Missed Qs Flashcards
Severe acute pancreatitis
Multiple Organ Failure, defined as: SBP < 90 Cr > 2.9 GIB PaO2 < 60mmhg Local complications: hemorrhage, abscess, pseudocyst
Sigmoid volvulus
Coffee bean appearance Points to RUQ Elderly who take psychotropic rx Colonic decompression High recurrence, so likely will need colectomy with primary anastamosis`
How many weeks of rx mgmt for ulcers before surgery?
12 weeks
Malignant facial mass
Modified radical mastectomy
How many LN do you need for colon cancer resection?
12
Which vasculature do you need for R side colon cancer?
all the way up to the R branch of the middle colic
If doing a left hemicolectomy, what vasculature do you need to ligate?
High ligation of the IMA
Norepinephrine has what effect?
All alpha and BETA-1! So increased contractility and sphlanchnic vasoconstriction
What is the tx for invasive inflammatory cancer?
Neoadjuvant CXRT, MRM (mastectomy + ALND) + XRT +/- endocrine theory
Ureter injuries b/w UPJ and UP brim (upper 1/3)
Ureto-uretostomy with debridement
Ureter injuries distal
Reimplantation into the bladder
If U-Urertostomy is not possibnle in a HD unstable patient, do..
a trans-u-uretostomy
What sizes of extremity tumor do you differentiate b/w excisional vs longitudinal incisional bx?
4cm
If a extremity tumor is < 4cm
excisional bx
If an extremity tumor is > 4cm
longitudinal incisional bx
Do you need negative margins for LCIS?
No because it’s not premalignant.
What do you need to talk to patients about if they have LCIS?
Ppx b/l mastectomy
What is GIP released by?
K cells
What does GIP do?
Stimulate insulin
What does pnuemoperitoneum do to lungs?
Decrease FRC
DCIS Comedo type characteristics
- central necrosis 2. lack of cribiform architecture 3. mitotic figures
What type of hip location is more common? A or P
Posterior
How do anterior hip location present?
ABduction and ER external rotation
What happens in Mag tox?
Everything goes down! Brady, loss of DTR, hypotension, flaccid paralysis
When you have ovarian carcinomatosis, what is the optimum ovarian residual you want for debulking
1cm
When do you consider splenic preservation in distal pancreatic ca?
benign (NOT AC!) lesions trauma NE tumors
Pericardial window approach?
8cm vertical incision along the subxiphoid
What nutritional marker is better for acute stress?
Pre-albumin, given its half life of 2 days (instead of 20 for albumin)
Glomus tumor
Fingernail, sensitivity to cold, pain on palpation (Love sign), blue-purple mass
An aggressive variant of fibroepithelial lesion is concerning for
Phyllodes tumor
PPI side effects
PNA, gastric cancer, OA-related hip fx
What is the treatment for afferent loop syndrome
Surgery
Hereditary diffuse gastric cancer
CHD1, ppx surgery b/w 18-40
How do you divide a carotid body tumor
Through a sharp knife adventitial plane
What type of arteriotomy do you do for a embolectomy?
Transverse
What type of diet should hepatic failure patients get?
Low in aromatics and high in branched chain LIV
What is a cutting seton? Indication
After draining seton. Tightened over regular intervals to cut the tissue
What is the order of operations for AV fistula
Radiocephalic, brachiocephalic, brachiobasilic, AV graft, then other arm
What are the steps to a Witzel?
Pursestring suture, make your enterotomy, insert catheter, tie the purse string shut. Create a serosal tunnel. Pexy to peritoneum. Bring out the stab incision.
What types of burns are blanchable?
First and superficial second degree
What is the oxygen extracction ratio
(CaO2-CvO2)/CaO2
What are the causes of afferent loop syndrome
Volvulus, adhesions, torsion. This is a surgical emergency.
What is Allen’s test? When do you do it?
Assesses collateralization b/w radial and ulnar palmar branches. Do before every radial artery catheterization
What type of arteriotomy do you perform for a embolectomy?
Transverse (reduces stenosis)
How do you treat an uncomplicated groin pseudoaneurysm?
US guided thrombin injection into the pseudoaneurysm directly
When do you use ppx abx in cirrhotics? (2)
GI hemorrhage and low protein (<10)
What anticoagulation metric do you use during a CABG?
ACT- Activated Clotting Time (goal 400-500 seconds)
What population do you consider an emergent trach in vs a crich
Pediatrics! (cricoid is too narrow)
What is the definition of power
1-beta (1- type 2 error) the probability of rejecting the null when there truly is a difference
What is the gold standard for diagnosing reflux-induced respiratory complaints?
Dual ambulatory pH probe
What are the types of gastric carcinoid tumors?
Type 1- slow growing, associated with chronic gastritis, rarely met Type 2- ZES, slow but met Type 3- fast, met
What are the risk factors for failed TRAM flap
Smoking and obesity
What is the most important survival factor for adrenal ca surgery?
Adequacy of resection
What is the treatment of TTP?
Plasmapharesis FAT RN symptoms
What type of incision for a felon?
Vertical incision
What is the superior imaging modality for peri-ampullary mass?
EUS
What is the false positive rate of PET scans?
10-20%
Lab findings for lymphoma
Elevated LDH, beta 2 microglobulin
What is the difference b/w primary and secondary contraction in grafts?
Primary- immediate, d/t skin elastin (more in full thickness) Secondary- wound bed over time (more in split thickness)
What are the Siewart classifications of the stomach cancer?
- Type 1- within 1-5cm from GEJ 2. Type 2- within cardia 3. Type 3- below cardia Treat Types 1 and 2 like Esophageal cancer, have to do esophegogastrectomy
When is resection for non small cell cancer contraindicated
N3
What is the Haggitt classification
Invasion of cancer into polyp 1. Head 2. Neck 3. Any part 4. Sessile polyps
What is the treatment for SMA syndrome?
Duo-J
What size tumor for pseudomyxoma peritonei do you have to debulk?
2mm anything less you can just HIPEC (41degreesC)
What state of cells reduces radiation treatment
hypoxic (O2 prolongs free radicals) G2,M are hte most sensitive n
What type of feeding do you give to the stomach? Jejunum?
Bolus to stomach, intermittent or continuous to everything else
What type of sutures for the heart?
Pledgeted, non-absorbable
What type of cardiac repairs require ECMO?
Coronary artery
How do you repair peripheral lung trauma?
Wedge resection
Can you transect the hepatic artery?
Yes because collateral blood flow from portal system
Tx of pneumatocele in HDS patient
Leave alone, but watch because it can get infected
Subclavian access
R: median sternotomy L: anterolateral thoracotomy
How do you repair a diaphragmatic injury?
Abdominal approach, interrupted horizontal mattress, non-absorbable sutures
What’s the best way to control pain for flail chest patient?
Epidural (reduce chance of intubation for elderly)
What injury are you concerned about for neck seatbelt sign?
Laryngotracheal injury
What is the ideal tidal volume for intubated patients?
4-6ml/kg of IDEAL body weight
Which renal vein can you ligate?
LEFT, because of collaterals. Right you have to do nephrectomy
What ventilator patients should NOT get a percutaneous dilation tracheostomy?
High reqs- FiO2>60% or PEEP > 12mmHg
What do you do with a RP bleed that is not stopped with a Pringle?
Pack it
Occluded renal artery in a HDS patient
Observe (revascularized patients don’t do well)
What is a complication of mid thoracic esophageal injury during endoscopy?
TENSION PTX!
What are normal CO levels?
5% nonsmokers 10% smokers 20% AMS 60% brain death
When should you close a fasciotomy?
7-10 days, otherwise you will need a skin graft
What do you do for penile shaft injuries?
Put in a foley and primary repair
What is the management for fight bites?
Admit, IV ABX d/t concern of deep space infections, septic arthritis, osteo
what type of collagen is in keloids? hypertrophic scars?
Keloids= disorganized type 1 and 3; hyperstrophic=type 3
What to do for a simple PTX patient before surgery?
Chest tube! Risk of tension PTX during positive pressure
what type of surgery for mid thoracic esophageal injury?
RIGHT POSTEROLATERAL incision
Rehab for Tendon rupture in finger
Active rehab (although concern for risk of tendon rupture)
What to look for if gluteal injury in trauma?
Vaginal, rectal, urethral imaging
What do you have to do if you ligate the IVC?
Elevate legs, wrap them, fasciotomy if pressure > 30mmgHg, prevent edema at all costs
IVC repair in HDS patient
Vein patch! Just make sure you prevent hourglass narrowing of IVC, which can cause thrombosis
What type of bacteria infect catheters of short gut patients?
GNR
What are you concerned about long term after caustic (lye) injury to esophagus?
SCC 15 years down the road. Get endoscopic surveillance then
How many LN do you need to resect for colon cancer?
12
What type of incision do you do to expose the trachea and mainstem bronchi?
RIGHT thoracotomy for both (left for distal left bronchus)
What is diagnostic for DPL?
100,000RBC/mL, 10mL blood, 500 WBC/mL
What is jersey finger?
Tendon of flexor digitorum profundus. Need surgical repair!
Simple extra-peritoneal bladder management? Complicatd?
Simple= Foley. Complicated= open surgery. Complicated defined as vaginal or rectal damage, unstable pelvic fx with concern of bone in bladder, uncontrolled hematuria
Extending zone 1 neck injury incision should go to?
Median sternotomy
Benefit of spleen preserving distal panc
Shorter hospital stay (no mortality benefit)
Chronic steroid use
Poor wound healing. Lysosome stability. Treat with vitamin A
When after post-splenectomy patient do you give vaccines? Follow up?
within 2 weeks after trauma (2 weeks before for elective). 4-6 years later after operation you need additional pneumo and meningo vaccs. Also again at 65.
Mgmt for radial artery occlusion? Ulnar?
Radial= observe Ulnar= revascularize
What types of aortic zone injuries need to be reexplored?
All penetrating Zone 2
What do you do if youre concerned intra-op about an esophageal injury but cant see it?
Flex esophagoscopy
Perimortem C section?
< 4 minutes, but no latera thn 20 minutes
What is the concern about a mesenteric tear?
Internal hernia
What margins do you need for gastric cancer?
`5cm margins
What are the microsatellites for Lynch syndrome?
MSH2, MLH1
What is ipilimumab?
CTLA-4 mAb
What is the purpose of omental sling?
To reduce radiation colitis
Mechanism of HER2+
Tyrosine kinase
When do you start screening for Lynch?
Age 20. Coloscopy and endomatrial TVUS
When is it okay to omit radiiation therapy in breast cancer?
Age 70, T1, ER+ so getting hormone therapy, no other cancer, no nodes
Breast acncer over nipple. Mastectomy?
Neo-adjuvant chemo first to reduce size
What is Li Fraumeni associated with?
p53 and hCHK2
What is bevacizumab used for
VEGF. Angiogenesis
FOLFOX indications
Colorectal cancer Fluoro-uracil Oxiplatin Leukovorin
What does cetuximab do?
EGFR bind
for monoclonal Ab, what is constant and variable
Human is constant, murine is variable
What is Bev Fox
used for metastatic colon cancer
What is the dose for c diff rx
Oral vanc, 125mg QID PO x 10 days
Dx for chylothorax
Pleural TG > 110mg/dL
What are the T stages for lung cancer
T1= <3cm, T3 >3cm but >2cm away from carina, T3 close to carina or local pleural/pericardial invasion, T4= great vessel invasion
What is SVC syndrome on CT
Non-opacification inferior, and opacification of collateral vessels of the chest
What is the result of histoplasmosis
Fibrosis mediastinitis
What T stage is pleural effusion malignant
T4. No resection
How often will sPTX reoccur
60%
chylothorax in a poor surgical candidate
angioembolization
What is the tx for small cell lung cancer
Etoposide, cisplatin
What is the tx for non-small cell
Taxol, carboplatin
What mediastinal structures are anterior
Innominate a/v, R pulmonary atery
What do you do for malignant SVC syndrome
XRT
What are the types of bronchial adenomas
Mucous, Mucoepidermoid (both slow, not many mets) Adenoid (fast, responsive, perineural invasion)
What size PTX do you do a hest tube
3cm
Palliative thoracentesis
Tunneled pleural catheter
How much fluid is required to show blunting of the costophrenic angle
300mL
What is the most common cardiac tumor in kids
Rhadomyoma. Associated with tuberous sclerosis. Often multiple.
How do you treat HOCM
Fluid resus and beta blockers
What lab value will you see in CBD distal tumors
Vitamin K deficiency –> increased PT
How do you treat proximal bile duct injury
HJ
How do you test Sphincter of Oddi dysfunction
Morphine/Neostigmine (Nardi) test
How do Klatskin tumors present
Painless jaundice and pruritis
What is cholesterolosis
no shadow, pedunculated, hyperechoic, non mobile
when do you ppx cholecystectomy
sickle cell patients not in active crisis
Tokyo guidelines for GB
Grade 2 disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 hours; and imaging studies indicating significant inflammatory changes in the gallbladder. Grade 3 (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.
Gallstone ileus, repair
2 surgeries. Take out stone. Let cool down. Then do repair of fistula. But watch out risk of cholangitis.
GIST
CD117, C-kit, Interstitial cells of Cajal (NE)
submucosa involvement. Will look like a posterior wall bulge with normal mucosa.
R0 margins
