NMS - Casebook Flashcards
What should blood glucose be in the immediate Preop period? What can be done to ensure this?
Between 100-250
Hold oral hypoglycemics, give 1/2 or 2/3 of NPH/insulin on day of surgery
What type of patient may not be a good candidate for laparoscopic surgery, and open surgery be preferred?
Patients with poor pulmonary function (specifically COPD with high pCO2), as CO2 from insufflation gas may be absorbed to blood stream in excess
Which five factors predict risk for cardiac complications after vascular surgery?
- Q waves on ecg
- History of ventricular ectopy requiring treatment
- Hx of angina
- DM requiring medical therapy
- Age > 70
When should aspirin and NSAIDs be stopped in the Preop period?
Aspiring 7-10 days before surgery, NSAIDs 2 days before, to ensure normal platelet function
What ECG finding is highly suggestive of underlying ischemic heart disease?
Left bundle branch block (never a normal variant)
What should be done for a patient who is found to have afib preoperatively?
- Find underlying cause
- Cardio version or beta blockers
- Oral anticoagulant
What is the main surgical risk in a cirrhotic patient?
Inability to tolerate even mild sedation
Check lab values and physical exam signs of cirrhosis
What factors need to be optimized in a patient with cirrhosis and as it’s to undergo surgery?
- Decrease ascites with K sparing diuretics and salt and water restriction
- Decrease Child risk classification
- Normalize PT with vitamin K
- Alcohol abstinence for 6-8 weeks
What should be done if ulceration is noted over a hernia?
Sign of pressure necrosis, thus increased risk of rupture
expedite surgery
What is the risk of hernia leaking ascitic fluid?
Risk of SBP, get cell count and culture of fluid and start IV Abx
Repair hernia urgently
What is the likely cause of capillary oozing in a chronic kidney failure patient and how can you treat this?
Platelet dysfunction due to uremia
- Desmopressin (ddAVP)
- FFP
- PostOp hemodialysis
What is the most likely cause of hypotension in a kidney transplant patient postop with no signs of hemorrhage? How can you treat?
Glucocorticoid deficiency, as patients are usually on steroids
Give hydrocortisone 25mg intraop and 100mg over 24 hrs
What should all patients with valvular abnormalities getting surgery receive?
Prophylactic Abx for prevention of subacute bacterial endocarditis
What is the equation for calculating intraop fluid requirements?
(EBL x 3 mL isotonic fluid / 1 mL blood loss) + UO - IVF given in OR = 700
What is the risk of continued IVF in the recovery period following surgery?
Fluid overload, edema, pulmonary edema (as 3rd spaced fluid goes back into IV space)
What is suppurative phlebitis and how do you treat it?
Infected thrombus in the vein and around indwelling catheter
Tx: remove catheter, surgical excision of infected vein
How do you treat enteric fistulas in patients without signs of peritonitis? Wha situations change this management plan?
NPO, TPN, replete electrolytes, close monitoring of fistula output: and in time fistula will close on its own
Will not close if FRIEND: foreign body, Radiation dmg, Infection or IBD, Epithelialization of fistulous tract, Neoplasm, Distal bowel obstruction
What is the cause of a very high fever (e.g. 105F) 12 hrs post op?
Major atelectasis (one whole lung or multiple lobes)
Or large abscess by gas forming bacteria (like after penetrating trauma)
How should wounds suspicious for gas gangrene (clostridium perfringens) be managed?
High dose penicillin G, wound debridement, hyperbaric O2, tetanus immunization
How do you treat hypertrophic scars and keloids?
Hypertrophic scars that are expanding and keloids should be revised and treated with steroid injection and pressure padding
What factors are involved in wound healing and how?
- Platelet derived GF - brings in macrophages, fibroblasts and PMNs
- TGF B - increases collagen synthesis
- FGF - hastens wound contraction
How can you differentiate malignant vs benign lesions on CXR?
Malignant - coin lesions in >50 yo, spiculated surface
Benign - calcification, bulls eye, popcorn shape
Besides size and stage of a tumor what is another important factor in determining the type of surgical resection for a lung cancer?
Location, if a main stem bronchus is affected Pneumonectomy may be required
What differentiates stage 2 vs 3 lung tumor? Treatment differences?
Stage2 affects hilar and peri bronchial LNs, can treat with surgical rsxn
Stage 3 - mediastinal LNs, requires chemo and RT, possible rsxn if tumor shrinks
What must be ruled out in older patients with pleural effusion? On DDX?
Cancer!
Ddx: CHF, infxn, empyema, TB
What is the only tx that is potentially curable for mesothelioma?
Extra pleural Pneumonectomy- rsxn of lung, all pleura, possibly diaphragm and pericardium
> 10% MM, 30% recovery
What should be done if the lung does not reexpand following chest tube placement for a PTX?
- Check for proper tube placement or leak at site of entry
- Check for leaks at tubing connections
- If all normal then cause is large leaks from lung parenchyma from large blebs –> do thorascopic excision of blebs and pleural abrasion
What is pleurodesis? When is it used?
Irritation (by abrasion) of visceral and parietal pleura causing adherence and future pneumothorax
Pts with recurrent spontaneous PTX, bilateral spontaneous PTX, and PTX that doesn’t improve with chest tube placement
Echocardiogram reveals severe AS in an elderly patient. what workup must be done following this finding if evaluating for surgery?
- Cardiac Cath to check for coronary artery disease, valve size and pressure gradient, and ventricular function.
- Carotid doppler studies to rule out internal carotid artery obstruction
What is the cause of most deaths following heart transplant?
Infection related to immunosuppressive drugs and accelerated coronary artery atherosclerosis, (chronic rejection??)
What is an epiphrenic diverticulum? How do you treat?
AKA pulsion diverticulum, at distal esophageal gastric junction -fills w/ undigest food, gets regurgitated and may be aspirated
Tx: Excision and esophageal myotomy at EG jct
How do you treat a pharyngeal diverticulum?
Cervical esophagomyotomy - Transection of cricopharyngeal muscle, to relax esophageal entrance and prevent uncontrolled contraction
-Removal of diverticulum if large size
What is a Heller myotomy?
Distal esophageal dilation to treat achalasia (incision through muscular layers of lower esophagus)
How do you stage an esophageal tumor?
- Endoscopic ultrasound examination to determine WALL PENETRATION and adjacent LN enlargement
- CT scan of upper abdomen and chest for celiac node enlargement
What is the primary treatment for cervical and upper third esophageal tumors? Middle third?
- IRRADIATION - chemo as well (resect only if obstruction persists)
- Irradiation and chemo to downstage, which may allow for surgical resection
What is the most likely anterior mediastinal tumor that will cause progressive weakness of upper and lower extremity and double vision?
What are the most common tumors of the middle mediastinum? posterior mediastinum?
Middle - Lymphatic tumors and various cysts
Post - Neurogenic tumors, adjacent to vertebral bodies (from nerves and nerve sheaths - e.g. neurilemoma)
What major risks must be discussed prior to endarterectomy?
1-3% stroke risk, injury to hypoglossal, vagus and marginal branches of facial nerve
Most likely cause of death after CEA procedure?
MI
What should be done for patients experiencing a small stroke?
Carotid duplex studies, aspirin, observe for improvement
Endarterectomy as early as 2-4 weeks depending on favorable recovery, regaining or stabilization of neurological fxn
What are the common sites of lower extremity arterial occlusion?
- Common femoral artery
- Aorta, common iliac, popliteal
- External iliac
- Posterior artery
What needs to be done for a patient with occlusion of a lower extremity artery?
Administer heparin and take to OR for a balloon catheter embolectomy
What is a common occurrence following revascularization of an acutely ischemic limb? What are the symptoms?
Compartment syndrome (ischemia-reperfusion injury)
Postop calf tenderness and inability to dorsiflex toes
Which artery is most likely affected in a patient with claudication?
Superficial femoral artery, at the adductor hiatus
What does claudication with absent femoral pulse(s) indicate? What would this patient require?
Aortoiliac occlusive disease
-Do ABI and Doppler as per usual; but may also require ballon dilation or stent placement
What should be done for patients with very low ABIs presenting with foot or toe ulcers?
Revascularization most likely to allow adequate tissue perfusion and healing of ulcer
Amputation in patients with severely limited mobility, severely limiting CV disease or short life span
What repair can be done for occlusion of superficial femoral artery with distal reconstitution?
Reversed or in situ saphenous vein graft from common femoral artery to popliteal artery
What increases the chances of graft failure in vascular surgery?
More distal and more diseases vessels
How do you treat bilateral occlusion of common and external iliac arteries?
If limited stenosis, PTA (angioplasty). If bad Aortobifemoral bypass (axillary bifemoral if high risk)
How do you manage patients following vascular bypass procedures?
Heparinization and long term anti platelet therapy
What must be done for all patients before revascularization procedures?
Thorough cardiac assessment, possibly including: carotid duplex study, stress test, dipyridamole-thallium scintigraphy (DTS scan) or cardiac cath, depending on risk factors
How does the management of a perforated ulcer change depending on the patients history of symptoms?
- perf requires immediate surgery
- if no prior history of PUD, close perf with a graham patch
- if patient on H2 blocker therapy for PUD symptoms for many months close the perf AND do HSV or a V&P for definitive cure (antrectomy or ST gastrectomy not usually done)
What is a likely cause of fever POD3 in a patient following AAA repair surgery (occurs in 2-3% of patients)? How does this arise and how should you manage it?
Ischemic colitis from compromised collateral flow from SMA and hypogastric arteries from clamping
-Do immediate sigmoidoscopy, bowel rest, NGT, Abx, frequent exams (if mucosal injury only), resection and end colostomy (for full thickness involvement)
What must be evaluated in any patient with aortic grafting surgery who presents later on with upper GI bleed? How can you Dx?
Aortoenteric fistula - do endoscopy, CT abd, or angiography (fistula often in distal duodenum)
How do you monitor a patient’s DVT treatment?
Follow PTT and maintain 1.5-2 times normal value, administer Heparin to therapeutic levels
Evaluate PTT 6 hrs after first dose, every 8 hrs for next day, once a day after
What tests must be done in postop patients who complain of SOB?
-Focused H&P, ECG for MI, ABG (low pCO2 in PE from hypervent) and pulse Ox. CXR for PNA and PTX and atelectasis, perfusion lung scan if no Dx is made
What factors can complicate a V/Q scan for PE? What may need to be done in these situations?
- Atelectasis, PNA, PTX, COPD (anything affecting ventilation)
- Pulmonary angiogram may need to be done
A patient on heparin and maintained at a therapeutically anticoagulated level presents with an acute episode of SOB, low BP, ashen and cyanotic appearance. What should you suspect and how can you treat?
- Recurrent PE or acute MI
- Do Pulse ox, ECG, ABG and CXR, check cardiac enzymes and PTT
- if PE confirmed (likely in this case) will require Greenfield IVC filter (this is a failure of anticoagulation therapy)
What is phlegmasia cerulea dolens? How do you treat?
“inflammation, cyanosis, painful” - acute interruption of venous outflow from obstruction 2/2 a pelvic malignancy
-Extreme form of ileocaval DVT, can impair arterial inflow to leg
Tx: anticoag and leg elevation, careful observation of tissue viability (duplex US and CT of pelvis, and rarely venous thrombectomy)
What is essential to patients being evaluated for patients refractory to GERD medical therapy being considered for surgery?
- EGD with biopsy and esophageal manometry (to demonstrate intact esophageal peristalsis, to ensure patient can swallow normally postop)
- Cine-esophagogram to visualize entire esophagus if dysphagia or short esoph suspected
- pH monitoring
What should be done for a patient found to have Barrett’s esophagus?
- H2 blocker therapy and PPIs to control reflux
- Surveillance EGD and biopsy every 1-2 years to determine if Barretts progresses to dysplasia
What should be done if distal esophagous biopsy shows barrett esophagous with severe dysplasia?
- Confirm diagnosis with experienced pathologist
- Distal esophageal rsxn
What is the positioning of a type II hernia and what is the danger of this condition?
- Stomach herniates into chest, GE jct in normal location
- Very risky, stomach can become strangulated and necrose (gastric volvulus)
- Surgical repair necessary
What is the utility of bismuth in H. pylori treatment?
Interferes with organism adhesion to gastric epithelium, inhibits organism’s urease phospholipase and proteolytic activity (bismuth + tetracycline + metronidazole + omeprazole has 98% eradication rate)
What is the indication for surgery in PUD affecting duodenum?
What are the surgical options?
-If Tx given for H. pylori (up to 8-12 weeks), failed medical therapy, and persistent/enlarged ulcer on f/u EGD
Tx: Highly selective vagotomy, truncal vagotomy and pyloroplasty, or vagotomy and antrectomy (HSV is the BEST)
What are the 4 different types of gastric ulcers and how are they differentiated?
Low acid output - related to breakdown of gastric mucosa (ask about NSAID or steroid use)
Type I - at incisura angularis on lesser curvature
Type IV - at gastric cardia
HIgh acid output - surgical treatment requires truncal vagotomy b/c of high output
Type II - antral ulcer + duodenal ulcer
Type III - prepyloric ulce
What needs to be done for persistent non-healing gastric ulcers that fail medical therapy?
- MUST BIOPSY to rule out malignancy
- if benign c/w medical therapy for 8-16 wks
- malignant or >16 weeks usually require surgical resection by partial gastrectomy (antrectomy), and even earlier if giant ulcer (>5cm)
- Vagotomy is not performed for gastric ulcers
What is the surgical treatment for ulcers near the GE jct?
- Distal gastric rsxn with vertical extension to include lesser curvature and gastrojejunostomy
- Roux en Y esophagogastrojejunostomy
What must be done before surgical resection of a gastric cancer?
- Staging via CT to assess distant mets or LN spread, Endoscopic US to evaluate depth or lymphatic involvement
- Laparoscopy may also be used for staging
What worsens the prognosis of gastric cancer?
Penetration through submucosa and presence of positive LNs
What is the prognosis and treatment for gastric cancer at the GE junction?
Worse prognosis, requires 6 cm distal gastric resection and esophagogastrectomy with reanastomosis using colon or small bowel interposition graft
What should be done first when suspecting a perforated ulcer? What is a typical exam sign for chemical peritonitis?
- Upright abdominal radiography or CXR to look for free air under diaphragm
- pt usually with rigid abdomen
What key factors alter the surgical management of perforated ulcer?
- TIME - if perforation occurred >12 hrs ago (fibrinous exudate and peritoneal cavity infection) do only graham patch, thorough debridement, Abx, ICU care, ulcer ppx with PPI
- History of symptoms - if Hx of PUD also do HSV or V&P
- NSAID/Steroid use - stop meds, but if they can’t, V&P is necessary
How would you manage a young woman getting treatment of pneumonia in ICU who develops UGI Bleed?
Initiate H2 blockade, sucralfate or antacids, with gastric pH monitoring (start these early if Hx of PUD)
Give misoprostol if on NSAIDS
How do you manage bright red blood coming from an NGT?
- RESUSCITATE - 2 large bore IVs, type and cross match blood
- NG lavage until no blood return
- H2 blocker, monitor gastric pH
- Endoscopy to determine source once stabilized
What is the management of a duodenal ulcer with adherent clot and visible artery at the base?
If this recently bled a lot, This has 40% chance of rebleed. Must be operated on within 1-2 days to prevent
What special considerations must be made for bleeding duodenal ulcer in a patient with acute renal failure (CR = 6)?
Platelet dysfunction caused by uremia may contribute to bleed. Give dialysis and desmopressin (ddAVP)
What is the difference when doing surgery for actively bleeding gastric ulcer vs duodenal ulcer? If no active bleed?
- excision rather than oversewing is necessary
- all gastric ulcers not excised warrant biopsy 2 weeks after stabilization
What are the options for treating gastric varices?
- banding and sclerotherapy, but not very effective
- cyanoacrylate glue may be better
- TIPS or splenectomy may be for non improving active bleeders
What is the likely cause of gastritis and gastric varices with a history of chronic pancreatitis? How can you treat?
Splenic vein thrombosis causing left sides portal (sinistral) HTN is very likely
Tx: splenectomy
When is balloon tamponade used for esophageal varices?
Massive uncontrollable bleeding temperature stops bleeding but patient must be intubated to prevent aspiration. High rate of rebleed likely. TIPS or Portosystemic shunt are definitive
How does staging determine treatment for gastric lymphoma?
- Helicobacter eradication if MALT lymphoma
- Stage 1 and 2 resect and possible RT and chemo
- 3/4 require chemo radiation
Which patients with asymptomatic gallstones may require prophylactic removal?
Immunocompromised, porcelain GB, stones >3cm
What is the most feared complication of cholecystectomy?
Common duct injury which can cause chronic biliary strictures, infection and cirrhosis.
Hepatic artery injury, may cause hepatic ischemic injury or bile duct ischemia and stricture
What is the best management of cholelithiasis in pregnant women?
- hydration and pain management for first episode
- if recurrent episodes, acute cholecystitis, obstructive jaundice, or peritonitis, can do surgery or ERCP
- prefer 2nd trimester for surgery
What must be done other than cholecystectomy if a patient has biliary pancreatitis? What if this involves symptoms of pancreatitis?
Cholangiogram
With symptoms, cholecystectomy must be delayed until patient stabilized; ERCP done if common bile duct stone
What is suppurative cholangitis?
Bacterial infection with gas forming bacteria. with bile duct obstruction
What is the best treatment for suppurative cholangitis?
Emergent ERCP with sphincterotomy, decompression of the biliary tree and stone removal
What is an alternate way in which elderly patients may manifest signs of sepsis?
Hypothermia and leukopenia
What is the management of acute cholangitis?
- IVF, Abx and ultrasound of biliary tree
- if obstructed or dilated, do ERCP or biliary decompression
What is a possible cause of acute cholangitis in a patient with previous cholecystectomy?
If Chole was 2 years primary duct stone, or Biliary stricture from common bile duct injury
What is the treatment for biliary structure?
Choledochojejunostomy
What does postop Fever following lap Chole indicate? What tests should be done ?
Infection or biliary leak
Do US and/or HIDA scan (BR must be
What must be determined before proceeding with any surgery for a pancreatic mass?
Acceptable general medical condition, no evidence of distant metastasis, normal chest x-ray, no neurological symptoms or bone pain
What factors determine unresectability of a pancreatic tumor?
Lymph node metastasis in the periaortic or celiac region, tumor involvement of the inferior vina cava, aorta, SMA/V, portal vein
What is a Klatskin tumor and how will it present? How can you diagnose?
Cholangiocarcinoma; intrahepatic biliary obstruction but no extra hepatic biliary obstruction the
Dx: ERCP or percutaneous transhepatic cholangiography
How can you treat ampullary or duodenal adenocarcinoma, what is the prognosis?
Whipped (or rsxn if duodenal and away from ampulla)
65% for ampullary, worse for duodenal
What is the Ranson criteria and what does it predict?
Assesses mortality risk for sever necrotizing pancreatitis:
Age >55,WBC>16K, glucose >200, LDH>350, AST>250
After 48hrs: Hct down 10%, BUN up 5, Ca 4, fluid sequestration >6
3 criteria = 28% mort, 5-6 = 40%, 7-8 = 100%
When should you worry about pancreatic abscess? How can you best identify?
S/S of sepsis, fever, leukocytosis, septic shock a few days after episode of severe pancreatitis
Get CT with contrast
How do you best control bleeding from eroded vessels associated with severe pancreatitis ?
Do angiograph to confirm, embolize bleeding vesssel
What S/S are associated with pancreatic pseudocyst?
Young alcoholic, initially recovers from acute pancreatitis, gets continued abd pain, persistent amylase high, inability to eat from early satiety
What is the initial treatment of pancreatic pseudocyst? Unresolved?
NPO, TPN and observe, as long as no infection present
If no improvement after >6 weeks, drain by cystogastrostomy
What are the general guidelines for removal of benign hepatic masses?
Symptomatic lesions, lesions with risk of spontaneous rupture, lesions with uncertain diagnosis
What is the best way to diagnose hemangioms?
Labeled RBC scan
Bolus enhanced dynamic CT or MRI can also confirm
What is the management for hepatic adenoma’s?
Watch for regression after discontinuation of OCPs
resect persistent or large lesions (to prevent rupture or development into HCC)
What should be suspected in SBO with no previous history of surgery?
Hernia, small or large bowel tumors, tumor mets to bowels or inflammatory process
What is the most common tumor to metastasize to intestine?
Melanoma
What should be considered in a patient with SBO who has localized tenderness with rebound? leukocytosis? metabolic acidosis?
First two - May warrant urgent surgical exploration: closed loop obstruction, perforation, ischemia, abscess
Met acid - ischemic or necrotic bowel (do urgent explore or mesenteric arteriography)
What are the signs of necrotic or ischemic bowel? What should you do if suspecting this?
- signs of SBO with elevated white count and mild fever, severe pain
- if symptoms are severe and thinking necrotic bowel go right to operating room
- if patient stable do sigmoidoscopy and mesenteric angiogram
How may CHF affect bowel function and how can you treat this?
Low flow nonocclusive state causing mesenteric ischemia, give direct mesenteric infusion of vasodilator
What should be done if ischemic bowel is questionable on exploratory laparotomy?
Finished the procedure, with diversion if necessary, and do a second look operation to investigate viability of the bowel segment(s) in question
What test should be done if a carcinoid tumor is found? How can you identify recurrence of such tumors?
Get baseline urinary 5HIAA and serotonin levels
CT scan of abdomen and octreotide scan
What should bowel strictures with ulcerative colitis raise suspicion for?
Cancer
What are the principles of surgery for long standing SBO from stricture from Crohn’s?
- Relieve obstruction - resect involved bowel if possible\
- Preserve as much normal bowel as possible
- Stricturoplasties for multiple strictures and recurrent obstructions
What are the risks of impaired bile acid absorption as in ileocecal surgery in Crohn’s?
Diarrhea, depletion of bile salt pool, malabsorption, oxalate stones
What medical treatments help with Crohn’s disease limited to the colon?
5-ASA compounds with steroids
What is the curative procedure for ulcerative colitis that has the highest success rate?
Total proctocolectomy with creation of ileal pouch and anastomosis of pouch to anus
How do you best treat pouchitis for patients with ileal pouch following proctocolectomy?
Metronidazole
What is the treatment for toxic megacolon?
NGT, NPO, TPN, IVF and broad spectrum antibiotics
IV steroids, freq abd exams and radiographs
Surgery if failed to improve in 3-6 days
Which patients are at risk of sigmoid volvulus and how can you treat?
Elderly, demented, nursing home, chronic laxative use
Barium enema + rigid proctosigmoidoscopy and rectal tube
What is the treatment of Ogilvie’s syndrome?
Endoscopic decompression and possibly neostigmine (may increase colonic tone and counteract dilation)
Surgical decompression of cecum or right colectomy, if those don’t work
Which histological features are associated with papillary and medullary thyroid cancer?
Medullary - amyloid deposits
Papillary - psammoma bodies
What determines the type of resection for a thyroid papillary cancer?
History of previous radiation to head and neck warrants total thyroidectomy.
No radiation a lobectomy will suffice
Which thyroid tumors warrant total thyroidectomy?
Any thyroid tumor in person with history of radiation to head and neck, follicular cell cancer >1cm, micro invasive follicular carcinoma >4cm, all medullary cancers
What are the variables that determine the prognosis of papillary cancer?
AGES - Age (40), Grade, extent of disease, and size of tumor
How can you monitor medullary cancer of thyroid?
Measure serum calcitonin and CEA levels
What treatments will not be effective for medullary thyroid cancer, and how can you treat?
Radioactive iodine and thyroid suppression post-op are not useful. Radiation may help
What is the initial treatment of acute hypercalcemia?
- Hydration with normal saline
- Calcium diuresis with furosemide
- INitiation of bisphosphonates
- Treatment of underlying cause
What is the indication for surgery in secondary hyper parathyroidism?
Bone pain fractures intractable itching or ectopic calcification in soft tissues
What imaging modalities are useful for identifying pheochromocytoma tumors that are difficult to localize?
Octreotide scan or nuclear M I BG
What is the most likely cause of a swollen and tender thyroiditis gland in a young female? Treatment?
De quervain’s thyroiditis
Analgesics and aspirin, steroids in some cases
What is the appropriate treatment for an unresectable insulinoma?
Diazoxide, inhibitor of insulin release
What are indications for further investigation and or possible resection of incidentalomas?
Lesions >5 cm, look for lung cancer bc adrenals are common met site, check cortisol, K+, catecholamines
