General Surgical, Urological, Gynaecological and Endoscopic Procedures Flashcards
The Glasgow Blatchford score is used to risk stratify:
a) Pulmonary haemorrhage
b) Traumatic intraperitoneal haemorrhage
c) PPH
d) SAH
e) UGI bleed
e) UGI bleed
Stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management. Use for adult patients being considered for hospital admission due to upper GI bleeding.
Components: haemoglobin, BUN, initial systolic BP, heart rate > 100, melena present, recent syncope, hepatic disease history, cardiac failure present.
Med-Calc
In a male patient with quadriplegia undergoing a rigid cystoscopy, the optimal
choice of anaesthesia to prevent autonomic dysreflexia is
a) Spinal
b) Epidural
c) GA with volatile at 1 MAC
d) Topical only
a) Spinal
Elective surgery.Urological. Recurrent urinary tract infections and long-term catheterization increase the risk of bladder cancer. Cystoscopy is a common procedure as is insertion of suprapubic catheters and botox injections for the management of neuro- pathic bladders.
Spinal anaesthesia is safe in patients with CSCI and is an effect- ive way of abolishing ADR15 and spasms. Spinal anaesthesia is becoming a widely accepted technique in patients with pre-exist- ing spinal cord pathology and is routinely used in Stoke Mande- ville Hospital, with a low dose (1.5–2 ml) hyperbaric bupivacaine 0.5%, for most procedures. Spinals can be challenging to site because of poor positioning as a result of spasms and contractures, the presence of spinal metal work, and bony deformities.
The effectiveness and the level of the block are difficult to ascertain. The loss of the Babinski reflex and a change in tone from spasticity to flaccid paralysis indicate an established block; although the height of the block remains difficult to assess. The anaesthetist must be vigilant for the signs and symptoms of a total spinal block.
Epidural anaesthesia has been demonstrated to be effective in reducing ADR in labouring women; however, it is less reliable for general and urological surgical procedures.
I asked a boss about this - he said if previous autonomic dysreflexia definitely needs an anaesthetic!
Perioperative management for patients with a chronic spinal cord injury. BJA 2015
A 39-year-old requires anaesthesia for a laparoscopic cholecystectomy. They have a history of mastocytosis and have never had an anaesthetic in the past. The non-depolarising muscle relaxant to avoid using is:
a) Atracurium
b) Cisatracurium
c) Pancuronium
d) Rocuronium
e) Vecuronium
MAYANK Atrac - histamine release is bad.
The MELD-Na (Model for End-Stage Liver Disease-Sodium) score includes all of the following parameters EXCEPT:
a) Bilirubin
b) INR
c) Albumin
d) Creatinine
Albumin
MELD uses the following parameters:
- Bilirubin
- INR
- Creatinine
- [Hyponatraemia]
○ Part of the MELD-Na score update in 2016
○ Sodium (Na) Values < 125 are set to 125 and values >137 are set to 137
4 MELD levels are:
- >/=25 (gravely ill)
- 24-19
- 18-11
- </=10
In patients who have undergone abdominal surgery an elevated MELD score was a better predictor of poor perioperative outcome than Child-Pugh Classification
- MELD score >15 should avoid elective surgery
Calculation:
MELD =
3.8loge(serum bilirubin [mg/dL]) + 11.2loge(INR) + 9.6*loge(serum creatinine [mg/dL]) + 6.4
MELD-Na =
MELD + 1.32 * (137-Na) - [0.033*MELD * (137-Na)]
You are anaesthetising an 18-year-old who has a Fontan circulation for exploratory laparotomy. They are intubated and ventilated with a ventilator that has been brought from the Intensive Care Unit. Their current arterial oxygen saturation is 70%. To improve oxygenation, you should INCREASE the:
a) Increase PIP
b) Increase PEEP
c) Increase inspiratory time
d) Increase expiratory time
D) increase expiratory time
Reworded repeat, but prev options don’t directly align with these
Answer from then
Patients who have undergone the Fontan procedure depend on blood flow through the pulmonary circulation without the assistance of the right ventricle. The difference between central venous pressure and systemic ventricular end-diastolic pressure (termed the “transpulmonary gradient”) is the primary force promoting pulmonary blood flow and, more importantly, cardiac output.
Circulation in the Fontan patient is promoted by low pulmonary vascular resistance. Positive-pressure ventilation with increased tidal volumes, as described above, can result in excessive intrathoracic pressures, leading to decreased venous return to the heart and increased pulmonary vascular resistance.
In periods of low oxygen saturation, 100% inspiratory oxygen is appropriate.
The addition of PEEP will increase intrathoracic pressure, reducing venous return.
Trendelenberg positioning would increase CVP and therefore bloodflow through pulmonary circulation.
BJA: fontan circulation:
For relatively short procedures, Fontan patients are probably better off breathing spontaneously, as long as severe hypercarbia is avoided. For major surgery, or when prolonged anaesthesia is required, control of ventilation and active prevention of atelectasis is usually advisable. Potential disadvantages of mechanical ventilation in Fontan patients relate to the inevitable increase in mean intrathoracic pressure. This causes decreased venous return, decreased pulmonary blood flow, and hence, decreased cardiac output. Low respiratory rates, short inspiratory times, low PEEP, and tidal volumes of 5–6 ml kg−1 usually allow adequate pulmonary blood flow, normocarbia, and a low PVR. Hyperventilation tends to impair pulmonary blood flow, despite the induced respiratory alkalosis, because of the increased mean intrathoracic pressure.
https://academic.oup.com/bjaed/article/8/1/26/277637
A patient presents for a trans-urethral resection of the prostate (TURP). He had a single drug-eluting coronary stent for angina pectoris inserted six months ago and is taking clopidogrel and aspirin. The most appropriate preoperative management of his medications is to:
a) Cease aspirin, continue clopidogrel
b) Cease aspirin for 10 days, cease clopidogrel for 5 days
c) Cease clopidogrel for 5 days, continue aspirin
d) Cease clopidogrel for 10 days, continue aspirin
e) Continue both aspirin and clopidogrel
REPEAT
c) Cease clopidogrel for 5 days, continue aspirin
- prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis
- For clopidogrel, we stop five days before surgery
- Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting
- suggest that surgery be performed in centers with 24-hour interventional cardiology coverage
UP TO DATE: Noncardiac surgery after PCI
Nonemergency noncardiac surgery — For patients who have undergone previous stenting with either BMS or DES and who will need cessation of one or both antiplatelet agents, we prefer to defer planned nonemergency, nonurgent noncardiac surgery until at least six months after stent implantation. The risks of noncardiac surgery before six months are increased after both BMS and DES.
For patients whose surgery requires cessation of one or both antiplatelet agents and cannot wait six months, and where the risks of delaying surgery outweigh the benefits, our recommended minimal duration of DAPT is four to six weeks, depending on the urgency of surgery and risk of thrombotic complication. This is based in part on evidence suggesting that the increased risk of MI and cardiac death is highest within the first month after stent placement and no clear difference in risk between BMS and DES. Although we prefer to wait at least six weeks when possible, in patients for whom earlier surgery is in their best interest after weighing risks and benefits, we sometimes refer patients as early as four weeks after stent placement.
The proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAPT and regardless of stent type during this early period after stenting. We believe this risk to be higher prior to the minimum duration of DAPT recommended above, but the final decision to continue or discontinue antiplatelet therapy in the perioperative period should be made only after an informed discussion among the surgeon, managing cardiologist (and other health care providers), and patient has taken place. In many cases, DAPT can be continued in the perioperative period, although for some surgeries, such as neurosurgery, posterior eye surgery, or prostatic surgery, the risk of major bleeding may be greater than the risk of stent thrombosis.
In these patients who undergo noncardiac surgery before the recommended minimum duration of DAPT, a platelet P2Y12 receptor blocker should be discontinued for as brief a period as possible. Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and clopidogrel and surgery can usually be safely performed on aspirin. The rationale to continue aspirin comes in part from the POISE-2 trial (PCI subgroup analysis), which is discussed separately. However, as many neurosurgical patients, for whom bleeding might be life threatening or lead to severe adverse outcomes, were not enrolled in POISE-2, the optimal strategy is not known.
●Minor surgical and dental procedures usually do not require cessation of antiplatelet therapy.
●With regard to stopping P2Y12 inhibitor prior to noncardiac surgery, we generally follow recommendations found in the manufacturer’s package insert for each drug.
- For clopidogrel, we stop five days before surgery; that is, the last dose is taken on the sixth day before surgery.
- For prasugrel, we stop seven days before surgery.
- For ticagrelor, we stop three to five days before surgery.
- Some experts are willing to recommend shorter discontinuation periods for procedures less likely to be associated with major bleeding.
●Clopidogrel, if stopped, should be restarted with a loading dose of 300 mg as soon as possible after surgery, perhaps later in the day if postoperative bleeding has stopped. Some experts recommend a higher loading dose of 600 mg to decrease time to effectiveness in the higher-risk postoperative setting.
●We suggest that surgery be performed in centers with 24-hour interventional cardiology coverage
A 45-year-old received a heart transplant one month ago. They develop a new supraventricular tachyarrhythmia without hypotension during gastroscopy. The most appropriate therapy is:
a) Adenosine
b) Amiodarone
c) Esmolol
d) Verapamil
e) Digoxin
REPEAT
d) Esmolol
Management of Arrhythmias After Heart Transplant
https://www.ahajournals.org/doi/10.1161/CIRCEP.120.007954
In asymptomatic patients, additional cardiac monitoring such as 24-Holter or an event monitor can be useful to assess the SVT burden, and a trial of atrioventricular nodal blockers (β-blockers preferably) can be attempted with caution in view of potential risk of bradycardia. Calcium channel blockers such as diltiazem and verapamil are contraindicated in patients taking immunosuppression such as tacrolimus and cyclosporine as it can impair the metabolism CYP3A, which increases the levels of these drugs potentially causing renal toxicity.
The use of adenosine in the management of SVT has remained a subject of controversy for over a quarter century. In the past, adenosine was contraindicated in patients post-OHT due to its supersensitivity and presumed risk of prolonged atrioventricular block.
Thus, based on the aforementioned data, in patients with OHT, adenosine is feasible and safe at reduced doses (starting at 1.5 mg for patients ≥60 kg) as long as patients are closely monitored, with dose escalation as needed. Furthermore, the 2010 American Heart Association guidelines on advanced cardiovascular life support also recommended lowering the initial dose of adenosine to 3 mg for the acute management of SVT in patients with OHT.
An open Ivor-Lewis oesophagectomy is performed via a:
a Laparotomy then left thoracotomy
b Laparotomy, left neck incision
c Laparotomy, Right thoracotomy
d Left thoracotomy, left neck incision
d Right thoracotomy, Laparotomy
REPEAT
B
Transhiatal - laparotomy & cervical anastomosis
Ivor-Lewis - laparotomy & R thoracotomy (tumour upper ⅔)
Thoracoabdominal - L throacotomy crossing costal margin & diaphragm (tumour lower ⅔)
Minimally invasive - thorascopic oesophageal mobilisation, laparoscopic gastric mobilisation & cervical
anastomosis
According to the RELIEF study, in major abdominal surgery a liberal fluid strategy
(10 mL/kg of crystalloid at induction followed by 8 mL/kg/hour during the case)
compared to a restrictive fluid strategy, results in:
A. Increased bowel anastomosis breakdown
B. Increased mortality
C. Decreased mortality
D. No difference in wound infection
E. Decreased acute kidney injury
REPEAT
E. Decreased acute kidney injury
Restrictive had more AKI
Otherwise no outcome significant statistically
https://www.thebottomline.org.uk/summaries/relief/
Kate
A 50-year-old patient with carcinoid syndrome undergoing resection of a peripheral hepatic metastasis develops a sudden fall in blood pressure from 110/70 mmHg to 85/50 mmHg without significant bleeding. The most appropriate management is:
a. Normal saline bolus
b. Octreotide 50mcg bolus
c. Metaraminol 0.5mg
d. Noradrenaline 5mcg bolus
e. Calcium 6.8mmol
REPEAT
b. Octreotide 50mcg bolus
Vasoactive hormone release intra-operatively is best treated with intravenous boluses of 20–50 µg of octreotide, titrated to haemodynamic response. Vasopressin as an alternative vasoconstrictor that may be useful if prolonged vasoconstriction is required; however, the evidence base is small.
It must be borne in mind that concomitant fluid losses, especially bleeding, may be responsible for intra-operative instability rather than hormone excess and that fluid resuscitation may be the answer rather than further octreotide therapy
https://academic.oup.com/bjaed/article/11/1/9/285683
21.1 A transhiatal oesophagectomy is performed via a
a) laparotomy + right thoracotomy
b) laparotomy + left neck incision
c) laparotomy + left neck incision + Right thoractomy
d) Laparotomy + left thoractomy
midline laparotomy and left cervical incision
https://academic.oup.com/bjaed/article/17/2/68/2907833
Transhiatal oesophagectomy classically involves laparotomy and dissection of the lower oesophagus through an enlarged diaphragmatic hiatus, followed by removal of the oesophagus and re-anastomosis via a left cervical incision, thereby avoiding thoracotomy altogether (Fig. 2e).
- useful in patients with malignancies of the lower third of the oesophagus where thoracotomy is undesirable, such as those who have previously undergone thoracic surgery. - Dissection around the mediastinum is frequently associated with arrhythmias and ventricular compression causing hypotension (although this frequently occurs in transhiatal surgery, it is not uncommonly encountered during the thoracic phase of other approaches).
21.1, 23.1 In patients without other co-morbidities, bariatric weight loss surgery is indicated when the body mass index (kg/m2) is greater than
a. 35
Major updates (2022) to 1991 National Institutes of Health guidelines for bariatric surgery
Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) 35 kg/m2 , regardless of presence, absence, or severity of co-morbidities.
MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2
BMI thresholds should be adjusted in the Asian population such that a BMI 25 kg/m2 suggests clinical obesity, and individuals with BMI 27.5 kg/m2 should be offered MBS.
Long-term results of MBS consistently demonstrate safety and efficacy.
Appropriately selected children and adolescents should be considered for MBS.
https://www.soard.org/article/S1550-7289(22)00641-4/fulltext#:~:text=The%201991%20NIH%20Consensus%20Statement,surgery%20that%20is%20applied%20universally
Contraindications:
- Inflammatory disease of GI tract (ulcers, oesophagitis, Crohn’s)
- Upper GI bleeding
- Portal Htn
- Liver Cirrhosis
- Chronic Pancreatitis
- Laparascopic surgery may be technically difficult in patients weighing >180kg and may be considered a relative contraindication
21.2, 22.2, 23.2 A 25-year-old woman is administered two doses of aprepitant for postoperative nausea and vomiting after a sleeve gastrectomy. She normally takes the oral contraceptive pill. You should advise her to use alternative contraception for the next
a) 3 days
b) 7 days
c) 14 days
d) 28 days
28 days
Aprepitant PI:
“Alternative or “back-up” measures of contraception should be used during treatment with this medicine and for one month following the last dose of this medicine.”
Pharmacokinetics:
- aprepitant is a CYP3A4 inhibitor
- caution is also advised with warfarin and phenytoin use
22.1 A 57-year-old female smoker presents for a laparotomy with the following pulmonary function tests
(normal FEV1 FVC, low RV and FRC only, normal DLCO)
They are consistent with a diagnosis of
a. Obesity
b. PE
c. Pulmonary fibrosis
d. COPD
a. Obesity
Obesity and pulmonary function testing
https://www.jacionline.org/article/S0091-6749(05)00164-8/fulltext
- Full pulmonary function tests are often necessary to better characterize the spirometric abnormalities seen in the obese patient
- The most sensitive indicator of obesity is a low expiratory reserve volume (ERV) and functional residual capacity
- Restriction is seen in more severe obesity, with reductions in TLC and FVC.
- However, residual volume is often preserved because of the relative high closing volume in relation to ERV.
20.2 You are seeing a 48 year-old woman in your pre-operative clinic for assessment for laparoscopic sleeve gastrectomy. Her co-morbidities include obesity (BMI is 65 kg/m2), hypertension, type 2 diabetes mellitus and polycystic ovary syndrome. Her neck circumference is 38 cm. Her husband states that she snores loudly, but he has never observed her having any apnoeic episodes and she reports no excessive tiredness during the day. Her score using the STOP-BANG questionnaire is
a. 3
b. 4
c. 5
d. 6
e. 7
a. 3 (snoring, BMI, Htn)
Snoring loudly
Tiredness during day time
Observed Apnoea
Pressure: Htn
BMI > 35
Age > 50
Neck circumference >40cm (43cms male)
Gender: Male
21.1 A woman is having a potentially curative primary breast cancer resection. Compared with a sevoflurane and opioid technique, using a regional anaesthesia-analgesia technique with paravertebral block and a propofol infusion will result in
a. Decreased cancer recurrence
b. Decreased chronic pain and recurrence
c. Decreased incision pain at 6 months
d. Decreased CPSP pain at 6 months
e. Decreased CPSP pain at 12 months
Fuck this question
e. Decreased CPSP pain at 12 months
or it could be updated with an option that says makes no difference
most likely they will just remove the question and this is a big waste of time
https://pubs.asahq.org/anesthesiology/article/135/6/1091/117748/Preoperative-Paravertebral-Block-and-Chronic-Pain
—>This says it makes no difference in 2021
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007105.pub4/full
—-> this says weak evidence but it helps prevent persistent post surgical pain at 3-12months in 2018
—-> ANZCA pain book references this article
ANZCA pain book
https://www.bjaed.org/article/S2058-5349(18)30101-X/fulltext
A recent review showed that, whilst there was little effect on intra- and postoperative opioid consumption and PONV, patients receiving either both single-shot injections or placement of paravertebral catheters had less acute pain in the first 72 h after surgery.
There is also a suggestion that the use of TPVB for acute postsurgical pain may protect against the development of chronic postsurgical pain after breast surgery at 6 months.
For breast cancer surgery any form of regional anaesthesia (18 RCTs, n=1,297) reduces CPSP 3 to 12 months after surgery compared with systemic analgesia (OR 0.43; 95%CI 0.28 to 0.68) (NNT 7); specifically paravertebral block (PVB) (6 RCTs, n=419) is effective (OR 0.61; 95%CI 0.39 to 0.97) (NNT 11).
In our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain.
https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(19)32313-X.
20.2 You are anaesthetising a 35 year old woman undergoing a laparoscopic appendicectomy. She uses a levonorgestrel-secreting intrauterine device (MirenaTM) for contraception and you have used sugammadex for reversal of neuromuscular blockade at the end of the procedure. Your post-operative
advice to her regarding contraception should state that
a. Barrier protection for a week
b. Barrier protection until the next period.
c. The mirena is sufficient
d. OCP for a week
e. OCP until next period
a. Barrier protection for a week
In the case of non-oral hormonal contraceptives, the patient must use an additional non hormonal contraceptive method for the next 7 days
A 35-year-old male, three days post laparoscopic sleeve gastrectomy has ongoing nausea and vomiting. His arterial blood gas measurement is as follows: (ABG shown) The best initial therapeutic option would be
Blood gas given:
hypokalaemia
hypochloraemia
alkalosis
normal lactate
a Laparoscopy
b IV fluids and KCL
c 4% albumin
d HCl infusion
e Acetazolamide
b IV fluids and KCL
UTD Stricture post Lap Sleeve Gastrectomy management
Although sleeve strictures have been reported in 0.26 to 4 percent of LSG operations, <1 percent result in symptoms that require endoscopic or surgical intervention
A stricture can manifest acutely, early after surgery, or more chronically.
Although strictures can occur anywhere along the long staple line, they are most often located at the level of the incisura angularis for anatomic reasons.
The etiologies of post-LSG strictures are either mechanical or functional. Mechanical strictures usually derive from the use of small bougies, stapling too close to the bougie (especially at the incisura angularis), twisting of the staple line creating a “spiral” sleeve, or aggressive imbrication of the staple line.
Functional stenoses derive from edema or hematomas at the staple line. As a result, functional stenoses are transient, which present immediately following LSG and resolve spontaneously with expectant treatment.
Patients who present with obstructive symptoms during the early postoperative period should be resuscitated with hydration and antiemetic medications and studied with an upper gastrointestinal (UGI) series.
Stable patients with a stricture can be observed to allow postsurgical mucosal edema to resolve, typically in 24 to 48 hours. Patients who cannot handle their own secretions require nasogastric tube decompression, preferably placed under fluoroscopic guidance.
Patients with an acute stricture who do not respond to conservative management require early surgical reintervention. Laparoscopy could demonstrate kinking of the gastric tube, a tight suture, or a compressing hematoma.
●Endoscopy is a good initial treatment for short-segment strictures, most of which can be dilated with balloons. Multiple treatments in four- to six-week intervals are sometimes needed to treat the stricture and improve patient symptoms. Stents have also been tried but are not effective for post-LSG strictures.
●Laparoscopic seromyotomy is a treatment option for long-segment strictures . In a small retrospective study, patients treated with laparoscopic seromyotomy had good symptomatic relief.
●Conversion to an RYGB is the last option for patients with a refractory stricture who have failed all other treatments.
23.1 In patients with primary adrenal insufficiency, a markedly elevated renin is most likely due to
A Insufficient corticosteroid replacement
B Insufficient fludrocortisone replacement
C Excessive corticosteroid replacement
D Excessive fludrocortisone replacement
b. Insufficient fludrocortisone replacement
In Primary Adrenal Insufficency, cortisol deficiency results in decreased feedback to the HPA axis, leading to increased secretion of ACTH to stimulate the adrenal cortex. Simultaneously, MCs deficiency causes increased release of renin by the juxtaglomerular apparatus of the kidneys.
22.1 Maintaining a CO2 pneumoperitoneum at a pressure of 15 mmHg is most likely to lead to
a) Lactic acidosis
b) Decreased arterial blood pressure
c) Decreased heart rate
d) Increased CVP
e) Increased renal blood flow
f) Increased SVR
f) Increased SVR
20.2, 22.2 An open Ivor-Lewis oesophagectomy is performed via a
a Laparotomy then left thoracotomy
b Laparotomy, left neck incision
c Laparotomy, Right thoracotomy
d Left thoracotomy, left neck incision
d Right thoracotomy, Laparotomy
c Laparotomy, Right thoracotomy
Ivor-Lewis transthoracic esophagectomy — The Ivor-Lewis transthoracic esophagectomy can be used to resect cancers in the lower third of the esophagus but is not the optimal approach for cancers located in the middle third because of the limited proximal margin that can be achieved. This procedure combines a laparotomy with a right thoracotomy and an intrathoracic esophagogastric anastomosis. This approach permits direct visualization of the thoracic esophagus and allows the surgeon to perform a full thoracic lymphadenectomy. We prefer a minimally invasive Ivor-Lewis approach to a thoracotomy.
Transhiatal esophagectomy — A transhiatal esophagectomy (THE) can be performed to resect cervical, thoracic, and esophagogastric junction (EGJ) esophageal cancers; it is performed through an upper midline laparotomy incision and a left neck incision, typically without a thoracotomy.
Modified Ivor-Lewis transthoracic esophagectomy (left thoracoabdominal esophagogastrectomy) — A modification of the Ivor-Lewis transthoracic esophagectomy includes a left thoracoabdominal incision with a gastric pull-up and an esophagogastric anastomosis in the left chest. This approach is most useful for tumors involving the gastroesophageal junction. Only one incision is required, but disadvantages include a high incidence of complications such as postoperative reflux and limitation of the proximal esophageal margin by the aortic arch.
Tri-incisional esophagectomy — The tri-incisional esophagectomy combines the transhiatal and transthoracic approaches into a transthoracic total esophagectomy with a thoracic lymphadenectomy and cervical esophagogastric anastomosis. The three-incisional technique allows the surgeon to perform a complete two-field (mediastinal and upper abdominal) lymphadenectomy under direct vision and a cervical esophagogastric anastomosis. We prefer a thorascopic approach to the chest rather than a thoracotomy to minimize the risk of respiratory complications.
Esophagectomy is a technically difficult operation, and the complication rate is high due to the anatomic challenges of the procedure.
The choice of surgical approach depends upon many factors, including:
●Tumor location, length, submucosal extension, and adherence to surrounding structures
●The type or extent of lymphadenectomy desired
●The conduit to be used to restore gastrointestinal continuity
●Postoperative bile reflux
●The preference of the surgeon
23.1 A 58-year-old man with alcohol-related cirrhosis is booked to undergo a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The calculation of his MELD-Na score to estimate his mortality risk requires all of the following EXCEPT
A. Sodium
B. INR
C. Cr
D. Albumin
E. Bilirubin
D. Albumin
https://www.tamingthesru.com/blog/r1-diagnostics/labs-in-hepatic-failure
22.1 Bowel preparation prior to elective colorectal surgery is associated with
a. No change
b. Decreased risk of surgical site infection
c. Decreased risk of anastomotic breakdown
d. Something about mortality/morbidity
No change in outcomes
repeat
22.2 A 21-year-old patient with a history of schizophrenia on quetiapine develops tremor, restlessness, hyperreflexia, nausea and vomiting in the post-anaesthesia care unit following an emergency laparoscopic cholecystectomy. Her heart rate is 80 / minute, blood pressure 130/90 mmHg, and her temperature is 37.0°C. The most likely diagnosis is
a. MH
b. NMS
c. serotonin syndrome
d. rhabdomyolysis
e. anticholinergic crisis
Serotonin Syndrome
Hyper reflexia
Usually has hypertension and hyperthermia
https://static1.squarespace.com/static/5e6d5df1ff954d5b7b139463/t/617242e2ab18df2dee31f417/1634878179720/ICU_one_pager_hyperthermic_toxidromes.png
