biliary complications and graft loss
  
  • additionally increased risk of biliary anastomosis with hepatic artery stenosis/thrombosis
• living donor liver tx - left lateral (2/3), left lobectomy (1-4), right lobectomy (5-8)
• liver tx - liver transplants require less immunosuppression compared to other solid organ transplants
  
  • graft loss from rejection is rare
  • induction immunosuppression is rare and post-op immunosuppression is tapered
  • 10-15% of pts develop renal failure w/i 10 yrs
  • malignancy post-transplant - most common is skin cancer
  • opportunistic infections - most common w/i first 6 mo

risk of malignancy is increased following solid organ transplantation - EXCEPT incidence of breast cancer, which is not increased post-transplant

• post-transplant lymphoproliferative disorder - small bowel mass w/wo GU bleeding, CNS mass (headache), new LAD, non-specific sxs

abd organ transplant recipients (esp liver tx) - are uniquely susceptible to candida

• post-op ppx with fluconaxole of echinocandin (ex caspofungin)
• IV caspofungin for non-ablicans species
• ampho B is a more toxic drug

immunosuppression - induction (antithymocyte globulinm basiliximab), maintenance agents

Question 7

traumatic chest injury

Answer 7

flail chest

• management is supportive care: 1) prevention of hypoxia (supplemental O2, intubation), 2) judicious fluid administration (d/t incidence of underlying pylmonary contusion), 3) analgesia
• pathophys - pain, abnormal chest mechanics, severe VQ mismatch

pulm contusion

• tx - supportive, supplemental O2, IS w flutter, pain control, and increased activity and mobilization, restrict fluids
• pain control - epidural and fentanyl patch (opioid) is best > intercostal nerve block, effective but short-lived > IV opioids (respiratory depression)
  
  • epidurals contraindicated with anticoagulation

Question 8

breast cancer

Answer 8

Imaging

BIRADS

• 0 incomplete
• 1 negative
• 2 benign
  
  • non-palpable birads 1-2 continue w routine screening
• 3 probably benign
  
  • non-palpable birads 3 lesions - repeat mammo in 6 mo
• 4 suspicious - between 2-95% risk of malignancy
  
  • features include - architectural distortion not related to prior intervention
• 5 highly suggestive of malignancy >95%
  
  • non-palpable birads 4-5 lesions should undergo bx
• 6 bx proven malignancy

Screening

• mammogram every 2-3yrs after age 40, then annually after 50
  
  • high-risk pt - mammogram 10 yrs before youngest age of dx of relative
• MRI - used in high risk screening or in women with mammographically occult breast ca
  
  • lifetime risk of breast ca > 20%, known BRCA, untested woman with first-degree BRCA relative, chest XRT bw ages 10-30, genetic syndromes
• annual diagnostic mammography for pts with breast conservation tx
• mammographic not routinely recommended for breast s/p mastectomy

Workup/Tx - screening mammo –> diagnostic mammo –> core needle bx –> +/- excisional bx

• core bx - US bx is preferred (easy if there is associated mass), otherwise stereotactic bx
• if results of core needle bx are discordant with imaging - get excisional bx
  
  • also if results are atypical ductal hyperplasia, atypical lobular hyperplasia, radial scar, LCIS, columnar cell hyperplasia with atypia, papillary lesions, phyllodes tumor
• bloody nipple dc - considered pathologic, though most is benign (intraductal papilloma, other causes include intraductal carcinoma, bleeding papilloma, fibrocystic changes with intraductal component)
  
  • women < 30 - US +/- mammo, women >30 - US + mammo
    
    • additional imaging if initial imaging is negative and pt has RFs
    • tissue bx for abnormalities
    • duct excision
• cystic lesions - usu in perimenopausal women over 40, lesions in postmenopausal women have increased association with breast ca –> aspirate (if symptomatic and palpable)
  • bloody aspirate –> surgical excision
  • non-bloody - complete drainage, repeat imaging 4-8 weeks, surgical excision for repeated cysts
• papillary lesion on core needle bx - check for mammographic-pathologic concordance and accurate sampling –> otherwise excision of lesion should be perfromed to rule out concomitant papillary carcinoma in situ or invasive dz
• fibroadenoma - F20-50, solitary, well-defined, mobile, rubbery mass, response to hormone changes
  
  • excisional bx to distinguish bw fibroadenoma and phyllodes tumor - can be observed if bx shows no atypia
• atypical ductal hyperplasia - re-excise to make sure there is no DCIS or invasive ca
  
  • atypical ductal and atypical lobular hyperplasia occur with equal frequency and confer similar risk of invasive breast cancer
• DCIS (non-invasive breast ca, px as clusters/linear pleomorphic microcalcifications) = pre-malignant lesion, 50% get cancer in ipsilateral breast
  
  • mastectomy + SLNBx (b/c cant stage axilla w SLNBx after youve done mastectomy) or lumpectomy with SLNBx later if invasive ca identified; and XRT
  • however it is rare to perform mastectomy for DCIS (too radical an approach for something that may never progress to ca)
  • for DCIS - 2 mm margins
  • DCIS does not met - if you have positive nodes in a DCIS sample, then that means pathologist missed focus of invasive cancer in specimen
  • high risk of recurrence for comedo type (most aggressive subtype) and lesions >2.5cm
• LCIS - risk factor for infiltrating ductal in both breasts (risk is 1% per year), but it is not a precursor or cancer itself so re-excision for negative margins does NOT need to be performed
  
  • no calcifications
  • enroll this pt for high-risk screening - MRI + mammo
  • likewise - atypical lobular hyperplasia is also a high-risk lesion, does not warrant re-excision
• inflammatory breast cancer - 1) neoadjuvant chemo, 2) radical mastectomy (c/f lymphatic obstruction by tumor cells ad high false-neg rate following neoadjuvant tx), 3) radiation
  
  • imaging –> punch bx if imaging is negative
  • skin-sparing mastectomy is NOT safe for inflammatory breast cancer
  • reconstruction should be delayed until cancer is fully treated (additionally plastics guys like to wait after radiation tx is completed to place implants)
• invasive ductal or lobular - mastectomy/lumpectomy with SLNBx
• Padget’s disease - dermatitis of nipple, 90% of cases are associated with underlying in situ lesion or invasive ca
  
  • px thought to be d/t cancer traveling through ductal system to nipple
• BRCA2 - prophylactic mastectomy OR tamoxifen (has been shown to reduce the risk of developing breast ca

Staging

T1: tumor < 2cm

T2: 2-5cm

T3: > 5cm

T4: direct extension to the chest wall (not including pec muscle), skin edema, skin ulceration, satellite skin nodules, or inflammatory carcinoma

Surgery details

• radical mastectomy - mastectomy + pec major/minor + nodes
  
  • modified radical mastectomy - mastectomy + most of nodes (pecs left behind)
• ax dissection - axillary vein (superior), serratus (medial), lat dorsi (lateral), clavipectoral fascia (anterior)
  
  • lat dorsi - thoracodorsal a. and n. - arm adduction, arm extension and internal rotation
  • serratus anterior - lateral thoracic a., long thoracic n. - winged scapula
  • for clinically palpable nodes - remove level 1 (lat to pec minor) and 2 (beneath pec) nodes, tissue inf to axillary vein and bw pec minor and lat dorsi
    
    • level 3 (medial to pec minor) nodes are not removed unless there is gross tumor
    • dissection is done without paralysis
    • nodes are the most important prognostic staging factor
  • median brachial cutaneous nerve is most commonly injured
• for invasive ca - “no ink on tumor” margins
  
  • locally advanced non-inflammatory breast cancer - neoadjuvant chemo, modified radical mastectomy, adjuvant radiation
• SLNBx - if LN cant be mapped with Tc or blue dye –> ax LND
• large extent of calcifications - can bracket disease, can use intra-op specimen radiograph to assess adequacy of resection, can get postlumpectomy mammogram (on post-op appointment 1)

Chemorads Tx

Chemo

• chemo before rads in breast ca
• neoadjuvant chemo - proven effective for reduction of tumor size (no disease-free survival benefits)

Radiation - performed after resection

• whole breast irradiation - frequently results in mammographic spiculated scar –> core bx will show fat necrosis (this is CONCORDANT with mammographic findings) –> 6 mo f/u mammogram
• radiation tx - pts are at higher risk for angiosarcoma

Oncotype Dx (21 gene assay, RT-PCR) - developed for use in ER-positive, node-negative pts by retrosepctive analysis of tumor tissue from pts tx with tamoxifen +/- chemo and risk of recurrence at 10 yrs was quantified

• independent validation performed - revealed recurrence score was superior in predicting prognosis
• additionally, high-risk gorup experienced benefit with addition of chemo to tamoxifen; low and intermediate risk groups received NO benefit from chemo

HER2 pos, tyrosine kinase activity - trastuzumab

• HER2 overexpression is a negative prognostic factor (shorter disease-free and overall survival)
• addition of trastuzumab to adjuvant chemo has cut risk of recurrence by 50% (compared to chemo alone)

Reconstruction - s/p radiation, autologous reconstruction is best option (fat transfer)

• now prior to planned adjuvant radiation - best option is tissue expander at time of mastectomy followed by implant once radiation is completed
  
  • autologous flap is NOT recommended - loss of reconstruction cosmesis
• implants
  
  • breast implant-associated anaplastic large cell lymphoma - rare, px yrs after implant placement as peri-implant fluid and breast warmth/tenderness –> aspirate collection, send for cytology and path

Special cases

Male with breast mass

• gynecomastia is common, ca is rare - get mammogram and US to evaluate
• if breast ca - refer to genetic counseling (likely BRCA2 mutation)
• advanced breast ca in men - 1) neoadjuvant chemo
  
  • BCT on standard of care in men

Pregnant women - chemo safe in 2nd and 3rd trimesters (except methotrexate), tamoxifen contraindicated, radiation contraindicated

• neoadjuvant chemo (allows for delay in tx) –> BCT/mastectomy

Pediatric Dz - be aggressive - CXR, LFTs, CT/MRI head/chest/abd, bone scan or PET

• locoregional dz - CXR and LFTs for staging –> tx BCS + whole-breast irradiation or mastectomy
  
  • contraindications to BCS - pregnancy, multicentric dz, previous chest wall radiation
  • relative contraindications - collagen vascular dz (concern with radiation), large tumor-to-breast ratio
• advanced locoregional dz (+nodes) - additional work-up
  
  • N0 - SLNBx
  • 3+ nodes on SLNBx - completion axillary LN dissection
  • clinical node pos dz - ax LN dissection

Question 9

G/J tubes

Answer 9

PEG tube - safe tract technique (to minimize risk of damage to intervening bowel)

1. transillumination and finger pressure
2. small caliber needle with fluid-filled syringe - aspirate syringe to detect intraluminal air –> if air bubbles are encounter prior to visualization of needle in stomach, needle should be removed and alternative puncture site should be selected

J-tube Witzeled in place - pt obstructed –> remove tube and Witzel it downstream (suscpect that obstruction is d/t lumen narrowing/occlusion after Witzel)

Question 10

thyroid

Answer 10

A&P - 1st and 2nd pharyngeal arches

• superior thyroid artery (1st branch off external carotid)
  
  • superior thyroid artery - along pharyngeal constrictor muscles –> A and P branches
• inferior thyroid artery (tracks behind carotid then goes medial) intersects with recurrent laryngeal nerve
• superior and middle thyroid veins –> IJ; inferior thyroid vein –> innominate vein
• superior laryngeal nerve (lateral to lobes) - MC nerve injured during thyroidectomy, injury results in loss of projection and easy voice fatigability
• recurrent larygneal nerve (posterior to thyroid) - vocal cords, L loops around aorta, R loops around innominate artery
• thyroglobulin - stores T3 and T4 in colloid (T3 is active form)
• pyramidal lobe - occurs in 10%, from isthmus toward thymus
• lingual thyroid - is the only thyroid tissue in 70% of pts who have it, 2% malignancy risk
  
  • tx - thyroxine suppression, abolish with I-131 –> resect if worried about cancer or if it does not shrink after medical tx

Hormone-based

• central thyroid disease (brain) - defect in thyroid hormone secretion (otherwise normal thyroid gland)
• thyroid storm - 1) b-blocker (to reduce end-organ effects), 2) Lugols solution (KI, takes time to work) 3) methimazole (to reduce production and release of hormones), 4) steroids to decrease T3 to T4 conversion

Hyperthyroid

• tx - methimazole (first line, not used in pregnancy), PTU (hepatotoxic), I-131 (radioactive I, for pts who are poor surgical risks or dont respond to methimazole, NOT for children or pregnants)
• pregnant pt - if NOT controlled by PTU –> thyroidectomy during second trimester
• Graves dz - toxic diffuse goiter, most common cause of hyperthyroidism
  
  • 1) medical tx, 2) I-131, 3) surgical tx (unusal to have to operate)
    
    • however pre-op prep - methimazole until euthyroid, b-blocker, Lugol’s solution (to decrease thyroid vascularity and friability)
    • b/l subtotal OR total w thyroxine replacement
• toxic multinodular goiter - surgery is preferred initial tx (consider I-131 in elderly/frail but doesnt work because of non-homogenous uptake)
• single toxic nodule - 1) medical tx, 2) I-131, 3) surgical tx

Hypothyroid (thyroiditis)

• Hashimoto’s - most common cause of hypothyroidism in adults
  
  • 1) thyroxine, 2) partial thyroidectomy if continues to grow despite thyroxine…
• bacterial thyroiditis (rare) - d/t contiguous spread (URI), abx, may need lobectomy to r/o ca
  
  • thyroid gland is relatively resistnat to infection (rich blood/lymphatic supply, fibrous capsule)
  • acute supparative thyroiditis - age20-40yo, HIV
    • orgs - S aureus, S pyogenes
    • labs - leukocystosis w normal TFTs
    • dx - FNA w gram stain and cx
    • if there is abscess or pyriform sinus fistula - may need surgical drainage
• post-partum thyroiditis - thyrotoxic state –> hypothyroid –> recovery (all d/t antithyroid antibodies, no issue with the gland, so antithyroid drugs are not indicated)
  
  • control of sxs w b-blockage
  • thyroid replacement for 6-9 mo until pt recovers
• De Quervains thyroiditis - can be associated with initial hyperthyroid, viral URI precursor, tx with steroids and ASA, again may need lobectomy to r/o ca
• Riedel’s fibrous struma - steroids and thyroxine, may need isthmectomy or tracheostomy for airway sxs

ASx nodule - 90% of nodules are benign

• FNA and TFTs
  
  • follicular cells - lobectomy (10% ca risk)
  • thryoid ca - thyroidectomy or lobectomy
  • cyst fluid - drain fluid, if recurs or is bloody –> lobectomy
  • colloid tissue –> thyroxine (most likely colloid goiter)
  • hot nodule - methimazole and I-131 if sx
  • cold nodule - lobectomy
• goiter - iodine replacement tx

Cancer - pissed, f-ed, autopsy

• RFs for malignancy - male >50, pervious neck XR, FHx of thryoid ca, MEN2a/b
  
  • nodules 1.0 cm with suspicious sonographic features (hypoechoic, microcalcifications, increased central vascularity, infilatrative margins, taller than wide in transverse plane) –> FNA
  • nodules > 1.5cm –> FNA
  • FNA and repeat FNA inconclusive –> thyroid lobectomyf
• pre-op work-up for thyroid surgery - Ca and parathyroid levels
  
  • parathyroidectomy should be performed concurrently if indicated
  • pts with sxs of recurrent laryngeal nerve injury or w/ hx of risk to that nerve - get laryngoscopy
• papillary ca - most common thyroid cancer
  
  • less than 4 cm with no nodal mets, no evidence of invasion, and normal contralateral lobe - thyroid lobectomy
    
    • LND is not required if nodes are clinically negative on pre-op imaging as well as on visual inspection during surgery
  • metastatic ca - total thyroidectomy, central neck dissection and lateral neck disection (of affected side)
    
    • if lateral nodes are involved (levels 2-5), then central nodes (level 6) are usually involved
  • lymphatic spread
  • prognosis baed on local invasion
  • pt presents for surveillance with evelated thyroglobulin - get US (majority of recurrences occur in neck)
    
    • PET if pt ha radioactive-I negative disease (CT scan with con is not used because it may affect RAI ablation)
• follicular neoplasm on FNA - unable to determine benign or malignant –> thyroid lobectomy
  
  • pathology will identify capsular or vascular invasion
  • heamtogenous spread - usu to bone
• medullary thyroid carcinoma - lymphatic spread (most have involved nodes at the time of dx), early mets to lung/liver/bone
  
  • total thryoidectomy with central neck node dissection +/- MRND for palpable thyroid mass, b/l tumor, or extra-thyroidal dz
  • ppx surgery at age 6 for MEN2a and at age 2 for MEN2b
• lymphoma - chemorads (R-CHOP), surgery is NOT indicated
• Hurthle cell caricnoma - most are benign, but again cant dx this on FNA, need lobectomy
• anaplastic thyroid ca - palliative resection/trach or palliative chemo rads (most present with late dz)
• lateral abberant thyroid = regional nodal mets
  
  • true ectopic thyroid tissue - central cervical compartment, mediastinum
• sudden growth - could be hemorrhage into previously undetected nodule/malignancy

Surgery/Adjuvants

when would you progress to total thyroidectomy

• tumor > 1cm, extra-thyroidal disease (beyond capsule, clinically positive nodes, mets), multicentric dz/bl lesions, previous XRT
• MRND? - for extra-thyroidal disease
• indications for post-op I-131 - tumor > 1cm, extra-thyroidal disease, need total thyroidectomy for I-131 to be effective

post-thyroidectomy

• pt is tachypneic, desaturating, has hoarse voice - d/t cord paralysis, intubate
• stridor - open neck and remove hematoma OR might be d/t b/l RLN injury –> trach

XRT effective for all thryoid ca

• I-131 only effective for papillary and follicular variants
  
  • can cure bone and lung mets
  • indications - recurrent cancer, inoperable tumors d/t local invasion, tumors thare are 1>cm or have extra-thyroidal disease
  • for pts with mets - need to perform total thyroidectomy to facilitate uptake of I-131 to metastatic lesions (otherwise it all gets absorbed by thyroid gland)
• note that thyroxine suppresses TSH, give only have I-131 tx has finished

Question 11

hemostasis

Answer 11

thrombin - converts fibrinogen into fibrin, activates multiple factors, activates plts

TXA - antifibrinolytic, competitively inhibits activation of plasminogen to plasmin –> prevents degradation of fibrin

• improves outcomes in trauma pts with hyperfibrinolysis if used wi first 3 hrs after injury

Question 12

groin cutdowns/incisions

Answer 12

pt later px with groin mass - ddx is lymph leak (get duplex to evaluate), open exploration may be necessary if mass does not resolve (dont aspirate or use abx if there is no evidence of infection)

• noted to have clear, serous fluid on groin dressing
  
  • c/f lymph leak - 1) bedrest w/ leg elevation (will treat most lymph leaks)
  • IV abx are given as ppx in cases of lymph leak - but they do not treat the lymph leak itself

Question 13

adenomatous polyposis syndromes

Answer 13

Peutz-Jeghers - cutaneomucosal pigmentation

Gardner syndrome - desmoid tumors

Turcot syndrome - intracranial brain tumors

Cowden disease - bx shows hamartomas that affect all 3 germ layers, no increased risk of colon cancer

Question 14

heart surgery

Answer 14

pt s/p CABG now with hypotension, distended jugular veins, and ST-segment elevation in all ventricular leads - acute MI 2/2 graft stenosis or occlusion

(fellowship level) pt s/p CABG w LIMA presents with angina pectoralis, found to have long occlusion of L subclavian artery from origin to origin of LIMA - tx is open revascularization with L carotid to subclavian bypass

• avoid endovascular stent placements due to risk of covering origin of internal mammary
• L subclavian transposition is not best option - requires clamping of L subclavian –> which would lead to prolonged coronary ischemia time

transvenous pacemaker - contraindicated in cases of mechanical TV

• dislodgement of pacer may appear as - failure to sense, failure to capture
• if unable to advance - use fluoro

AVOID in pts underdoing CABG d/t 2-3 fold increase in CV complications (…not necessarily done in practice)

Question 15

kidney transplant

Answer 15

calculating GFR precisely (serum Cr and estimate GFR are surrogates)

• 24hr urine collection to calculate CrCl
• MAG-3 or DTPA renal scans also calculate GFR

advantage of retroperitoneal placement and anastomosis to iliac vessels

• avoids peritoneal contamination, provides multiple options for vascular reconstruction, easy percutaneous bx, places kidney close to bladder so length of ureter can be kept short and risk of ischemia minimized
• no difference in terms of approach time, bleeding, infection, or pain

Question 16

steatorrhea

Answer 16

intestinal: <20g fecal fat (24hr stool collection)
pancreatic: >20g fecal fat, low basal and meal-induced PP levels, abnormal secretin stimulation test

Question 17

esophagus injury

Answer 17

CAUSTIC injury

• CT CA to look for free air - if NO perf or suspected perf –> EGD to assess lesion
• serial exams and plain films
• primary burn (hyperemia), secondary burn (ulcers), tertiary (deeper ulcers, charring, lumen narrowing)
  
  • conservative tx for primary burn - IVF, NPO, dilation for future strictures
  • secondary and tertiary - may progress to esophagectomy
    
    • indications are sepsis, medistinitis/mediastinal air, free air/peritonitis, contrast extrav, PTX, large effusion
    • cant perform primary repair bc of extensive damage

PERF

dx - Gastrografin swallow

Boehaave - distal esophageal rupture, associated L-sided pleural effusion (mid-thoracic esophageal rupture associated with R-sided pleural effusion)

Cameron’s criteria for non-op management - low grade fever/leukocytosis, mild pain, no systemic sxs, injury confined to mediastinum with drainage back into esophagus, no free air

• NPO, NG decompression, BSAbx

esophageal perf - can place esophageal stent

• 30% rate of stent slippage esp in nonmalignancy - pt will have new dysphagia and fever after stent placement
• pt will often require VATS several days after stent placement for pleural washout

esophageal injury in stable trauma pt - direct repair of laceration with CT placement, NPO, and abx

• longitudinal myotomy to reveal full extent of injury
• if injury cant be closed with primary repair –> attempt closure over T tube, if that fails –> esophagostomy
• failure of initial primary repair –> pt now in septic shock - BSAbx, re-exploration via thoractomy, wide drainage, T tube placement
  
  • for small leak, nl vitals - consider esophagoscopy and esophageal stent placement

esophageal perf with mediastinitis (mediastinal gas pockets, fluid collections) - primary repair

Question 18

ID miscellaneous

Answer 18

HUS - 1) blood diarrhea –> 2) microangiopathic hemolytic anemia, TCP, AKI

• bug - E coli O157:H7 (undercooked meat), less often Shigella (toxin implicated is Shiga toxin)

Mucor - lethal fungal sinus infection, septated hyphae with broad branching angles (Aspergillus has narrow branching angles)

• tx - lipid amphotericin B plus aggressive debridement of all infected tissue

Histoplasmosis - causes mediastinal granuloma, chronic or fibrosing mediastinitis (distorts architecture, causes recurrent pulmonary infections)

SIBO tx - rifaximin for 14d

STOP IT Trial - Study to optimize peritoneal infection tx - abx duration of 4d was equivalent to 10d of tx

• end points - SSI, recurrent intra-abdominal infection, death

MRSA resistance - d/t alteration of the antibiotic target site (PBP)

Pseudomonas - b-lactamases

hollow viscus injury - repair and control of spillage - tx with pre-op abx and 24hrs of post-op coverage…

Question 19

Zollinger-Ellison syndrome

Answer 19

= gastrinoma - increased gastrin secretion

• pathognomic - fasting serum gastrin levels greater than 1000pg/ml plus hyperacidity and ulcer disease
• secretin stim test - 1) baseline gastirn level –> 2) inject 2u/kg of secretin –> 3) gastrin levels drawn at 5 min intervals for 30 min –> increase in gastrin of more than 200 pg/ml above baseline level supports the diagnosis of gastrinoma

Question 20

TOS

Answer 20

vTOS - paresthesia, swelling after repeated strenuous activity

• if pt returns with more pronounced sxs (more swelling and pain) - c/f DVT of UE secondary to repetitive motion
  
  • get Duplex

nTOS

• dx test - elevated arm stress test - goal post arms, ask pt to open and close hands –> will experience sxs in 30s-1min (nl pts can perform test for 3+ min)

Question 21

renal artery stenosis

Answer 21

renal artery stenosis dx - PSV > 180 cm/s, RAR > 3.5

• note - nl resistive index of kidneys is 0.8

CORAL trial - multicenter RCT, ~1000 participants, looked at pts who received medical therapy plus renal artery stenting or medical therapy alone

• percutaneous tranluminal angioplasty should not be considered superior to medical therapy alone
• there is evidence that open revascularization offers recovery of renal function in half of pts with atherosclerotic dz
• additionally patency rates are better in open surgery

Question 22

varicose veins

Answer 22

significant reflux > 0.5 sec

• anterior accessory saphenous vein runs lat to medial on anterior thigh and enters saphenofemoral junction

Tx

• 1) conservative management
• 2) operative tx - endovenous ablation of GSV, foam sclerotherapy, stab phlebectomies of varicosities (treating side branches only does not fully treat the problem)

Sclerotherapy

• contraindications to sclerotherapy - advanced PAD; late complications of DM, cellulitis, and hyperthyroidism; hypercoagulable pts
• pt experiences neuro sxs (visual disturbance, migraine, confusion) after sclerotherapy - can occur, more frequently in pts with PFO
  
  • tx - 100% O2
  • neuro sxs are typically transient
• after sclerotherapy, pt presents wtih telangiectasias and formation of reticular veins at injection sites - reassurance, this is self-limiting process that will resolve in 3-12 mo
• can also px with superficial phlebitis after the fact - removal of coagula via puncture extraction

*in contrast - deep venous insufficiency leads to edema, +/- hyperpigmentation, and healed/active venous ulcers

Question 23

carotid

Answer 23

carotid dissection - dual antiplt or warfarin for medical management (CADISS study, equivalent outcomes between dual antiplt vs anticoag, however overall stroke rate in study was low)

stenosis

• ACAS and ACST trials - for asx pts with stenosis of 60-99%
  
  • medical tx - RF management, ASA, statin –> overall risk of stroke becomes 2%, may be as effective as CEA or CAS

CEA

anatomy

• nerves hypoglossal (crosses ICA, tongue deviation), vagus (posterior to carotid, hoarseness), spinal accessory (shoulder/neck weakness), marginal mandibular
• bleding distal ICA, unable to clamp - advance Fogarty and inflate balloon in intra-osseus portion of ICA

perioperative stroke after CEA - post-op thromboembolism is most common cause

• neuro deficit in PACU after CEA - get bedside duplex US

pt presents with neurologic defect after CEA –> surgical exploration (will typically find intraluminal thrombus) - study showed that 2/3 of pts had complete resolution of their neuro deficit after surgical exploration

Question 24

appendix

Answer 24

appendicitis - ddx PID, tubo-ovarian abscess, ectopic pregnancy

• dx - US in children
  
  • CT in adults - diameter > 7mm, wall thickness > 2mm
• Alvarado score (predicts likelihood of acute appy dx) - localized RLQ tenderness, leukocystosis, pain migration, left shift, fever, N/V, anorexia, and peritoneal irritation
• pathophys - luminal obstruction (lymphoid hyperplasia in kids, fecalith in adults) –> distention, venous congestion and thrombosis, ischemia/necrosis/rupture

complicated appendicitis (30% of pts will present with this) - dt venous outflow obstruction and appendiceal wall ischemia –> bacterial invasion of appendiceal wall –> bacterial extrav

• RFs - young children (<4) or elderly, M, duration of sxs > 48hr, hispanic/AA/asian (unequal access to care), self-insured/public insurance, immunodeficiency, more than 3 comorbid conditions
• most likely to perforate at midpoint of anti-mesenteric border
• abscess - POD7, get US to evaluate in children (no radiation, pts with CT scans had higher rates of intervention…)
  
  • tx - percutaneous drainage, abx to continue for 2d after fever and leukocystosis have resolved (short course is as efficacious as long course for tx of intra-abd abscesses)
• interval appy in 2-3 mo - that is when acute inflammation has resolved
  
  • AND there is increaed incidence of appendiceal neoplasms in pts with perforated appendicitis

appendix is the most common site for incidental carcinoid tumors (and carcinoid is the most common appendiceal mass)

• appendectomy is sufficient for tumors < 2cm at tip of appendix - mets from these lesions are rare
• lesions > 2cm or lesions, those located at base, those associated with mets or high risk features –> RHC (30-60% of tumors > 2cm have nodal/distal meds)
  
  • high risk features - mucosal cell origin, mucin production, lymphovascular invasion, LN involvement, positive margin
• compared to small bowel carcinoids - smaller bowel carcinoids have greater metastatic potential at smaller size, 20-30% of small bowel carcinoids 1 cm or smaller will present with nodal/liver mets

appendix mucocele

• open appy, RHC if malignant
• pseudomyxoma peritonei (jelly-like substance fills abdomen) - increasing abdominal girth is most common px sx, second is inguinal hernia (25% of pts)

*general tenet* - if you go to do an appy and find a normal appendix, still take the appendix - prevents cofounding of future dx

Question 25

Budd Chiari syndrome

Answer 25

in major cause of obstruction of hepatic veins in Western countries = hematologic disorders

• myeloproliferative disorders, PVera (less commonly, OCP, collagen vascular disease, disorders of the coagulation cascade)
• other - venous membranes, tumors, trauma, post-op changes

Question 26

bypass graft

Answer 26

surveillance - US q3mo for 1st yr, q6mo after that

graft failure/thrombosis - immediate therapeutic heaprin gtt (goal is to halt thrombus propagation), duplex US –> then consider thrombectomy/revision

• causes
  
  • vein caliber and quality are most important determinants of graft patency - veins < 3.0 mm diameter perform poorly
  • early failure - technical error, compression of the graft, hypercoagulable state
• aortofem bypass grafts - long-term patency rate is quite good, graft failure is due to recurrence or progression of inflow disease
  
  • single limb failure - thrombectomy and revision of outflow obstructive problem
  • entire graft failure - redo, new graft

graft infections

• mo to yrs after implantation - px with failure to thrive, back pain, anastomotic pseudoaneurysms, perigraft fluid, or draining cutaneous sinus, no signs of sepsis
• bug - staph epidermidis

Question 27

gallbladder

Answer 27

A&P

• triangle of calot- cystic duct, common hepatic duct, liver
• CBD < 8mm and < 10 mm s/p chole, GB wall < 4mm, pancreatic duct < 4mm (according to fiser)
• HIDA scan - indication for chole include 1) gallbladder not seen (chronic obstruction), 2) > 60 min emptying time (biliary dyskinesia), 3) EF < 40% (again biliary dyskinesia)

Acute chole - obstruction of cystic duct by stone, most common orgs are E coli followed by Klebsiella and enterococcus

• pregnancy and acute cholecystitis - NPO and abx (cefoxitin)
• Acalculous cholecystitis - critically ill pts, systemic malperfusion (esp to organs with end arterial perfusion), bile stasis –> GB ischemia and gangrene
  
  • …thickened GB wall (>3mm, most reliable features seen in pts with acalculous chole)
• emphysematous GB - clostridium, emergent chole

Choledocholithiasis

• ERCP should be performed early in pts with high-mod suspicion of choledo and CBD dilation, so pts with
  
  • CBD stone on US, clinical ascending cholangitis, bili > 4, dilated CBD (>6 mm) + elevated bili (1.8-4)
  • moderate factors warrant MRCP, endoscopic US, IOC, or intraop US - so abnormal LFTs, age > 55, clinical gallstone panc
  • note - can see pneumobilia following ERCP

Mirizzi syndrome - external compression of CHD d/t stone in cystic duct –> subtotal (?) cholecystecomy

Acute cholangitis

Tokyo guidelines

• grade 2 (moderate) - 2 of following: WBC < 4 or > 12, fever > 39, age > 75, hyperbilirubinemia (t bili > 5), or hypoalbuminemia (< 0.7 of lower limit of nl)
  
  • 1) fluid resuscitation, blood cultures, IV abx, 2) early biliary drainage

Tx - ERCP, chole prior to dc

Gallstone ileus w complete SBO - ex lap with enterolithotomy followed by interval takedown of cholecystenteric fistula with cholecystectomy

• if you incidentally find duo adherent to GB - examine remainder of bowel

Sphincter of Oddi dysfunction

• morphine-neostigmine (both result in sphincter contraction) - would benefit from ERCP
  
  • glucagon - sphincter relaxation
• pt presents with intermittent RUQ pain s/p chole, CBD dilated on imaging - ERCP with sphincterotomy

Cholecystectomy

• lap chole w IOC - 1) fluoro and water-soluble contrast after administration of 1 mg glucagon (for small stones, flushing duct with saline is sufficient)
  
  • CBD exploration for stone impacted in ampulla and you are unable to get any instruments past stone - transduodenal sphincteroplasty
    
    • ERCP vs transduodenal sphincterotomy (duodenal incision) - decreased incidence of restenosis with transduodenal approach
• bile ducts
  
  • most common mistake during lap chole - mistaking CBD for cystic duct
  • biliary tree is only supplied by arterial anatomy - that is why it is very susceptible to injury
    
    • MCC of bile duct injury is excess cephalad retraction of GB fundus
  • choledochotomy - longitudinal incision below level of cystic duct
    
    • blood supply to CBD are along the duct in the 3 and 9oclock position - transverse incision may compromise blood supply
    • incise CBD instead of CHD to reduce risk of stenosis
  • bile duct injury identified after surgery - endoscopic stent placement
    
    • primary repair of injury < 50% circumference, othewise cholechoJ or hepaticoJ (cant anastomose to duo because it wont reach)
    • consequences can be stricture - dilation –> if that fails, procedure with resection of stricture and choledochoduodenostomy (distal injury) or hepaticoJ (proximal injury)
    • of note - bile ducts > 4mm are significant ducts that are in need of repair
    • side-to-side choledochoduodenostomy - stones, sludge, debri accumulating in distal CBD and obstruct = sump syndrome –> can also result in acute cholangitis or pancreatitis
      
      • tx is ERCP
  • T-tube placement after open bile duct exploration - cholangiogram prior to T-tube removal
    
    • if stones - repeat cholangiogram in 4-6 wks (allows for tract maturation), then ERCP + sphincterotomy or percutaneous extraction via T-tube if stones still present
• unable to identify planes, cant obtain CVS - lap tube cholecystotomy (allows resolution of sepsis, good in critically in pt), subtotal chole for pts who are more stable but still w bad planes
• unable to extract stones with ERCP –> open CBD exploration, choledoctomy, still duct is unable to be cleared of stones –> choledochoduodenosotmy or RNY hepaticoJ, T tube drainage (and percutaneous extraction of stones via tube), transduodenal exploration and sphincteroplasty
• pt 1 week s/p stent placement - perform cholecystostomy on full anticoagulation and lap chole in 6 mo
  
  • dont stop anti-coagulation (not even conversion to hep gtt) in immediate post-stent period
• N/V, jaundice following lap chole - US
  
  • fluid collection –> place drain - if drain is bilious –> ERCP + stent
  • dilated hepatic ducts - c/f duct transection –> hepaticoJ early (if injury is caught wi 7d) or after 6-8 weeks (if injury presents after 7d, tissue too friable 7d after surgery)
    
    • leak after hepaticoJ - ERCP + stent
• shock after lap chole - early d/t clip falling off cystic artery, late d/t CBD being clipped (cholangitis, septic shock)
• indications for asx cholecystectomy - pts underoing liver tx or gastric bypass

Biliary strictures

• d/t ischemia after chole, other causes include chronic pancreatitis, or cancer - for non-cancer causes, perform choledochoJ
• PSC - multiple strictures –> portal HTN, hepatic failure (doesnt get better after colon resection for UC) –> needs liver txp, cholestyramine, UDCA for sx relief

Hemobilia ​- most commonly d/t fistula bw hepatic artery and bile duct –> px w UGI bleed, jaundice and RUQ pain –> dx angiogram –> tx angioembolization (if that fails, surgery)

Polyps

• majority of polyps are cholesterol - will be multiple, hyperechoic, pedunculated (and also non-mobile?), non-shadowing
• polyp > 1cm or polyps in pts > 60 - worry about malignancy
• tx - chole

GB adenocarcinoma - 5% 5-yr survival

• stones is #1 RF, remove porcelain GB, liver most common site for mets
• dx MRCP
• if muscle not involved - open chole
• if muscle involved - open chole + 4/5 wedge resection
• if beyond muscle (T2 lesion) - open segmental 4b/5 resection (extended cholecystectomy) with portal lymphadenectomy
• aortocaval LNs are N2 LNs - considered stage 4 disease, in which case pt should receive chemo (no resection)
• liver tx is used for hilar cholangiocarcinoma (not for intrahepatic/distal cholangiocarcinoma, or GB cancer)

Cholangiocarcinoma - classically painless jaundice (or later px with weight loss), again dx MRCP, 5-yr survival 20%

• upper 1/3 Klatskin tumor - most common, worst prognosis, usu unresectable
  
  • unresectable - given chemorads (+ intraluminal tx)
  • Involvement of the hepatic ducts to include secondary biliary radicals bilaterally
  • Involvement of secondary biliary radicals on one side and vascular encasement (portal vein or hepatic artery) on the contralateral side
  • Tumor involvement requiring hemihepatectomy plus pancreaticoduodenectomy
• middle 1/3 - hepaticoJ
• lower 1/3 - Whipple

Question 28

parathyroids

Answer 28

A&P

• sup parathyroid glands (4th pharyngeal pouch) - inferior thryoid artery, RLN - inf parathyroid glands (3rd pouch)
  
  • inf thyroid artery (off thryocervical trunk)
  • inf parathyroids are more likely to be ectopic, occasionally found in tail of thymus
• most common cause of hypOparathyroidism - previous thyroid surgery

Primary Hyperparathyroidism

• can get hyperchloremic metabolic acidosis, osteitis fibrosa cystica, most pts are asx
• work-up - H&P, CXR (to look for emts, PTHrP source), SPEP to r/o MM, 24-hr urinary calcium (familial hypocalciuric hypercalcemia), MEN, PTH level
• surgery - sx disease or asx w Ca > 1mg/dl ULN, decreased Cr Cl (<60), kidney stones/nephrocalcinosis, osteoporosis/compression fractures, age < 50, ucal > 400/24hrs or high-risk stone panel

Hyperplasia - four-gland parathyroidectomy; adenoma - resect adenoma and inspect other glands to r/o other adenomas/hyperplasia

• single adenoma - 80% of pts
• get Tc sesatmibi scan and US of neck - to identify adenomas and thyroid pathology (not good for 4-gland hyperplasia)
  
  • of note - 4% of pts will have thyroid cancer
• ectopic glands - can be located in mediastinum, cartoids, vertebral body, superior to pharynx, and thyroid
• intra-op PTH level - should fall to 1/2 of pre-op value in 10 min
• scenario - you have identified 3 parathyroid glands, cant identify R inferior gland (location of inferior glands is less constant than upper) –> 1) mobilize and resect thymus –> 2) ligate middle thyroid vein, mobilize thyroid lobe (exposes esophagus and trachea) –> 3) thyroid lobectomy –> 4) abandon procedure
• scenario - pregnant pt, resect in 2nd trimester, increased risk of stillbirth if not resected

Carcinoma (rare cause of hypercalcemia)

• lung is most common site of mets, 50% recurrence
• initial op - radical resection of involved gland, ipsilateral thyroid lobe, regional LND
• locally recurrent dz - reexploration and resection (considerations, scar tissue)
• little role of chemorads for parathryoid carcinoma

Post-op

• for all post-parathyroidectomy pts - all will experience temp hypocalcemia –> start on po ca supplements, vitamin D supplements (even if symptomatic), and possibly IV calcium (if hypocalcemia is refractory to oral supplementation)
  
  • esp pts with secondary hyperPTH (renal dz) who do not have hypercalcemia at baseline

Secondary hyperparathyroidism - renal failure, high PTH d/t low Ca, most dont need surgery; tx w Ca supplement, cinacalcet, surery for bone pain

• tertiary hyperparathyroidism - s/p renal tx, still overproducing PTH, 3.5 gland parathyroidectomy

Question 29

DVT/PE

Answer 29

post-op DVT - dual therapy (LMWH plus warfarin) followed by long-term monotherapy (DOACs)

• LMWH - advantage is SQ administration
• of note - superficial vein thrombosis is managed expectantly with repeat duplex ultrasound in 1 week (systemic anticoagulation is not indicated in absence of DVT)
  
  • adding ppx fondaparinux (2.5 mg) is associated with lower rates of DVT, extension of thrombus into saphenofemoral junction, recurrence of SVT, composite outcome of DVT/PE, and need for surgery of SVT

iliofemoral DVT - thrombolysis superior to anti-coagulation (anticoagulation alone results in high incidence of chronic venous insufficiency)

isolated calf DVT - serial duplex imaging (to assess for resolution vs extension of clot) for asx, anticoagulation for sx pts and pts with RFs for extension of thrombus

phlegmasia alba dolens (tense compartments, diminished arterial pulses) –> phlegmasia cerulea dolens –> venous gangrene –> ischemia - therapeutic anticoagulation w/o thrombolysis and/or thrombectomy

• absolute contraindications to therapeutic anticoagulation - hx of intracranial bleeding, active bleeding/severe bleeding diasthesis, TCP, recent emergent procedures with elevated bleeding risk, major trauma
• relative contraindication - recurrent GI bleeidng, neuroaxial tumors, plt < 100K, AAA w HTN, stable aortic dissection, recent/emergent procedures with low bleeding risk

DVT in young pt (fellowship level) - strong association between DVT in young, low risk individuals and congenital absence of IVC

• minimal sxs - hep and compression stockings
• severe chronic sequalae - open venous reconstruction

******************************************************************************************

PE tx - hep bolus and infusion

• if massive (R heart decompensation) - tPA

IVC filter

• when would advanced techniques be required - if in place longer than 7 mo
• filter type, tilting of filter, protruding struts, and position above/below renal veins were not factors

Question 30

lobar emphysema

Answer 30

lobar emphysema - incidental or symptomatic (in first 6 mo of life) finding

• monitor for enlargement with radiographs until 6 mo of age - surgery for enlargement, no intervention for asx

Question 31

pancreas

Answer 31

Congential abnormalities

• pancreatic divisum (instead of fusing to form a main pancreatic duct, dorsal and ventral pancreatic ducts remain) - diagnosed by MRCP (sensivity can be further increased by injection of secretin)
  
  • most (95%) pts are asx, but some can have chronic upper abd pain w/ N/V

Non-cancer dz

• chronic pancreatitis (50% of cases are d/t heavy alcohol consumption)

Malignancy

Cysts

• cf pancreatic malignancy
• sxs?
• stratification
  
  • worrisome features indicate need for endoscopic US/imaging and possible resection - >3cm, thickened enhancing cyst walls, mural nodule <5mm (or non-enhancing mural nodules), main pancreatic duct 5-9mm, elevated CA-19-9, increased growth (>5mm over 2 yrs), main pancreatic duct caliber change with atrophy, LAD, and pancreatitis
  • high risk stigmata of BD-IPMN - mural node > 5mm or enchancing solid component, main duct >10 mm, obstructive jaundice
• MCN or IPMN on cyst fluid analysis - high CEA
• MCN - walls of cysts contain “ovarian-type” stroma
  
  • pre-malignant lesion - resect
• amylase - high in pancreatic pseudocysts and IPMNs
• serous cyst neoplasm - can be located anywhere, most pts have sxs, can be

Neuroendocrine tumors - enucleate

• non-functioning tumors with concern for malignancy - traditional resection (pancreatic head resection OR pancreatic tail resection w splenectomy, also peripancreatic lymphadenectomy)
• for tumors < 3cm with no overt malignant features - parenchyma-sparing operations are safe
• pancreatic NETs associated with familial syndromes are often multifocal
• insulinoma - 72hr in-hospital fast, measure serum glucose and insulin levels

high risk for metastatic dz (weight loss, large tumor, hypoalbumenia) - staging laparoscopy and possible resection

Pancreatic necrosis - 25% risk of developing pancreatitis after open debridement

Surgeries

• Frey procedure - duodenal-sparing pancreatic head resection and lateral pancreaticojejunostomy (pancreatic duct drainage and focal pancreatic head resection), achieves pain relief, lower morbidity compared to whipple
  
  • indicated for - chronic pancreatitis
• Beger procedure - division of pancreatic neck, construction of two pancreatic anastomoses
  
  • good for small pancreatic ducts
• Putesow - requires dilated pancreatic duct for lateral PJ
  
  • anastamosis of 6cm of greater, longer than 10cm will involve pancreatic head whcih is difficult to localize and suture to
• total pancreatetcomy with islet cell autotransplantation - small pancreatic duct, minimal change pancreatitis, hereditary pancreatitis
• Whipple - focal pancreatitis, indeterminate mass, biliary and pancreatic duct stricturing, pancreatic divisum
• lateral PJ - dilated pancreatic duct, doesnt achieve durable pain relief when compared with Frey procedure
• celiac block - short term relief, reserved for terminal malignancy

Traumatic injury

​pancreatic tail injury

• trauma, but can also occur s/p L nephrectomy (pt with midepigastric pain, clear fluid leaking from port sites) - drain amylase > 5x serum amylase
• debridement and drainage
  
  • NOT a good option if pancreatic duct is transected - debridement and drainage alone puts pt at high risk for developing pancreatic fistula
• distal panc w splenectomy (faster, appropriate in pt with unstable vital signs)
• spleen-sparing pancreatectomy

Question 32

penetrating abd trauma

Answer 32

to OR for

• exlap HDUS, peritonitis, evisceration, free air
  
  • pt with gross blood in stool after stab wound –> ex lap
• ex laparoscopy - for stable pts with L thoracoabdominal penetrating wounds (eval diaphragm injury will not be seen on CT)

selective nonop management of PAT - stable, no peritonitis

injury to infrarenal aorta - expose this vessel by reflecting the transverse mesocolon cephalad and incising ther retroperitoneum

• Mattox maneuver (left medial visceral rotation) - for suprarenal aortic exposure
• Cattell-Braasch maneuver (right medial visceral rotation) - visualize infra-renal IVC
  
  • sometimes ligation of the R internal iliac artery is required to expose underlying venous injury

injury to infrarenal IVC

• unstable pts - ligate and measure compartment pressures prior to leaving OR

liver lac and diaphgram injury –> complication is biliary pleural fistula

• place CT AND decompress biliary tree with ERCP and sphincterotomy or PTC/PTBD

Question 33

burns

Answer 33

Parkland formula - 4 ml/kg/%BSA over first 24hrs

• half of volume divided over first 8hrs
• after 8hrs, cut fluid rate in half and give over the next 16hrs

inhalation injury dobules mortality associated with burn injuries - 1) direct thermal injury, 2) injury d/t combustion products, 3) CO tox

• CO tox - tx w 100% O2
  
  • carboxyHb - 20% causes confusion, 60% causes drain death
• risk for developing ARDS (calculate P:F) - low TVV
  
  • in general low TVV results in lower incidence of PNA, ARDS, and respiratory related death in pts with acute lung injury
  • permissive hypercapnia, pH > 7.0 - low volume/high frequency ventilation, allows low intrathoracic pressures and decreases barotrauma

ppx abx are CONTRAindicated

Question 34

adrenal mass

Answer 34

Anatomy

• rich blood supply - inf phrenic –> sup adrenal, aorta –> mid adrenal, renal artery –> inf adrenal
• L adrenal vein –> L renal vein
• R adrenal vein –> IVC

Sweeter as you go deeper, GFR, salt - sugar - sex steroid

Cortisol - inotropic, chronotropic, increases vascular resistance, gluconeogenesis, anti-inflam

• CAH - inability to make cortisol, excess androgens, variable mineralocorticoid effect
  
  • 21 def - in 17-OH progesterone, precocious puberty, salt wasting and hypotension
  • 11 def - inc 11-deoxycortisone, precocious puberty, salt saving and HTN
  • tx for both - cortisol, genitoplasty
• hypocortisolism (adrenal insufficiency, Addison’s dz) - feature is decreased cortisol and aldosterone
  
  • 1 cause) withdrawal of exogenous steroids, 1 dz) autoimmune
  • dx - cosyntropin stim test (ACTH given, cortisol measured, cortisol will remain low)
  • tx - dexamethasone
• hypercortisolism (Cushings syndrome)
  
  • most commonly iatrogenic - for rest of people, 90% of cases are ACTH-dependent (80-90% d/t pituitary adenoma, 10-20% d/t ectopic ACTH-producing tumors), 2) solitary cortisol-producing adrenal adenoma, 3) b/l adrenal hyperplasia
  • ex pt presents with weight gain - hypercortisolism - urine cortisol, dexamethasone suppression test
  • measure 24hr urine cortisol and ACTH
    
    • if ACTH low and cortisol high, pt has secreting lesion (adenoma or hyperplasia)
      
      • again resect adenomas
      • hyperplasia - 1) medial tx (metyrapone blocks cortisol synthesis, aminoglutethimide inhibits steroid production), 2) b/l adrenalectomy with post-op steroid and mineralocorticoid supplementation
    • if ACTH high –> give high-dose dexa suppression test to distinguish between pituitary adenoma and ectopic lesion (small cell lung ca)
      
      • for ectopic lesion - CT chest, abd
    • one other case where you would perform b/l adrenalectomy - if you cant resect/local ectopic ACTH producing tumor or pituitary adenoma

Aldosterone (stimulated by ang 2) - reabsorps Na, secretes K and H

• primary hyperaldosteronism - 1 adenoma (85%), 2 hyperplasia (15%), ovarian tumors and cancer (rare)
  
  • salt-load suppression test (urine aldosterone will stay high), PRA > 20
  • localization - CT –> NP-59 scintigraphy –> adrenal vein sampling
  • pre-op - control of HTN and K replacement
    
    • start pt on spironolactone, lisinopril, and amlodipine for pre-op HTN control
      
      • these meds can be stopped wo taper post-op (a-blockers and b-blockers need to be tapered down)
  • adenoma - resect
  • hyperplasia - 1) medial tx, 2) surgical tx for refractory hypokalemia, post-op fludrocortisone
• secondary - more common than primary dz, high renin (low intravascular volume, renin-secreting tumor)

Excess androgens and estrogens - almost always cancer

Asx adrenal mass

• check for functioning tumor - biochemical testing - urine metanephrines/VMA, urinary hydroxycorticosteroids, plasma R:A
• consider ca work-up - CXR, colonoscopy, mammogram to check for primary tumor
• surgery if - ominous CT, >4-6cm, functioning, or enlarging
  
  • concerning features on imaging - > 20 hounsfield units (less than 10 suggests benign adenoma), calcifications, size > 4cm, unilateral location, heterogenous appearance on CT
• benign (asx) adenoma - f/u CT in 6-12 mo (Fiser says q3mo for 1 yr, then annually)

Adrenocortical carcinoma = 50% are functioning, 80% have advanced dz at time of dx

• no bx indicated if imaging characteristics suggest carcinoma - open resection because MIS approach is likley to result in capsular disruption and tumor fracture
  
  • actually DONT bx carcinoma
• radical adrenalectomy - adrenal + kidney
  
  • debulking heps sxs, prolongs survival
• R0 resection - surveillance for recurrence of disease (CT/MRI CAP q3mo fo 2 yrs, q6mo for 5yrs)
• R1 resction (or vascular capsular invasion, intra-op tumor spillage, high-grade disease) - adjuvant mitotane

Pheochromocytoma (medulla) - 10% rule (malignant, b/l, childnre, familial, extra-adrenal [RP, organ of Zuckerkandl at aortic bifurcation])

• plasma metanephrines - pheo (but fiser says urine metanephrines are teh best test)
• dx - CT/MRI –> MIBG scan (also available is FDG 18F-DOPA imaging, mentioned in SCORE)
• of note, neuroblastoma (kids) - also secrete catecholamines
• pre-op - volume replacement and a-blocker (then b-blocker)
  
  • unopposed a-blockade can cause HTN crisis, stroke, HF, MI
• operation - ligation of adrenal veins –> adrenalectomy

Mets to adrenals - lung*, breast, melanoma, renal Ca

• cancer hx with asx adrenal mass - have to get bx, FNA
• can get adrenal insufficiency because of potential for replacment of normal adrenal tissue with tumor (occurs in 30% of pts)
• have to first get urine catecholamines and metanephrines to r/o pheo bx prior to bx - can get surge of catecholamines if you bx a pheo
• biochemical testing - 8AM cortisol level and ACTH levels
  
  • cortisol insufficiency shouldd be adequately treated prior to operation to prevent periop adrenal crisis
• can proceed with metastatectomy - but know that resection of stage 4 disease may not impact overall survival

Operation specifics

L adrenalectomy

• mass is removed with multiple feeding vessels and aberrant vein anatomy - mass is distal pancreas

hypertension intra-op - give nitroprusside (other choices are phentolamine, nicardipine, labtelol, esmolol)

Question 35

post-op problems

hypotension

UOP

afib

Answer 35

hypotension - bleeding/under-resuscitation, MI, vasovagal episode (hypotension plus brady, give atropine), oversedation (anesthetics can cause hypotension, effects of anesthesia should wear off quickly)

• s/p angiogram - retroperitoneal hematoma (d/t high stick above inguinal ligament)

UOP

anuria = complete ureteral obstruction (think in hysterectomy)

Afib (d/t volume overload) - metoprolol for rate control followed by IV lasix

• unstable pt - cardiovert
• stable pt - workup with EKG, lytes, labs –> amio, dilt

Question 36

pectus

Answer 36

pectus carinatum (pigeon chest) - 1) brace, 2) reverse Nuss bar (if chest not too stiff) or Ravitch procedure

• Ravitch procedure - removal of affected costal cartilages, sternal osteotomy and sternal reconstruction

pectus excavatum - correction results in improvement in MVP (no change in lung volumes)

• Nuss procedure (bar placement) - key steps are safe passage of bar and stabilization of the bar

Question 37

pseudoaneurysm

Answer 37

tx options

• observation and re-exam for spontaneous thrombosis
• compression - less successful in setting of pain and if pt is on anti-coagulation
• US-guided thrombin injection
• groin exploration - neuropraxia, infection, skin necrosis

Question 38

PAD

Answer 38

claudication

• in calf claudication - short segment occlusion of SFA is most common
  
  • in cases of severe dz/occlusion - profunda fem can provide collateral flow to distal SFA or pop
• thigh+buttock claudication - iliac occlusive dz
• pop - geniculates can compensate for pop dz
• young claudicant
  
  • popliteal artery entrapment (compression of pop on angiography with provocative maneuvers) - musculotendinous release
  • adventitial cystic disease
  • popliteal aneurysm
  • Beurger disease - smokers, smoking cessation
• strong predictor of CV M&M - 20% of claudicants will experience nonfatal MI or stroke at 5yrs (progression to critical limb loss occurs in only 5-10% of pts lifetime risk; 1-3% risk in next 5 yrs if appropriately medically treated)

Question 39

osteomyelitis

Answer 39

osteo of calcaneus - calaneus is weight-bearing, flaps unlikely to heal here –> BKA

Question 40

ARDS

Answer 40

lung-protective TV are based on pred BW

• F = 45.5kg + 2.3 (in over 5’)
• M = 50kg + …

Question 41

AAA

Answer 41

Px/Tx

Initial imaging - CT AP wo IV contrast

Some pts with ruptured AAA may presented stabilized d/t tamponade (fellowship level) - limit resusication allowing hypotensive with maintenance of mental status

Open vs endovascular - 5% vs 2% 30d-mortality, enodvascular repair confers advantage in first 2 years, open has advantage thereafter

Anatomy

supraceliac aorta - L lobe of liver, divide triangular ligament; reflect esophagus to left

infrarenal aorta - mobilize duodenum and root of mesentery to R; sometimes L renal vein is in the way and must be ligated

caudate lobe overlies IVC

retroperitoneal approach - risk to L ureter

Complications

Colon ischemia (1-3% risk after EVAR) - get colonoscopy if pt is stable

• at watershed areas - rectosigmoid junction (Sudeck point) > splenic flexure (Griffith point)
• risk factors - IMA coverage and embolization of hypogastric artery, ruptured aneurysm, prolonged operative time, renal insufficiency
• grade 1 - patchy mucosal necrosis - bowel rest and serial physical exams, repeat endoscopic eval in 1-2d to evaluate for progression of ischemia
• grade 2 - mucosal and muscularis involemvent
• grade 3 - transmural necrosis, gangrene, perforation

Intra-abdominal HTN - concern after AAA rupture…abdominal compartment syndrome is sustained pressure >20 mm Hg with evidence of organ dysfunction

Question 42

vertebral artery

Answer 42

Dissection

stroke from dissection - poor outcomes, ~50% of pts develop permanent deficits

dissection wo evidence of stroke - infarction after dissection is usually secondary to distal embolization (rather than low flow) –> current recommendations are to tx with warfarin for 3-6mo (or antiplt…)

• surgical indications - deteriorating neuro status, expanding/symptomatic aneurysms

Vertebrobasilar insufficiency - V1-V4 segments

• vetebrobasilar insuffiency happens when one artery is >70% diseased AND the contralateral artery is >70% diseased, hypoplastic, or absent

Question 43

blood pressure

Answer 43

different pressure waveform in aorta compared to peripheral arteries - propagating pressure wave –> systolic pressure gradually increases –> peak systolic pressure in peripheral arteries is higher then in aorta (due to less vascular elastic tissue, greater impedance)

• propagation of blood into peripheral tissues is determined by MAP
• amplification of peak systolic pressure in peripheral arteries is counterbalanced by narrowing of systolic waveform = MAP is unchanged

Question 44

colitis

Answer 44

ischemic colitis - abdominal pain, bloody diarrhea –> unprepped colonoscopy (bx) –> erythematous and edematous with petechiae and ulcerations –> black/gray mucosa (full-thickness ischemia)

Question 45

acute limb ischemia

Answer 45

Px - emboli will lodge at birfurcation sites (thats where the lumen narrows)

• most common site is common fem > aortoiliac > pop, SFA, external iliac
• limb ischemia on exam is found 10-15cm beyond occlusion level

Stage 1 viable - pain, no sensory/motor impairment, audible pulses

Stage 2a marginally threatened (sensory loss, intact motor, loss of arterial signal, venous audible) - anticoagulation (heparin, prevents clot propagation) and angiography –> wire passes through occlusion –> thrombolysis and stenting of underlying lesion

• –> wire can’t be passed through –> fixed occlusion, bypass

Stage 2b immediately threatened (sensory loss, motor impairment, loss of arterial signal, venous audible) - prompt revascularization - surgical thrombectomy with completion angiogram

Stage 3 irr (no sensation/motor/signals)

all pts suspected of ALI should be started on IV anticoag

thrombolysis vs open surgery - incidence of major hemorrhage in pts undergoing thrombolysis is significantly higher than in pts undergoing open surgery (TOPAS trial)

• otherwise in general, thrombolysis > open surgery

Question 46

local anesthetics

Answer 46

local anesthetic tox - first sxs are neuro (ringing in ears, perioral numbness –> seizures)

• cardiac tox from local anesthetics - tx with 20% lipid emulsion

spinal - intrathecal/subarachnoid space

• can get total spinal anesthesia - cephalad spread of anesthetic –> hypotension, dysphagia, hoarse voice
• dermatomes for organs (spinal needs to be administered at the right dermatome)
  
  • stomach - T6-T9
  • SI - T8-T10 (appendix T10)
  • ascending and transverse - T10-T11
  • proximal descending colon - T12-L1
  • distal descending colon - L2-L3
  • rectum - S2-S4
  • uterus - T11

scalene block - phrenic nerve runs over these muscles –> can get anesthetic spread and inadvertent phrenic nerve block –> hemidiaphragm paralysis and dyspnea and low O2 sats (can progress to reintubation)

epidural space - dural - subdural space - arachnoid mater - subarachnoid space/intrathecal space (CSF) - pia mater

• goal is to get epidural in epidural space - aspirate (should see minimal fluid, some air bubbles)
• if intrathecal space is entered - can get profound hypotension and tachy
• if intravascular - can get HTN and tachycardia

Question 47

AVF

Answer 47

pre-op - progression is radial-cephalic > brachial-cephalic > brachial-basilic > graft

• Basilic is Base
• many surgeons will avoid radial-cephalic site in older women (poor maturation in even w adequate mapping)
• min vein diameter is 2 mm

rule of 6s (for maturation) - less than 6mm below skin, more than 6 weeks old, more than 6 mm in diameter, and an AVF flow rate of more than 600 mL/min

• takes at least 2 weeks to mature
• best surveillance after initial maturation - monthly determination of access flow by US diluation
• flow < 600 ml/min or flow < 100ml/min that has decreased by 25% over 4 month period –> further evalution with duplex +/- fistulogram
• fistulas are about *flow rate* during dialysis - no benefit to prophylactic repair of hemodynamically significant stenosis noted on duplex

c/b pseudoaneurysm

• non-op management IF - asx, stable, not infected, <4cm diameter, no overlying skin compromise, and does not prevent cannulation for dialysis

most common cause of graft thrombosis (fellowship level) - venous anastomosis stenosis d/t intimal hyperplasia

• graft thrombosis - responds poorly to thrombectomy, pt will need new AVF –> so place long-term dialysis catheter under fluoro if possible

indications for emergent dialysis - acidosis < 7.1, refractory K > 6.5, intoxications, refractory fluid overload, uremic pericarditis/encephalopathy

Question 48

hiatal hernia

Answer 48

Type 1 (95%) = sliding - GEJ migrates above diaphragm

• Cameron ulcer (linear ulcer in stomach) - d/t repetitive movement of GEJ through hiatus (occult GI bleed and anemia)
• tx is PPI

Type 2 - GEJ in nl position, fundus herniates through hiatus

• need Nissen, diaphragm repair can affect LES

Type 3 - Type 1 + 2

Type 4 (giant PEH) - structure other than stomach herniates through hiatus

evaluation - upper GI series - tells about type, location of GEJ…

operative steps

• 2-3cm of intra-abdominal esophagus to minimize recurrence risk
  
  • if unable - perfom Collis gastroplasty to lengthen esophagus
• fundoplication is often performed (may reduce GERD sxs and herniation recurrence), though this is not an essential step

Question 49

anal cancer

Answer 49

definition of anal margin - from intersphincteric groove to radius of 5 cm

causes - AIDS dz (Kaposi sarcoma, B cell lymphoma), HPV, s/p XRT

px - mass, inguinal LAD (get FNA/excisional bx, most tumors are FDG/PET avid, and 29% of pts with anal carcioma px with enlarged nodes on clinical or radiographic exam)

tx for squamous cell ca in anal canal

• modified Nigro regimen (5FU, mitomycin C, pelvic rads)
  
  • adverse effects of raidation - proctitis, diarrhea, incontinence, anal ulcers, stenosis, need for permanent colostomy in 10% of pts
• residual tumor after Nigro protocol (chemorads) - tumor response on exam in 8-12wks after tx –> then serial exams q4 wks until resolution of suspicious findings
  
  • after complete remission (for T1/T2 lesions) - DRE, endoscopic exam, groin exam q3-6mo for 5 yr, imaging annually for 3yrs
  • persistent disease - f/u @ 6 mo to see if further regression occurs
  • for locally advanced dz (T3/T4) or those with slow regression - CT or PET q1yr for 3yrs (??)
  • persistent disease @ 6 mo - bx to confirm disease progression, restaging w PET, consider salvage APR
    
    • perineal wound problems are common - bc surgery takes place in irradiated field
      
      • and wound complication rate is higher in pts w anal cancer compared to pts in the same tx situation w rectal cancer

other cancer in anal cancer - APR

• adenocarcinoma - APR + chemo/XRT
  
  • WLE if <4cm, <1/2 circumference, limited to submucosa (T1, 2-3 mm margin needed), well-differentiated, and no lymphovascular/neural invasion
• melanoma - APR, margins based on depth
  
  • 3rd most commons site for melanoma (after skin and eyes), 1/3 has spread to mesenteric LNs, hematogenous spread accounts for most deaths
    
    • sx - rectal bleeding

anal margin lesions (below dentate line)

• squamous cell - WLE for < 5cm; chemo-XRT for > 5cm, involving sphincter, or pos nodes (inguinal nodes)
  
  • goal is to preserve sphincter thats why you avoid APR
  • need inguinal node dissection for pos nodes
• basal cell ca - WLE with 3mm margins

nodal mets

• superior and middle rectum - IMA
• lower rectum - IMA or internal iliac
• anal canal - internal iliac
• anal margin - inguinal nodes

anal intraepithelial neoplasia

• low grade - observe with surveillance q4-12 mo (b/c rate of progression and malignant potential is low)

Question 50

stent

Answer 50

indications for stenting - stenosis, occlusion (NOT aneurysms)

Question 51

gastric cancer

Answer 51

Gastric adenocarcinoma

Antrum has 40% of ca

• RFs - adenomatous polyps (resect), tobacco, previous gastric operations, intestinal metaplasia, atrophic gastritis, pernicious anemia, type A blood, nitrosamines
• intestinal type - subtotal gastrectomy w 10cm margins
  
  • resection margins - 5-6cm proximal margins, 2cm distal margins
  • Surveillance
    
    • stage 1 - CT CAP as needed
    • stage 2 - CT CAP q6-12mo for 2yrs, then annually for 5 yrs
• diffuse gastric cancer (linitis plastica) - diffuse lymphatic invasion (no glands), total gastrectomy
• chemo (poor response)
• pallation - stent proximal obstructions, surgically bypass distal lesions
  
  • bleeding/pain - XRT

GIST - most common benign gastric neoplasm (though can be malignant), Ckit pos

Staging (size, mitotic rate [low is <5], mets)

• TNM: T1 < 2cm, T2 2-5cm, T3 5-10cm, T4 >10cm
  
  • 1A: <5cm size, low mitotic rate (most likely benign?)
  • 1B: 5-10cm, low mitotic rate
  • 2: <5cm with high mitotic rate; >10cm with low mitotic rate
  • 3A: 5-10cm, high mitotic rate
  • 3B: >10cm, high mitotic rate
  • 4 (metastatic dz): LN mets and/or distant mets
• malignant = >5cm or >5 mitoses
• resect with 1cm margins, no nodal dissection, adjuvant imatinib if malignant

Prognostic indicators in order of importance - mitotic index, tumor size, site of origin

• tumors <1cm have better prognosis
• SB GISTs have worse prognosis than gastric GISTs

MALToma - H pylori infection, triple tx abx for H pylori, XRT if does not regress

Lymphoma - stomach is the most common location for extra-nodal lymphoma

• usu non-Hodgkins (b cell)
• dx - EGD w bx
• tx - chemo and XRT (surgery for complications)

Question 52

malignant small bowel tumors

Answer 52

most common is adenocarcinoma - rare, usu in duo

• positive surgical margin associated with poor prognosis

leiomyosarcoma - usu JI, most extraluminal, r/o GIST (check for C-kit)

• tx - resect, no adenectomy required

lymphoma - in ileum

• dx - abd CT, LN sampling
• tx - wide en bloc resection + nodes
  
  • unless it is in the 1st or 2nd portion of the duo - chemo-XRT, no Whipple

Question 53

pressors

Answer 53

dobutamine - b1/b2 (b2 vasodilates, decreases afterload)

Question 54

colon cancer

Answer 54

c-scopes

• diverticulitis/sigmoid thickening - get c-scope in 6 wks to r/o neoplasm, IBD, or ischemia
• q3yr surveillance - for pts w 3-10 tubular adenomas, single adenomas > 10 mm, adenomas with villous features/high-grades dysplasia, sessile polyps, and serrated adenomas

FAP (AD, APC gene) - dx for colorectal ca is 40yrs (compared to 60 yrs in gen pop)

• polyps are also found in stomach and duo - so periodic anoscopy and EGD necessary s/p resection

molecular markers

• MSI (loss of function of mismatch repair genes, leads to DNA replication errors that are not remediated) - associated with sporadic colon cancer

Surgeries

• adeno - 5 cm proximal and distal margins
• adjuvant chemo for high-risk stage 2 and stage 3 CRC

Surveillance

near obstructing colon cancer - lesion could not be traversed –> colectomy

• next colonoscopy 6 mo post-op (because proximal colon could not be examined) –> 3 yrs –> 5 yrs
• if colon was entirely surveyed - next colonoscopy at 1 yr –> 3 yrs –> 5 yrs

elevated CEA s/p colectomy

• solitary liver met - imaging alone is sufficient for dx for metastatic dz without bx
  
  • for pts with isolated hepatic mets, established locoregional control, and good overall oncologic prognosis - resection with negative margin and systemic chemo
  • consider 5FU for pts with unresectable mets confined to liver
• higher CEA levels are associated with lower incidence of successful resection

metastatic dz - no further resection

Question 55

ob miscellaneous

Answer 55

fundus at umbilicus = 20 wks, add 1 cm for each week

• measurement of biparietal diameter can provide accurate estimation of fetal age

trauma to pregnant woman

• O2 requirement increased and FRC decreased in pregnant lady - always consider intubation (regardless of GCS) when they come in as trauma
• get CT to evaluate injuries

perimortem c-section - emergent c-section should not be performed more than 20 min after maternal arrest because fetal distress precedes maternal sxs (ideally perform section wi 4 min of arrest)

• perimortem c-section should be considered for any moribund pregnant woman of more than 24 wks gestation (viability)

C-section

• abx - IV ancef + azithro –> RCT showed redcution in endometritis, wound infection, or other infection

malignant germ cell tumor- typically TAH w BSO, pelvic and para-aortic LND, pelvic washings, omentectomy, cytology of diaphragm

• fertility-sparing surgery - unilateral SO, LND, pelvic washings

Question 56

bladder injury

Answer 56

repair dictated by size of defect

• minimal defects in bladder dome <2 mm injury - expectant management
• small defects < 1 cm injury - op repair or place foley for 10-14d with confirmatory cystogram
  
  • if no extrav of contrast - defect has sealed and foley can be removed
  • if extrav, keep foley in place - 25% of pts will have delayed healing or require surgical intervention
• all other defects - 2 layer closure (simple running 3-0 absorbable, followed by running imbricating 2-0 or 3-0 absorbable surture)
  
  • test repair by instilling methylene blue of sterile milk into foley

Question 57

SBP

Answer 57

orgs - pneumococcus or gram-negative enterics (S pneumo)

Question 58

NEC

Answer 58

px - abdominal distention, ileus, pneumatosis with distal intraluminal gas

tx - medical management (decompression, bowel rest, BSAbx) –> operative intervention (NECSTEPS trial showed that peritoneal drainage and laparotomy have equivalent outcomes in terms of mortality, LOS, an TPN dependence)

• operation = bowel resection + diverting ileal stoma
  
  • get barium enema or mucus fistulogram prior to restoring intestinal continuity (tells if additional resection will be required)f

70-80% of post-NEC strictures occur in the colon

• SI strictures can occur but are much less likely than colonic stricures (10-40%)

Question 59

intussusception

Answer 59

children

• px - feeding intolerance, non-bilious emesis, bloody stool
• lead points - *hypertrophic lymphoid patches, Meckel’s, polyps, intestinal duplication, appendiceal stump/mucocele, abd trauma, tumors
• dx - US
• tx for sx ileocolic intussusception - air enema
  
  • of note - SB-SB intussusception is often noted incidentally (no tx required if asx)
  • observe in ED, po challenge, then d/c (recurrent intussusception occurs in 10% of pts, 1/2 occurs in first 48hrs, return precautions advised)

adults - 95% d/t cancer (clinically seen lipoma)

Question 60

renal injury

Answer 60

Grades

1. contusion/hematoma: no parenchymal lac
2. hematoma/lac: <1cm parenchymal depth of renal cortex, no urinary extrav
3. lac: >1cm parenchymal depth of cortex, no injury to collecting system, no urinary extrav
4. lac: through cortex, medulla, and collecting system; vascular hemorrhage with contained hemorrhage
5. lac vascular: shattered kidney, avulsion of renal hilum and devascularization of kidney

• stable pt with grade 3 or lower renal lacs (regardless of mechanism of injury) - non-operative management
• grade 4-5 lacs or clinical complication (decreased uop, rising Cr, ongoing blood loss, abd distention, ileus) - follow-up imaging

occlusion of renal artery wiith normal contralateral kidney - observe

• revascularized kidneys have functioned well only 20% of the time

Question 61

SIRS

Answer 61

T >38 or <36

HR > 90

RR >20 or PaCO <32

WBC > 12 or <4

SIRS - 2 criteria

Sepsis - SIRS plus presumed infection

Severe sepsis - sepsis plus end-organ dysfunction

Septic shock - sepsis plus refractory hypotension

Multi-system organ failure - 2+ organs failing

sepsis - BSAbx (within 1 hr of recognition of sepsis), drainage of drainable fluid collections

• 30 cc/kg over the first 3 hrs –> then vasopressor (norepi) –> steroids for refractory HTN
• sodium bicarb for pH < 7.15
• restricting fluid restriction after source control and administration of BSAbx improves outcomes
• 2012 Surviving sepsis campaign - use low dose hydrocortisone (200mg in divided doses qd for 5-7d or for at least 24hrs after cessation of vasopressors) for pts who are refractory to fluid resuscitation and vasopressor therapy
  
  • septic shock - does not respond to pressors (because of upregulation of iNOS or NOS2 in vessel wall, produces large quantities of NO for sustained periods of time)
• decreased mixed venous O2 sat - indicates lack of adequate tissue perfusion

Question 62

arteritis

Answer 62

Takayasu arteritis - large-vessel vasculitis, stenoses form gradually so collaterals are present

• three phases: 1) acute inflammatory phase, 2) vessel inflammation w vessel pain, 3) burned out phase (vessel fibrosis or aneurysm formation)
  
  • initial tx - immunosuppressive tx (steroids)
• surgery indications - lifestyle-limiting extremity ischemia, HTN in setting of RAS, cerbral ischemia, greater than 70% symptomatic stenosis of the cerebral vessels, mod-severe aortic regurg, severe aortic coarctation, progressive aneurysmal enlargement/dissections
• open treatment is first line
  
  • pts should be followed - they are likely to require revisions or develop symptomatic lesions in other vascular beds
  • endovascular tx have low success (possibly due to poorly complaint vessels)…but PTA (percutaneous transluminal angioplasty) has shown success in RAS secondary to Takayasu

Question 63

aneurysm

Answer 63

iliac arterial system - repair > 3cm (for hypogastric…)

• choose covered, self-expandable stents to allow good apposition bw stent and iliac vessel wall
• to prevent stent from jutting into lumen, need 15mm landing zone

splenic artery aneurysm - all should be followed for growth

• repair indicated for female of childbearing age (any size) - if pt were to become pregnant, she would be at increased risk for rupture

SMA aneurysm (fellowship level)f - most common cause is infection (IVDA)

Question 64

pre-op risk/testing

Answer 64

ASA>3 good predictor of cardiac risk (some institutions require EKG in pts over age 50, but data does not support this practice)

hold ACEi morning of surgery - to avoid hypotension with anesthesia

H&H for thoracic/cardiac/procedures with sig blood loss (also in pts with major organ dysfunction or known anemia)

Question 65

esophagectomy

Answer 65

esophageal conduit - place in L posterior mediastinum

• substernal placement is technically easier - but less desirable d/t risk of herniation into chest and kinking of conduit, also higher incidence of colonic conduit redundancy many years post-op

LNs that should be taken are subcarinal, lower esophagus, celiac axis, diaphragmatic crux

• difficult to take subcarinal LNs with transhiatal approach
  
  • if remainder of nodes are negative (?) –> f/u CT in 6 mo after operation, then annually

Question 66

anti-coag/anti-plt

Answer 66

hold meds

• Warfarin - hold for 5d pre-op, check INR pre-procedure
• plavix - hold for 7d
• DOACs - hold day of surgery (2 day washout?)
• continue meds for pts with more than 10% annual risk of thromboembolic event

for pts on dual antiplt - continue ASA, stop plavix

PCC faster than FFP

warfarin - good for pts with renal failure

VW disease - low factor 8 and plts are unable to adhere to vessel wall

Question 67

rhabdo

Answer 67

serum CK > 50K, dark urine w/ no RBCs

tx - increaing uop (>100 ml/hr, hydration, diuresis), alkalinization of urine pH (to greater 6.5) to prevent myoglobin from precipitating within renal tubules

Question 68

gastric injury

Answer 68

w/ intra-peritoneal hemorrhage - greater curvature of stomach

injury of GEJ - extend myotomy, close in 2 layers, use fundus as anterior fundoplication butress, GJ tube, abx (+ antifungals), NPO until UGI in 7-10d

• extend myotomy because mucosal injury is greater than muscularis injury

Question 69

spleen

Answer 69

SPLEEN anatomy- short gastrics and splenics are end arteries

function - 85% red pulp (filter for damaged RBCs), 15% white pulp (antigen processing center), reservoir for plts

hypersplenism - hypotension, abd tenderness, splenomegaly

splenectomy - if greater than 1/3 the spleen remains, no clinically significant loss of function is evident

• try to perform after age 5 - so children have time to form antibodies
• risk of post-splenectomy sepsis is greatest in pts with underlying hematologic conditions - higher in children than adults (<15, but mostly <5)
• overwhelming post-splenectomy infection - URI quickly followed by sepsis, can develop years after splenectomy
• children < 10 yo should be given ppx abx for 6 mo (daily augmentin)
• most common post-splenectomy changes - increased RBCs, WBCs, and plts
  
  • if plts are >1 mil - give ASA

ITP - most common nontraumatic condition requiring splenectomy, tx is splenectomy

• cause - anti-plt antibodies
• tx - 1) steroids, 2) gammaglobulin, 3) splenectomy for pts >10 who fails steroids (children < 10 have spontaneous resolution of dz)
• pt px with TCP following splenectomy - get radionucleotide scan to identify accessory spleen (most commonly found in splenic hilum, after that splenic vascular pedicle and greater omentum) and blood smear to look for Howell-Jolly bodies (indicates functional asplenia, spleen normally removes nuclear remnants aka Howell-Jolly bodies )
• vs TTP - loss of plt inhibition –> thrombosis –> TCP
  
  • tx is plasmapheresis, splenectomy is rarely indicated, death is most commonly due to intracerebral hemorrhage

sickle cell crisis - splenic sequestration can be life-threatening (and risk of recurrent sequestration is ~65%)

• allow child to recover from sequestration event, receive appropriate immuniziations, then elective splenectomy
• additionally - indications for splenectomty include sequestration crises, symptomatic/massive infarct, and abscesses
• usually with sickle cell however, spleen autoinfarcts - splenectomy is not required

vEDS - characterized by medium-sized arteriopathy

• rupture and bleeding from “end” arteries are ideal anatomic circumstances for embolization - pt with vEDS presents with ruptured splenic artery aneurysm with abd pain and hypotension –> transfemoral coil embolization
  
  • laparotomy and vascular reconstruction may be to aggressive in vEDS - pts have fragile tissues (risk of tissue injury, bowel tears, and mesenteric hematomas)

pancreatitis - most common cause of splenic artery or vein thrombosis

abscess - splenectomy (bleeding risk with percutaneous drainage)

tumors - hemangioma is 1 tumor overall, non-hodgkins lymphoma is 1 maligannat splenic tumor (splenomegaly, tx is chemo), angiosarcoma is 1 malignant non-blood cell splenic tumor

splenic injury

1. lac < 1cm deep, subcapsular hematoma < 1cm diameter
2. lac 1-3cm, subcapsular/central hematoma 1-3cm
3. lac 3-10cm, subcapsular/central hematoma 3-10cm
4. lac >10cm, subcapsular/central hematoma >10cm
5. splenic tissue maceration or devascularization

Question 70

infusaport (portacath)

Answer 70

infusaport/portacath is different from CVC

• most common complication from CVCs is infection - most common source of infection is from surrounding skin (barrier precatuiosn should be used prior to placement)
• lower risk of infection with infusaport because intact skin covers the catheter

Question 71

thoracic artery aneurysm

Answer 71

LCC and LSC arteries - L vagus and phrenic nerves are located here

LSC vein - thoracic duct and L phrenic nerve

Question 72

EC fistula

Answer 72

usu result of prior operative intervention c/b anastomotic leak or inadvertent enterotomies

• other causes - IBD, radiation enteritis, malignancy
• locations - stomach, SI, colon, rectum

low outptut < 200 cc/d, intermediate 200-500, high > 500

• low output are more likey to spontaneously close than high-output
  
  • other features that suggest closure - free distal flow, heatlhy surrounding bowel, tracts greater than 2cm, enteral defects less than 1 cm (w no discontinuity)

if fistula remains open for 6-8 wks - surgical intervention will be necessary

Question 73

epididymitis

Answer 73

d/t STI or bacterial infection

tx

• yonger than 35yo and sexual active - IM CTX and oral azithromycin (tx for GC)

Question 74

lap/robotic surgeries

Answer 74

pneumoperitoneum - CO2 insufflation - decreased venous return –> decrease in preload and SV (and CO) –> associated increase in SVR

capnothorax (from hiatus or diaphragmatic defect) - will resolve quickly after desufflation (d/t soluble nature of CO2 and rapid absorption into systemt circulation

• ptx - insufflation can lead to increased airway pressures –> barotrauma –> bronchopleural fistula

Question 75

crich

Answer 75

incise skin and cricothyroid membrane –> place Trousseau dilator –> insert tracheostomy tube –> remove obturator, insert inner cannula

Question 76

penetrating chest injury

Answer 76

chest tube - 4/5 space, anterior axillary line (to avoid injury to long thoracic)

large airleak, hemoptysis, and extensive subcutaneous emphysema - c/f tracheobronchial injury –> bronchoscopy

• if pt had > 1500 cc bloody output immediately or > 300 cc/h for 3 hrs –> thoracotomy

diaphragm injury - laparotomy and primary tension-free repair with monofilament non-absorbable suture (polypropylene)

• laparotomy - bc that is the only way to survey intra-abdominal organs w/o making another incision
• if defect is large - mesh may be required (avoid synthetic in the setting of peritoneal contamination, place biologic mesh on pleural side to prevent adhesions)

Question 77

fascial dehiscence

Answer 77

start BSAbx

Question 78

hidradenitis suppurativa

Answer 78

path - follicular hyperkeratosis, plugging, and dilation + lymphocytic perifolliculitis

Question 79

risk of in-hospital adverse events?

Answer 79

10%

Question 80

hepatorenal syndrome

Answer 80

d/t vasodilation of splanchnic circulation (caused by portal HTN and production of NO)

• CO increases as SVR and MAP decrease, despite efforts of renal vasoconstriction and RAAS activation
• peripheral SVR increases but splanchnic circulation remains dilated
• end effect is decreased renal perfusion –> decreaed GFR
• tx - vasopressing/terlipressing to decrease splanchnic vasodilation
  
  • clonidine can be used to reduce sympathetic tone of renal artery and increase GFR

type 1 - acute renal injury in the presence of oliguria and liver failure

• 2 fold increase in Cr to above 2.5 in < 2wks w oliguria
• more severe type
• more likely to lead to death

Question 81

ventilators

Answer 81

VAP bundle - bed elevation, SBTs, daily sedation breaks, oral care

• early VAP - S aureus, H influenza, S pneumo (d/t aspiration)
• late VAP - P aeruginosa, Acinetobacter (MDR)

Question 82

aortic dissections

Answer 82

Type A - from aortic root, more dangerous

Type B - distal to LSC artery

• most common anatomy is for L renal to come off false lumen and for R renal to original from true lumen

Question 83

choledochal cysts

Answer 83

*fusiform* spindle shaped, tapering at both ends

1a - saccular dilation of distal choledochus (85% of cases)

• 1b - saccular dilation of common hepatic duct and choledochus
• 1c - fusifrom dilation of common hepatic duct and choledochus

2 - extrahepatic supraduodenal diverticulum (normal GB and CHD)

3 - intraduodenal diverticulum, choledochocele

*************************************************************************************

4a - fusiform dilation of extra-hepatic duct and intrahepatic cysts

• 4b - multiple extrahepatic cysts

5 - multiple intrahepatic cysts (Caroli’s disease when associated with hepatic fibrosis)

*4 and 5 - partial liver resection or liver txp

caused by abnormal reflux of pancreatic enzymes during uterine development

• female, Asians
• px - episodic pain, fever, jaundice, cholangitis in elderly; biliary atresia sxs in children

Reason to excise - b/c pts are at 1000x increased risk fo biliary tract carcinoma

• d/t stasis, chronic inflammation, and dysplastic cyst epithelium
• operation - cyst excision + chole with hepaticoJ
• risks of excision - biliary leak, anastomotic stricture, cholangitis
  
  • outcomes comparable in lap and open cases

Question 84

MEN syndromes

Answer 84

MEN1 - 3Ps, pituitary lesions (prolactinoma), *parathyroid hyperplasia, pancreatic lesions (gastrinoma)

MENIN

• to evaluate for gastrinoma - pt should be off PPIs
• parathryoid adenoma - 3.5 gland resection (these pts have a defect in all their cells, all glands have propensity for hyperplasia), b/l thymectomy (b/c these pts have a greater incidence of supernumerary/ectopic glands as well as thymic carcinoids)

MEN2A - parathyroid hyperplasia, medullary thyroid carcinoma, pheo

MEN2B - mucosal neuromas, marfan body habitus, medullary thyroid ca, pheo

RET

• medullary thyroid ca (100% prevalance in MEN2a and b) - diarrhea is the most common sx
• plasma calcitonin
• adrenal masses - CT –> FDG-DOPA if still not visualized
  
  • pheos end up being benign
  • adrenalectomy prior to total thyroidectomyectomy w central neck dissection and 4-gland parathyroidectomy with autotransplantation
  • at risk for synchronous or metachronous b/l adrenal pheos
    
    • for pt who develops contralateral recurrence after total adrenalectomy - perform partial adrenalectomy (laparoscopically)

RET proto-oncogene mutation (of the highest risk category) - total thyroidectomy recommended prior to age 1 or at time of diagnosis

• work-up - calcitonin and US, also test for pheo

Question 85

kid swallows a …

Answer 85

1 get KUB

coins - vast majority of coins will pass on their own - observe pt and then send home if no signs of obstruction

• if coin remains in stomach for more than 3-4 wks - remove endoscopically

batteries

• sx pts - emergent endoscopy and removal
  
  • use a flexible double-channel endoscope with esophageal overtube and forceps
    
    • double-channel - to pass instruments down scope
    • esophageal overtube to protect esophageal mucosa and upper airway when retrieving objects
    • forceps - to retrieve flat objects
• asx pts - repeat film after 48hrs, endoscopic removal in 10-14d (specific child age and battery size criteria, but just in general)

magnets - AP and lateral (b/c magnets can stack), single magnet can be observed, multiple must be extracted

• or adult* - who comes in with pain following ingestion of bony food (etc.) –> radiographs –> EGD if unable to localized anything on radiographs
• dont perform contrast study d/t aspiration risk and constrast coating of object and esophagus (can make EGD harder)

Question 86

C diff

Answer 86

causes - clinda

• rate of infection increases 3-fold if abx are continued for more than 24hrs post-op
• NOT always associated with abx use - esp in immunocompromised pts (with antiretroviral tx, C diff is not the most common species isolated in HIV pts)

tx

• po vanc is first line (125 mg q6 for 10-14d)
  
  • po flagyl only if vanc is not available
  • +/- cholestyramine (sometmes used as toxin binder)
• mild disease - contact precautions, stool studies, start abx after studies result
• fulminant disease - send tests, empiric tx with po vanc and IV metro

recurrent C diff

• if initial infection was treated with 10d po metronidazole - give 10d po vanc
• if initial infection ws treated with vanc - give pulse-tapered vanc or po fidaxomicin
• multiple recurrence - consider fectal transplant

surgery - open total abd colectomy w end ileostomy (high mortality rate, 50%)

• absolute operative indications - toxic megacolon (cecal diameter > 12 cm, colonic diameter > 6 cm), bowel perf, or peritonitis (high operative mortality, > 0%)
• relative indications - fulminant disease, failure of medical management, worsening clinical course

Question 87

ureteral injury

Answer 87

location - medial aspect of broad ligament

ureteral injury intra-op - lac and ligation are more immediately identified

• devascularization - presents as ureteral stricture mo after initial op
• thermal injury - post-op fistula
• traumatic injury (GSW) - tissue necrosis and disruption or distal remnant
  
  • injury to distal ureter - ureteroneocystostomy and psoas hitch (tension-free reapir)
  • ureteral ligation and delayed nephrostomy is better for unstable pts

tenets of repair - debride, tension free repair (<2-4cm length loss), close over stent, absorbable suture

Question 88

branchial anomalies

Answer 88

most branchial anomalies aris from the second cleft/pouch - px –> fistula, cysts, sinus tracts, cartilaginous remnants

• most common px in infants and young children - sinus tract draining along anterior border of SCM

Question 89

methemoglobinemia

Answer 89

Fe in hemoglobin becomes oxidized - unable to bind O2 –> central cyanosis and chocolate brown arterial blood

causes - benzocaine anesthetic (thats why you can see desaturation after intubation)

pulse ox is unreliable, have to diagnose with co-oximetery

tx - methylene blue

Question 90

rectus sheath hematoma

Answer 90

type 1 - confined wi rectus muscle, does not cross midline or dissect fascial planes

2 - confined wi rectus muscle, can dissect along transversalis fascial plane or cross midline (b/l hematomas)

3 - below arcuate line, blood in prevesical space of Retzius/hemoperitoneum

Question 91

stoma

Answer 91

placement - located within rectus muscle in 4-5cm area of healthy skin devoid of creases/bulges

• ostomy triangle useful in non-obese pts - ASIS, pubic tubercle, umbilicus
• in obese pts - place stoma above umbilicus

stomal necrosis

• emergent intervention NOT required if necrosis remains above level of fascia - will slough off on its own
  
  • d/t tension, congestion, or excessive traction or thinning of mesentery (not by mesenteric ischemia)

stoma stenosis - usu d/t ischemia, dilate if mild

Question 92

biopsies

Answer 92

biopsies on extremities should be done with longitudinal incisions in order to not compromise lymphatic drainage

• additionally, transverse incisions may necessitate a large defect after wide local excision

Question 93

atherosclerotic disease

Answer 93

ABI - 0.9-1.2 nl, 0.5-0.9 is claudication, < 0.5 is ischemic rest pain/tissue loss

occlusive atherosclerotic disease and claudication

• medical management of RFs, exercise tx, and trial of cilostazol
  
  • incidentally this is the same tx for asx thrombosed popliteal aneurysm - plus screening for other aneurysms and f/u serial ABIs
• severe claudication (walking disability, arterial lesion) - balloon angioplasty and stenting
  
  • pts with proximal arterial lesions (aortoiliac) can be considered for endovascular tx w/o undergoing medical tx
• goals of revascularization - inflow (can recanalize to obtain adequate inflow), outflow, conduit (preferrably GSV)

critical limb ischemia

• peroneal artery is most likely to remain patent in diabetics with vascular disease (located in deep compartments of leg)

Question 94

SCIP guidelines

Answer 94

single dose of ppx abx should be given 60 min prior to incision - note cefoxitin is appropriate for colorectal surgery

Question 95

compartment syndrome

Answer 95

sxs - pain with passive ROM (first), loss of pulses is late finding

causes - 1 reperfusion injury (usu > 6-8 hrs of ischemia), 2 fractures and crush injuries

• reperfusion - increased capillary permeability –> interstitial edema

dx - ICP > 30 or (MAP - ICP) < 40 or (DBP - ICP) < 10

tx

• calf - four compartment fasciotomies
  
  • anterior compartment most commonly affected - deep peroneal nerve (1st and 2nd websapce)
  • lateral fasciotomy incision - one finger in front of fibular, terminates 2-3 fingerbreadths above malleolus
  • superficial peroneal nerve lies between anterior and lateral compartments - prone to injury during fasciotomy –> loss of sensation to dorsum of foot (but deep peroneal sensation remains intact)
  • tibial nerve is between soleus and deep posterior compartment - can avoid damage by avoiding medial approach
  • sural nerve - runs behind the fibula

Question 96

deceleration injury

Answer 96

most commonly lead to proximal ureter or UPJ obstruction –> retrograde pyelogram and operative reconstruction

Question 97

liver mass

Answer 97

Cancer

RFs - alcoholic hepatitis, hep B and C, A1AT deficiency, excessive androgen use, hemochromatosis, aflatoxin or vinyl chloride

• px - elevated AFP

liver bx or not?

• absolute to PCT contraindications (recommend lap or open) - inability to cooperate with procedure and inability to identify adequate bx site
  
  • relative contraindications - cirrhosis, morbid obesity, intra-abdominal infection
• pt with hx of melanoma and now liver mass - get bx because melanoma commonly mets to LNs and subQ tissue (can also spread to lungs, viscera, brain, or liver but this is less common)
• alcoholic cirrhosis with elevated AFP and new liver mass - dx of HCC can be made by imaging alone with AFP is elevated

indications for transplant in HCC - single lesion 2-5cm OR 2-3 tumors <3cm each without evidence of microvascular invasion or extrahepatic disease

palliative options - transarterial chemoembolization

Other

• hemangioma (most common benign lesion) - peripheral nodular enhancement on arterial phase, centripetal fill-in on portal venous phase
• FNH (second most common) - benign, observe, does not require resection unless symptomatic
• hepatic adenoma - HRT
  
  • risk of rupture and malignant degeneration - esp if > 5cm in size
  • stop OCPs and re-image - if lesion persists, recommend resection
• liver fluke
  
  • can lead to chronic inflammation of bile ducts, stone formation, recurrent pyogenic cholangitis, and cholangiocarcinoma
• hydatid disease - Echinococcus granulosus, cyst w/ calcification and daughter cysts, start albendazole
  
  • cyst rupture can cuase anaphylaxis
  • surgical treatment (if it is required) - injection of HTS/alcohol sol to kill scoleces, then cyst aspiration
• pyogenic abscess - IV abx + drain –> if bigger abscess despite tx –> upsize drain and continue IV abx

Question 98

MELD

Answer 98

6-40

variables - Cr, Tbili, INR

prioritize which pts receive liver transplants first - higher MELD score is associated w higher mortality wo transplantation

• MELD < 15 is associated with mortality rate less than mortality rate of undergoing liver transplantation

Question 99

renovascular HTN

Answer 99

removal of atrophic kidneys (<2-3cm) in pts with renovascular HTN can lead to improved BP control and renal fx

for kidneys of normal size - aortorenal bypass with internal iliac artery graft

Question 100

blunt abdominal trauma

Answer 100

duodenal hematoma - NGT decompression (5d), TPN –> CT w po contrast/UGI to confirm resolution of obstruction

Chance fractures(seat belt bruising) -

Question 101

liver injury

Answer 101

grade 1 - lac (< 1cm depth), subcapsular hematoma (< 10% SA)

2 - lac (1-3cm), intraparenchymal hematoma (<10cm diameter), subcapsular hematoma (10-50% SA)

3 - lac (>3cm), intraparenchymal hematoma (>10 cm or active bleed wi parenchyma), contained active bleed, subcapsular hematoma (>50% SA), vascular injury

4 - parenchymal disruption (25-75% hepatic lobe disruption), active bleed extending into peritoneum

5 - parenchymal disruption (>75% hepatic lobe disruption), caval/central major hepatic vein injury

transection of R hepatic artery - ligate R hepatic artery (50% of O2 blood to R lobe of liver is supplied by R portal vein)

• also perform cholecystectomy if it is proximal R hepatic artery injury

Question 102

LE wounds

Answer 102

infected toe, non-palpable pulses, faint doppler signals - 1) amputate toe, 2) revascularization to allow amputation to heal

• in general: dry gangrene, uninfected ulceration - revascularize then amputate
• wet gangrene - amputate then revascularize

chronic wound longer than 3 mo - arrested in inflammatory stage of wound healing

amputation - palpable pulse one level above amputation predicts 100% healing rate

Question 103

meconium ileus

Answer 103

pts typically have microcolon on KUB

non-op management - gastrograffin enema (hyperosmolar, water-soluble) –> transient osmotic diarrhea and osmotic diuresis occur (aggressive fluid resuscitation is important)

• risks of non-op management - delay in operative intervention for those who fail enema, intestinal perf/injury

pt develops peritonitis - enterotomy with evacuation of bowel contents and placement of NGT

• significant bowe resection leaves child at risk for short gut syndrome

Question 104

head injury

Answer 104

tenets of management - avoidance of hypoxia and hypotension

step 1 - place ICP monitor in any pt with GCS < 8 and intracranial pathology

• mannitol - avoid in hypotensive pts
• hyperventilation - causes vasoconstriction and reduces ICP, but may be more hazardous early in pt’s course (when CBF may be depressed)

Question 105

ERAS

Answer 105

entereg (alvimopan) - opioid antagonist (peripherally acting), studies have shown that it decreases time to resumption of bowel function, has been approved by FDA for peri-op use after small or large bowel resections w p anastomosis

Question 106

nutrition

Answer 106

enteral vs TPN –> enteral nutrition - better substrate utilization, prevents gut mucosal atrophy, attenuates stress response, maintains immunocompetence, preserves gut flora, fewer infectious complications, less glucose intolerance

• contraindications - pressors

enteral nutrition should be initiated w/i 24-48hrs of admission in critically ill pt - studies have shown that this is associated with decreases in mortality and infectious morbidity

when to start TPN? - start immediately post-op in a pt malnourished pt

• wait 5-10d in well-nourished or midly nourished pt

RQ - CO2 production/O2 consumption (different depending on substrate), RQ > 1 indicates potenital overfeeding

• additionally, increased production of CO2 may contribute to difficulities with ventilation

Question 107

pancreatitis

Answer 107

acute pancreatitis

• infected necrotic pancreas - necrosectomy, irrigation, and wide drainage

gallstone pancreatitis - lap chole that admission (25% incidence of recurrent pancreatitis in pts whose chole is delayed even 2 wks after hospital dc)

• according to SCORE - no role for ERCP unless pt ongoing obstruction (elevated serum bili and choledocho is suspected)

pseudocyst - 50% of pts develop pseudocysts after episode of severe acute pancreatitis, 70% of pseudocysts will resolve spontaneoulsy

• asx - observe
• sx (persistent abd pain, inability to eat, N/V) or inability to exclude cystic neoplasm - procedure

Question 108

sigmoid volvulus

Answer 108

tx - colonoscopic decompression

Question 109

NM blockade

Answer 109

nondepolarizing agents (curonium/curium) - can be reversed, sugammadex is reversal for roc

• additionally can give cholinesterase inhibitor (neostigmine) to inc Ach in synapse and displace med

Question 110

spine/back

Answer 110

steroids are controversial in blunt spine trauma

inferior lumbar triangle (Petit) - iliac crest, lat dorsi, external oblique

Question 111

emesis in infant

Answer 111

Bilious

duodenal obstruction - duodenal atresia (corrective surgery is elective), duodenal stenosis (such as by preduodenal portal vein, however affected infants are not fussy), midgut volvulus

• duodenal atresia - get ECHO pre-op, ~20% of infants have CHD
  
  • tx until op - NPO, NGT, TPN

Non-bilious

hypertrophic pyloric stenosis - fluid resuscition at 1.25-2x maintenance rate, pyloromyotomy

• notice bile leak from pylorus during incision - close pylorus with 2-layer repair +/- coverage with omental patch and perform pyloromyotomy on posterior surface

Question 112

neuroblastoma

Answer 112

retroperitoneal mass w speckled calcifications in young child

• MYCN amplification (>10 copies) is associated with advanced disease, tumor progression, and is strongest predictor of poor outcome
• age < 18 mo is correlated with improved outcomes
• high TrkA expression is good prognostic indicator

4S neuroblastoma (7-10% of neuroblastoma), metastatic dz, infants - subQ mets (blue nodules), positive bone marrow (small round blue cells), and massive HSM (hepatic mets)

• majority of disease spontaneously regresses, overall survival > 90%
• palliative radiation for sx pts

Question 113

angiogram

Answer 113

vascular closure device

• bedrest encourage to achieve hemostasis after procedure
• complications - ALI
  
  • dissection during device deployment, use of intraluminal device, intraluminal thrombotic material used in device (collagen, hydrogel plug), plaque rupture

Question 114

acidosis

Answer 114

respiratory acidosis

• acute - each increase in PaCO2 above 40 results in 0.08 decrease in pH
• chronic - less decrement in pH d/t compensatory metabolic alkalosis

Question 115

chemo/rads

Answer 115

transarterial chemoembolization (TACE) - complication is tumor lysis syndrome (ischemic effect in tumor from embolic agents, massive acute necrosis of tumor)

systemic chemo - GI upset, neurotoxicity

Question 116

GU trauma

Answer 116

kick to scrotum - c/f testicular rupture –> surgical exploration, debridement, and repair

Question 117

condyloma

Answer 117

anal condyloma - evidence of HPV infection, further testing of cervix may be warranted

• tx - topical or excisional, for circumferential disease may require staged excision to reduce risk of anal stricture
  
  • fiser - laser surgery

Question 118

chylothorax

Answer 118

chyle - has high concentration of lymphocytes –> immune deficiency, is bacteriostatic (so rare rate of empyema in setting of chylothorax)

injury above T5-6 leads to L-sided chylothorax, injury below T5-6 leads to R-sided chylothorax

• s/p neck dissection - pt returns with pleural effusion - it is a chylothorax

tx - CT, ocreotide, TPN –> ligation of thoracic duct on R side (thoracic duct is on R, crosses at T4-5 and then dumps into LSC vein)

• malignant causes - talc pleurodesis +/- chemo rads

Question 119

peds abdomen

Answer 119

abdominal mass/increasing abdominal girth - mesenteric cyst, omental cyst

abdominal wall defects

• gastrochisis - intestines herniate through skin defect, atresia may be present too
  
  • omphalocele - bowel covered with peritoneum has herniated through skin defect (cele-d w/ peritoneum)
  • tx - placement of silo, closure of fascia/skin, sutureless closure
    
    • of note - pts will have a malro but will nto undergo Ladd procedure at initial repair
  • watch for abd compartment syndrome after repair - decreased uop, difficulty ventilating (respiratory acidosis, decreased cardiac output)
• get echo, cxr, chromosomal studies prior to surgery
  
  • also check blood glucose (defects are often associated with Beckwith-Wiedemann syndrome)

Question 120

monoclonal antibodies

Answer 120

*note - tumor antigens are self-antigens (but have potential to stimulate T cell response in the setting of tumor)

PDL-1 - nivolumab/pembrolizumab/atezolizumab can be used as adjuvant chemo

• expressed in melanoma, NSCLC, RCC, and urothelial carcinoma

CTLA-4 - ipilimumab, melanoma

CD20 - ritubximab, B cell leukemia, lymphoma, autoimmune RA (B-cell mediated)

infliximab - TNF blocker, immune diseases (RA, AS, IBD, psoriasis, hidradenitis suppurativa, refractory asthma

Question 121

cloaca

Answer 121

common channel connecting urethra, vagina, and rectum

• can have hydrocolpos - dilated vagina –> can obstruct distal ureters –> hydronephrosis - this is an indication for vaginostomy

Question 122

NIPPV

Answer 122

good for - COPD exacerbation, cardiogenic pulmonary edema, obesity hypoventilation, decompensated OSA, NM disease

• contraindications - depressed mental status, copious secretions and inability to protect airway, massive hemoptysis/hematemesis, recent UGI surgery or bowel obstruction, CPR, severe arrhythmias
  
  • clinically - no PPV with esophagectomies (more to protect conduit [risk of kinking] than to protect anastomosis)

Question 123

GCS

Answer 123

Eye opening - 4 spontaneous, 3 to voice, 2 to pain, 1 none

Verbal - 5 oriented speech, 4 confused conversation, 3 inappropriate speech (words), 2 incomprehensible sounds, 1 none

Motor - 6 following commands, 5 localizes to pain, 4 withdraws to pain, 3 flexor, 2 extensor, 1 none

Question 124

rectal cancer

Answer 124

TX

• rectal ca - neoadjuvant chemorads for stage 2 and stage 3 ca
• low rectal cancer and extensive metastatic disease - *systemic chemo* is a priority
  
  • APR associated with substantial peri-op M&M, should be deferred until disease control has been achieved
    
    • instead perform sigmoid loop colostomy –> chemo –> APR at later date?

candidates for transanal resection - T1 tumor, mobile tumor, less than 3 cm in size, < 30% circumgernce, margin clear (>3mm)/no lymphovascular invasion/no perineural invasion/no LAD, w/i 8 cm of anal verge, well-mod differentiated

• 1 cm resection margins

ileostomy reversal - get contrast enema to ensure anastomosis is intact and patent

Question 125

hernias

Answer 125

Reduction

• inguinal hernias - maneuver for success is applying adequate pressure on inguinal canal above external ring (most common failure during reduction is pushing sac over top of external ring)
  
  • indirect - most common​​
  • RFs - age, obesity, heavy lifting, increased intra-abd pressure (COPD, constipation, straining BPH, ascites, pregnancy, PD)
  • ​vas medial to cord structures
  • ilioinguinal nerve - loss of cremasteric reflex
  • female children - can have sliding inguinal hernias with fallopian tube (most common), ovary, or uterus present
    
    • open sac prior to high ligation (note - high ligation is the repair technique in children)
  • sliding hernias in men - cecum or sigmoid is most common
  • cord lipoma - remove
• femoral hernia - coopers ligament (periosteum, posterior), inguinal liagment (anterior), femoral vein (lateral), lacunar ligament (medial)
  
  • hernia will be medial to vein (NAVEL lat-med)
• obturator hernia (defect in obturator membrane) - difficult to dx, usu b/l, majority present with bowel obstruction
  
  • incise membrane if reduction is difficult
• umbilical hernia - delay repair until after 5yo

Repair

• child with incarcerated inguinal hernia - repair within 5d (regardless of childs age)
  
  • may miss direct hernia d/t swelling if you repair w/i 24hrs
  • risk for recurrent incarceration if you delay past 5d
• spigelian hernia - semilunar line, narrow neck, surgical repair
• Lichtenstein - mesh repair
• inlay repair - fascial defect isn’t closed, mesh is used to bridge dect, higher rate of reccurrence
• lap inguinal hernia repair
  
  • triangle of doom = inferior-lateral - vas (medially), spermatic vessels (laterally), peritoneal fold (inferiorly)
    
    • containes ext iliac artery/vein, deep circumflex iliac vein, genital branch of genitofemoral nerve, and femoral nerve
• most common early complication after hernia repair - urinary RT

Question 126

trachea

Answer 126

Tracheal surgery

• early complication - laryngeal edema –> reintubation, racemic epi, steroids
• late complication - granulation tissue

post-intubation stenosis - 1) serial dilation, 2) resection (bronchoscopic or surgical)

tracheo-esophageal fistula - usu d/t prolonged intubation

• place large-volume cuff ETT below fistula, may need decompressive G tube

Trach

tracheoinnominate fistula (<1% risk, mortality is >50%)

• acute vs chronic - 2 week mark
• RFs - neck radiation, low trach placement (avoid by keeping bw 2-3 tracheal ring), persistent neck extension, malnutrition, steroid use, (clinically, over-inflating cuff)
• sentinel bleed followed by massive hemorrhage
• management - intubate, finger pressure through tracheostomy (caudal and anterior), partial sternotomy and resection + ligate of involved segment of innominate artery with coverage of fistula are with muscle or tissue flap

Question 127

brain death

Answer 127

no confounding variables - T >36deg, BP > 90, no sedation or paralysis

Question 128

dyspepsia

Answer 128

pH monitoring will only detect 70% of reflux, bile reflux is highly associated with Barrett’s metaplasia

upper gastrointestinal study - location of GEJ, hiatal hernias, esophageal motility fluoroscopy, gastric morphology, and possible volvulus

dyspepsia - 1) trial of PPIs (escalating doses, 3-4 wks)

• if failure of PPIs - proceed to EGD w/ bx (r/o H pylori, bx from all 4 quadrants of ulcer margins)
  
  • other diagnostic tests include - pH probe (best test), manometry
• surgical tx - Nissen fundoplication - divide short gastrics, pull esophagus into abdomen, approximate crura, and wrap
  
  • Collis gastroplasty - to create neoesophagus
  • complications - injury to surrounding structures (spleen, diaphragm, esophagus, ptx)
  • most common cause of dysphagia after Nissen is = wrap too tight - resolves on own (CLD for 1 wk, can dilate after 1 wk)

uncomplicated PUD - sxs are abdominal pain and night pain

• ketoralac is the most potent NSAID
• misoprostol > lansoprazole in preventing EGD-proved gastric ulceration (but is less well tolerated)
• PPI, clarithromycin, and amoxicillin or flagyl for 2-3 mo of treatment on SCORE (2 weeks clinically?)
  
  • PPIs require acidic environment to work - so dont use with antacid or H2 blockers

duodenal ulcer - most common peptic ulcer (d/t increased acid production and decreased defenses)

• 90% of duodenal ulcers occur in the bulb
• bleeding duodenal ulcer - EGD –> IR –> GDA ligation
  
  • if pt is stable - vagotomy and pyloroplasty would also be indicated because pt has known PUD
• perforated duo ulcer - Graham patch repair
  
  • pts who are negative for H pylori or have failed medical tx in past should also have acid reducing procedure completed - vagotomy and pyloroplasty
• obstruction 2/2 duo ulcer - PPI and serial dilation
  
  • majority open up with conservative treatment otherwise –> antrectomy and truncal vagotomy (include ulcer if proximal to ampulla of Vater), bx to r/o cancer
• if pt has been on PPI, need acid reducing procedure
  
  • proximal vagotomy - lowest rate of complications, higher recurrence rate (10-15% ulcer recurrence)
  • truncal vagotomy and pyloroplasty
  • truncal vagotomy and antrectomy - lowest rate of ucler recurrence, highest rate of mortality (2%)
    
    • reconstruction with RNY gastroJ (less dumping syndrome and alkaline reflux gastritis compared to Bilroth1 or 2)

gastric ulcer

• RFs - male, tobacco, EtOH, NSAIDs, *H pylori*, uremia, stress, steroids, chemo
• type 1 (most common) - lesser curve at level of incisura (d/t decrased mucosal protection)
• 2 - body and duo (d/t increased gastric acid)
• 3 - prepyloric area - again d/t high gastric acid
• 4 - high on lesser curve - d/t decreased mucosal protection
• 5 - anywhere, associated with NSAIDs
• tx - PPI and H pylori tx
  
  • truncal vagotomy and antrectomy - includ ulcer in resection (extended antrectomy) or separate ulcer excision (high risk of gastric cancer)

stress gastritis - occurs 3-10 after physiologic stress event, appear in fundus, tx w PPI

• vs chronic gastritis - pernicious anemia, autoimmune disease, H pylori, again tx w PPI

Other surgeries

• bilroth 2 aka loop gastroenterostomy (antecolic or retrocolic) - antecolic bilroth 2 recontructions with long afferent limb (> 30cm) are associted w blind loop syndrome (diarrhea, nausea, bloating after meals)

Question 129

nutcracker syndrome (fellowship level)

Answer 129

compression of L renal vein (by SMA, etc.)

• highly suspicious features - hematuria + L flank pain
• related features - dysmenorrhea, dysuria, varices (vulvar, scrotal, LE, gluteal)
• proximal:distal renal velocity ratio > 5 is suggestive of NCS
  
  • renocaval gradients are variable - d/t decompression from collaterals, but gradient over 3 mm Hg c/w L renal vein HTN
• tx - L renal vein transposition

Question 130

alcoholic

Answer 130

rectal varices - IMV –> middle rectal veins –> internal iliac veins –> systemic circulation

• manage portal HTN

pt w alcoholic cirrhosis w new onset ascites and umbo hernia, px with ooze of clear odorless fluid from hernia - tx with bedrest, IVabx, aggresive medical diuresis (and sodium and fluid restriction), and hernia repair during this admission

• umbilical hernia repair in cirrhotics with uncontrolled ascites is associated with high M&M
• if emergent operation required (true rupture) or diuretic tx fails to control ascites –> umbilical herniorraphy with PV shunt

Question 131

benign anorectal disease

hemorrhoids

fissures

abscess, pilonidal cyst

fistulas

fecal incontinence, constipation

Answer 131

hemorrhoids

• thrombosed external hemorrhoid - lance open (> 72hrs), elliptical excision (<72hrs) to relieve pain
• internal hemorrhoids
  
  • for grade 1 and 2 - rubber band ligation for pts who are not on blood thinners and dont have bleeding disorders
  • surgery for grade 3-4 - 3 quadrant resection, resect down to internal anal sphincter
    
    • post-op - sitz baths, stool softners/fiber/fluids
    • most common complication of hemorrhoidectomy - URT (d/t fluid overload, anesthetic to anterior perineum)

anal fissure - d/t high resting anal sphincter pressure

• px - pain after bowel movements, 90% in post midline, sentinel pile for chronic ones
• tx
  
  • diltiazem ointment and fiber - dilt is better tolerated than topical nitrates (can cause headaches)
  • lateral internal sphincterotomy - <5% risk of incontinence to stool (actually most common sx is incontinence to flatus)
    
    • NO surgery in IBD

anorectal abscess - most can be drained through skin, supralevator abscess need to be drained transrectally

• intersphincter and ischiorectal abscesses can present as horseshoe abscesses
• r/o anal cancer

pilonidal cysts

• management - hair removal and cleansing of pits (may require curettage) –> disease can disappear or become asymptomatic
  
  • fibrin products can be used to close pits
  • surgical excision - can have high morbidity (worse than dealing with recurrent episodes)
    
    • excision and primary wound closure OFF midline - midline closure has extremely high failure rate, AVOID

fistulas

• dont need to excise tract but…
• tx
  
  • lower 1/3 of external anal sphincter - drainaing seton +/- fistulotomy
  • upper 2/3 of external anal sphincter - draining seton (rectal advancement flap if that fails)
    
    • no fistulotomy b/c of risk of incontinence
• rectovaginal fistual
  
  • low is d/t obstectric trauma - most close spontaneously, otherwise use rectal mucosa advancement flap
  • high is d/t diverticulitis - abdominal/perineal closure approach, temp ileostomy

fecal incontinence

• neurogenic - in general no good tx but 1) medical tx (fiber) –> 2) endoanal US
• sphincter defect found - overlapping sphincteroplasty (efficiacy decreases with time), other option is sacral nerve stimulation
• note - defecaography is used to assess the amount of descent in the pelvic floor (useful for prolapse or consitpation, NOT fecal incontinence)

constipation

• 1) diet modifications, fiber
• 2) sitzmarker study, fMRI/defecography - if abnormal, refer for PT/biofeedback (retrains pelvic floor to relax properly)

reduction

• 1) reduction in immediate period - gentle steady pressure (adjuncts include table sugar, perianal msucle paralysis, general anesthesia for relaxation)
  
  • medical tx - high fiber diet
• 2) surgical tx is gold standard - sigmoidectomy with suture rectopexy (note: best to reduce rectal prolapse to allow edema to decrease)
  
  • pts usu have redundant sigmoid
  • other options - Altemeier (perineal rectosigmoidectomy) and Delorme (perineal muscosal/muscular plication) are for pts who cant tolerate abdominal procedure, also ahve higher recurrence rates (30-50% recurrence)
  • any tx for incontinence should be withheld until 1 year after the procedure - incontience will resolve w/i 1 year of correcting rectal prolapse

Question 132

esophageal cancer

Answer 132

Barrett’s esophagus - squamous to columnar metaplasia –> adenocarcinoma

• uncomplicated - treat like GERD - PPI or Nissen and annual surveillance (note that ca risk is not reversed following PPI or Nissen)
• high grade dysplasia - esophagectomy or close EGD surveillane (q3mo), same principles for squamous cell CIS, etc.

tumors are almost always malignant, early invasion of nodes

• sxs - dysphagia, weight loss –> esophagram, CT CA to evaluate for resectability
  
  • non-resectable - hoarseness, Horner’s syndrome, phrenic nerve invasion, malignant pleural effusion, malignant fistula, invasion of other structure, nodal dz outside area of resection (supraclavicular, celiac nodes)
    
    • malignant fistula - most die w/i 3 mo d/t aspiration, tx is esophageal stent for palliation
• RFs - ETOH, tobacco, achalasia, caustic injury, nitrosamines
• most common is adeno –> mets to liver
  
  • squamous –> mets to lung
• staging
  
  • T1 - invasion into LP, muscularis mucosa, or submucosa
  • T2 - invasion into muscularis propria
  • T3 - invasion into adventitia
  • T4 - invasion into adjacent structure
  • N… - most important prognostic factor is nodal mets (for pts who dont have stage 4 dz)
  • pre-op chemo-XRT for T2 or greater tumors
• surgery - 6-8 cm margins
  
  • R gastroepiploic artery - p. blood supply to stomach after replacing esophagus (because you have to divide L gastrics and short gastrics in process)
  • post-op strictures - can be dilated
• post-op chemo for node-pos disease

Benign tumors

• leiomyoma - esophagram, endoscopic US, CT to r/o cancer
  
  • dont bx - can form scar and make subsequent resection difficult
  • for >5cm or sx - extra-mucosal enucleation via thoractomy
• polyps

Question 133

stomach injury

Answer 133

1 contusion/hematoma, partial thickness lac

2 lac in GED or pylorus < 2cm, in proximal stomach < 5cm, in distal 2/3 stomach < 10 cm

3 greater than #s above

4 tissue loss or devascularization

*advance one grade for multiple lesions up to grade 3

Question 134

access

Answer 134

a-line - MAP will be reliable regardless of factors which may affect pulse pressure (…MAP = CO*SVR + CVP)

• overdampened sx - partial thrombus/air bubbles/kinking - decreased SBP, increased DBP
• underdampened - long tubing - increased SBP, decreased DBP

CVC –> SVC syndrome - remove catheter and 1) PCT transluminal dilation or stent placement, 2) emergency surgical thrombectomy

• anatomy - azygos and hemiazygous (run along spine, give off intercostal veins) –> hemiazygous dumps into azygous –> azgyos into SVC
• IJ and innominate into SVC

peripheral vein suppurative thrombophlebitis - orgs are S. aureus, enterobacteria, streptococci

Question 135

wounds

Answer 135

closure

• ok to close facial wounds < 24hrs - use suture (no staples in cosmetic areas)

infection

• mild - skin and subQ, < 2cm of surrounding erythema, most commonly GPC
• mod - to tendon and bone, more than 2cm erythema, +/- abscess
• severe - SIRS, sepsis

brown recluse spider bite - papule, central necrosis, coagulation disorders

Question 136

stomach A&P

Answer 136

parietal cell - secretes IF

blood supply

• celiac trunk –> gastrics (lesser curvature) and gastroepiploics/short gastrics (greater curvature)
  
  • L gastroepiploic and short gastrics comes from splenic
  • R gastroepiploic is branch of GDA
  • R gastric is a branch of proper hepatic (after GDA takeoff)
• pylorus - GDA

vagus

• truncal vagotomy (division at level of esophagus) - increased emptying of solids
  
  • truncal vagatomy and pyloroplasty - decreased solid emptying
  • other effects of truncal vagatomy - decreased acid ouput (increased gastrin), decreased exocrine pancreas fx and bile flow, increased diarrhea (MMCs force bile into colon, tx cholestyramine and loperamide)
• proximal vagotomy (selective, preserves crows feet) - nromal emptying of solids
• both - increased liquid emptying??

gastric emptying

• rapid - d/t previous surgery (#1), ulcers
• DGE - DM, opiates, anti-cholingerics, hypothyroid

bezoar - trichobezoar (hair) –> EGD inadequate, gastrostomy and removal; phytobezoar (fiber, DM) –> EGD, diet changes

gastric voluvulus - usu in type 2 HH

• UGI - greater curvature of the stomach is superiorly displaced above level of GEJ
• Borchardt triad - epigastric pain, inability to vomit, inability to pass NGT –> OR
• tx - reduction and nissen

Question 137

HIT

Answer 137

autoantibody directed against hep-PF4 complexes –> switch to other anti-coag - d/t 1) risk of thrombosis from HIT and 2) indications after index operation

Question 138

intestinal anatomy

Answer 138

mucosa (epithelium, LP, muscularis mucosa) - submucosa - muscularis propria (circ, long) - serosa

• cystic pneumatosis intestinalis - submucosa (can be confused with fecal matter in LI)
• linear pneumatosis - muscularis and subserosa (outlines wall of SI)
• pneumatosis is a sign of compromised bowel (mesenteric ischemia, closed loop obstruction)

blood supply

• duo - pancreaticoduodenals (superior from GDA, inf from SMA)
• IMA - supplies collaterals to small bowel
  • ligated during sigmoid colon resection…

hormones

• gastrin (G cells, antrum) –> acts on parietal cells and chief cells –> increased HCl, IF, and pepsinogen secretion
• somatostatin (D cells, antrum) - great inhibitor
• CCK (duo) - GB contraction + relaxation of sphincter of Oddi, increased pancreatic enzyme secretion
• secretin (duo) - pancreatic bicarb release
• VIP - intestinal secretion

bowel recovery - small bowel 24hrs (will persistals in bucket), stomach 48hrs, large bowel 3-5d

size - SB/tranvserse colon/cecum - 3/6/9cm

Question 139

scar

Answer 139

keloid - disorganized type 1 and 3 collagen

hypertrophic scar - type 3 scars, within boundaries of original wound, regress spontaneously

Question 140

bowel obstruction

Answer 140

SBO - 1) adhesions, 2) hernia (in US)

• proximal small bowel - intermittent, colicky, large volume emesis (which relieves pain), epigastric/periumbilical pain, - distention, -/+ obstipation
• distal small bowel - intermittent-constant, not as much emesis, diffuse and progressive abd pain, + distention, + obstipation
• closed loop small bowel - rapidly worsening, + vomiting, diffuse and progressive abd pain, - distention, +/- obstipation
• 10-30% of SBOs require operative management
• when dx of adhesive SBO is certain - attempt SBFT followed by serial exams (according to SCORE)

LBO - cancer

• continuous pain, diffuse on exam, + distention, + obstipation

malignant bowel obstruction - octreotide significantly decreased N/V in pts (octreotide slows down secretions)

Question 141

Meckel diverticulum

Answer 141

pathophys - vitelline duct/omphalomesenteric duct (connects yolk sac to midgut), normally obliterates during 9th week of gestation

• when this fails - pts can have narrowing of ileum and Meckels

RFs associated with symptomic px - M, aage < 50, diverticulum length > 2cm, *ectopic gastric tissue*

Question 142

soft tissue tumors

Answer 142

soft tissue sarcomas generally do not spread to LNs

• those that do are - rhabdomyosarcoma, epitheloid sarcoma, clear cell sarcoma, synovial sarcoma, and vascular sarcoma

granular cell myoblastoma - Schwann cell origin, benign lesions that have been described in all body organs (1 skin/subQ, 2 digestive tract)

• generally asx, but can have bleeding or local discomfort
• tumor found in colon/rectum - 1) endoscopic resection –> 2) transabdominal resection if endoscopic resction is unsuccessful
• recurrence is unusual, even in the case of positive margins - close observation after resection is appropriate

Question 143

NSTI

Answer 143

usu polymicrobial - mero/zosyn + vanc

tx - ICU admission, 24hr takebacks

c/f NSTI after surgery - murky drainage –> OR for wound exploration

Question 144

cancer syndromes

Answer 144

Li Fraumeni (p53, TS) - variety of ca, breast, sarcomas, brain tumors, leukemia, adrenocortical ca

Cowden (PTEN) - breast, mucocutaneous lesions, thyroid, endometrial ca

Ataxia telangiectasia (ATM mutation) - brast, cerebellar and NM deterioration, lymphoma, leukemia

Muir-Torre syndrome (MLH1 and MSH2) - skin tumors, GI, GU tumors

Question 145

laryngoscopy

Answer 145

grade 1 - full view of glottis

2 - partial view of glottis

grade 3 - only epiglottis, no glottis

grade 4 - neigther glottis or epiglottis

Question 146

diaphragmatic hernia

Answer 146

repair of congenital diaphragmatic hernia on ECMO may be best approach (controversial) - BUT associated with increased bleeding

• strategies to limit bleeding - minimize anticoag (and lower ACT, PTT targets), initiate aminocaproic acid pre-intra-post op, …

Question 147

cardiac trauma/major vessel

Answer 147

cardiac injury - d/t direct transmission of force to the heart

• pt hemodynamically unstable with normal GCS and pericardial fluid on FAST - OR for median sternotomy and pericardial decompression
  
  • resusciative ED thoracotomy - severe hypotension, impending/witnessed arrest, high likelihood for correctable intrathoracic injury

penetrating trauma to heart - will affect RV, because that is most anterior

• signs of pericardial tamponade - RA collapse occurs before RV collapse, biatrial collapse increases S&S that cardiac tamponade is present

aortic injury - signs include widened mediastinum, apical cap, loss of aortic knob, depression of L mainstem bronchus, fractures of first rib and sternal fracture, tracheal/esophageal deviation to R, L HTX

Question 148

skin cancer

Answer 148

basal cell carcinoma - more common in general pop (note SCC is more common in s/p transplant)

melanoma

• ABCDE - diameter > 6mm
• excisional bx - w 2mm margins
• tx
  
  • WLE + SLNBx for lesion with clinically negative nodes
  • palpable node - FNA to confirm that it is melanoma –> therapeutic LND or neoadjuvant tx + imaging to r/o metastatic dz

squamous cell carcinoma

• can develop from actinic keratosis

Question 149

anaphylaxis

Answer 149

0.3 mg (1:1000) IM epi, 0.5 mg IV epi (1:10,000)

of note - 1 mg epi given for cardiac arrest

Question 150

cardiac arrest

Answer 150

CPR should be continued for 20-25 min before pt is pronounced dead

non-shockable rhythms - PEA, asystole; shockable - vfib and pulseless vtach

criteria for resuscitative thoracotomy? ***

Question 151

retroperitoneum

Answer 151

zone 1 - central/midline

zone 2 - perinephric space

• R renal vein injury in unstable pt - nephrectomy
  
  • there are no collateral veins for drainage on R (compared to L where ther are L gonadal and adrenal veins)

zone 3 - pelvic retroperitoneum

Question 152

serotonin syndrome

Answer 152

sx - akathesia, tachy, sweating, HTN, hyperthermia, clonic seizures

• severe cases - muscle rigidity, T > 40C, coma

meds - SSRIs (citalopram, etc), St. Johns wort, certain opioids are proserotonergic and can exacerbate the problem

Question 153

radiation enteritis

Answer 153

amifostine - radioprotectant, binds free radicals

meds during RXT - ACEI and statins are protective against radiation enteritis

radiation enteritis (GI upset) - 1) analgesics and anti-spasmodics, 2) surgery

Question 154

Krunkenberg tumor

Answer 154

primary is most often stomach (70% of cases) - remainder of sites are colon, appendix, breast

• spreads by retrograde lymphatic spread

mets to ovaries - usu b/l

Question 155

testicular mass

Answer 155

seminoma - favorable prognosis compared to non-seminoma

• metastatic disease is radiosenstive (not the case for other cancers)

non-seminoma - younger pts, subtypes include embryonal carcinoma, choriocarcinoma, yolk sac, and teratoma

• markers - AFP, bHCG, LDH
• of note - AFP should decline to adult levels (<10 ng/ml) by 8 mo of age

hydrocele - d/t patent processus vaginalis , less commonly reactive (in the setting of torsion, epididymitis, malignancy, torsion)

• tx - identify and ligate processus vaginalis

pts with CAH can develop hyperplastic nodules of adrenal tissue w/i testis - give glucocorticoid supplementation and mass will regress

Question 156

biliary atresia

Answer 156

etiology unknown

direct hyperbilirubinemia

Question 157

small bowel transplant

Answer 157

for pts in whom intestinal rehab attempts have failed and who are at risk for life-threatening complications of TPN - liver failure, limited central access

survival is good - 75% and 48% at 1 and 5 yrs

of note - short gut syndrome is 2m of SI (normally 6 m of SI)

Question 158

LE swelling

Answer 158

malignant melanoma - pelvic adenopathy, outflow obstruction

May-Thurner - L common iliac vein compressed by R common iliac artery

lymphedema tarda - lymphedema that occurs later in life (age > 35)

Question 159

ortho miscellaneous

Answer 159

felon - penetrating injury –> tender, pussed out fingertip

• abx + incision over pulp (risk for compartment syndrome)

paronychia - infection where skin and nail meet - elevate and remove nail bed, then incise preionychial groover with blade pointed away from nail bed

fracture - fracture w loss of distal pulses - step 1) fracture reduction (may restore arterial flow to extremity)

Question 160

electrolyte imbalances

Answer 160

hyponatremia - rapid correction can lead to CPM

• chronic alcoholics are at risk for hyponatremia

hypercalcemia - 90% from hyperparathyroidism or cancer (lytic lesions; PTHrP eg SCLA, breast ca)

• other causes - hyperthryoid, familial hypercalcemic hypocalciuria, immbolization, granulomatous dz, excess vitamin D, milk-alkali syndrome, thiazides
• hypercalcemic crisis (usu 2/2 another surgery in pts with hyperparathryoidism) - fluids, furosemide

hypocalcemia - give mag cl

Question 161

esophageal atresia

Answer 161

leak post-op - contained; manage expectantly with CT, NPO, and IV abx; most will seal in 1-2 wks

Question 162

thoracotomy

Answer 162

proximal L subclavian injury - anterior L thoracotomy (3rd intercostal space, supraclavicular approach)

R subclavian - median sternotomy (again supraclavicular or anterior SCM-type dissection)

L proximal CC - median sternotomy

injury to upper 2/3 of intrathoracic esophagus - R posterolateral thoractomy (4/5th intercostal space)

• lower 1/3 of intrathoracic esophagus - L posterolateral thoracotomy (6/7th intercostal space)

complications

• L phrenic and vagal nerves pass anterior to aortic arch
  
  • L phrenic then courses anterior to L lung hilum along lateral surface of pericardium - important that pericardial incision is made longitudinally and anterior to L phrenic –> otherwise can get hemidiaphragm paralysis and prolonged vent dependence
  • L vagus descends in the posterior mediastinum - less prone to injury
    
    • L reccurent laryngeal comes of L vagus - ascends under aortic arch (medial to LSC)

Question 163

dysphagia

Answer 163

dysphagia/odynophagia - get barium swallow

most cases are d/t benign strictures at squamocolumnar junction - 1) serial dilations until sxs resolve + PPI

• Schatzi’s ring - almost all pts have sliding hiatal hernia

Zenker diverticulum (false) - get barium swallow (barium is inert, doesnt cause severe lung injury but can)

• cricopharyngeal myotomy (pathophys is failure of cricopharyngeus to relax), resection of diverticula is not necessary
• L-sided incision - this is how you approach cervical esophagus
  
  • Dohlman procedure - endoscopic repair, requires maximal extension of neck
  • open repair - myotomy of proximal and distal thyropharyngeus and cricopharyngeus muscles - may be enough in cases of small diverticulum (<2cm)
    
    • plus diverticulectomy in cases of large sac (>5cm)

Traction diverticulum (true) - d/t inflammation, granulomatous disease, tumor; mid-esophagus; exicsion and p closure if sx, nothing if asx

Achalasia - dysphagia worse for liquids

• manometry - lack of persistalsis and partial/absent relaxation of LES
  
  • need EGD to r/o cancer
• tx - balloon dilation of LES (effective in 80% of pts), nitrates, CCBs –> Heller myotomy (L-sided approach, myotomy of LES, partial Nissen fundoplication)
• POEM (peroral endoscopic myotomy) - ablates LES
  
  • associated with highest incidence of GERD

Diffuse esophageal spasm - strong non-peristaltic unorganized contractions (LES relaxes normally)

Nutcracker esophagus - high-amplitude peristaltic contractions (LES relaxes normally)

• tx for both - CCB, trazodone –> Heller myotomy (upper and lower esophagus, R-sided approach to access upper thoracic esophagus)

Scleroderma - loss LES tone with massive reflux and structures (manometry will show low LES pressure and aperistalsis)

• tx - PPI and reglan, esophagectomy if severe

Question 164

penetrating neck injury

Answer 164

zone 1 - cricoid to clavicle

2 - cricoid to mandible

3 - mandible to base of skull

esophagram (constrasted study, diatrizoate or dilute barium) + endoscopy has 95% sensitivity for esophageal injury

• of note - pneumomediastinum is not sensitive for esophageal injuries

Question 165

skin graft

Answer 165

many methods of securing

• staples - for irregular wound
• absorbable sutures - in children (dont have to removed)
• fibrin glue - where you are concerned that a stitch or staple may cause formation of ECF (ex granulated abd wound)
• wound vac - highly contoured wounds, to help opposed graft to wound bed (ex axilla)

Question 166

benign breast disease

Answer 166

fibrocystic change - can be associated with yellow-brown nipple dc

• cancer risk is if there is atypical ductal or lobular hyperplasia - excisional bx, dont need negative margins

fibroadenoma - can have large, coarse calcifications (popcorn lesions) on mammogram (occurs d/t degeneration)

• in pts < 40yo - 1) mass needs to feel clinically benign, 2) US/mammo should be c/w fibroadenoma, 3) need FNA/core bx to show fibroadenoma –> need all 3 to observe –> otherwise get excisional bx
• if growing - excise
• if pt > 40 –> excise

radial scar - stellate arrangement of ductal structures with sclerotic background and central fibroelastic core (core pulls and distorts the ducts and lobules)

Nipple dc - most nipple dc is benign

• intraductal papilloma - contrast ductogram, needle localization of duct, duct resection
• serous, spontaneous, unilateral d/c c/f ca - excisional bx

Infection

lactational mastitis - supportive care, abx (if systemic sxs are present, usu S aureus), continue breastfeeding

• failure to improve sxs in 48-72hrs - re-evaluate for presence of abscess development

abscess

• usu associated with breastfeeding, S aureus - I&D, abx, pump and dump
  
  • failure to resolve after 2 weeks - get excisional bx including skin to r/o necrotic breast cancer (of note, breast abscess in non-lactating woman is cancer until proven otherwise)
• chronic subareolar abscess - smoker
  
  • for recurrent infections - excise affected duct (first treat active infection)

periductal mastitis (mammary duct ectasia or plasma cell mastitis) - noncyclical mastodynia, erythema, nipple retraction, creamy discharge, +/- sterile/infected subareolar abscess

• RFs - smoking, nipple piercing
• tx for creamy dc with no nipple retraction - abx, continue breastfeeding
  
  • for other presentations or recurrence - incisional bx including skin to r/o cancer

Other

Mondor dz - idiopathic, thrombophlebitis of superficial veins of breast (cord-like)

• tx - NSAIDs, heat, supportive bra, sxs should resolve in 2-8 wks

mastodynia - rarely represents breast ca

• tx - danazol, OCPs, NSAIDS, evening primrose oil, bromocriptine
• d/c caffeine, nicotine, methylxanthines

Question 167

carcinoid

Answer 167

sites - appendix > ileum, rectum

• carcinoid in appendix < 2cm - appendectomy
  
  • > 2cm or involving base - RHC

once there are liver mets - serotonin produced by tumors overwhelm hepatic clearance –> systemic sxs (diarrhea, etc)

• if metastectomy is performed - also take gallbladder in caes of future embolization

post-op complications

• hypotension refractory to fluids and presssors - give somatostatin analogue

Question 168

anesthesia miscellaneous

stress-dose steroids…

Answer 168

ETT - most accurate means of confirming ETT placement - end-tidal

difficult intubation - indirect laryngoscopy with flexible bronchoscopy and spontaneous ventilation

demerol (meperidine) - has active metabolite that accumulates and causes CNS excitation and seizures

stress-dose steroids - pts on low-dose steroids (< 5mg of prednisone equivalent) for less than 3 weeks do not need periop stress dose steroids

Question 169

lung cancer

Answer 169

Most common cause of ca-related death in US (10% 5-yr survival), nodal involvement has strongest influence on survival, brain is most common source of mets, recurrence presents with disseminated mets (majority of recurrences are w/i 1-3 yrs)

Pulm mass evaluation - CXR, spiral CT, fiberoptic bronchoscopy, sputum analysis, FDG-PET

• coin lesion - MC lesion is granuloma, MC tumor is hamartoma, MC ca is adenocarcinoma
  
  • if suspicious - need bx or VATS wedge resection
• stage 1 and 2 dz - resectable (+- chemo rads)
• mediastinal LAD > 1cm, FDG-avid nodes –> cervical mediastinoscopy/anterior mediastinotomy/thoracoscopy –> stage 3 –> definitive chemo-XRT
• staging
  
  • T1 < 3 cm
  • T2 > 3 cm but >2cm away from carina
  • T3 invasion of chest wall, pericardium, diaphragm or <2cm carina
  • T4 invasion into mediastinum and farther structures
  • N1 ipsilateral hilar nodes, N2 ipsilateral other nodes (unresectable), N3 contralateral nodes (unresectable)
  • stage 2b - T2N1M0, stage 3 - T3N1 or TxN2 onwards
• non-small cell lung ca - squamous cell (PTHrP), adenocarcinoma (most common cancer)
• small cell (neuroendocrine) - usu unresectable at time of dx, chemoXRT
  
  • ACTH and ADH neoplastic syndrome
• mesothelioma - most malignant tumor, distant mets common at time of dx
• carcinoid - better prognosis, resect

contraindications to resection

• invasion of brachial plexus (morbidity with UE weakness is too high)
• division of symphatetic chain is OK - complications include Horner syndrome (though this can be avoided if upper stellate ganglion can be preserved)
  
  • Horner syndrome - ptosis, miosis, anhidrosis
• malignant pleural effusion - indicates stage 4 dz, talc pleurodesis for tx

Benign masses

• bronchial adenoma - MC carcinoid (90%), remainder of adneomas are malignant tumors
• hamartoma - most common benign adult lung tumor, popcorn lesion with calcifications, do not require resection, repeat CT in 6 mo

Question 170

mediastinitis

Answer 170

causes - dental abscess –> retropharygneal space –> mediastinum

tx - thoracotomy and placement of CTs

Question 171

bowel ischemia

Answer 171

nonocclusive SMA stenosis/spasm

• if pt on pressors –> wean of pressors and supportive care

diffuse mesenteric vasoconstriction (no thrombosis or emboli) - can leave SMA stent in place and start papaverine (vasodilator, does not increase intestinal blood flow)

Question 172

short gut syndrome

Answer 172

dx by sxs not bowel length - sxs include steatorrhea, weight loss, and nutritinal deficiency

• tx - restrict fat, PPI, and lomotil

Question 173

problems in elderly

Answer 173

adverse effects of medication occur because of low serum albumin level –> higher free drug concentrations

phenotypic frality - unintentional weight loss, weak grip strength, self-reported exhaustion, slow walking speed, low physical activity

Question 174

primary biliary cirrhosis

Answer 174

women, medium-sized hepatic ducts, d/t antimitochondrial antibodies

• cholestasis –> cirrhosis –> portal HTN
• tx - liver txp, UDCA and cholestyramine for sxs

Question 175

esophagus anatomy

Answer 175

upper 1/3 - striated muscle

lower 2/3 - smooth muscle

upper esophageal sphincter = cricopharyngeus muscle (normal pressure at rest 60 mm Hg, pressure with food bolus 15 mmHg)

• cricopharyngeus - most common site of esophageal perf - usu occurs w EGD
• pharyngoesophageal disorders - trouble transferring food from mouth to esophagus, liquids worse than solids, Plummer-Vinson syndrome (dilation of esophageal web, screen for oral ca)

LES - anatomic zone of high pressure (not a sphincter), relaxation mediated by inhibitory neurons

length ~25cm (23cm in females)

blood supply

• cervical esophagus - inf thyroid a
• thoracic esophagus - supplied by vessels off aorta
• abd esophagus - L gastric a, inf phrenic a
• venous drainage - hemi-azygous and azygous

nerves - LARP

• R vagus –> celiac plexus
  
  • also has criminal nerve of Grassi - can causes persistently high acid levels post-op if left undivided after vagotomy

Question 176

non-cancer lung disease

Answer 176

phrenic nerve - anterior to hilum; vagus nerve - posterior to hilum

PFTs

• predicted post-op values - FEV1 > 0.8, DLCO > 10 (represents O2 exchange capacity)
• no resection if pre-op pCO2 > 50 or pO2 <60 at rest, if VO2max < 10-12 ml/min/kg
• complications after surgery - air leak after segmentectomy/wedge, atelectasis after lobectomy

lung abscess - S aureus (MC), tx w abx (95% successful)

empyema - usu secondary to PNA and subsequent parapneumonic effusion

• exudative phase (1st wk) - CT, abx
• fibro-proliferative phase (2 wk) - CT, abx, possible VATS deloculation
• organized phase (3-4 wk) - VATS decortication
  
  • VATS decortication - if this fails (unable to remove rind, lung does not re-expand) –> proceed to open thoracotomy

massive hemoptysis >600cc/24hrs (bronchial arteries), most commonly 2/2 infection

• bleeding side down –> intubate mainstem on opp side –> rigid bronch/surgery, bronchial artery embolization if not suitable for surgery

pleural fluid

• transduate (d/t increased BP or low serum protein): WBC < 1000, pH >7.45, fluid to serum protein < 0.5, fluid to serum LDH < 0.6
• recurrent pleural effusions - mechanical pleurodesis (vs talc pleurodesis for malignant effusions)

sarcoidosis - non-caseating granulomas (TB has caseating granulomas)

• BAL (cant be used to dx alone) - lymphocytic predominance, CD4:CD8 >2, BAL can give info about disease course and progression but there is no advantage compared to PFTs

traumatic injury - tx w wedge resection (or trachotomy)

spontaneous ptx

• asx pt with small ptx (<3cm) - observe, repeat CXR in 6hrs
• non-op treatment - risk of recurrcence is 60% (typically w/i first year)

hemothorax - if retained and infected –> VATS decortication

• if not evacuated in a timely manner, pt can develop subsequent fibrosis and development of trapped lung (fibrothorax)

Question 177

mediastinal tumors

Answer 177

most are asx

MCC of mediastinal LAD - lymphoma; MC tumor - neurogenic tumors (resect)

Anterior (most common site) - thymoma, thyroid ca/goiter, T-cell lymphoma, teratoma (and other germ cell tumors), paraThyroid adenoma

• thymoma - 50%: are malignant, have sxs, associated with myasthenia –> resect
• teratoma - resect +/- cehmo
• seminoma - 10% are bHCG+ (NO AFP), sensitive for XRT (that is first line, chemo and surgery if rads fails)
• non-seminoma - chemo, surgery for residual dz

Middle - bronchiogenic cysts, pericardical cysts, enteric cysts, lymphoma

Posterior - enteric csyts, neurogenic tumors, lymphoma

Question 178

vascular trauma

Answer 178

hard signs - absent distal pulse, palpable thrill, audbile bruit, expanding hematoma, pulsatile bleed

Question 179

malrotation

Answer 179

pt presents with hx of reflux, imaging reveals duo that does not cross midline –> ex lap (now or elective depending..)

Question 180

GIB

Answer 180

UGIB - more common than LGIB

• RFs - previous UGIB, PUD, NSAIDs, moking, liver disease, esophageal varices (bands, sclerotherapy, TIPS), splenic vein thrombosis, sepsis, burns, trauma, severe vomiting
• tx - EGD
  
  • clean ulcer base, no bleeding - bx for H pylori detection, PPI, abx
  • hemorrhage (active bleed, oozing, adherent clot, visbile vessel) - hemostasis, bx for H pylori –> inpatient obs with PPI, abx
    
    • biggest RF for rebleeding - 1) spurting blood vessel (60% chance of rebleed), 2) visible blood vessel (40%), 3) diffuse oozing (30%)

BRBPR

• Hx - recent weight loss, change in bowel habits, FHx of colon ca
• PE - if exam demonstrates bleeding hemorrhoids/fissure, no additional work-up is needed in pts younger than 40
• no bleeding - flexible sig (no sedation required)/ colonoscopy
  
  • for pts 40-50 with no risk of colon cancer - get colonoscopy if no bleeding is found on sigmoidoscopy
  • for pts older than 50 - get colonoscopy first

Question 181

obesity

Answer 181

morbid obesity - almost all comorbidities get better after surgery, EXCEPT PAD

RNYGB > banding

• complications - marginal ulcers, leak, necrosis, B12 deficiency, fe deficiency anemia (duo is bypassed), gallstones (take GB if stones present at time of op)
• leak - most common d/t ischemia, re-op for early leak, drain and abx for late leak
  
  • get labs and plain films to eval for free air
  • more common from GJ than JJ
• marginal ulcers (on jejunal site) - PPI
• stenosis - serial dilation
• SBO = surgical emergency (high risk of small bowel herniation, strangulation, infarction, and necrosis)

post-gastrectomy complications

• dumping syndrome (can also occur after vagotomy and pyloroplasty) - d/t rapid entering of carbs into SB - 1) hyperosmotic load causes fluid shifts, 2) hypoglycemia (d/t recative insulin secretion, rarely occurs)
  
  • dx - gastric emptying study
  • tx - small, low-fat, low-carb, high protein meals, ocreotide
    
    • surgical options are rarely needed - B1 –> B2 or RNYGJ
• alkaline reflux gastritis (bile reflux) - tx with PPI, cholestyramine, metoclopramide
• chronic gastric atony –> DGE, give metoclopramide and prokinetics –> near-total gastrectomy with RN
• small gastric remnant - early satiety, metoclopramide and prokinetics –> jejunal pouch
• blind loop syndrome - d/t poor motility, stagnant flow (blind intestinal loops, large diverticula, fistulas, strictures) –> bacterial overgrowth
  
  • pain, steatorrhea (bacterial deconjugation of bile), B12 deficiency (megabaloblastic anemia), malabsorption
  • d-xylose test - metabolism of carbohydrate substrates from bacteria leads to production of H/methane (breath tests)
  • EGD of afferent limb
  • tx - tetracycline, flagyl, metoclopramide to improve motility –> can also reanastomose with shorter afferent limb
• afferent loop obstruction - balloon dilation or can also reanastomose with shorter afferent limb to relieve obstruction
• effect loop obstruction - balloon dilation, surgical relieve obstruction
• post-vagotomy diarrhea - d/t bile salts hitting the colon, tx cholestyramine and loperamide
• duodenal stump blow-out - duodenostomy tube and drains

Question 182

G6PD

Answer 182

triggers for hemolysis - infection, sulfa, fava beans, antimalarials, nitrofurantoin

Question 183

pelvic fracture

Answer 183

pelvic fracture + bladder/rectal injury - repair fracture (it is in contaminated field)

Question 184

thrombocytopenia

Answer 184

consumptive (sepsis), pepcid (H2 blockers), abx

DIC panel - d-dimer will be pos in most people in ICU (inflammatory response)

• d-dimer pos, fibrinogen negative = not DIC

Question 185

bites

Answer 185

rattlesnake

• immobilize ankle and keep it at level of heart or dependent (no tourniquet because it leads to venous congestion and increased edema and ischemia w/o benefit)