General and Pediatric Surgery Flashcards
What are the three types of gastric carcinoids?
Type I: most common, pernicious anemia and strophic gastritis
Type II: MEN 1 and zollinger-Ellison, intermediate malignant potential
Type III: aggressive solitary lesions with normal gastrin levels. 33% five year survival vs 85% for type I and II
What is the most common presentation of nasopharyngeal carcinoma?
A painless neck mass
What is a common metabolic abnormality after pancreas transplant?
Systemic hyperinsulinemia
What were the key findings of the NECSTEPS trial?
No difference in 90-day mortality, LOS, TPN dependence between Laparotomy and peritoneal drainage
What is the most common location for an alimentary tract duplication?
Jejunum and Ileum
What cardiac abnormality is commonly associated with osmium premum ASD?
Mitral insufficiency
Which type of benign tumors is Gardner syndrome associated with?
Desmoid tumors
What is Cowden’s syndrome?
PTEN mutation
Hamartomas/cancers in skin, mucosa, breast, thyroid, endometrium, colon, brain
What are the findings of the ECST and NASCET trials?
Benefit to carotid endarterectomy with 70-90% stenosis, and symptomatic pts with 50-69%
What is a Billroth I reconstruction?
Gastroduodenostomy
When do skull fractures require intervention?
Epidural Hematoma
Severely depressed
Dural disruption
What is likely to be seen on contrast enema for Hirschprung’s in the neonatal period?
Normal contrast enema
What does a microcolon imply about intestinal atresia?
That it is a distal atresia
What forms the inguinal ligament?
External oblique fascia
What forms the cremasteric muscle?
Internal oblique
What forms the inguinal canal floor?
Transversalis muscle and conjoined tendon (aponeurosis of internal and transversalis)
Where is Cooper’s ligament?
Posterior to the femoral vessels and lies along the bone
What is the relationship of the vas deferent to the cord structures?
It is medial
What is a sliding hernia?
When a retroperitoneal organ makes up part of hernia sac (ovaries, sigmoid, bladder)
What is a coopers ligament repair?
Approximation of conjoined tendon and transversals fascia to Cooper’s ligament + relaxing incision in external abdominal oblique fascia
What is the most common cause of pain after hernia?
Compression of ilioinguinal nerve
What are the symptoms of ilioinguinal nerve injury?
Loss of cremasteric reflex, numbness on ipsilateral penis and scrotum and thigh
Where is the ilioinguinal nerve usually injured?
near the external ring
Where is the genitofemoral nerve usually injured?
During laparoscopic repairs
Where does a spigelian hernia occur?
Between muscle fibers of internal oblique and insertion of external oblique aponeurosis into the sheath
What is the Howship-Romberg sign?
Inner thigh pain with internal rotation
What is Fothergill’s sign?
Increased mass prominence and pain with rectus muscle flexing -> Rectus Sheath Hematoma
What is the medical treatment for unresectable Desmoid Tumors?
Sulindac and Tamoxifen
What is main symptoms of retroperitoneal fibrosis?
Obstructed ureters and lymphatics
What is a characteristics of benign vs. malignant mesenteric tumors?
Root of mesentery -> Malignant (Liposarcoma, leiomyosarcoma)
Peripheral -> Benign
What shouldn’t you do to omental tumors?
Biopsy, they can bleed
What worsens the effects of pneumoperitoneum?
Hypovolemia and PEEP
What is the signs of CO2 embolus?
Sudden rise in ETCO2 and Hypotension
What is the difference between vortex and dacron?
Dacron allows fibroblast ingrowth
What is the definition of low birth weight?
< 2.5 kg
What is the bolus amount for kids?
Fluid: 20 cc/kg
Blood: 10 cc/kg
What is the best indicator of shock in kids?
Tachycardia:
Neonate > 150
Infant > 120
Rest > 100
What are the anatomic features of a pulmonary sequestration?
Anomalous systemic arterial supply
Extra-lobar -> systemic venous drainge
Intra-lobar -> pulmonary vein drainge
Do NOT communicate with the tracheobronchial tree
How does a pulmonary sequestration present and what is the Tx?
Infection
Tx: Lobectomy
What is the defect in congenital lobar emphysema?
Cartilage fails to develop -? air trapping
LUL most common
What is the treatment for congenital lobar emphysema?
Lobectomy
What is the anatomy of congenital cystic adenoid malformations?
Communicate with the airway
Lung tissue is present but poorly developed
What is the effect and treatment for congenital cystic adenoid malformations?
Sx: respiratory compromise, recurrent infections
Tx: lobectomy
What is the characteristics of a bronchogenic cyst?
Mediastinum posterior to carina
Extra-pulmonary formed from bronchial tissue and cartilage
Mediastinal mass with milky liquid
Tx: Resect cyst
What is the differential of a mediastinal mass in children?
Neurogenic Tumors (most common)
Anterior -> T cell lymphoma, Teratoma, thyroid CA, other germ cell tumors
Middle -> T cell lymphoma, teratoma, cyst
Posterior -> T cell lymphoma, neurogenic tumor
What symptoms are common to all mediastinal masses in children?
Respiratory symptoms
Dysphagia
What is the cause of choledochal cysts?
Reflux of pancreatic enzymes into biliary system in utero
What are the types of choledochal cyst?
I -> fusiform dilation of CBD and CHD
II -> Diverticulum off CBD
III -> Dilation of distal CBD including Oddi
IV -> multiple cysts intra and extrahepatic
V -> Caroli’s disease (intrahepatic cysts)
What is the treatment for choledochal cyst by type?
I: resection, hepaticoJ II: Resection, hepaticoJ if needed III: Resection, choledochoJ IV: Resection, lobectomy, possible TXP V: Resection, lobectomy, possible TXP
What do you do with fluctuant LAD in children?
FNA, culture, and abx
Chronic: cat scratch, atypical mycobacteria
What is the workup of asymptomatic LAD in kids?
Abx for 10 days, excision biopsy if no improvement
Where is a cystic hygroma (lymphanioma) usually located?
Lateral to the SCM
What are a Bochdalek’s and Morgagni’s hernia?
Bochdalek -> located posteriorly
Morgagni -> located anteriorly
Where are the three different branchial cleft cysts located?
1st: angle of mandible (associated with facial nerve)
2nd: anterior border of mid SCM (goes to tonsilar pillar)
3rd: lower neck, medial or through lower SCM
What is elevated in most neuroblastoma?
Catecholamines, VMA, HVA, metanephrines
What is seen on AXR with neuroblastoma?
Stippled calcification in the mass
What characteristics of neuroblastoma are worse prognosis?
NSE, LDH, HVA, diploid tumors, N-myc amplification (> 3 copies)
What marker is increased in all patients with metastases?
NSE
What is neoadjuvant therapy for neuroblastoma?
Doxorubicin
What is the staging for neuroblastoma?
I - complete excision II - Incomplete excision, does not cross midline III - Crosses midline +/- regional nodes IV - Distant mets IVs - Localized tumor with distant mets
What is the mean age at diagnosis of neuroblastoma vs. Wilm’s tumors?
Neuroblastoma 1-2 years
Wilm’s 3 years old
What is prognosis based on for Wilm’s tumors?
Grade (anapestic and sarcomatous worse)
What is differentiating feature of Wilm’s from neuroblastoma on CT?
Wilm’s replaces renal parenchyma and does not displace it
Who gets adjuvant chemo for Wilm’s tumor?
All patients unless Stage I and < 500 g tumor
What is adjuvant chemo for Wilm’s tumor?
Actinomycin and Vincristine
What is the staging for Wilms Tumor?
I - Kidney, completely excised II - Beyond kidney but completely excised III - Residual nonhematogenous tumor IV - Hematogenous metastases V - Bilateral renal involvement
What marker is increased in hepatoblastoma?
AFP
What are signs of hepatoblastoma?
Fractures Precocious puberty (bHCG release)
What is the treatment of hepatoblastoma?
Resection
Can downstage with doxorubicin + cisplatin
What is the best histology for hepatoblastoma?
Fetal Histology
What are the most common malignancies in children?
#1 overall: Leukemia (ALL) #1 solid tumor: CNS tumors #1 General Surgery Tumor: Neuroblastoma Child < 2 years: Neuroblastoma Child > 2 years: Wilm's tumor #1 Liver tumor: hepatoblastoma #1 lung tumor: carcinoid
What is the #1 cause of painless LGIB in children?
Meckel’s
Painful: benign anorectal
What are ultrasound characteristics of pyloric stenosis?
> 4 mm thick
> 14 mm long
How should you resuscitate children with pyloric stenosis?
NS till making urine then D5NS + 10 of K
Avoid K containing in hypovolemia
Avoid non-salt containing in infants as can be hyponatremic
What are max acceptable pressure for attempting reduction of intussusception?
120 mmHg of air
1 meter of barium
How should you reduce intussusception in the OR?
Place traction on the distal limb
What ist he cause of intestinal atresia?
Intrauterine vascular accidents
What is duodenal atresia associated with?
Cardiac, renal and other GI anomalies
Polyhydramnios in mother
What are the two most common types of TEF?
Type C - Proximal esophageal atresia and distal TE fistula
Type A - Esophageal atresia and no fistula (gas-less abdomen on AXR)
What is the repair approach for TE fistula?
Right extra-pleural thoracotomy
What is the Tx for TEF in premature < 2,500 g infants?
Place Replogle tube, treat respiratory symptoms and place G-tube
DELAY REPAIR
What causes bilious vomiting in malrotation?
Duodenal obstruction from Ladd’s bands
What blood vessel is compromised in volvulus from malrotation?
SMA
What study should any child with bilious vomiting get?
UGI to r/o malrotation
What do you see on a UGI with malrotation?
Duodenum does not cross midline
Duodenal-Jejunal junction displaced to the right
What is the treatment for malrotation?
Resect Ladd’s bands, counterclockwise rotate
Place cecum in LLQ
Place duo in RUQ
Appendectomy
Where is the obstruction located with meconium ileus?
Distal ilium
What test must be ordered for a meconium ileus?
Sweat chloride test
What do you see on AXR for meconium ileus?
Dilated loops without AFLs
What is the treatment of meconium ileus?
Gastrografin enema or NAC enemas
What is the classic presentation of NEC?
Blood stools after first feeding in a premature neonate
What do you need to obtain prior to taking down NEC ostomy?
Barium enema to r/o stenosis
What are surgical indications for congenital vascular malformations?
Hemorrhage, ischemia, CHF
non-bleeding ulcers
Functional impairment
Limb-length discrepancy
What syndrome should you think of with imperforate anus?
VACTREL
What is the treatment for imperforate anus?
Above Levators -> Colostomy and then posterior sagittal anoplasty
Below Levators -> posterior sagittal anoplasty
What are the characteristics of gastroschisis?
Right of midline
No peritoneal sac
Stiff bowel
Origin: Intrauterine rupture of umbilical vein
What is the cantrell pentology?
Cardiac defects
Pericardium defects (usually along diaphragm)
Sternal cleft or absence of lower sternum
Diaphragmatic septum transverse absence
Omphalocele
What is the #1 cause of colonic obstruction in infants?
Hirschprung’s disease
What do you see on biopsy for Hirschprung’s disease?
Absence of ganglion cells in the myenteric plexus
What does Hirschprung’s colitis present as?
Distention and foul-smelling diarrhea
Tx: Rectal irrigation to empty colon
What are indications for umbilical hernia repair?
Age > 5
Incarceration
VP shunt
When should you consider a contralateral groin exploration during IHR?
< 1 year
Left sided (right is more common, 10% bilateral)
Female
What is the typical presentation of biliary atresia?
Progressive jaundice persisting > 2 weeks after birth
What do you see on liver bx with biliary atresia?
Periportal fibrosis
Bile plugging
Progressive cirrhosis
What is first treatment for biliary atresia?
Kasai procedure before 3 months of age
What serum markers are increased in teratoma?
AFP and bHCG
Where is the most common site of teratoma in neonates and adolescents?
Neonates -> sacrococcygeal
Adolescents -> Ovarian
What is the key time point for sacrococcygeal teratomas?
< 2 months -> usually benign
> 2 months -> usually malignant
At what age should you treat undescended testes?
2 years
What if you cannot get the testicles to come down during an orchiopexy?
Close incision and wait 6 months prior to trying again
If still not successful, divide spermatic vessels
What is the surgery for tracheomalacia?
Aortopexy
What is the natural history of laryngeal papillomatosis?
Usually involutes after puberty
