Old Exam Questions 2 Flashcards
After an uncomplicated appendectomy for acute appendicitis, pathologic exam reveals a carcinoid tumor in the specimen. All of the following are indications for repeat operation and R hemicolectomy EXCEPT
A. Tumor size <1 cm B. LVI C. Presence of goblet cell features D. Invasion of the appendiceal mesentery E. Tumor location at the base of the appendix
A
Neuroendocrine tumors (NET aka carcinoids) of the appendix are the most common malignant neoplasm of the appendix. Histologically identified in <1% of appy specimens, they are typically dx post op as an incidental finding on path review.
Indications for R hemi, regardless of tumor size, include LVI, presence of goblet cells, invasion of the appendiceal mesentery, and tumor location at the base of the appendix. With tumor size as the most important prognostic factor for risk of mets, repeat OR with R hemi should be performed for NET >2 cm. Mgmt of NET between 1 and 2 cm is controversial; R hemi should be considered b/c up to 1/2 of pts may have regional LN mets. Long term follow up incl plasma chromogranin A levels and CT imaging at 6 and 12 months post op and then annually
36M has an abdo CT scan after MVA. No injuries are found but his bp is 160/100 mmHg. The CT scan shows a 3 cm adrenal mass. Appropriate initial biochemical evaluation should include all of the following except
A. Plasma metanephrines B. Plasma aldosterone level C. Low dose overnight dexamethasone suppression test D. Plasma renin level E. Serum ACTH
E
Adrenal mass incidentally discovered for nonadrenal indications is often called an adrenal incidentaloma. Patients with identified adrenal mass should be evaluated for risk of malignancy and hormonal activity. Pts with hyperfunctioning or potentially malignant tumors should undergo adrenalectomy.
Biochemical eval is performed to dx hormonally active tumors, including pheo. aldosteronomas, and cortisol producing adenomas.
Plasma metanephrines and normetanephrines are the most sensitive markers for pheo; levels 2x N or higher dx. If doubt of dx, 24 hr urine metanephrines and catecholamines should be done.
Concern for primary aldeosteronoma, characterized by HTN and hypokalemia, should be evaluated with plasma aldosterone and renin; an aldosterone to renin activity ration > 20 is suggestive of dx. Confirmatory 24 hr urine aldosterone should be performed.
Hypercorticolism from an autonomously secreting tumor is best dx with a low dose overnight dexamethasone suppression test. a single 1 mg dose of dexamethasone is given at 2300 followed by a morning cortisol level; if this does not suppress the morning cortisol level to less than 5, confirmatory testing with 24 hr urine free cortisol should be performed.
Biochemical eval includes plasma metanephrines. plasma aldosterone, low dose overnight dex suppression test and plasma renin. Screening ACTH is not indicated at this time. Midnight salivary cortisol determination can also be used to dx hypercortisolism. If hypercortisolism is confirmed, an ACTH would be required to ensure the adrenal mass and not the pituitary or an ectopic source is the cause of the elevated cortisol
73M undergoes lap for perf’ed diverticulitis with widespread feculent peritonitis. Resusc incl 7L crystalloid and 2 units PRBCs. At lap, diverticulitis is identified with free perf of the sigmoid and widespread feculent peritonitis. Pt continues to receive fluid resus and requires norepi to maintain SBP >90. Indications to perform a damage control procedure include all of the following except
A. Arterial pH <7.2 B. Plt count <50 C. PTT >50% of normal D. Temp <35 E. Lactate > 5
B
Damage control surgery is used in pts who are in extremis and dying due to the triad of hypothermia, coagulopathy and acidosis. Limit the operation to essential interventions, namely controlling hemorrhage and limiting enteric contamination and to return the pt to the SICU for physiologic restoration.
Common indications include arterial pH <7.2, PTT >50% of normal, Temp <35, lactate >5, and base deficit > 15 mmol/L (or >6 mmol/L in pts >55 yrs). PLt count is not typically used as a variable in the decision process. Once pts are resusc and their lab parameters have normalized, they are returned to the OR for definitive repair and closure of abdo
All of the following are indications for elective splenectomy in adults except
A. Hairy cell leukemia with splenomegaly
B. Warm autoimmune hemolytic anemia without response after 3 weeks of steroids
C. Persistent thrombocytopenia in ITP after failure of medical mgmt
D. Severe neutropenia with Felty syndrome
E. Persistent anemia requiring transfusion with hereditary spherocytosis
A
Splenectomy may be considered for multiple hematologic disorders.
Warm autoimmune hemolytic anemia is most comomnly dx between age 40 and 70. Initial tx is with corticosteroid therapy (up to 2 mg/kg/day); improvement in Hb is typically seen within 1 week and remission occurs in up to 60%. If remission does not occur within 3 weeks or if hemolysis is not controlled with low dose of steroids (15 mg/day), splenectomy is indicated
ITP is characterized by circulating antiplatelet antibodies that bind plts resulting in thrombocytopenia due to macrophage clearance in spleen and liver. Pts with ITP present with N sized spleen. petechiae, and purpura. Secondary causes that should be excluded include HIV< SLE, antiphospholipid antibody, hep C, lymphoproliferative d/o, cocain, gold, heparin, quinidine, and certain abx and anti-HTNs. Initial tx is medical. Prednisone at 1-1.5 mg/kg/day is administered once plt counts are < 20-30; although 50-75% of pts will iniitally respond to steroids, more than 80% will relapse. Pts who fail steroids may be tx with IVIG and rituximab. Splenectomy is indicated for those who fail medical mgmt.
Felty syndrome consists of neutropenia, splenomegaly and RA. Neutropenia is caused by immune complexes coating the WBCs with resultant sequestration and clearance by the spleen. Initial tx is MTX, corticosteroids, and antirheumatic drugs. Splenectomy is indicated in pts with severe neutropenia or failed medical therapy with recurrent infections.
Hereditary spherocytosis, an autosomal dominant d/o, is the most common RBC membrane d/o in NA. Spherical erythrocytes are destroyed by the spleen, resulting in hemolytic anemia. Although some pts may have a mild form of disease with only mild jaundice, those with persistent anemia, particularly pts requiring repeated transfusions, should undergo splenectomy. To reduct the risk of overwhelming postsplenectomy infection, splenectomy may be delayed in pts <5 yrs.
Splenectomy was originally adovocated for tx in hairy cell leukemia with up to 70% improvement. new purine analog tc with pentostatin and cladribine has become tx of choice with 80-90% remission rates. Splenectomy is no longer performed as part of staging laparotomy for pts with Hodgkin lymphoma
All of the following can be used as first line therapy for ongoing bleeding from esophageal varices except
A. Endoscopic band ligation B. IV beta blocker C. TIPS D. IV somatostatin E. IV vasopressin
C
Pts who present with UGIB from esophageal varices need to be stabilized rapidly and a definitive dx and hopefully therapeutic procedure will need to be performed expeditiously. Airway control with intubation may be necessary for emergency endoscopy. Two large bore IVS should be placed and resusc with NS whould be begun. Pt should be typed and crossmatched and coag profile and CBC sent.
Pts with a hx of esophageal varices may already be on a nonselective beta blocker for ppx again variceal bleeding. This may be continued if they are hemodynamically N after volume resusc.
Vasoactive drugs, such as somatostatin and vasopressin, should be started if variceal bleeding is suspected. When using vasopressin for severe variceal hemorrhage, a nitroglycerin drip may be beneficial to counteract the severe vasoconstrictive properties on the coronary vessels.
Endoscopic band ligation in combo with pharmacotherapy has beomce a mainstay in tx of acute variceal bleeding. It can be effective in >85% of pts. Although sclerotherapy is also possible, the complictions exceed those of band ligation, thereby making ligation the preferred technique. TIPS should be used in hemodynamically N pts who are refractory to medical and endoscopic mgmt.
All of the following statements about closure of abdominal wounds are true, EXCEPT
A. Continuous closure with rapidly absorbing sutures has a significantly higher incisional hernia rate compared with continuous closure with slowly absorbing suture closure
B. Abdominal wall closure with continuous nonabsorbable sutures has a higher incidence of suture sinuses and prolonged wound pain compared with absorbable suture closure
C. Significant differences in the incidences of incisional hernia are found between continuous and interrupted abdominal wall closure
D. Midline incisions should be closed with suture length to wound length ratio of at least 4 and a stitch length <1 cm from wound edge
E. When a long stitch length is used, bites of >1cm from the edge can lead to higher incidence of wound infections and incisional hernias
C
Statistically sig incr in ventral incisional hernia when rapidly absorbing sutures are used as opposed to slowly absorbing sutures in continuous midline closures. Failed to prove differences in rates with continuous slowly reabsorbing sutures adn nonabsorbable. Incr wound pain and suture sinuses when using nonabsorbable sutures. Did not shows any significant difference between continuous and interrupted midline abdominal wall closures. Most studies favored continous b/c of ease and decr OR time.
Suture length to wound length ratios of <4 might incr the risk of ventral incisional hernia. Recent prospective RCT comparing short stitches (5-8 mm from wound edges) with long stities (>1 cm from wound edge) demonstrate shorter stitches at shorter intervals have a significantly lower rate of surgical site infectinos (SSIs) and incisional hernias. Can be assoc with an incr in OR time. Longer stitch is also assoc with a significantly higher incidnece of SSIs and incisional hernias on multivariate analysis. Postulated mechanism of higher SSI and hernia formation with longer stitches suggest that longer stitches cut through or compress tissue, leading to necrosis and surgical site infection, such as slackening and eventual hernia formation.
Each of the following is true about paraduodenal hernias EXCEPT
A. Paraduodenal hernias may present to the L or R side of the duodenum
B. L sided paraduodenal hernias are encased in a peritoneal sac that lies between the stomach and pancreas
C. Majority of pts with paraduodenal hernias present with SBO
D. Pts with paraduodenal hernias may present with chronic intermittent, non specific GI symptoms
E. Paraduodenal hernia presenting on the L side accounts for 75% of reported cases
C
Internal abdominal hernias not related to acquired adhesions are rare. >50% pts with such hernias have congenital paraduodenal hernias.
Approx 75% hernias occur on the L side of the abdomina through Landzert fossa. This congenital defect in the descending mesocolon is located behind the 4th portion of the duodenum. Formed by a peritoneal fold creased by the IMV and L colic artery as they course along the lateral side of the ascending duodenum. Cross sectional imaging demonstrated sac encased small intestinal loops between the pancreas and the stomach to the L of the ligament of Treitz.
Most patients experience non specific symptoms such as N/V, and abdo pain but do not have typical symptoms and signs of SBO.
Rarer R paraduodenal hernias present with small intestinal hernia through Waldeyer fossa located in the first portion of the jejunum mesentery inferiot ot eh 3rd portion of the duodenum and posterior to the SMA. Cross sectional imaging of these hernias demonstrates sac encased small intestinal loops lateral and inferior to the descending duodenum in the R transverse mesocolon or behind the ascending mesocolon.
53M smoker presents with a 3 cm symptomatic umbilical hernia. Which of the following herniorrhaphies is least likely to lead to recurrence?
A. Figure of 8 suture B. Simple interrupted suture C. Simple continuous D. Mesh E. Vest over pants
D
Umbilical hernias account for 10% of all primary hernias. Reported recurrence rates excessed 25%. Classic repair is Mayo hernioplasty. Vest over pants imbrication of the superior and inferior aponeurotic segments is performed. Smaller umbilica hernias are closed with a simple interuppted, figure of 8, or continuous nonabsorbable sutures. Mesh herniplasty is often used for umbilical defects >2-3 cm and are usually placed in an onlay (abve the anterior rectus fascia) or sublay in the preperitoneal space. In RCT and observational studies, there was a significantly lower recurrence rate (10 fold) when the repair was perforemd with mesh than without. There was no significant difference in rates of wound complications
65M underwent a total proctocolectomy with end ileostomy for Crohn’s colitis. He now presents with a large reducible parastomal hernia.
What is the least likely reason for which this pt developed a parastomal hernia?
A. Preop siting B. Aperture size at creation C. Patient age D. Ileostomy rather than colostomy E. Length of follow up
D
Parastomal hernia is a freq complication of stoma formation. Overall incidence may be as high as 50%. Multifactorial and relative contribution of several factors varies from 1 pt to another. In general, length of follow up is assoc with an incr in parastomal hernia dx. Stoma siting throug the rectus abdominis may decr herniation rates b/c the strong muscle provides support to the stoma. Preop siting in lying, standing and sitting decr the chances that the stoma will be placed in a less than optimal site than when the surgeon tries intraop to guess the best site. Aperture size at time of somta creation directly affects the rate of hernia formation: in 1 study, each additional 1 mm incr in aperture size awas assoc with a 10% increase in risk of hernia formation. Older pts and obese patients with a waist circumference >100 cm are at higher risk for stoma herniation. Colostomies are 2x higher risk for parastomal hernias than ileostomies
65M underwent a total proctocolectomy with end ileostomy for Crohn’s colitis. He now presents with a large reducible parastomal hernia.
What would you recommend initially to maange the patient’s symptoms?
A. Weight loss B. Hernia belt C. Local revision with fascial repair D. Local hernia repair with mesh E. Stoma relocation
B
Most parastomal hernias do not require surgical intervention. Overall, 10-30% of pts with a parastomal hernia eventually undergo surgery. Conservative mgmt with abdominal support devices such as a hernia belt, counselling regarding wt loss, reevaluation and modification of the stoma appliance by et nurse will often provide symptomatic relief. Sx is reserved for complications such as impairment of stoma function (obstructive symptoms), incarceration, strangulation, or inability to maintain skin integrity.
65M in otherwise excellent health develops jaundice. CT scan demonstrates a mass in the head of the panc and a solitary lesion in the liver. Percutaneous core needle bx of the liver lesion confirms a neuroendocrine tumor. Which of the following is the best tx option?
A. Peptide receptor therapy
B. RFA of the pancreatic lesion followed by octreotide
C. Radiation
D. Enucleation of both lesions
E. Whipple with resection of the liver lesion
E
Gastroenterohepatic neuroendocrine tumor (GEP-NET) is a unifying concept of related tumors including carcinoid tumors, functional endocrine tumors (e.g. insulinoma, gastrinoma), and nonfunctioning neuroendocrine tumors (e.g. islet cell tumors). Broad range of clinical presentations and behaviors. Approx 1/2 are malignant, the endoendocrine carcinomas behave in an indolent fashion.
Resection is potentially curative, even in the face of mets. Functional GEP-NETs should be resected, if possible, to palliate symptoms from hormonal production. If surgical tx is being considered, nonfunctional tumors with mets should undergo resection of both theprimary and met lesions and can lead to significant long term survival.
In this pt who is an otherwise excellent surgical cnadidate, a combo of Whipple with liver resection with concurrent or staged resection of the liver is the best tx option.
Peptide receptor therapy can be used to palliate endocrinopathies for pts with met neuroendocrine tumors but would not be appropriate for tx of the primary. Octreotide is a valuable tx in functinoal neuroendocrine tumors that are otherwise not resectable but does not have a role as a sole therapy for resectable lesions. Primary neuroendocrine tumors do no usually respond to radiation therapy. Although enucleation is an acceptable tx for isolated small tumors involving the body and tail, a larger tumor involving the head of the panc is not amenable to enucleation. In addition, enucleation does not address the liver met. Patients with multiple hepatic lesions not amenable to resection can undergo liver direct tx with chemoembolization, RFA, cryotherapy or other regional therapies.
Which of the following is the best mgmt approach for a symptomatic splenic cyst?
A. Percutaneous aspiration only
B. Percutaneous aspiration with injection of a sclerosing agent
C. Operative unroofing of the cyst
D. Partial splenectomy including the cyst
E. Splenectomy
D
Splenic cysts are categorized as parasitic, usually from Echinococcus infection, or non parasitic. Nonparasitic cysts can be further subdivided into primary (congenital) or secondary (pseudocysts). Primary cysts are relatively rare entities. Symptoms are generally vague LUQ discomfort, although many cysts are completely asymp and are discovered when imaging is done for other purposes.
Indications for surgical intervention include symptoms and cysts > 5cm. Perc aspiration leads to poor results with reaccumulation of the cystic fluid being the norm. Variety of sclerosing agents added to perc aspiration are used. Although success rates for eradicting the cyst have improved, recurrence rates remain high. Unroofing of the cyst still leaves behind a portion of the cyst lining on the spleen. Therefore recurrences are still possible. Splenectomy would be an effective tx of the cyst and was prev considered the standard of care. However with splenectomy, all of the functionining splenic parenchyma is removed, with the subsequent short and long term complication assoc with the asplenic state.
Newer technique of partial splenectomy offers best mgmt option of eliminating the entire cyst wall thereby minimizing recurrences, yet maximizing the the remaining functional splenic parenchyma. Done open or laparoscopically.
Which of the following is TRUE regarding surgical outcome fro pts with cirrhosis and painful umbilical hernia?
A. Surgical repair should be performed only if the hernia becomes incarcerated
B. Use of mesh should be avoided
C. Preop control of ascites is essential
D. Recurrence rates are identical to the noncirrhotic population
E. Presence of a patent umbilical vein should not affect the decision for repair
C
Historically, umbilical hernia repair with cirrhosis is assoc with a high periop morbidity and mortality. Led many surgeons to limit repair to pts presenting with life threatening emergencies, such as incarceration or skin ulceration with ascitic leak. Safe elective repair comparable to noncirrhotic populations can be accomplished, however, with appropriate pt selection. If ascites is not clearly present on physical exam, it is essential to use imaging to look for evidence of hepatic decompensation. Preop control of ascites significantly decr hernia recurrence and allows safe use of mesh for closure of the abdominal wall defect. Ascites control may be accomplished through medical diuresis coupled with serial abdo paracentesis or TIPS. Peritoneal drains may be used to aid postop ascites mgmt if a more urgent repair is required. Herniorraphy should be avoided in the presence of a patent umbilical vein b/c ligation during herniorraphy may alter the portal circulation and lead to acute portal vein thrombosis. Ensuing liver failure may necessitate emergent liver transplant.
23F with brittle diabetes has been referred for cholecystectomy. She states that she has frequent bouts of N/V 3 hrs after a meal. In the last month, she has had 4 episodes of severe ketoacidosis assoc with RUQ pain and prolonged vomiting lasting for up to 6 hrs. An US of the gallbladder is N. All liver function tests, amylase, and bilirubin are N. Which of the following would you recommend?
A. Lap chole
B. Gastric emptying test
C. ERCP
D. Oral cholecystography with rapid cholecystokinin infusion
E. Cholecystokinin cholescintigraphy during an episode
B
Although biliary like symptoms in the presence of a N gallbladder by US may represent gallbladder dyskinesia and potentially warrant chole, this dx requires careful evaluation to exclude other etiologies of episodic abdo pain. In this case, severe gastroparesis, a common complication of diabetes could readily account for the pt’s presenting symptoms and can be rapidly evaluated by a radiolabeled gastric emptying test. Serologic testing of liver and pancreatic enzymes and upper endoscopy to r/o peptic and other primary gastric d/o are also essential before proceeding to surgery.
Assessment of gallbladder emptying with oral cholecystography, both with and without CCK stimulation has sufficiently variable results to make it an unreliable diagnostic tool. Currently CCK cholescintigraphy provides the most reliable measure of gallbladder EF. Should be avoided during an acute episode of abdo pain and it should not be used as a provocative test. GBEF <35% in conjunction with episodic RUQ/epigastric pain lasting >30 mins –not relieved by antacids, BM, or position change–and assoc with N serum liver enzymes and amylas is highly supportive of biliary structural abN and aid evaluation of possible sphincter of Oddi dysfunction, this relatively invasive test would not be a 1st step in the WU of this pt. Furthermore, a low GBEF may ocur in healthy asymp individuals; pts with a varied of medical conditions, including diabetes, celiac, and IBS and as a side effect of opiods, CCBs, OCPs, histamine 2 receptor antagonists, and benzos. Cholecystectomy should be undertaken only when there is a high index of suspicion coupled with supportive evidence of primary gb dyskinesia and when other dx have been eliminated
CT scan was performed on a 56F for epigastric pain. CT revealed a cystic lesion in the tail of the panc. Patient underwent a distal pancreatectomy with splenectomy. Histology was consistent with a 4 cm, well differentiated, nonfunctional neuroendocrine cystic neoplasm, metastatic to 1 of 9 peripancreatic nodes. Which of the following would you recommend?
A. Octreotide injecitons (long acting release( B. Sunitinib C. Hepatic artery embolization D. Temozolonide chemo E. Observation
E
NETs are generally divided into 3 types: well differentiated tumors or carcinoids, which are benign; well differentiated carcrinomas or malignant carcinoids, which show a low grade of malignancy and poorly differentiated carcinomas or small cell carcinomas, which have a high grade of malignancy.
Intestinal tumors are more freq than primary panc tumors, with the ileum as the most common site. Panc NETs account for ~3% of panc malignancies. Although the classic clinical syndromes of hormonally active tumors, such as insulinomas and gastrinomas, are well recognized, the majority are non secretory and metastatic at dx.
Mgmt of localized moderately to well diff neuroendocrine pancr tumors is primarily surgical with resection to clear margins. 5 yr survival rates range from 92% for pts with stage 1 disease (tumor up to 4 cm and limited to panc) to 525% for stage IV tumors ( any T, any N, M1). Histologic grade is a strong prognostic indicator although functional tumor status for panc NET does no significantly affect median survival. This pt would be staged as stage II (T2N1M0) and would be expected to have an 85-90% 5 yr survival after resection alone
Adjuvant therapy for NET is generally reserved for mets and may vary depending on the site of origin and presence or absence of a clinical syndrome, suggesting a “functional” tumor with a biologic target. Tx with octreotide improves progression free survivial in pts with advanced mid gut carcinoid. Pts with panc NET mets to liver may also respond to streptozocin and temozolomide based chemo. The tyrosine kinase inhibitor sunitinib improves progression free survival for some intestinal primary NET but has not been applied to the panc ENT subset. Limited hepatic resection or hepatic artery embolization may be beneficial for those pts with hepatic predominant met disease
54 alcoholic man was adm with S&S of acute panc 6 mos ago. His course was complicated by panc necrosis and the development of a large pseudocyst, which was found to be infected on percutaneous aspiration. The cyst was tx with external catheter drainage and abx for 1 month, at which time the catether was removed. He now returns with early satiety and epigastric discomfort. His abdo CT scan shows a fluid collection posterior to the stomach and perigastric varices. What would be your recommendation?
A. Percutaneous drainage B. Endoscopic transgastric drainage C. Operative cyst-gastrostomy D. Transpapillary endoscopic drainge E. Continued observation
C
Presence of complication (infection, GOO or biliary obstruction or bleeding) or persistent symptoms should prompt consideration of a drainage procedure for patient with chronic panc pseudocyst. Endoscopic drainage, whether transpapillary or transmural (gastric or duodenal) is becoming the preferred approach, b/c it is less invasive, avoids the necessity of an external drain, and has a high long term success rate. Perc external drainage is generally reserved for infected pseudocysts,. However, open surgery may still be reqd, particularly when portal HTN results from compression or obstruction of the splenic vein/portal vein, either by the cyst alone or in conjunction with underlying chronic pancreatitis. Under these circumstances, open cyst gastrostomy, with or wtihout splenectomy, may be the only safe tx modality. This pt’s CT shows perigastric varices making endoscopic drainage less desirable. A persistent pseudocyst due to a panc stricture that is not amenable to stenting or duct occlusion may also require open internal drainage.
35 y.o. healthy woman presents to ER with complaints of LUQ pain. She gives a hx of having been in a MVC 3 mos ago. Exam reveals that she is febrile, tender in the LUQ, and has a WBC of 19. CT scan of abdo and pelvis heterogenous collection in LUQ with a bubble of air. After 1 week of abx, she remains febrile with continued elevation of her WBC. Which of the following is the most appropriate next step?
A. Internal cyst drainage B. Aspiration C. Percutaneous drainage D. Operative drainge E. Splenectomy
E
Although uncommon, splenic abscesses can be lethal if not tx appropriately. Most common etiology is hematogenous spread to the spleen from another septic focus, such as endocardidits, diverticulitis, or directly from IV drug abuse. Trauma to the spleen can make the organ more susceptible to infection if there is a devascularized segment of splenic parenchyma. Pts present with fever, elevated WBC and LUQ pain. Dx is made by CT.
IV Abx and splenectomy provide the best means of source control. Aspiration or perc drain may occasionally be successful; they are assoc with incr rates of abscess recurrence (50-60%). This is not a cyst and internal drainage of an abscess is usually not performed. Common organisms include staph and strep and gram neg enteric organisms.
OPSI is a highly lethal complication of splenectomy. Seen more commonly in pts who have eihter had seplnectomy for hematologic reasons, in those who are immunocompromised or in children. When elective splenectomy is considered, the pt should receive vaccines for the following encapsulated organism: streptococcal pneumoniae, haemophilus influenzae and neisseria menengitides.
23F has had 2 days if nausea, emesis and mid epigastric abdo pain. On physical exam, her temp is 36.8, HR 76, bp 124/54, and RR 14. Scleral icterus is present and her abdo is soft with tenderness in the mid epigastrium and RUQ. Lab data are as follows WBC 56, ALP 128, T bili 4.1, D bili 2.9, Lip 2430. An abdo US confirms cholelithiasis without any gallbladder wall thickening or pericholecystic fluid and a CBD of 6 mm. She is adm to the hospital and 24 hrs later remains afeb; her abdo pain has resolved. Which of the following is the most appropriate next step for this pt at this time?
A. CT scan of the abdo B. Lap chole w/intraop cholangiogram C. ERCP D. IV abx E. Continue monitoring liver function and symptoms
B
Transient obstruction of the CBD and panc duct by gallstone migration may trigger acute biliary pancreatitis. Typical presentation includes nausea, emesis and midepigastric abdo pain. Dx is confirmed with elevation in serum lipase in the setting of cholelithiasis on abdo U/S. Initial mgmt includes NPO, IV fluids and control of symptoms. Lap chole is the cornerstone of surgical tx to prevent recurrent attacks, which may occur in up to 60% of pts.
Timing of lap chole depends primarily on severity of pancreatitis. Early lap chole within 48 hrs of adm in pts with mild to mod biliary pancreatitis reduces the length of hospitalization (4 days vs 7 days). Waiting for normalization of preop lab data does not reduce morbidity and mortality in pts with mild to mod biliary pancreatitis undergoing lap chole
Abdo CT in pts with biliary pancreatitis is indicated in the setting of clinical deterioration concerning for sepsis. IN the absence of cholecystitis and acute cholangitis, use of IV abx is not indicated. Preop ERCP in pts with mild to moderate pancreatitis without evidence of cholangitis has not been shown to affect overall complications or mortality. Approx 60% of pts with biliary pancreatitis and ampullary obstruction show spontaneous relief of obstruction within 48 hrs of symptom onset. In RCT of preop ERCP in pts with mild to moderate biliary pancreatitis without cholangitis, only half of the pts were found to have CBD stones
Which of the following regarding mgmt of choledocholithiasis is TRUE?
A. ERCP is assoc with higher morbidity than lap CBDE
B. Stone impaction, periampullary diverticula and Mirizzi syndrome incr the possibility of failure of endoscopic CBD stone clearance
C. Predictors of successful stone clearance include proximal stones, large stones and numerous stones (>5)
D. LCBDE is less effective in clearing CBD stones than ERCP
E. Surgical CBD exploration requires placement of a T tube
B
Lap CBDE is an ideal alternative to pre or post op ERCP in the mgmt of CBD stones. Review of RCT comparing LCBDE and ERCP demonstrated equivalent duct clearance rates (87.6%), morbidity, and mortality with a trend toward shorter hospital stay in pts undergoing LCBDE. Selection depends largely on local expertise, in addition to anatomic and pathologic considerations.
ERCP requires at least 1 additional procedure unless performed intraop, with potential complications inlcuding pancreatitis, duodenal perf, and bleeding. In addition, stone impaction, hx of gastrectomy, Roux en Y anatomy, recurrent bile duct stones after hepaticojej, periampullary diverticular and Mirizzi syndrome have been shown to incr the incidence of failure of endoscopic CBD stone clearance. Failure of post op ERCP, which occurs in 4-10%, mandates surgical CBD exploration and clearance
Various methods to remove stones from CBD include flushing, Fogarty catheters, and use of choledochoscope and basket retrieval device. USed with either of the 2 primary techniques for LCBDE. Transcystic approach is successful in up to 90% of cases for small stons (<6 mm) and for stoens in the CBD distal to the insertion of the cystic duct. After performed an intraop cholangiogram, a wire is placed through the cholangiogram catheter, followed by a dilating balloon and sheath. Used of a flexible choledochoscope aids in visualization of the stones, which can be removed with a basket retrieval device. Proximal stones, strictures and the presence of numerous stones limit the success of transcystic LCBDE. Alternatively, presence of numerous stones limit the success of transcystic LCBDE. Alternatively, the CBD may be explored laparoscopically by making a choledochotomy. Mgmt options for the choledochotomy includ primary closure, external drainage via an externalized cystic duct drain, or closure over a T tube. Advantages of T tube closure include access to the biliary system for postop evaluation and stone removal but may be complicated by bile leak, peritonitis, biliary fistula and later stricture. Studies comparing T tube and primary closure show similar complication rates, morbidity, and mortality.
39F is referred for splenectomy for ITP. Which of the following preop factors is most likely to be predictive of a positive response to splenectomy?
A. Age < 40 yrs B. Response to corticosteroids C. Time from dx to sx D. Preop platelet count E. Sex
A
ITP is an autoimmune disease characerized by the production of antibodies against platelet surface antigens. The spleen has a dual role in pathogenesis, b/c it serves as the primary site of antibody production and platelet sequestration and destruction. Acute ITP is most common in children and is self limiting in 70% of cases. Typical manifestations include petechiae, purpura, and bleeding. Medical mgmt including corticosteroids and IVIG, has only a 20-25% remission rate in adult pts. Splenectomy results in long term remission rates in 66-85% of pts with ITP and this is the preferred option for definitive tx in medically refractory pts.
Multiple factors have been evaluated to assist in predicting clinical response to splenectomy. Age < 40 is the most widely acknowledged predictor of positive response to splenectomy. Refractor or recurrent disease is more common in older pts. Use of surface nuclear scanning to aid in the identification of the site of plt sequestration suggests that older ppl have a higher likelihood of developing extrasplenic sites of sequestration (liver), which may explain failure with splenectomy. Response to cortiocsteroids, time from dx to sx, preop plt count, and gender have not been consistently shown to affect response to splenectomy in patients with ITP
35F currently on OCPs has a 12 cm lesion in the R lobe of the liver. On review of the triphasic CT scan, the arterial phase displays nodular peripheral asymmetrical enhancement and delayed filling in the same area. Which of the following is the most likely dx?
A. Adenoma B. Hemangioma C. Met neuroendocrine D. HCC E. FNH
B
Adenomas typically have heterogeneous enhancement on arterial phase and are hypointense on the venous phase. They are also without a central scar on imaging. They are typically present in women and are assoc with risk of rupture and malignancy
Hemangiomas are the most common benign lesion seen in the liver. They are not assoc with OCPs and carry no malignant risk. On CT, periphearl asymmetrical enhancement with delayed vascular filling is characteristic. Risk of rupture is exceedingly low and the indication for resection is typically pain
Met neuroendocrine cancer is hypervascular on the arterial phase and hypoattenuating on the venous phase
HCC shows hypervascular enhanacement on the arterial phase and a characteristic portal venous washout on the venous phase
FNH shows enhancement on the arterial phase and the lesion is difficult to see on the venous phase. A central scar may also be present for FNH. With the exception of its characteristic central scar, FNH enhances homogenously during the arterial phase of contrast enhanced imaging studies. They are typically present in women and are not assoc with risk of rupture or malignancy
In addition to total bilirubin and creatnine, which of the following is included in the Model of End Stage Liver Disease (MELD) score?
A. Presence of ascited B. Encephalopathy C. Plt count D. Ammonia E. INR
E
MELD score is an accurate and reproducible scoring system for severityy of liver disease.It is a prospectively developed and validated scale that uses the quantitative, objective values of serum bili, serum Cr and INR. It was iniitially developed to predict death within 3 mos of surgery in pts who had undergone a TIPS. MELD score can prognosticate for mortality from major interventions, such as nontransplant s in pts with cirrhosis. Mortality correlates linearly with the MELD score. Mortality at 30 days ranged from 6% for a MELD score < 8 to mroe than 50% for a MELD score >20.
Child classification is a commonly used scoring system that was originally used to predict the likelihood of variceal bleeding in cirrhotic pts. Uses the presence of clinical ascites, encephalopathy, and serum bilirubin, INR and albumin. Total score of 5-6 is considered grade A (well compensated disease), 7-9 is grade B (significant functional compromise), and 10-15 is grade c (decompensated disease).
Studies comparing MELD and Childs show MELD scoring to be more accurate at predicting mortality in cirrhotic pts undergoing surgery due to a greater scale of objectivity.
Which of the following is a TRUE statement regarding peritoneovenous shunt for intractable malignant ascites?
A. Complication rates are high B. Quality of life is improved C. Survival is improved D. Medical mgmt is inferior to shunting E. 30% of pts have symptomatic relief of ascites
A
Medical mgmt of scites include specific tumor therapy, active diuresis, dietary restriction, and repeat paracentesis.
Diuretics and salt restrictive diets make sense but they are used inconsistenytly and no good clinical trials support these approaches in pts with malignant ascites. Paracentesis is useful for pts with symptomatic intraabdominal pressure and dyspnea, nausea, and pain are often temporarily relieved. Complication rates are low with this approach but repeat paracentesis are often required to achieve approx 95% effective control.
Major complications of peritoneovenous shunting include pulmonary edema, PE, CV events, overt DIC, infection and hemorrhage. Minor complications including shunt failure, subclinical DIC (which occurs in most pts), wound infection, ascites leak, and the like are common. Thus, the overall complication rate of PVS is very high. The potential for improved survival cannot be clearly states. Same is true for quality of life measures. Wide range of results reported or the control of malignant ascites by PVS (40-100% relief of ascites). As such, individual considerations are the key
After a severe episode of acute alcoholic pancreatitis a 42M presents with painless hematemesis. Initial upper GI scope reveals N duodenum, mild esophagitis and prominent vessels in stomach. Which of the following is the most likely dx?
A. Splenic vein thrombosis B. H pylori infection C. Mallory Weiss tear D. Budd Chiari syndrome E. Dieulafoy lesion
A
Images show prominent gastric varices and a N duodenum and the patinent has mild esophagitis. With this hx of recent acute pancreatiits, splenic vein thrombosis with resultant R sided or sinistral, portal HTN leads the ddx. Splenic vein occlusion causes the spleen to engorge and the short gastric vessels become the route for venous decompression. B/c gastric mucosal folds can mimic gastric varices, it is important to fully distend the stomach during endoscopy to reveal whether HTN veins can be displayed. Fastric varices are sometimes difficult to appreciate on routine endoscopy, so alerting the endoscopist to this
likelihood is important.
Tx options for portal vein HTN generally do not apply to sinistral HTN b/c the portal vein is not hypertensive. BUdd Chiari is not assoc with gastric variced. Dieulafoy lesions are usually not detectable by endoscopy. H pylori infection is not assoc with gastric varices. A MW tear would usually present after a bout of forecful vomiting and would be obvious in EGD
A pt, 3 wks after an alcoholic binge, arrives in the ER with intense upper abdo and back pain. Vital signs are N. He is tolerating a regular diet and is not experiencing diarrhea. A CT scan is obtained in ER and shows a large pseudocyst. Which of the following represents the best surgical care at this time?
A. Stapled cyst gastrostomy plus bx B. Perc aspiration and drain placement C. Endoscopic cyst gastrostomy D. Octreotide and NPO E. Multivitamins and pain meds
E
By hx, pseudocyst is just forming. Most pseudocysts, even large ones, will resolve without invasive procedures. Best approach is to provide pain control and replace B vitamins from pt’s diet. Octreotide does not improve the resolution rates of panc pseudocysts and should be used very selectively, if at all, for high output panc fistulae. The invasive options are competitive and complementary and should be reserved for mature pseudocysts (>6 wks old) that are symp and large. Cysts < 6 cm usually resolve without invasive procedures. Cysts > 6 cm also usually resolve without invasive procedures but these cysts are more likely to remain symptomatic and large.
Complications of unresolved, large panc pseudocyts include chronic pain, compression of surrounding structures, bleeding, pseudocyst infection, and other life threatening problems. When it comes time to intervene, a cyst gastrostomy with bx of the cyst wall to r/o malignancy is the gold standard option, especially if the etiology of the cyst is in question. This procedure can be accomplished through an open or a lap approach. Endoscopic cyst gastrostomy can be accomplished with the placement of drainage stents into the cyst. Percutaneous aspiration or drain placement can be achieved although the results are not as good as surgical drainage.
Which of the following is TRUE regarding infected pancreatic necrosis?
A. They can be tx with abx alone
B. mgmt w/perc drain and abx is effective
C. Octreotide prevents development of panc fistula
D. Panc necrosectomy is ultimately required in all pts
E. Incidence is incr in acute pancreatitis with enteral feeding
B
Panc necrosis occurs in ~10% of pts with pancreatitis and put pt at risk for multiple organ failure, infection of necrotic tissue, or both. Risk of death is estimated 20-30% for pts with these complications. Dx is best made with CT to determine which areas of the pancreas are perfused. Nonperfused areas are considered necrotic. Definitive dx of infected panc necrosis is more difficult and can be made with a FNA and gram stain/cultures of the aspirate or visualization of the presence of gas within the fluid collection on CT. Pts with sterile necrosis can still have multiple organ failure. Decreasing mortality as low as 4% due to better ICU, avoidance of early open intervention to allow for stabilization, and demarcation of peripanc fluid collections and liquefied necrosis. Intervention should be delayed until ~4 wks after onset of pancreatitis to allow this walling off and demarcation, as well as liquefaction.
Classical tx of infected necrosis is laparotomy and panc debridement; however, this approach is being challenged. MIS panc necrosectomy is described as endoscopic debridement performed via transgastric, laparoscopic, or RP routes. Study prospectively compared open necrosectomy with a step up approach in which the first step was perc drain, followed, if necessary by VARDs with end points of major complications or death. Patients tx with step up had a lower incidence of multiple organ failure and systemic complications but not difference in rate of death. 35% required only perc drain and did not need to go on to necrosectomy
Tx with abx alone is not described. Effectiveness of abx used ppx to prevent infection in cases of nec panc is hotly debated and a 2010 Cochrane review stated “although we cannot confirm benefit from the use of ppx abx, consistent trend towards a beneficial effect nonetheless remain”.
Somatostatin analogs such as octreotide are used to tx panc fistula, although they are not thought to be of benefit. Octreotide is not effective as a preventive measure for panc fistula
Enteral nutrition, compared with TPN, reduces mortlaity, multiple organ failure, systemic infections and the need for operative interventions in pts with acute pancreatitis.
25F is 12 wks pregnant and presents to ER with R sided abdo pain for 24 hrs, fever, emesis, and WBC 12. Her exam reveals a gravid uterus and R sided tenderness without focal peritoneal signs. Her UA is N; US reveals a viable fetus and no cholelithiasis. The appendix is not seen on the US study. Which of the following is the most appropriate next step?
A. Perform laparoscopic exploration B. Obtain CT Abdo/Pelvis C. Perform open appy D. Obtain MRI of abdo and pelvis E. Admit and observe
D
Acute appy occurs in approx 1 in 1500 pregnancies and is 1 of the most common indications for sx in pregnancy. During pregnancy, physiologic incr in WBC and upward migration of appendix makes dx of acute appy more difficult. Delay in dx ca be assoc with serious complications. Uncomplicated appy results in a 2% rate of fetal loss and 4% rate of early delivery. Perf appy can result in fetal loss rates between 6-30% with an 11% rate of early delivery. B/c of the difficulties in dx, failure to use preop imaging resulted in a neg appy rate of 23-33%
US avoids use of ionizing radiation and assists in identification of gyne dx and is the initial imaging for suspected appy in preg pts. Sensitivity of US in the dx of appy is as low as 20%. If the dx cannot be ascertained via US, MRI avoids ionizing radiation and has a high sensitivity and specificity for appy and alternative dx in pregnant women. Although the cost of MRI is greater than CT or US, it is a minor expense compared with that incurred during a neg appy.
65 y.o. obese male smoker with DM presents to ER with a 3 yr hx of foul smelling purulent drainage from his abdo wall. He has experienced incr pain, fevers, and chills. His hx is notable for a colostomy, colostomy takedown complicated by a surgical site infection (SSI) and ventral incisional hernia (VIH) and 2 prior VIH repairs with prolene mesh. Which of the following statements is TRUE?
A. An occult underlying enterocutaneous fistula can present as a mesh infection
B. Any tx must remove all existing mesh
C. Gram neg bacteria are the most likely cause
D. Prior use of expanded PTGE would lower the risk of mesh explantation
E. Bowel resections at the time of VIH repair do not alter SSI rates
A
This pt has a mesh infection based on purulence draining from his abdo wall in the setting of an implanted mesh Definitive dx of a mesh infection relies on postive deep cultures of fluid surrounding the mesh or mesh cultures. Mesh infections occur with a reported incidence of 6-10% in open repairs and 0-3.6% in laparoscopic ventral incisional hernia repair. Mesh infections in the early post op period are more likely to be assoc with an enterocutaneous fistula. They are the 3rd leading cause of mesh explantation. Staph aureus is the organism most implicated in mesh infections, although other organisms, such as staph epi, strep pyogenes and gram negs are implicated. Tx of mesh infections depends on the pt’s clinical status. Pts who may be septic require abx and explantation. Concomitant procedures performed via the same incision as hernia repair, enterotomy, surgical site infection and ECF are assoc with higher rates of of mesh explantation. Expanded PTFE mesh used in open ventral incisional hernia repairs is significantly more likely (4x) to need explantation than prolene or expanded PTFE mesh used in lap repairs. Well incorporated mesh does not need to be removed during an explantation procedure
Which of the following is TRUE aout bile leaks from subvesical ducts of Luschka?
A. They are the 2nd most common cause of postcholecystectomy bile leaks
B. They are the sole drainage from assoc liver parenchyma
C. They represent disruption of drainage into the gallbladder
D. They are most commonly seen after cholecystectomy for acute inflam
E. Enteric drainage is usually required for tx
A
Leaks from the subvesical ducts of Luschka are next in freq to those from the cystic duct. Luschka ducts are accessory, not aberrant, biliary ducts that drain subsegmental areas of liver into the extrahepatic bile ducts. Ducts of Luschka are estimated to occur in up to 50% of pts. Aberrant hepatocystic ducts are the only source of drainage from their assoc liver parenchyma, whereas accessory ducts are not. The hepatocystic duct may drain into the gallbladder or cystic duct. Luschka ducts do not. Injuries to Luschka ducts are not predicted by the presence of acute chole or by the elective or urgent nature of a chole. Tx of a Luschka duct leak not recognized at the time of chole is often successfully accomplished by sphincterotomy and transampullary stenting to decr the pressure in the biliary tree. Enteric drainage is not usually required.
83 y.o. emacited female resident of a nursing home who has never undergone abdominal operation presents with a distal small intestinal obstruction and R thigh and knee pain that began 3 days earlier. Which of the following is TRUE?
A. Celiotomy is unlikely to cure this patient
B. Abdominal/pelvic CT is useful in establishing the dx
C. Hip osteoarthroplasty with assoc ileus is the most likely cause
D. NG suction should resolve the pt’s symptoms
E. End of life care should be provided
B
Mechanical SBO in elderly pt who have not undergone prior sx suggest the dx of malignancy or internal hernia. Obturator hernia are rare but thay are identified typically in such patients, particularly multiparous women. Ipsilateral thigh and knee pain (the Howship Romberhg sign) is caused by obturator nerve compression. Sign occurs in approx half of pts. CT have improved the dx accuracy of obturator hernias. 1/3 of pts have evidence of intestinal ischemia at the time of sx and hernia reduction. B/c many elderly pts have degenerative joint disease, nonspecific nature of pain in patients with obturator hernias may suggest a more common finding of hip and lumbar spine disease. However, mechanical SBO confirmed by CT should raise suspicion for an obturator hernia. Early dx of this disease is assoc with a mortality of only 5% in a group of pts with a mean age of 80.
Which of the following statements about spigelian hernias is MOST accurate?
A. They should always be repaired using an open anterior abdominal approach
B. They can be dx solely bt Hx and Px
C. They penetrate hte transversus abdominus and internal oblique muscles and lie posterior to the external oblique aponeurosis
D. They develop above the arcuate line
E. The present in or before the 3rd decade of life
C
May present without significant abdo wall bulges b/c they are generally interparietal, penetrating the transversus abdominis and internal oblique muscles, but lying posterior to the external oblique aponeurosis. Pts present most freq in 5th and 6th decades of life. Hernias occur anywhere along the Spigelian fascia that runs between the lateral edge of the rectus abdominis and the semilunar line. Most freq develop at or inferior to the arcuate line. Often cannot be dx on hx and px alone. Physical exam false neg in 36% of pts and false positive in half of pts. CT improves dx accuracy but false neg scans in 1/3 of pts. RCT of open vs las repairs found that both techniques were effective inn preventing recurrences. Advantages of laparoscopic; these were greater number of pts having outpt sx and shorter hosp stays
Compared with open repair, lap ventral hernia has
A. Lower recurrence rate B. Less post op pain C. Fewer post op seromas D. Fewer surgical site infections E. Higher enterotomy rate
D
Meta analysis of 10 RCTs involving 880 patients, there was no statistical difference between recurrence rates for lap or open repair of ventral hernias, although follow up was limited. In the 4 trials in which early post op pain was recorded, there was no difference in pain intensity between the two techniques Seroma formation was relatively common with both techniques. Most consistent finding across all studies was a significant decr in incidence of surgical site infections (3% vs 13%). Enterotomy was uncommon in both groups.
Laparoscopic abdominal wall hernia repair had a significantly lower likelihood of developing morbidity but there was no effect on mortality
Compared with delayed lap chole (>6 weeks), early lap chole for acute cholecystitis (<7 days) is assoc with
A. Incr open conversion rate B. Higher bile duct injury rate C. Higher rate of bile leak D. Lower mortality rate E. Lower cumulative length of stay
E
Initially there was concern that lap chole at the time of acute inflam would result in higher open conversion rate and a higher incidence of serious bile duct injuries. Despite growing evidence with lap chole, some surgeons still cool the pt off with abx and delay OR for 6 wks.
In a meta analysis (5 trials of 451 pts) of RCTs comparing early (<1 week after onset of symp) vs delayed lap chole (>6 wks after onset of symp) for acute chole, there was no difference in rates of conversion to open, bile duct injury or bile leakage. No mortality in either group. Early lap chole results in a 4 day reduction in total hospital LOS
26F presents to ER with a chief complaint of RUQ pain for 12 hrs. On physical exam, she is afeb, anicteric, has mild RUQ pain to palp and has no Murphy’S sign. Labs shows a WBC of 7, AST28, ALT 32, ALP 331, and Total bili 3.2. U/S shows a N size CBD and no evidence of acute chole. Which of the following studies is most likely to confirm the presence of choledocholithiasis preop?
A. HIDA scan B. CT scan C. MRCP D. ERCP E. EUS
C
Option for preop ERCP if CBD stone is suspected.
Deciding factor to pursue preop eval of CBD depends on probability a CBD stone would be present based on clinical findings, findings on preop labs and US. Very strong = CBD stone on US, Clinical ascending cholangitis, Bili >40; Strong = dil CBD on US >6 mm with gb in situ and bili 1.8-4; Moderate = AbN liver tests other than bili, Age >55, Clinical gallstone panc
If low probability of choledocholithiasis–> surgery. High probability of choledocholithiasis–> ERCP. Intermediate probability–> Surgery + IOC or preop imaging
HIDA is reasonable if acute chole is being considered but limitations in evaluation of CBD.
MRCP sensitivity is greater than 90% and specificty >95% which is better than CT of US.
ERCP and EUS are invasive. EUS has sensitivity and specificity similar to MRCP. More sensitive for stones <5 mm. ERCP typically reserved for pts with very high probability of CBD stones. B/c incr risk of complications includ pancreatitis, hemorrhage and perf.
Pt has 1 strong risk factor present (elevated bili). Make her intermediate probability . 2 options are MRCP or EUS.
30M involved in MVC. He is evaluated and his only injury is a grade IV liver injury with an active blush. He is taken for angio, where as arterial bleed is identified and managed with selective embolization. Seven days later he develops a fever of 39. CT scan shows a large collection with air in the liver. Which of the following is the most likely dx?
A. Recurrent hepatic arterial bleed B. Biloma C. Hepatic parenchymal necrosis D. Hepatic abscess E. Hemobilia
D
Liver is one of the most commonly injured organs after blunt trauma. Range from minor to severe, most are managed without surgical intervention. As grade of liver injury incr, likelihood that the pt will require some sort of intervention incr. With intro of angio evaluation of liver injuries, arterial abN that otherwise would have gone unnoticed are now being identified and tx. Most common tx is embolization.
After significant liver injury, complications are assoc with the injury itself as well as the perc intervention. Complications broken down into early and late. Most significant early complciation is ongoing or recurrent bleeding. Typically seen within first 48 hrs after injury. Presentation may include incr abdo pain, distension, peritonitis, hemodynamic instability, abd dec hct.
Late complications incl hepatic necrosis, abscess, and biloma. Differentiated on CT by their appearance. Enhancement is more characteristic of hepatic abscess. Another test to differentiate is the measurement of serum bilrubin. If this is elevated, dx is more consistent with biloma
Hemobilia is a late bleeding complication assoc with liver injury. It presents with a sudden drop in Hct sometimes assoc with hemodynamic instability. Bc the CBD is filled with blood, an elevation of serum bili also occurs.
In addition to abx, which of the following approaches to infected panc necrosis has the lowest incidence of morbidity?
A. Observation B. Perc drain C. Perc drain and min invasive RP drainage D. Open necrosectomy E. Open necrosectomy and panc packing
C
Panc debridement with either open packing or drainage is assoc with significant complications. Open technique with packing of peripanc space and RP gave reasonable control of infectious and necrotic processes but led to significant complications assoc with fistula formation and prolonged inflamm response. With debridement and drainage there was the ned for multiple procedure to ensure that a complete debridement was undertaken. Injury to the intraabdominal viscera was not uncommon with the many procedures. In addition, b/c the operative procedures, there was a continued generation of inflam response.
Minimal access technique for panc necrosectomy. Placement of drain into the RP space and then serial dilation of the drain tract until a RP endoscopic approach can be undertaken. Area is debrided and irrigated, and drain catheters left at the completion of the procedure. Significant decr in complications assoc with nec panc. Decr rates of postop organ failure, ICU support and complications (e.g. multisystem organ ffailure, bleeding, visceral perf, and death)
2010 study compared open mgmt vs step up approach and found the step up approach has statistically significant decr in number of complications. New onset multisystem failure also occurred less freq. No difference in the number of deaths in each group. Step up with perc drain and advancement to endoscopic drainage appears to provide best outcome for these complicated pts.
As part of a study protocol, a healthy, asymp 22F undergoes an abdo US. A 3 mm polyp is found in her gb. What would you recommend for this pt?
A. FU US in 6 months B. EUS C. CA 19-9 and CA125 D. ERCP with biliary cytology E. Lap chole
A
Use of screening US often leads to incidentalomas. With regard to gb, most common incidental findings include gallstones and gb wall polyps. Cholelithiasis is an asymp pt is a relatively straightforward dx. If a pt is not having symptoms from gallstones, chole is not indicated. A gb polyp, conversely, has the potential to be neoplastic. For this reason, in the past, it was recommended that gb poylps, even if asymp, necessitated cholecystectomy
Most recent data have providede guidelines to the val and mgmt of gb poylps. Recommendations divided into gb assoc sympts, assoc conditions, polyp size, and polyp morphology. Pt with sympts attributed to gb who has a polyp on US should undergo chole. Chole is indicated in the asymp pt if the polyp is >6 mm or sessile, or if the pt has PSC. If the pt is asymp, polyp is pedunculated and 6 mm or smaller, follow up US is indicated. If on repeat US, polyp incr to more than 6 mm or beings to develop sessile features, chole is indicated.
In this pt with an asymp 3 mm polyp, a follow up US 6 months would be the correct recommendation. No further eval is required if the polyp is stable and the pt remains asymp.
Regarding parastomal hernias, which of the following is TRUE?
A. Use of mesh at initial stoma formation reduces the incidence of parastomal hernia
B. Mesh placement at initial stoma formation increase the complication rate compared with no mesh placement
C. Primary repair of a parastomal hernia provides durable long term results
D. The complication rate is similar whether synthetic mesh or biologic mesh is used for parastomal hernia repair
E. The results of laparoscopic parastomal hernia repair are superior to open repair.
A
Ppx mesh placement at the time of stoma formation has conclusively been shown to reduce the incidence of parastomal hernia. Two systematic reviews of mesh vs no mesh stoma formation did not identify any incr morbidity or mortality with the use of mesh. Analysis included biologic and synthetic mesh
Mesh placement is used in the repair of established parastomal hernias, b/c primary direct suture fascial repair leads to unacceptable recurrence rates (46-100%). Type of mesh used may affect the rate of complication; synthetic mesh repair is assoc with a higher rate of complications than biologic mesh, often leading to the need for mesh explantation. Mesh infection, extrusion or erosion, chronic pain, bowel obstruction, seroma formation, and intestinal fistulization occur more often synthetic mesh. Sufficient robust long term data are not currently available to conclude that lap mesh placement is superior to open mesh placement
25M presents to ER with a newly identified R inguinal hernia. It is easily reducible and you are now counseling him regarding the mgmt of his hernia. Which of the following statements is TRUE?
A. Risk of strangulation is currently 5%
B. Risk of chronic groin pain at 5 yrs after hernia repair is 10-20%
C. Risk of chronic groin pain at 5 yrs is the same whether an open or lap repair is performed
D. Likelihood of conversion from watchful waiting to surgical repair is 80%
E. Likelihoof of developing chronic testicular pain is higher with an open repair than a lap repair
B
In RCT comparing watchful waiting and early surgical repair with open tension free techniques, only 2 of 364 watchful waiting pts experienced acute incarceration and non experiences strangulation during the 4.5 yr follow up. 23% converted from watchful waiting to surgical repair during this time and hernia related pain was the most common reason providede. Surgical outcomes from pts initially assigned to surgical repair and those who crosed over to repair were similar.
Chronic pain after surgery is also an important outcome to consider. In randomized multicenter study analysing outcomes after lap TEP or open Lichtenstein hernia repair, authors folowed 1370 pts and found the total incidence of chronic pain to be 9.4% vs 18.5%. This finding includs pts reproting mildpain, defd as occ discomfort or pain not limiting daily activities. By contrast, moderate or severe pain, defined as occ or daily interference with daily activities was noted in only 1.9% and 3.5% after 5 yrs. Long term follow up of RCT reported that testicular pain was more common finding in pts who underwent a TEP compared with open mesh repair.
18M presents to trauma room after sustaining a single GSW to the lower abdo. He is initiall resusc and taken to OR for abdo exploration. On exploration, he is found to have multiple small bowel enterotomies as wellas a R ureter injury. Bowel is repaired. Which of the following statements is TRUE regarding injuries to the ureter?
A. Injuries to the lower third of the ureter are managed by ureteroneocystostomy
B. An anterior wall bladder (Boari) is the preferred technique to repair an injury to the upper third of the ureter
C. A psoas hitch is appropriate for injury to the middle third of the ureter
D. Ligation with neph tube drainage and delayed repair decr morbidity
E. Mobilization of the ureter is safe secondary to its collateral blood supply
A
Ureter injuries are relatively rare, but missed injuries lead to significant morbidity adn mortality. Injuries to the ureter are classified and managed based on the degree and location of injury. Divided into upper, middle and lwoer thirds. Upper extends from UPJ to the area where it crosses the SI joint. Middle ureter courses the bony pelvis to the iliac vessels. Lower portion extends from the iliac vessels to the bladder. Blood supply to the ureter (utreteral artery) is tenous and runs longitudinally along the ureter without collateral flow in 80%. Reconstruction options for the upper 1/3 include ureteroureterostomy or ureteropyelostomy. Recon options of the middle 1/3 include ureteroureterostomy, transureteroureterostomy or anterior wall bladder flap (Boari). Recon options for the lower 1/3 include ureteruneocystostomy with direct reimplantation and ureteruoneocystostomy with a psoas hitch. Early identification and surgical repair improves overall morbidity; therefore drainage and delayed operative repair is not a preferred mgmt strategy
57M presents to Er wuth a 4 day hx of vague abdo pain, low grade fever, and mild nausea. Evaluation demonstrates N vitals except temp 38.8. He is tender in RUQ without diffuse peritonitis. CT shows a heterogenous collection in liver . Beside broad spectrum abx, which of the following is the most appropriate therapy?
A. Open sx drainage B. Lap resection C. Perc drain D. Hypertonic saline injection E. Thiabendazole
C
Pt presents with pyogenic liver abscess. As tx of appy, diverticulitis and other intra abdominal infections has improved, incidence has decr. Biliary obstruction, stenting or instrumentation is now a more common primary source than seeding through portal blood flow.
Tx is primarily abx and perc drain. Needle aspiration of small <5 cm, simple abscesses may suffice but large multiloculated abscesses freq require multiple catheters and interventions to resolve the abscess. In the presence of yeast in the abscess or demonstration of communication with the biliary tree may predict failure of perc tx strategy. Perc drain found to produce statistically significant improvements in morbidity, LOS, and hospital costs. Preferred to open or lap drainage or liver resection
53F with prior hx of Bassini repair of a R inguinal hernia presents with c/o R groin pain, nausea and vomiting. Evaluation revelas N vitals and distended, non tender abdo. Exam reveals a firm mass in the R groin below the level of the inguinal ligament. Mass is non reducible and moderately tender. In the OR a piece of dusky small bowel is found. Which of the following statements is TRUE regarding this condition?
A. The most likely dx is a recurrent inguinal hernia
B. Lap inguinal hernia repair decr the risk of this complication
C. Men are more likely to present with this dx
D. Exp lap is necessary
E. This hernia, if asymp, should not be repaired
B
Pt presents with strangulated femoral hernia after prev open inguinal hernia repair. Fem hernias comprise 2-8% of all groin hernias in adults and are extremely rare in children. Most are found in adults age 40-70 and are 4-5x more common in women. In contast to inguinal hernias, 30-50% of femoral present as emergencies due to incarceration or strangulation. B/c of higher risk of incarceration or strangulation, once dx, femoral hernias should be repaired in pts of suitable surgical risk. Some physicians now recommend lap repair of all inguinal hernias in women b/c of higher risk of clinically undetectable femoral hernias (37%). If a strangulated hernia is encountered during open groin exploration, the bowel may be freed by dividing the inguinal ligament and then assessing for viability. If a bowel resection is necessary, this can most often be accomplished through the groin incision without converting to laparotomy. Repair of the hernia will depend on the level of suspected contamination of the surgical field. If the bowel is incarcerated but viable, standard tension free techniques can be used. If there i contamination, mesh should be avoided and either a tissue repair or implantation of a bioprosthetic should be considered
48F presents with several months of chronic abdo pain, 48 hrs of incr jaundice, and low grade fever. An ERCP shows no ductal stones but a smooth narrowing of the CBD where the cystic duct enters the CBD. Which of the following statements about this condition is TRUE?
A. Lap chole is the operative approach of choice
B. Cystic duct is at R angles to CBD
C. Gallstone ileus is a common complication
D. It is assoc with a 25% risk of gb cancer
E. Prev chole excludes the dx
D
Pt has Mirizzi syndrome. Obstructive jaundice due to extrinsic compression of the CHD caused by a stone impacted in the neck of the gb or cystic duct. Depending on degree of impairment and chronicity of condition, may be a cholecystocholedochal fistula. Rare complication of gallstones occurs in approx 0.1-0.7% of pts who have gallstones and this condition is distinct from gallstone ileus. Up to 25% of pts have incr risk of gallbladder cancer
4 factors contribute to development: 1) cystic duct must be anatomically parallel to CHD, 2) stone must become impacted in cystic duct or gallbladder neck, 3) CHD must be obstructed by the stone or by the secondary inflammatory response, 4) longstanding obstruction must cause intermittent or constant jaundice with occasional cholangitis
B/c stone is characteristically in either the neck of the gb or cystic duct, prev chole does not rule it out as a possible dx.
Csendes
I - Pressure on CHD due to an extrinsic stone in cystic duct
II- A cholecystobiliary fistula <1/3 circumference of duct wall
III- A cholecystobiliary fistula involving 2/3 circumference of the ductal wall
IV- A cholecystobiliary fistula involved the entire circumference of the ductal wall
Lap chole can be successful with Type I Mirizzi syndrome or external compression of the CHD by a stone impacted by the cystic duct or Hartmann pouch but the authors cautioned that open chole is the method of choice for type 2 Mirizzi syndrome, a fistula between the gb and common duct from inflam and erosion. Another retrospective study indicated that of 14 pts who underwent laparoscopic sx, 11 required conversion to an open procedure.
49M with hx of anemia presents with mild abdo pain and bloating. 5 sm (<1cm) gastric polyps in the proximal stomach are identified by upper endoscopy. These polyps are confirmed to be carcinoid tumors. The histopathologic analysis also confirms strophic gastritis. Pt’s serum 5 HIAA (1.0) is normal but his serum gastric is elevated (1500). Which of the following statements regarding this pt is TRUE?
A. These polyps are the result of enterochromaffin like cell proliferation
B. The atrophic gastritis is likely caused by antibodies directed against the goblet cells
C. The incidence of nodal mets from these tumors is 50%
D. Endoscopic surveillance of this pt is not recommended
E. Gastric resection of the lesions to include the Antrum is recommended
A
Gastrin is secreted by G cells in the gastric Antrum. Acts on parietal cells to stimulate HCL after ingestion of food. Gastrin production is inhibited by somatostatin secreted by D cells in response to gastric acid. Hypergastrinemia can can occur secondary to uninhibited gastric production or in response to decr acid secretion. Pts who have a gastrinoma as their source of uninhibited gastrin secretion usually present with peptic ulcers secondary to acid hypersecretion. By contrast, unopposed gastrin secretion in response to achlorhydria typically occurs in pts with atrophic gastritis or who take PPI. Hypergastrinemia occurring with gastritis related to H pylori infection is caused by the decr somatostatin release by D cells due to incr pH and circulating cytokines around D cells.
Gastric carcinoid also termed NETs are rare in US, comprising 4.1% of all carcinoid tumors. Subclassified into 3 distinct groups: those assoc with chronic atrophic gastritis/pernicious anemia (Type 1 70-80%), those assoc with MEN type 1 ZES (type 2 2.5%) and sporadic NETs of the stomach (type 3 15-20%). Both type 1 and 2 NETS of the stomach are assoc with hypergastrinemia. Type 3 develop in the absence of hypergastrinemia and tend to pursue an aggressive clinical course
B/c type 1 and 2 pursue an indolent course, tumors <2 cm (up to 6 in number) should be resected endoscopically, with subsequent interval follow up. Pts with tumors >2 cm, those with recurrent tumors or those with >6 tumors generally require more aggressive mgmt and local sx resection is recommended. In Type I NET arising in the setting of chronic atrophic gastritis, antrectomy may be performed to eliminate source of gastric production. Antrectomy results in tumor regression. In Type 2 NET of the stomach secondary to ZES/MEN I syndrome, tx with somatostatin analogs may be initiated and result in tumor regression. The surgical mgmt of type 3 isolated sporadic NETs of the stomach require more aggressive surgery, generally with partial gastrectomy and LN dissection
This pt has anemia, hypergastrinemia, and atrophic gastritis consistent with Type I gastric carcinoid. Tumors in pts with type 1 gastric carcinoid are caused by gastric stimulation of ECL cells proliferation which can progress to ECL cell hyperplasia and type 1 gastric carcinoid. This progression occurs in approx 5% of pts with pernicious anemia, an autoimmune condition in which antibodies are directed against parietal cells. Destruction of parietal cell mass results in atrophic gastritis, loss of acid production, hypergastrinemia, and macrocytic anemia from loss of intrinsic factor and vit b12 absorption. Risk of LN mets in this pt is low. Reduction in gastrin from Antrum through antrectomy alone should result in regression of the tumors without resection of the tumors themselves
Which of the following statements regarding the nutritional sequelae after RYGB is TRUE?
A. Patients should consume 30 g of protein daily
B. Oral replacement of thiamine is unnecessary
C. Microcytic anemia is common
D. Fat malabsorption is uncommon
E. An incr in serum PTH levels indicates an overdosing of oral vitamin D
C
RYGB combines gastric resection with a minor malabsorptive state to achieve wt loss. Affects gut hormone, such as gherkin, glucagon like peptide 1 and peptide YY that influence eating behaviours and body wt. Change in eating habits combined with the malabsorptive state can result in significant nutritional consequences.
Major physiologic consequence of RYGB involves lipid absorption. Under physiologic conditions, fat passes into duodenum and stimulated CCK. CCK stimulates gb and pancreas to release bile and lipolytic enzymes. After RYGB, secretion of bile and lipolytic enzymes is reduced, b/c lipids never pass through the duodenum. Lipids including triglycerides, phospholipids and cholesterol travel through the Roux conduit as intact structures until they reach the jejunojejunostomy. Delayed breakdown of dietary fats and the delayed formation of micelles limits the amt of fat available for absorption. Undigested fat passes into the colon, producing fat malabsorption and steatorrhea.
Intolerance of protein rich foods, such as meat and dairy products, is common. Many pts fail to meet the recommended protein intake, which should avg 60-120 g/day. Meat and dairy products also contain sever critical moicronutrients; therefore routine supplementation and monitoring for deficiencies in iron, vit b12, calcium, vit D, folate (vit B9), and thiamine (vit B1) is recommended. In addition, iron, calcium, and thiamine are absorbed primarily in the duodenum, which is precluded in RYGB.
Iron stores decline after gastric bypass, making iron deficient microcytic anemia very common. Orally administered ferrous sulphate, fumarate or gluconate may be needed to prevent iron deficiency. Vit C should be added to incr iron absorption and ferritin levels. Oral iron supplements can decr absorption of ca, mg, and zn, so these should be taken at different times of day. RYGB alters the absorption of vit B12 by isolating the source if intrinsic factor, the distal stomach, from the alimentary system. However, substantial deficiencies in vit B12 do not occur until at least 1 yet after surgery. Deficiency can result in macrocytic anemia and neuropathy.
Wt loss that occurs after RYGB is commonly accompanied by calcium deficiency and bone loss. Loss of fat absorption is believed to contribute to vit D def b/c it is a fat soluble vitamin. This is believed to incr bone turnover and to decr bone mass. However, calcium deficiency and loss of bone density can occur in the presence of normal vit D and PTH levels. For. This reason, monitoring of bone density and serum levels of calcium, vit D and PTH is recommended. An incr in serum PTH is indicative of neg calcium balance or vit D deficiency. If deficient vit D can be supplemented with ergocalciferol or cholecalciferol.
You are performing a sphincter preserving, LAR of a rectal ca 2 cm from the anal verge. The proximal site of transection is the jcn of the colon and rectum. To obtain adequate length of proximal colon for reconstruction, you divide the IMA at its origin. After this maneuver, you detect no arterial flow at the level of the bowel transection with intact flow to the remainder of the bowel. Which of the following is the most likely etiology?
A. Inadvertent ligation of the L colic artery and not the IMA
B. SMA occlusion with an intact arc of Riolan
C. Occlusive disease of L iliac artery
D. Incomplete marginal artery of Drummond
E. Aneurysm also dilation of the infrarenal aorta and L common iliac artery
D
Division of IMA at its origin from the aorta (high ligation) is often performed to remove the LN basin at risk for mets and provide adequate mobilization of the proximal bowel for a tension free anastomosis. In this case, arterial flow occurs through collateral vessels.
Anatomic variations and postsurgical alterations in arterial anatomy can greatly alter the collateral arterial flow necessary to provide oxygenized blood to the proximal bowel necessary for healing a low colorectal or coloanal anast and prevent leak or stricture. Line of division describes in the questions is at the Sudeck point and the IMA is divided at its origin
Ischemia of the proximal bowel would not occur if the L colic were divided instead of IMA, b/c superior hemorrhoidal branches arising from IMA trunk provide arterial flow. Arc of Riolan is an inconstant artery that connects proximal SMA or 1 of its primary branches to the proximal IMA of 1 of its primary branches. It is classically described as connecting the middle colic branch of the SMA with the L colic branch of the IMA. Forms a short loop that runs close to the root of the mesentery. An important connection between SMA and IMA in the setting of arterial occlusion or significant stenosis such as proximal SMA occlusion. In this event, high ligation of proximal IMA would result in ischemia within the SMA distribution (sm bowel and R colon) as well as the transected distal colon
Marginal artery of Drummond is the anastomoses of the terminal branches of the ileocolic, R colic and middle colic arteries of SMA and of the L colic and sigmoid branches of the IMA. Form a continuous arterial circle or arcade along the inner border of the colon known as the marginal artery of Drummond. Important connection between SMA and IMA and provides collateral flow in the even of occlusion or significant stenosis. Jcn of SMA and IMA territories is at the splenic flexure. Vascular anast here are often weak or absent, hence the marginal artery at this point, known as Griffiths point, is often vocally small or discontinuous. Poor arterial flow across this point is most likely to produce ischemia at the point of transection of the distal colon.
The aorta and its iliac branches are within the systemic arterial circulation; therefore occlusive or aneurysmal disease of these vessels is unlikely to cause ischemia at the point of bowel transection. AAA can occlude the origin of IMA, resulting in collaterals that should be carefully preserved
Which of the following is the primary tx for nonulcerated, nonnodular Barrett esophagus with high grade dysplasia?
A. Observation B. Antireflux operation C. Endoscopic radiofrequency ablation D. Photodynamic therapy E. Esophagectomy
C
Barrett’s is a pathologic change in the squamous epithelium of the esophagus to intestinal metaplasia. Places pts at high risk for esophageal adenoca. Risk of progression of Barrett esophagus to adenoca is dependent on the pathologic grade of its dysplasia. When no dysplasia is present, risk of 0.7% per year. High grade dysplasia carries highest risk, with 15-30% of resected esophagectomy specimens already harbouring carcinoma and a detection rate of approx 14.6% per yrs. This group of pts require intervention to reduce the risk of adenoca
Observation with PPI is accepted mgmt strategy. Requires endoscopy with bx q3-6 months. Strategy does not actually address carcinoma risk, but rather relies on early detection of carcinoma. This strategy is inferior to RFA. Antireflux operations, although good for treating the symptoms of GERD, have not been conclusively demonstrated to reduce the cancer risk. Photodynamic therapy, usually with light sensitizing agen such as porfirmer sodium, has fallen out of favour due to issues related to buried glands (i.e. Islands of Barrett’s under a layer of seemingly normal squamous epithelium) and stricture formation. Esophagectomy was considered an acceptable option b/c of the high rate of occupation carcinoma with high grade dysplasia. However, given the efficacy of RFA, esophagectomy is reserved for pts in whom the high grade dysplasia cannot be completely eradicated or in whom other signs incr the suspicion of carcinoma presence. A randomized, sham controlled trial showed that endoscopic RFA can eradicate Barrett metaplasia and dysplasia and reduce the progression to carcinoma. Now considered the primary tx for Barrett’s esophagus with high grade dysplasia in pts without other signs of carcinoma, such as ulceration or nodularity.
Which of the following is the most common presentation of jejunal diverticulosis?
A. Perforation B. Hemorrhage C. Obstruction D. Recurrent abdominal pain E. Wt loss
A
Small bowel diverticula are categorized by location and type. Location categories include duodenal and jejunoileal. Type categories include true and false (pulsion) diverticula. Duodenal and Meckel’s diverticula are true diverticula and are the most common, with duodenal diverticula accounting for 15% of all small bowel diverticula. These are generally found in the periampullary region and are asymp, although occasionally can cause biliary obstruction. Diverticula of the jejunum and ileum are pulsion diverticula similar to that of the colon. Although the exact incidence of ileojejunal diverticulosis is unknown, b/c most of these pts are asymp, it is generally considered far less common than colonic diverticulosis. Prevalence of jejunoileal diverticula at approx 2% or less. Jejunum is a more common site of diverticula than ileum. Diverticula occur on the mesenteric side of bowel where the blood vessels enter the bowel from the mesentery. Perforation, bleeding and obstruction are the most common urgent presentations. Perforation accounts for >20% of emergency surgical interventions for jejunoileal diverticula compared with hemorrhage, which accounts for <2%. Recurrent abdo pain is rarely assoc with jejunoileal diverticulosis and wt loss is not likely related to jejunal diverticula.
In the repair of paraesophageal hernia
A. Primary suture repair has a recurrence rate of 20-30%
B. Biologic meshes have recurrence rates similar to nonabsorbable synthetic meshes
C. Rates of esophageal erosions and strictures by nonabsorbable mesh are less than 1%
D. Symptomatic improvement is superior with mesh compared with primary repair
E. Radiologic hiatal hernia is frequently symptomatic
A
Repair of PEH has several areas of controversy. First is whether they should be repaired at all. Repair of symptomatic PEH in pts who are acceptable surgical risk is indicated; however, many surgeons now chooses to observe asymp pts b/c the risk of catastrophic incarceration, and gastric necrosis is rarely the first presenting symptom.
Other areas of controversy are open vs lap repair, need for an esophageal lengthening procedure, and routine use of mesh. Primary suture repair has recurrence rates of 20-30%, although some reports as high as 50% exist. Recurrences are usually identified radiographically, and most are asymp sliding hiatal hernias. Only a minority of radiographically identified recurrences are symptomatic
No difference in rates of symptomatic improvement between primary and mesh repair, as long as complications do not occur. If mesh is used, the next area of controversy is whether a prosthetic mesh or a biologic mesh should be used. Meta analyses comparing biologic with prosthetic meshes have generally shown that prosthetic meshes have a lower recurrence rate. However, there is no standardization as to the type of mesh, its configuration or fixation. In addition, studies have varied as to type and length of follow up. One of the most devastating complications of mesh use, especially prosthetic mesh, is erosion and stricture formation. Although data for the rate of these occurrences are limited, erosions and strictures appear to occur in more than 2% of pts. If this occurs, the only tx is esophagectomy, gastrectomy or some combo of both.
For colon cancer, which of the following factors is assoc with lower survival rates?
A. Bleeding at presentation B. Longer duration of symptoms C. Intestinal obstruction at presentation D. FamHx of colon cancer E. Peutz-Jeffers syndrome
C
Colon cancer may be dx by routine screening before symptoms develop, but when symptoms are the reason the pt seeks medical attention, those symptoms are usually LGIB, change in bowel habits (incl stool caliber), abdo pain, or obstruction. Bleeding as the presenting symptom is not assoc with worse prognosis, and there is no assoc between duration of symptoms and survival in pts with colon ca.
Patients with intestinal obstruction as their presenting sign of colon cancer form a subgroup that tends to have a short duration of symptoms with a poorer prognosis. Both a famhx of colon cancer and Peutz Jeghers syndrome incr the risk of colon ca with approx 40% of pts with Peutz Jeghers developing colon ca. However, these pts are subjected to incr screening compared with the general population. Thus, their cancer is often detected at an earlier stage, resulting in a good prognosis and improved survival
Which of the following statements is TRUE about pancreatic adenocarcinoma?
A. Resection of the tumor without curative intent is superior to bypass alone
B. Chemo and radiation improve progression free survival in pts with unresectable cancer
C. In resectable tumors, neoadjuvant chemo improves survival compared with those with primary resection and adjuvant chemo
D. Neoadj chemo and radiation commonly convert unresectable tumors into resectable ones
E. Median survival for an R0 resection is 5 yrs
B
Significant more morbidity in pts with panc adenoca undergoing palliative resection compared with those undergoing bypass procedures without a significant incr in the length of survival: 8.2 mos for palliative resection and 6.7 mos for bypass. 2009 meta-analysis of chemo for locally advanced and met panc ca showed improved progression free survival in pts receiving gemcitabine based combo therapy, but that improvement was offset by toxicity in those pts
Survival for pts with unresectable tumors by preop imaging is reported to be essentially the same, whether they were given neoadj chemo or were resected followed by adj chemo. It is uncommon for neoadj chemo and radiation to convert unresectable tumors into resectable ones. In pts with resectable tumors, medial survival is <2 yrs in most reports.
50M with hep C undergoes a CT scan after screening US suggests a liver mass. A CT shows a 8 cm liver mass. His AFP is 1200. His bili is 10. All other liver function tests are N. Which of the following tx would you recommend?
A. Liver transplant B. Transarterial Embolization C. RFA D. Primary liver resection E. Interferon alpha
D
Pt has an 8 cm solitary isolated focus of HCC in R hepatic lobe and evidence of well compensated cirrhosis. HCC is one of the most freq encountered malignancies worldwide. Degree of underlying cirrhosis directly influences choice of therapy and its efficacy. Surgical resection is reserved for non cirrhotic pts or those with well preserved liver function and relatively limited tumor burden (ideally a single lesion). Bili values >11 and evidence of portal HTN (esophageal varices, ascites, thrombocytopenia, portal vein pressure >10mmHg) are predictors of post op hepatic failure and preclude resection
RFA and alcohol injection are therapies usually reserved for pts who are not primary surgical resection candidates due to # or distn of lesions. Both are most effective for masses <3 cm. TACE involves injection of chemo agent such as doxorubicin or cisplatin, in conjunction with occlusion of hepatic artery supplying the liver lobe containing the tumor. Generally used in pts with sufficiently high tumor burden or more advanced cirrhosis to obviate either resection or ablation. B/c recurrence and progression of malignancy can be very rapid under immunosuppresion, strict pt selection criteria if liver transplant is considered. Milan criteria limit selection to a pt with a single tumor 6.5 cm or smaller or 2-3 lesions 4.5 cm or smaller, totalling 8 cm or less, who shows no evidence of vascular invasion or extrahepatic spread. Ideal transplant candidates may benefit from bridging ablative or TACE while awaiting an organ. Interferon alpha has no role in tx of HCC but is used in mgmt of active hep C.
Despite high risk of multicentric recurrence (70% at 5 yrs), primary resection offers best therapeutic option for this pt, with potential for a 50% survival rate at 5 yrs.
55F has undergone Whipple for adenoca in the head of the panc. At the time of the OR, the remainder of the panc was noted to be soft, and the primary panc duct measured 3 mm. On POD 6, she resumes oral intake and the output from a peripancreatic drain changes from serous to cloudy. Output over the next 24 hrs is 575 cc and the amylase in the effluent is 28,000 units/mL. Which of the following statements regarding the use of octreotide in the pt is TRUE?
A. Preop octreotide prevents fistula development
B. Octreotide decr fistula output
C. Use of octreotide decr the length of ICU stay
D. Reoperation can be avoided by the use of octreotide
E. Octreotide prevents assoc post op pancreatitis
B
Incidence of post op pancreas fistula after Whipple ranges from 10-40%. Several studies have documented small duct size, residual soft panc parenchyma, BMI, poor nutritional status, and malignancy as factors contributing to increased risk of postop fistula development. Although somatostatin analogues such as octreotide do decr fistula output, a cochrane review of 17 RCTs concluded that its use does not affect the development of perioperative pancreatitis, post op mortality, reoperation rates, or the ICU length of stay. Preop use of octreotide has not been shown to prevent fistula development, even in high risk pts.
Which of the following statements is TRUE regarding the mgmt of a pt with an uncomplicated pilonidal sinus?
A. Excision with primary closure decr the incidence of recurrence
B. Carcinoma in the pilonidal sinus accounts for up to 5% of recurrences
C. Shaving and local hygiene decr the necessity for a surgical procedure
D. Preop IV abx before chronic sinus excision will decr wound complications
E. Excision should be recommended for obese pts, even if asymp
C
Pilonidal sinus disease is widely attributed to hair follicle in growth and subsequent fb reaction. Local hair control with shaving or laser epilation, coupled with improved hygiene, has been demonstrated to decr total hospital admission days and the necessity for surgical procedures, even in obese pts.
Pilonidal disease presenting as an abscess should be tx with simple incision and drainage; approx 60% of such pts will heal without further surgical intervention after this initial episode. Formal surgical mgmt should be reserved for chronic or recurrent disease. Preop IV abx before excision of a chronic sinus has not been shown to decr wound complications, improve healing or affect recurrence. Surgical options include complete sinus excision with primary closure or healing by secondary intention, with or without marsupialization of the wound edges. Success of primary closure requires a narrow field of excision and care to avoid sitting in the immediate post op period. Sinus recurrence, however, is more freq after primary closure compared with healing by secondary intention. Carcinoma arising in a pilonidal sinus is rare, accounting for approx 0.1% of pts with chronic untx or recurrent pilonidal disease. These tumors classically present as an ulcer with rapidly progressing, fungating margins, and show an aggressive biology.
54M present with progressive dysphasia and a 10 lb wt loss. His serum albumin is 2.9 and his serum transferrin is 11. EGD is performed and shows a mass at the GE junction. Bx demonstrates presence of invasive adenoca. Based on staging with esophageal US and CT, pt is scheduled for neoadjuvant chemo and radiation, followed by surgical resection. Which of the following is the preferred form of alimentation for this patient?
A. TPN
B. Enteral nutrition via nasojejunal feeding tube
C. Enteral nutrition via perc endoscopic gastrostomy tube
D. Oral alimentation after placement of an uncovered metal stent
E. Oral alimentation after placement of a covered silicone stent
Pts with esophageal ca often present with progressive dysphagia. Along with tumor induced cachexia, this progressive dysphagia can lead to malnutrition, manifested as depressed levels of serum albumin and transferrin on lab testing. Predicts incr risk of morbidity and mortality at the time of esophageal resection.
Neoadjuvant chemorads presents an additional burden on these pts, further compromising their nutritional parameters. Radiation induced esophagitis develops in 15-28% of tx pts, further worsening dysphagia. Side effects of 5 FU and cisplatin, the most common chemo regimen include N/V and diarrhea. Malnutrition reduces the response of the tumor to chemorads and impairs the pt’s ability to tolerate full course of tx. Nutritional deficiencies may also contribute to the trend of incr period morbidity and mortality among esophageal ca patients receiving neoadj therapy compared with pts undergoing esophageal resection alone. For esophageal ca pts with dysphagia receiving neoadj therapy, relief of symptoms, maintenance of nutrition and minimization of periop complications are important tx goals.
Correction of malnutrition before sx can markedly reduce the morbidity and mortality of esophageal resection. Traditional options for nutritional supplementation during weeks to allow for wound healing and resolution of local inflam and contamination at insertion site. Avoid PEG b/c of potential to render stomach unusable as replacement conduit for the esophagus. NJ tubes freq become dislodged, resulting in an interruption in nutrition support or more serious complications, including aspiration pneumonia. Complications of feeding tube placement can be devastating in esophageal ca pts b/c of their malnourished state and ongoing malignancy. In addition, use of enteral tube feeding does nothing to address dysphagia, typically the dominant symptom.
Preop esophageal stenting has emerged as an alternative approach to promote nutritional repletion in pts undergoing neoadj chemorads before esophageal resection. Options include uncovered bare metal stents or covered silicone stents. Uncovered metal stents are best suited for palliation of pts with inoperable esophageal cancer, b/c they become incorporated into the wall of the esophagus and are not removable. Covered silicone stents offer more effective relief of dysphagia and can be removed later, either endoscopically or at the time of surgery.
Compared with enteral feeding, oral alimentation after placement of a covered silicone stent results in better relief of dysphagia, higher performance status, better tolerance of chemorads and better mean improvement in albumin. Reduces incidence of major operative complications by >50% compared with enteral feeds. Incidences of stent related complications are <5%. No difficulties with stent removal or intraop dissection at time of sx are reported. Oral alimentation after placement of a covered silicone stent is a safe and effective means to relieve dysphagia and promote nutritional repletion in pts undergoing neoadj chemorads followed by surgical resection for esophageal ca
73M with hx of cirrhosis and ascites presents 48 hits after the acute onset of chest and upper abdo pain after an episode of vomiting. CXR and gastrograffin swallow are performed and show a leak of contrast into the L chest. Which of the following is the next best step in the mgmt of this pt?
A. L tube thoracostomy and covered stent placement to distal esophagus
B. L thoracotomy and direct esophageal repair
C. L tube thoracostomy and bare metal stent placement to the distal eosphagus
D. Exclusion of the esophagus in the neck and at the GE jcn and creation of an end esophagocutaneous fistula in the neck
E. Creation of a side esophagocutaneous fistula in the neck and placement of PEG
A
Acute onset of chest and upper abdo pain after an episode of vomiting suggests a spontaneous perf of esophagus. Spont perf of esophagus known as Boerhaave syndrome, is a full thickness longitudinal tear in the esophageal wall as a result of vomiting. Perf typically occurs in the intrathoracic esophagus just above the GE jcn. Significant delay in dx and continued PO intake result in mediastinal contamination are common. Of the factors that critically influence prognosis in these pts, including pre existing comorbidities and esophageal disease, the most significant is delay in dx
Successful mgmt of an esophageal leak requires prompt control of sepsis and elimination of ongoing contamination of the mediastinum. Traditional therapy had been urgent operative repair, including primary surgical repair when possible, exclusion and diversion or esophagectomy. Despite advances in critical care, antimicrobial therapy, diagnostic imaging, and surgical technique, spontaneous esophegeal perf continue to be assoc with excessive rates of morbidity and mortality. When tx is performed within the first 24 hrs, mortality rates are between 16 and 24%. When tx is delayed and performed after >24 hrs, mortality rates incr rapidly up to 50%. B/c of these high mortality rates, some surgeons have advocated nonop mgmt, with cessation of PO intake and iv abx until healing is confirmed. Approach is also assoc with long hospital stay in many pts and it often requires enteral or parenteral nutrition support.
With the improvement in endoscopic techniques and ICU mgmt, additional of endoluminal stent placement to nonop mgmt has emerged as a feasible and safe alternative for the tx. Stent placement closes the site of perf, stops ongoing contamination of the mediastinum, preserves esophagogastric continuity, avoids potential morbidity and mortality of open sx and allows for earlier oral intake and a decr in hosp stay. Plastic stents are mainly using for the tx of leaks and strictures of benign disease b/c of their ability to be removed more easilty with less damage to the esophageal wall. To ensure complete occlusion, it is important to allow adequate stent coverage on either side of the leak and the stent length chosen should be at least 3-4 cm longer than the leak. Easily performed under direct endoscopic control with an occlusion rate of 94%. Stent migration occurs in <5% of cases. Stent removal is typically 4-6 wks after implantation
Pt’s delayed presentation and hx of cirrhosis and ascites markedly incr the risk of surgical intervention to repair the site of perf. At 48 hurts after spontaneous perf, both direct esophageal repair and esophageal exclusion are assoc with mortality rates approaching 50%. Creation of a side esophagocutaneous fistula in the neck and placement of a PEG tube does not close the site of perf and allows ongoing contamination of the mediastinum. Under these circumstances, a less invasive approach that seals the site of perf is a safer option. Placement of a chest tube will drain infected material from the involved hemithorax.
38 y.o. Black F is seen in ER with 4 days of dizziness, SOB, and melena. She has no abdo pain or significant findings on exam. Hb on adm is 72 and she is FOBT positive. After transfusion, she undergoes upper endoscopy, which shows a 5 cm submucosal mass in the body of the stomach along the greater curve. There is an adherent clot of over the mass. CT abdo confirms the presence of a gastric mass without any other abN. Which of the following is the next best step in the mgmt of this pt?
A. EMR B. Subtotal gastrectomy with lymphadenitis you C. Imatinib D. Gastric wedge resection of mass E. Epirubicin, cisplatin, and 5 FU
D
GISTs are the most common mesentery all tumors of the GI tract. Most are found incidentally at the time of endoscopy or radiologic imaging. Symptoms may include abdo pain, GI bleed, or obstruction, depending on the size and location of the tumor. Most commonly found in stomach (60%) and small bowel (35%). GISTs originate from interstitial cells of cajal which express cd117 (c-kit), present in 95% of tumors.
Complete surgical resection to grossly neg margins is tx of choice. Lymphadenectomy is not required for GISTs b/c these tumors spread hematogenously. Lap vs open depending on tumor size, location and extent of invasion. EMR suggested for smaller tumors.
Resection offers potential for cure, disease recurs in 40-90% of surgically tx pts. Prognostic indicators include tumor size, mitotic index, tumor location and tumor rupture during sx. Adjuvant therapy with imatinib, which targets the tyrosine kinase c kit receptor, is recommended for intermediate to high risk GISTs and may have a role in cytoreduction and organ preserving sx but it is not indicated. Epirubicin, cisplatin, and 5FU are the chemo agents used for gastric adenoca.
Which of the following preop factors are predictive of symptomatic relief in pts with achalasia undergoing lap esophagomyotomy?
A. Prior response to injection of Botox
B. Megaesophagus or sigmoid esophagus
C. Resting lower esophageal sphincter pressure >30 mmHg
D. Prev tx with pneumatic dilation
E. Presence of lengthy, high amplitude esophageal contractions on manometry
C
Achalasia or impaired relaxation of LES, is the most common d/o of esophageal dysmotility. Symptoms incl dysphagia and CP. Dx eval includes barium swallow, endoscopy and manometry. Classic radiologic findings incl a dilated esophagus with narrowing and the GE jcn (bird’s beak). Endoscopy is used to exclude malignancy, b/c pt with achalasia are at incr risk of both SCC and adenoca of the esophagus. Manometric findings of achalasia incl elevated resting LES pressure and a peristalsis of the body with secondary and tertiary contractions.
Tx options include medical mgmt, Botox, pneumatic dilation and surgical myotomy. Medical mgmt consists of CCB and nitrates, which are reserved primarily for pts who are not candidates for more invasive therapies. Effects of these meds are short lived with variable symptom relief and significant side effects. Botox inhibits the release of acetylcholine, resulting in reduction in LES pressure. Efficacious in reducing CP and dysphagia in pts with achalasia; however its effects are time limited with relapse of symptoms in >50% after 3 months. Repeated injections in initial responders may confer some long term benefit up to 2 yrs. Endoscopic pneumatic diln is considered a good 1st line option. Compared with Botox, pneumatic diln has much higher long term response rates, with low complication rates. Age and successful disruption of LES fibres, as measured manometrically, are predictors of symptom relief with pneumatic diln.
Surgical myotomy results in complete disruption of the LES fibres from the stomach to the esophagus, thus reducing resting LES pressure. A partial funds may be performed with the myotomy, depending on the presence of reflux symptoms preop. Most consistent preop predictors of successful surgical myotomy is elevated resting LES pressures >30 mmHg. Failure of surgical myotomy is assoc with megaesophagus and lengthy, high amplitude esophageal contractions. Prior pneumatic dilation and tx with Botox have not been shown to significantly affected surgical outcomes in pts with achalasia
87M presents to ER with N/V for 2 days. CT shows air in gb, air fluid levels in the small intestines and TP in the distal small intestines. Operative mgmt will require which of the following?
A. Cholecystostomy B. Stricturoplasty C. Enteroscopy D. Enterotomy E. Cholecystectomy
D
Biliary enteric fistula (gallstone ileus) is a recognized complication of cholelithiasis. Presentation may be intestinal obstruction when the gallstone lodges in the distal ileum. Classic radiographic findings comprise a triad of gastric or small bowel diln with pneumobiliar and intraintestinal gallstone on CT.
B/c the cholecystenteric fistula is usually large, recurrent symptoms are rare and choelcystostomy and fistula mgmt are not mandatory. Abdo exploration will involve an enterotomy proximal to the site of obstruction to remove the stone. Operative intervention should include manual exam of the entire small intestine, b/c a second stone may be present. Drainage of gab has occurred by means of the fistula, thus cholecystostomy is unnecessary. Enteroscopy is not recommended in this setting.
An 18M undergoes a CT scan to assess for injury after a MVC. Although no acute injuries are identified, a 3 cm fusiform CBD is noted. Which of the following would you recommend as the next step?
A. Repeat CT in 1 year B. Ca 19-9 C. ERCP with brushing and stent D. MRCP E. EUS with FNA
D
Choledochal cyst disease may present as diln in a variety of locations within the biliary tree.
Type I fusiform dilation of extrahepatic duct
Type II DIverticulum of the extrahepatic duct
Type III Intraduodenal (choledochocele proper)
Type IVa Intra and extra hep diln of the bile duct
Type IVb Multiple diln of extrahepatic bile duct
Type V Multiple intrahepatic biliary cysts (Caroli disease)
Incidence of carcinoma in bile duct cysts is estimated to be 2.5-15%, compared with an incidence of 0.012-0.48% in pts without bile duct cysts. Classical triad of jaundice, RUQ pain, and abdo mass, occurs in <20% of all pts with biliary cysts. Choledochal cysts should be surgically resected when possible to avoid long term consequences of cholangitis, liver cirrhosis, pancreatitis and malignant transformation
MRCP provides a noninvasive test to image the biliary tree and assess feasibility of surgical resection. Such imaging should supersede ERCP, brushings, tumor markers or FNA
Compared with standard open hemorrhoidectomy, stapled hemorrhoidectomy is assoc with which of following?
A. Lower rate of infection B. Lower recurrence rate C. Improved patient satisfaction D. Delayed return to normal activities E. Less post op pain
E
Stapling device for hemorrhoidectomy has less pain at the cost of higher recurrence rates. Comparison trials have shown that patient satisfaction is similar between procedures–possible due to patient self selection, that is, one is often likely to be happy with the chosen option. Less pain results in a quicker return to N activities in controlled studies. Infection rates are similar.
Conventional hemorrhoidectomy may be used more often in pts with prominent external skin tags, and this is the source of the incr pain scores. Randomization of subjects removes this selection bias but pts in the conventional hemorrhoidectomy group may suffer the pain of skin tag removal. With these differences between stapled and open hemorrhoidectomy, it is clear that patient selection and a good preop discussion of options is relevant
One yr after a lap RYGB, a 42F presents with a bowel obstruction. Her original OR indicates that her gastric bypass was performed in a retrocolic antegastric fashion. Which of the following is the most likely cause of her symptoms?
A. Obstruction secondary to adhesions B. Port site hernia C. Internal hernia D. Stricture of gastrojejunostomy E. Stricture of jejunojejunostomy
C
Adhesive SBO is less common after LRYGB than open, the overall rate of bowel obstruction remains approx equal between 2 approaches and is possibly even higher with lap. Due to incr incidence of bowel obstruction caused by internal hernia, which occurs at a rate of approx 2-5% after LRYGB.
3 potential spaces of internal herniation are created during the procedure. First is Peterson defect between the Roux limb mesentery and the mesocolon. Second is jejunojejunostomy meseteric defect. Third occurs only in retrocolic RYGB.
Overall incidence of SBO in retrocolic cohort is 5.1%. Internal hernia causes half of these bowel obstructions and approx half were adhesive disease, scarring at the mesocolic space, port site hernia and jejunojejunostomy stenosis. 3/4 of internal hernias were at the defect in the transverse mesocolon, a space that is not created in the anetocolic technique. In antecolic LRYGB, overall incidence of SBO was 1.7% and obstructions were caused by stenosis at the jejunojejunostomy, adhesive disease, internal hernia and port site hernia, in desc order of freq.
When evaluation a pt with bowel obstruction after LRYG, important to note the route of Roux limb and timing of the obstruction. Early obstruction (within 30 days) are more likely caused by technical error causing obstruction at the jejunojejunostomy. Late obstruction is more likely due to internal hernia or adhesive disease. Internal hernia is thought to be a late complication b/c the pt’s wt loss causes a decr in intraperitoneal fat and subsequent enlarging of mesenteric defects.
Dx can be difficult. Valuable diagnostic tool is lap reexploration and may SBO after LRYGB can be tx laparoscopically.
Stricture at gastrojej causes a GOO rather than SBO. Pts are intolerant of even small amts of food and generally do not have bloating and abdo distension.
Which of the following is TRUE regarding the mgmt of sigmoid diverticulitis?
A. Patients with perforated diverticulitis require sigmoidectomy and end colostomy (Hartmann procedure)
B. Likelihood of needing emergency surgical therapy is not affected by the number of prev episodes of uncomplicated diverticulitis
C. Colonoscopy is not recommended in pts <40 yrs after resolution of uncomplicated diverticulitis
D. Elective diverticular disease resection is assoc with lower rates of morbidity and mortality than elective CRC resection
E. In men <40 yrs, an episode of uncomplicated diverticulitis warrants elective sigmoidectomy
B
Hinchey I Pericolic or mesenteric abscess
Hinchey II Walled off Pelvic abscess
Hinchey III Generalized purulent peritonitis
Hinchey IV Generalized feculent peritonitis
Tx of sigmoid diverticulitis continues to evolve. Significant morbidity and mortality assoc with Hartmann’s and subsequent colostomy take down. This OR is commonly considered for Hinchey III or IV. However in clinically stable pts with favourable anatomy, it is possible and perhaps better to perform resection with colorectal anastomosis with or without diverting loop ileostomy. Subsequent ileostomy takedown is easier. Other approaches for Hinchey III and IV include damage control sigmoid resection with a delayed anastomosis as well as irrigation and drainage alone. Thus, all pts do not need a Hartmann.
Applying elective resection after a first attack of uncomplicated diverticulitis has little effect on the incidence of pts requiring emergency procedures, b/c the type of presentation tends to be similar to their first attack and not necessarily more sever. The ASCRS now recommends “the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in defining the appropriateness of sx”. Studies based on decision analysis models suggest that life expectancy will be optimized if elective sx is performed after the 3rd or 4th attack of uncomplicated diverticulitis. This finding is particularly relevant b/c elective diverticular disease resection has a significant rate of morbidity and mortality–higher than that of elective CRC resection
Colonoscopy is recommended after nonop tx and before operative tx of sigmoid diverticulitis in pts of all ages.
US of RUQ incidentally reveals a 5 mm polyp in the gallbladder. Mgmt consists of which of the folllowing?
A. Cholecystectomy with excision of gb bed
B. Repeat US in 6 months
C. CT scan and EUS
D. An extended cholecystectomy with LN dissection
E. Lap Chole
B
Polyps of go are typically incidental findings detected during radiologic imaging of the abdo. Significance is related to their potential for malignancy.
Polyps <0.5 cm are usually benign and most freq represent cholesterolosis. Asymp pts with cholesterol polyps do not need tx. However, a repeat US exam at 6 and 12 months may be appropriate. FU exam are not necessary if polyp is unchanged.
Polyps at least 1 cm in diameter may represent cholesterol polyps, adenomas, or carcinomas. Multiple polyps, pedunculated polyps, and those that are hyperechoic compared with the liver are usually cholesterol polyps, whereas solitary and sessile polyps are isoechoic with the liver are more likely to be neoplasticism and a lap chole should be performed
Lesions >1.8 cm are usually malignant. B/c these lesions may represent advanced cancer, pts should undergo preop staging with CT scan and EUS. If malignancy is proven, an extended cholecystectomy with LN dissection and partial hepatic resection of the gb bed is required.
Which of the following statements is TRUE regarding Meckel diverticulum?
A. Most common neoplasm in a Meckel diverticulum is adenocarcinoma
B. It is a true diverticulum
C. A Grynfellt-Lesshaft hernia contains a Meckel diverticulum
D. Stapled diverticulectomy is adequate tx for a bleeding Meckel diverticulum
E. Heterotophic mucosa is best detected by capsule endoscopy
B
Meckel diverticulum is a true diverticulum, containing all 3 layers of the intestinal wall. Neoplasms within Meckel are exceedingly rare, but of such neoplasms, carcinoid is most common. In a population based study 77% were carcinoid.
A hernia containing a Meckels is a Littre hernia. These hernias can be inguinal (50% in 1 series), umbilical or femoral. A grynfeltt-lesshaft hernia refers to a hernia of abdo contents through the superior lumbar triangle (formed by quadratus lumborum, 12th rib and internal oblique).
Acid producing heterotrophic gastric tissue within a Meckel’s can result in ulceration of adjacent N small bowel mucosa, resulting in GI bleed. An adequate resection needs to include both the diverticulum and the ulcerated intestinal mucosa. A diverticulectomy alone is insufficienct mgmt of a bleeding Meckel diverticulum if it does not resect the ulcerated intestinal mucosa.
In the elective setting, a technetium 99 pertechnetate scan is the study of choice to detect heterotrophic tissue within a Meckel’s. Capsule endscopy is often used in the WU of small intestinal bleeds but it is not the preferred study if a Meckels is suspected
Which of the following statements is TRUE regarding surgical tx of diverticular disease?
A. A single episode of uncomplicated sigmoid diverticulitis mandates resection
B. Two separate episodes of uncomplicated sigmoid diverticulitis mandate resection
C. Surgical resection should include all areas of diverticulosis
D. The distal resection margin should be at the peritoneal reflection
E. The proximal resection margin should be located in an area without hypertrophy of the muscularis propria
E
Controversy remains regarding the need for elective colectomy in pts who are successfully managed nonop during an acute diverticulitis episode. After a single episode of uncomplicated sigmoid diverticulitis, risk for recurrent diverticulitis is low; however, with the second episode, the risk for a third episode becomes substantial. Data indicate that although the risk of subsequent episodes of acute diverticulitis is high, risk of complicated diverticulitis remains low. IT is currently recommended that the decision to proceed should be made on a case by case basis and that the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in determining the appropriateness of sx.
For pts who experience diverticulitis complicated by abscess formation requiring perc drain, sigmoid resection is recommended even if otherwise full recovery from the episode of diverticulitis with conservative mgmt is achieved.
When performing elective sigmoid resection for diverticular diseases, not all diverticula bearing colon must be removed. Distal margin of resection should extend to where the taenia coli diverge into the upper rectum, b/c diverticulum formation below this level is very uncommon. Proximal margin should be an area of pliable colon without hypertrophy or inflammation.
Pancreatic anastomotic lead after Whipple
A. Occurs in <5% of cases
B. Typically gives rise to chronic pancreatic fistula
C. Is best tx with early operative intervention
D. Does not resolve quicker with octreotide
E. Occurs less often with pancreaticogastrostomy
D
Anast leaks after Whipple are a significant source of morbidity and mortality from this procedure. Anast leaks occur in 15-25% of cases. Fortunately, most leaks heal with conservative mgmt and do not give risk to chronic panc fistulas. When a chronic fistula does occur, early operative intervention should be avoided, b/c most of these fistulas will close spontaneously with observation. Although the use of octreotide can decr the output from a panc fistula, octreotide therapy dose not aid in the healing of a fistula. Meta analysis of RCTs has not shown a significant difference between pancreaticojejunostomy and pancreaticogastrostomy with regard to panc anast leak or fistula formation
57F recently found to have an invasive adenoca of the cecum. Her preop work up should include a PET CT under which of the following circumstances?
A. Routinely
B. When initial CT abdo fails to show met disease
C. When initial CT abdo shows a single met to the R lobe of the liver
D. When initial CT abdo shows >5 met lesions to the liver
E. When the patient has UC
C
Preop work up should include full inspection of colonic mucosa, preferably by colonoscopy, CBC, chem, CEA and CT scan of Chest/Abdo/Pelvis.
PET CT is not routinely indicated as part of preop work up. If CT scan demonstrates potentially curable met disease, further evaluation with PET-CT is warranted. Under such circumstances, purpose is to evaluate unrecognized mets that would prevent possibility of surgical cure. Pts with clearly unresectable mets (>5 met lesions in liver) should not have a baseline PET CT b/c the results will not affect the clinical mgmt. Should not be used to assess the response to chemo, b.c the scans can provide a transient falsely neg result after the use of chemo. False positive PET can occur in presence of tissue inflam such as in active UC
Rectoanal inhibitory reflex
A. Is elicited by distension of the distal rectum
B. Results in relaxation of the external anal sphincter
C. Is accentuated in Hirschsprung disease
D. Is best measured with perineal electromyography
E. Is absent in pts with pelvic floor dysmotility
A
Rectal inhibitory reflex (RAIR) is normal reflex that occurs in response to distension of the distal rectum. With the RAIR, there is a relaxation of the internal anal sphincter. RAIR allows rectal contents to be “sampled” by the sensory area of the proximal anal canal, thus providing a means to determine stool from gas.
RAIR is absent in Hirschsprungs, b/c the aganglionic segment prevents the relaxation of the internal sphincter. Patients with other forms of chronic constipation, including colonic inertia and pelvic floor dysfunction, will typically have a detectable RAIR. The RAIR is best measured with anal manometry. RAIR does not result in relaxation of the external anal sphincter. In fact, transient contraction of the external sphincter is often seen with the reflex
Hirschsprung disease in adults
A. Typically occurs in pts >40 yrs old
B. Usually involves > 10 cm of distal rectum
C. Results from an aperistaltic proximal colonic segment
D. Is best tx with mechanical anal dilation
E. Is assoc with the absence of the rectoanal inhibitory reflex
E
Hirschsprung is a functional obstruction that results from aperistalsis due to congenital loss of ganglion cells within the distal colon and rectum. Occurs in 1 in 5000 births, with the majority being dx and tx in neonatal period. Rare cases, remain undx in adulthood. Adult Hirschsprung is same entity as in peds, differing only in its degree of severity and timing of dx. Clinical course of adults is characterized by chronic debilitating constipation since birth. Most pts are dx before age 40. Oldest person dx was 69 yrs. Almost always involves a short segment of distal rectum and thus gives rise to less severe symptoms. Dx is suggested by abscence of rectoanal inhibitory reflex as measured by anal manometry. RAIR is a normal reflexive response where distension of the distal rectum results in decr in internal anal sphincter tone. Appropriate tx consists of proctectomy and removal of aganglionic segment and anal mucosectomy with coloanal anastomosis. Anorectal myomectomy provides varying success. Simple anal dilation is not likely to affect the clinical course of Hirschsprung disease
45M has a 5 yr hx of idiopathic UC. Although the last few yrs he has been asymptomatic from his colitis, he was recently dx with early PSC. Which of the following mgmts should this pt undergo?
A. Total proctocolectomy with ileal pouch anastomosis to prevent progression of PSC
B. Annual screening colonoscopy to assess for presence of dysplasia beginning at 10 yrs from dx of UC
C. Annual screening colonoscopy to assess for presence of dysplasia beginning at 5 yrs after the dx of PSC
D. Annual screening colonoscopy to assess for the presence of dysplasia begnning now
E. Screening colonoscopy beginning at the age of 55
D
PSC is characterized by inflam and fibrosis of the intrahepatic and extrahepatic bile ducts. PSC is immune mediated progressive disorder than can progress to the development of cirrhosis, portal HTN, and hepatic decompensation. Occurs in ~5% of pts with UC. IN a majority of such cases, dx of UC precedes dx of PSC by several yrs. Colectomy for UC does not appear to improve or prevent PSC. In fact, PSC may develop several yrs after colectomy. Patients with idiopathic UC are at an incr risk for development of CRC. Risk of cancer is related to the duration of colitis. B/c of this risk, all pts suffering from UC should undergo annual surveillance colonoscopy, with multiple bx beginning 8-10 yrs after dx of colitis. Pts who suffer from both UC and PSC are known to be at incr risk for development of dysplasia and CRC compared with other pts with UC. Given this incr risk, UC pts with PSC should undergo annual surveillance colonoscopies beginning at the time of dx of PSC.
Which of the following statements about cholecystectomy after endoscopic clearance of choledocholithiasis is TRUE?
A. Ppx cholecystectomy reduces mortality
B. Deferring chole does not incr the risk of cholangitis
C. Deferring chole does not incr the risk of biliary tract symptoms
D. Conversion rate to an open operation is unchanged if chole is deferred
E. Pancreatitis is common in pts who defer chole
A
Cochrane analysis of RCTs found that early chole after endoscopic choledocholithotomy decr the risk of mortality by 78% compared with wait and see approach. In ASA IV or V groups, mortality was decr from 13% in wait and see to 7% in early chole. Significant decr in incidence of biliary pain and cholangitis. In pts managed by wait and see, 5.4% developed recurrent jaundice or cholangitis, but only 0.9% developed pancreatitis. In a prospective RCT, 47% managed nonop developed greater than 1 biliary related event during 2 yrs of follow up compared with 2% of pts who underwent lap chole after initial endoscopic choledocholithotomies. Significant incr in conversion to open in wait and see pts who underwent choles after symptomatic recurrence (55%) compared with early chole pts (20%). Early removal of gb after clinical presentation with choledocholithiasis decr risk of death and complications and this improvement is seen even in pts at high operative risk
Compared with urgent operation for acute, left sided colonic obstruction due to a potentially curable colon cancer, use of self expanding metal stents as a bridge to elective operation has
A. Higher medical complications B. Lower hospital length of stay C. Lower risk for stoma formation D. Worse long term oncologic outcome E. Higher mortality rate
C
~15% of pts with CRC present with obstruction. Mgmt must include decompression to avoid subsequent perf. Accomplished by either a palliative stoma or Hartmann procedure in 25% of pts. However in up to 40% of Hartmann’s are never reversed. Morbidity of operation for acute obstructing CRC is high and mortality rates are 9-27%. Self expandable metal stents are advocated as an alternative to operation. For pts with mets, self expandable metal stents may allow palliation without operation or stoma formation. For pts with potentially curable CRC, these stents may serve as bridge to sx by allowing for decompression and subsequent 1 stage surgery without stoma formation.
Approx 50-60% of pts with acute obstructing CRC are candidates for self expandable metal stents. Technical success rate, defined as the ability to deploy stent and relieve obstruction is high (88-100%). Results in a shortened hosp stay by up to 5-8 days, as well as decr need for ICU admission. With relief of obstruction, need for emergency OR and stoma formation at any point in tx is reduced. Use of stents as a bridge to subsequent resection in colon ca is not assoc with worse oncologic outcome or higher mortality, although better long term data are needed.
Patients with short segment obstruction and distal obstructions are the best candidates for self expandable metal stents. Overall complication rate is ~20% with migration betting the most common problem (10%). Perf from stent placement occurs in up to 4%. Most important risk factor for perf is the use of balloon dilation
2 weeks after a ventral hernia repair, a 30F returns to ER with a 24hr hx of nausea and intractable bilious vomiting. Her hx is remarkable only for remote antrectomy and RYGB for GIST. A CT is obtained and shows intussusception of small bowel in L side of abdo. Which of the following is the next step in her management?
A. NG decompression and medical mgmt B. Barium upper GI study C. EGD D. Exp Lap and small bowel reduction E. Exp Lap and small bowel resection
E
Intussusception is an uncommon cause of adult bowel obstruction (<5%). Ped intussusception is benign and idiopathic in 80% of pts anc can be tx with reduction (air or barium). However, adult intussusception has a pathologic lead in up to 90% of pts. Approx 65% of colonic intusussception has a malignant lead point. In the small bowel, up to 30% of these lead points are malignant. Benign causes include polyps, Meckels, strictures or benign neoplasms. Thus, up to 90% of adult intussusception cases require definitive tx with surgical resection. In select cases, when a benign etiology is firmly established, the intusussception may be milked out to limit the extent of bowel resection.
CT Abdo is considered to be the best diagnostic imaging modality, with an accuracy of 60-100%. Classic finding is the “target sign” which is caused by bowel within bowel. Mesenteric vessels within a bowel lumen may be seen as well.
In this pt, CT has established the dx, and given her past hx of GIST, she is very likely to have a pathologic lead point. Thus, ongoing medical mgmt is not appropriate.
74F presents to ER for evaluation of a 2 day hx of epigastric abdo pain and bloating. During the course of this eval, her pain has become more severe. She is tender and tympanic in the upper abdo but has no guarding. Her WBC and amylase are normal. A CT Abdo shows dilated colon pointing to LUQ. Which of the following is the most appropriate next step in her mgmt?
A. Hydrostatic barium enema B. Colonoscopy C. Operative detorsion D. R hemi E. Cecopexy
D
Patient has cecal volvulus. Volvulus occurs when a large, mobile loop of intestin and its mesentery twist on a fixed point. This torsion leads to a closed loop obstruction with bowel distension. Depending on degree and duration of torsion, ischemia, gangrene and perf can occur. Volvulus occurs most commonly in sigmoid colon, followed by cecum
Cecal volvulus occurs in 2 types: axial ileocolic volvulus (90%) and cecal bascule (10%). In axial ileocolic volvulus, cecum and TI rotate up and over to the LUQ. Cecal bascule occurs when cecum flips upward and anterior in a horizontal plane. Both types require a highly mobile cecum, which is though to occur from failure of mesentery to fuse to the posterior parietal peritoneum in the R parabolic gutter.
Preferred tx of cecal volvulus is operative, which is generally a R hemi. Non viable bowel should be resected without detorsion, b/c this may lead to septic shock. Majority of pts can be reanastomosed after resection even with gangrene and obstruction. however, ileostomy with or without a mucus fistula, remains an option if there is peritonitis or severe bowel distension.
Radiologic guided hydrostatic enema with a water soluble contrast can be used to reduce sigmoid volvulus but is less successful in cecal volvulus. In addition, barium would not be used in this pt b/c of risk of perf. Similarly, colonoscopy can decompress a sigmoid volvulus but has a high failure rate for cecal volvulus (put to 70%). Detorsion of volvulus accompanied with fixation, either cecopexy or cecostomy, is assoc with high complication and failure rates
Which of the following is TRUE regarding the possible risk factors for post laparotomy adhesive SBO
A. Rates of SBO after open appy are higher than after lap appy
B. Separate closure of peritoneum decr adhesion formation
C. Open adnexal operations have the highest rate of adhesion related admission
D. Age and gender are strong predictors of SBO
E. Presence of cancer incr postop SBO
C
Postop adhesions are freq after abdo and pelvic sx and occur in 50-95% of pts who undergo subsequent laparotomy. Adhesion related SBO occurs in nearly 5% of pts who have undergone prior abdo or, of which 3-8% required operative intervention. Although risk factors are difficult to identify, type of sx and method of operation play important roles in development of adhesive SBO. Open chole and hyst are assoc with higher rates of SBO compared with laparoscopy; however, with appy, the rates are similar. Open adnexal OR have the highest rate of adhesion related readmission (23%), mostly due to SBO, followed by ileal pouch anal anast (19%), TAH (15%) and colectomy (9%). Age, gender and presence of cancer do not appear to affect post op adhesion formation, readmission, or SBO. Closure of peritoneum as a separate layer appears to incr adhesion related readmission and SBO
Which of the following choices regarding the mgmt of pts with nonvariceal UGIB is TRUE?
A. Pts with high risk stigmata of recent hemorrhage can be safely managed as an outpt after endoscopic hemostasis
B. Percutaneous or transcatheter embolization should not be used as an alternative to surgery
C. Upper endoscopy should be delayed until INR is normalized
D. A high dose IV PPI reduces rebleeding and the need for surgery
E. Second look endoscopy is required before d/c
D
UGIB has an incidence of 1/1000 pts and has a substantial mortality of approx 10%. Initial mgmt is focused on ABCs, correction of coagulopathy and risk assessment, followed by early endoscopy (within 24 hrs of presentation) focused on hemostasis. Upper endoscopy should not be delayed until correction of coagulopathy.
At upper scope, hemostatic therapy (clips, thermocoagulation, or sclerosant injection) is indicated for all lesions with high stigmata of recent bleeding (active bleeding or visible vessel in an ulcer bed). Epi injection alone is not sufficient. Second look endoscopy not recommended unless bleeding recurs. If upper endoscopy reveals findings of low risk stigmata (clean based ulcer or clot in an ulcer bed), hemostatic therapy is not indicated and pts can be fed within 24 hrs and d/c’ed early with oral PPI. Pts deemed as high risk should be hospitalized for >72 hrs and should received IV PPI. Percutaneous embolization or surgery can be considered when endoscopic therapy has failed.
Which of the following statements about colon cancer in pts with UC is true?
A. Cancer risk incidence exceeds 50% at 30 yrs after dx
B. Use of 5 ASA decr incidence of cancer
C. Complete mucosectomy significantly reduces a the incidence of cancer
D. Colon cancer is more common in adult onset UC than in childhood onset UC
E. Risk of cancer is unaffected by extent of disease
B
Incidence of cancer in pts with UC corresponds to cumulative probabilities of 2% by 10 yrs, 8% by 20 yrs and 18% by 30 yrs. In patients with use of 5 ASA, lower risk of CRC. Mucosectomy does not confer benefit in terms of disease control and there is no significant improvement in cancer risk with mucosectomy
Consensus that CRC is highest in this pts with long duration of disease (adult compared with child) and extent of disease
Transanal endoscopic microsurgery has limited application in which of the following?
A. Lesions < 10 cm from anal verge B. Lesions occupying <30% of the circumference C. Lesions <5 cm in diameter D. Mucosal lesions E. Lesions located above the anal canal
E
TEM provides a minimally invasive technique for excising a wide variety of beings and malignant rectal lesion. Large diameter operating proctoscope is inserted into the anal canal. With an airtight seal, rectum can be distended with CO2, providing clear visualization of rectum was a small calibre videoscope. Precise dissection for both full thickness and partial thickness excision. Better imaging and access facilitate control of hemostasis. Accurate dissection within the proper planes and with appropriate margins can be achieved. Polyps above the peritoneal reflection of the rectum (>15 cm), polyps > than 8 cm in diameter, and polyps occupying >50% of rectal circumference are amenable to TEMS resection. TEMS is applied to a variety of anorectal diseases. Other benign rectal and extrarectal masses such as carcinoids, and some retrorectal cysts, can also be excised with TEMS. TEMS does not allow for visualization of the anal canal. It used is limited to lesion located above the anal canal.
For each numbered statement, select the correct lettered statement
- Restrictive and malabsorptive
- Superior resolution of metabolic comorbidities
- Operative mortality <0.5%
- Mean excess wt loss > 70%
A. Duodenal switch with sleeve gastrectomy (biliopancreatic diversion)
B. RYGB
C. Both
D. Neither
- C
- A
- B
- A
RYGB is most commonly performed bariatric procedure. 60 mL proximal gastric pouch is created and anastomosed to Roux limb. Creating a Roux limb 150 cm long enhances wt loss by means of malabsorption of ingested foods. Small gastric pouch restricts volume of food intake, and pts must dramatically reduce meal size to avoid complications. Mean excess wt loss approaches 60% at 1 yr and is somewhat less at 3 yrs. 30 day operative mortality ranges from 0.1-0.5% in large series
BPD includes a sleeve gastrectomy by stapling along a 60 Fr Bougie placed along the lesser curve of the stomach. Duodenum is divided 2 cm distal to pylorus, preserving blood supply and vagal innervation of antrum. Roux limb is created by dividing small intestine 250 cm proximal to IC valve and anastomosing this to the postpyloric duodenal cuff. Bypassed biliopancreatic lumb is sewn to Roux limb 100 cm proximal to IC valve. Technically more challenging than RYGB. Clearly a restrictive procedure, pt acceptance is higher b/c gastric capacity is larger and there is less dumping than RYGB. More effective in reversing premorbid metabolic conditions such as DM, dyslipidemia, and HTN in super obese. 30 day operative mortality 0.5-1.1%. For super obese pt, BPD results in significantly superior sustained wt loss than RYGB at 3 yrs postop
For each numbered statement, select the correct lettered statement
A. Lap Nissen fundoplication
B. Lap Toupet fundoplication
C. Both
D. Neither
- 270 degree wrap
- Requires extensive division of short gastrics
- Requires posterior esophageal dissection
- Less early post op dysphagia
- B
- D
- C
- B
Lap Nissen involves a 360 degree wrap of esophagus with or without division of short gastric vessels. Division of short gastric vessels is rarely necessary to acheive adequate mobilization of the fundus for either Nissen or Toupet. Results are the same without dividing the short gastric vessels and division of short gastric vessels may actually incr postop bloating. Lap Toupet requires a similar posterior esophageal dissection. However, the fundus is sutured to the R diaphragmatic crura, creating a 270 degree wrap, as opposed to a 360 degree wrap.
Toupet is assoc with less postop dysphagia and markedly less need for esophageal dilation in the early post op period. Nissen and Toupet are equivalent in terms of symptom resolution at 5 and 10 yrs follow up. IN prospective RCT, 85% have clinical success at 5 yrs
For each numbered statement, select the correct lettered statement
A. UC
B. Crohn’s
C. Both
D. Neither
- Infliximab therapy is indicated for active disease resistant to 1st line therapy
- Mesalamine is effecfive as first line maintenance
- 6MP is used as adjuvant therapy for steroid dependency
- Infliximab therapy increases the risk of wound complications after stomal closure
- C
- A
- C
- D
Combining oral meslamine with mesalamine enemas is better than oral monotherapy for pts with mild to mod active, extensive UC. Combo induces 64% remission within 8 weeks, compared with 43% with oral monotherapy. Combo is appropriate for initial therapy. For pts who need escalation in therapy, moving straight from mesalamine to infliximab is an effective option that can avoid steroids; 33% acheived remission after 8 weeks of therapy with infliximab
Mesalamine cannot be recommended for Crohn’s disease b/c results are inconsistent. Cochrane review found no benefit In meta analysis, infliximab maintained remission in more pts than placebo and incr response and spared pts from corticosteroir therapy.
No significantly incr postop complications after ileostomy closure in pts who received infliximab or other immunosuppresive meds compared with pts who did not.
Both 6 MP and azathioprine are successful in managing disease for pts who are steroid responsive ileal disease or UC.
For each numbered statement, select the correct lettered statement
A. Lap adjustable gastric band
B. Lap sleeve gastrectomy
C. Both
D. Neither
- 30 day mortality >1%
- Excess wt loss at 1 yr after procedure >50 %
- Plasma ghreline levels decr
- D
- B
- B
Obesity exceeds 30%. 3 major procedures are LRYGB, lap gastric band, and lap sleeve gastrectomy
All 3 reverse insulin resistance in msot pts. Ghrelin levels are dec with lap sleeve gastrectomy. This finding has theoretical importance in that lowered levels should decr appetite. 30 day mortality is low in all 3 procedures, wich the highest being in LRYGB (0.4%). Incidence of early reoperation with LRYGB is approx 2% with the other 2 procedures, early reoperation is necessary in approx 1%
30 day complication rate is highest in LRYGB group (4%) but the 1 year complication rate is the same for all 3 (8%). At 1 year, the % of excess wt loss is 60% for LRYGB and lap sleeve gastrectomy and 40% for the lap gastric band.
For each numbered statement, select the correct lettered statement
A. Adult intussusception
B. Adult malrotation
C. Both
D. Neither
- Chronic vague symptoms
- Target sign
- Whirlpool sign
- Assoc with cecal volvulus
- PSBO
- Currant jelly stool
- En bloc resection
- C
- A
- B
- B
- C
- D
- A
Intusussception and anomalies of intestinal rotation are usually assoc with the peds population, commonly in the neonatal period, particularly with respect to malrotation. Both conditions are also identified in the adult population and some have suggested that these conditions occur with equal incidence to the peds population. These 2 entities should be kept in ddx for adult pts who present with vague or nonspecific abdo complaints. Acute symptoms do occur in adults but not as commonly as they do in children. Classic findings of intusussception in children–palpable sausage shaped abdo mass, currant jelly stools or an acute abdo catastrophe–are not seen in adults. When identified in the adult population, assoc congenital abN are not common.
Intusussception in adults may present without a lead point, in contrast to children, and may occur without symptoms as an incidental finding on CT performed for other reasons. Finding of bowel within bowel or target sign is pathognomonic. Presentation in adults with a lead point may manifest with atypical clinical findings, b/c may are related to neoplastic processes, commonly disseminated carcinomatosis. Some intususscpetions may present with acute bowel obstruction. En bloc resection is recommended and attempts at hydrostatic reduction should not be undertaken
Intestinal rotational anomalies in adults can be complete or incomplete. Often, like in intussusception, they are found during work up for vague abdo complaints or incidentally at the time of sx for other reasons. Contrast intestinal imaging may identify R sided small bowel, a L sided cecum, and inverse relationship between the SMA and SMV or aplasia of the uncinate process of the pancreas. A whirlpool sign, wrapping of the SMV around the SMA with dilation of SMV, is a common CT finding. Cecal volvulus occurs with malrotation, and partial SBO is common with both malrotation and intusussception in adults
For each numbered statement, select the correct lettered statement
A. Adenoca of stomach intestinal type
B. Adenoca of stomach diffuse type
C. Both
D. Neither
- Diets high in preserved foods
- Antral location
- Routine splenectomy
- A
- A
- D
Classic histopathologic classification used for gastric cancer describes 2 distinct adenocas: intestinal and diffuse.
Diffuse gastric adenoca has an approx equal male:female ratio, with an infiltrative submucosal growth pattern, resulting in classic thickened, non distensible stomach known as linitis plastica. It tends to being in the corpus or proximal fundus of the stomach and generall mets directly into peritonum
The intestinal types tends to occur in the older population with a higher male: female ratio. It is somewhat assoc with atrophic gastritis and mets often by hematologic spread to the liver. Assoc with environmental factors such as a diet high in salted, smoked and preserved foods. Surgical resection is the only realiztic modality for cure of the pt. IN large clinical studies, there has been no benefit to ppx splenectomy for curative resection in gastric ca, unless there is macrocystic disease involving the spleen or parasplenic LNs
For each numbered statement, select the correct lettered statement
A. Rubber band ligation
B. Stapled hemorrhoidectomy
C. Both
D. Neither
- Mixed hemorrhoids
- Sepsis
- External hemorrhoids
- Above the dentate line
- Sphincter injury
- D
- C
- D
- C
- B
Rubber band ligation and stapled hemorrhoidectomy are used in the mgmt of internal hemorrhoids. Neither can be used in the tx of external hemorrhoids. Internal hemorrhoids originate above the dentate line and have visceral innervation but lack somatic innervation. As a result, internal hemorrhoids may be managed with relatively minimal discomfort to the patient. External and mixed internal-external hemorrhoids are covered by anoderm, a modified squamous epithelium that contains pain fibers. Rubber band ligation of external hemorrhoids would be pain ful and stapled hemorrhoidectomy does not remove external hemorroids
Rubber band ligation is office based procedure, performed withou anesthesia or bowel prep. Redundant hemorrhoid tissues is grasped above dentate line through an anoscope and a double rubber band is applied at the base of the sensation free hemorrhoid effectively cinching the redundant tissue. Depending on pt tolerance, multiple site may be tx in a single visit.
Stapled hemorrhoidectomy is an operative procedure. Circumferential purse string suture is placed above the dentate line through a specialized anoscope and the redundant hemorrhoid tissue excised with a hemorrhoid stapler. 1 to 3 cm ring of mucosa and submucosa is excised. Care taken not to include the sphincter muscle or vagina in the staple line. Fecal incontinence and rectovaginal fistula may result from inaccurate stapler placement
Pelvic sepsis may occur after both rubber band ligation and stapled hemorrhoidectomy. This complication is rare yet may be lethal if not recognized. Pelvic sepsis is usually manifested by pelvic pain, fever, and urinary retention. Initial mgmt consists of EUA, debridement of any compromised tissue and broad spectrum Abx.
For each numbered statement, select the correct lettered statement
A. Fourth degree strangulated hemorrhoids with necrosis
B. Fourth degree stranfulated hemorrhoids with edema, no necrosis
C. Both
D. Neither
- Requires emergency OR
- Urinary retention
- Staples hemorrhoidectomy
- A
- C
- D
Both presentations are representative of hemorrhoid crisis. Patients present with acute pain and nonreducible prolapse, and they may experience urinary retention with either presentation
Gangrene, necrosis and ulceration are absolute indications for a emergency hemorrhoidectomy. There is no role for office based mgmt. All devitalized tissue must be debrided. Wounds should be left open to prevent post op sepsis. Best done under GA.
Visible strangulated prolapsing hemorrhoids may be tx with formal surgical hemorrhoidectomy or may be tx more conservatively in the office with a perianal block, gentle reduction and multiple rubber band ligation. Rubber band ligation can be done either at the time of initial reduction or after edema is resolved. Perianal block is obrained with 0.25% bupivicaine with 1:100,000 epinephrine and hyaluronidase. This approaches is particularly useful in late pregnancy.
Stapled hemorrhoidectomy is used in the mgmt of uncomplicated second and thrid degree internal hemorrhoids. It does not address the external hemorrhoid component and is contraindicated in the face of tissue necrosis.
All of the following are true of Meckel’s diverticulum except
A. Meckels is most common congenital GI malformation
B. 80% of pts present with symptoms before 2 yrs of age
C. GI bleeding is most common symptom in children
D. The cause of bleeding is ulcerated gastric mucosa
E. More than 10% are symptomatic
B in answer key
D is also wrong
Most common congenital Gi malformation. Anomaly results from an incomplete obliteration of the omphalomesenteric duct during gestation. Only 4-6% of pts develop symptoms. When discovered incidentally at exp lap, routine resection is not recommended, regardless of age
GI bleeding is the major clinical finding in children and occurs in up to 50% of cases. Cause of GI bleed is assoc with ectopic gastric tissue in the diverticulum. Symp of intestinal obstruction are most commonly seen in adults and this presentation is second most common clinical finding in children. <50% of pts present with symptoms before 2 yrs of age.
Patients who are TPN dependent should be considered for small bowel transplant for any of the following except
A. Impending liver failure
B. Thrombosis of at least 2 central veins
C. At least 2 episodes of systemic line sepsis in 1 yr
D. Residual small bowel length <100 cm
E. Freq hospitalizations for pseudo obstruction
D
Intestinal transplan is a viable surgical option for pts with irreversible chronic intestinal failure who cannot toelrate or be maintained on TPN. Hepatic injury is the most common reason for pts with intestinal failure symptoms (short gut syndrome) not to be able to toelrate PTN. Most common indication for transplant. Complciations related to venous access such as catheter thrombosis and line sepsis can make TPN impractical. Accepted indications include impending or over liver failure, central venous catheter related thrombosis in at least 2 central veins, or at least 2 episodes per year of systemic sepsis secondary to line infections.. Indicated when freq hosp are required for the mgmt of complications related to intestinal failure such as episodes of volume depletion or repeated episodes of pseudo obstruction. In general, the absolute length of residual small bowel alone is no an indication for transplant, except in those situations where ultrashort bowel exits (<20 cm in adults) and where unmanageable complications of volume depletion and electrolyte imbalances are certain to occur.
65 M underwent a LAR with primary anastomosis without proximal diversion after neoadjuvant chemoradiationfor a 6 cm rectal cancer located 4 cm from the anal verge. His preop albumin was 3.0. What would be the least likely risk factor for developing anastomotic leak?
A. Baseline albumin < 3.5 B. Tumor size >5 cm C. Neoadj chemoradiation D. Low anastomosis E. Absence of protective stoma
C
Anastomotic leak can occur after any colorectal sx, especailly after sphincter sparing surgeries with low anast for rectal ca. Leak is assoc with longer hospital stay, incr morbidity, and incr mortality and is reported to occur in 2-15% of cases. RF for leak after LAR are large tumors size (esp >5 cm), low serum albumin (<3.5), low anast, higher ASA score and intraop soilage. Temp DLI remains somewhat controversial given the need for an additional operation with potential morbidity, yet when they are used, they are assoc with lower anast leak rates, rates of pelvic sepsis and reoperation. Most experts believe than diversion is appropriate for pts who are at high risk fo anast leak, such as the pts with a large and low tumor. Neoadj chemorads does not appear to influence rate of anast leak.
Best management of a 2cm anal margin SCC A. Nigro protocol B. Wide Local Excision C. APR D. Topical Imiquimod
B
Anal margin is WLE
Anal canal is Nigro
Patient with rectal cancer, EUS shows invading internal sphincter. Best mgmt? A. Chemo/rad B. Chemo C. APR D. Low ant resection E. TAE F. Intersphincteric dissection
C
T2; doesn’t need NACRT, shouldn’t change operation based on NACRT.
Internal = T2
Intersphincteric = T3
External = T4
Patient with rectal cancer 1cm from the dentate line with normal sphincter function and no evidence of sphincter invasion. What is the best management? A. APR B. Chemo/rad C. Chemo D. Low ant resection
A
Dentate line is within anal canal. 1cm proximal would put distal margin at the anorectal ring. Possible could do a coloanal, but APR is safer.
Patient has a 1 (or 2)cm lesion within the anal canal. Biopsy shows poorly differentiated “carcinoma”. What is the best next step? A. Path review B. Chemoradiation C. APR D. Local excision
A
Adeno? SCC? Adenosquamous? Path needs clarification.
Anal margin lesion 1.5cm. biopsy showed SCC. palpable lesion A. Local excision B. Imiquimod C. APR D. Mitomycin C, 5FU, radiation
A
Perianal skin cancer behaves as skin cancer, not anal canal SCC. Treatment of choice is WLE. ASCRS text indicates WLE with 1 cm margins, accepting that APR may be necessary if large or involves sphincter. Up to Date is incorrect when it says that perianal SCC should be treated as anal canal SCC.
ASCRS: Local excision is an appropriate consideration only for small superficial lesions outside the anal canal at the anal margin in most instances
A 45 yo male patient is found to have SCC in a Pilonidal Sinus. What is the best management?
A. Resect with SLNB
B. Neoajduvant Chemo/Rad then Reesect
C. Resect with Flap
D. Resect with Negative Pressure and delayed closure
D
NPWT is Canada consensus; SCC in scar is aggressive with high risk of local recurrence, so covering with a flap is controversial as may hide a recurrence. Ideally need to know margin status before closing; VAC as temporizing measure while waiting for path then followed by flap closure once margins confirmed clear.
Patient refuses an APR for T3 rectal tumor invading the sphincter complex. What is the best management? A. Refer to colleague for second opinion B. LAR and coloanal C. Transanal excision D. Chemorads but do not resect
A
Anal canal SCC with positive inguinal node A. Chemorads and groin dissection B. APR and groin dissection C. APR D. Chemorads
D
Chemoradiation is the treatment of choice for inguinal lymph node disease. Similar to management of the primary anal lesion, the mainstay of treatment for concomitant disease of the perirectal or inguinal nodes is chemoradiation. A complete response has been reported in 79% to 92%. With the identification of any positive inguinal lymph node, bilateral inguinal basins should be incorporated into the radiation fields with the addition of a boost technique. Metachronous lymph nodes are seen in 10% to 20% of patients, normally within 6 months of completing treatment of the primary lesion. These metachronous nodes should also be treated with CRT, and typically respond well. Elective prophylactic lymphadenectomy is generally not warranted and is associated with high wound complication rates as well as lower-extremity complications. Selective inguinal node dissection may be considered for persistent disease following CRT. In small case series, long-term survival has been reported after successful removal of disease.
Patient is found to have a 2cm polyp 7cm above the dentate line. This is removed endoscopically and pathology returns as a well-differentiated adenoCa with invasion to muscularis mucosa with 1mm margin EUS is performed and shows no lymphadenopathy. CT shows no evidence of distant mets. What is the best treatment? A. Observation B. Neoadjuvent therapy C. LAR D. APR E. Transanal excision F. TEMS
F
T1N0
Need margins >1mm
Rectal cancer 2cm in size at 7 cm. Invasion into muscularis propria. Node negative on imaging. Mgmt? A. Neoadjuvant then TME LAR B. TME LAR C. TEMS D. APR
B
POD 5 LAR. Now presents with tachycardia, spreading LLQ peritonitis and imaging showing a 1cm leak into left pericolic gutter (exact wording). What to do? A. Operative drain and diverting loop B. Conversion to Hartmanns C. Observe/ABx D. Perc drain
A
ASCRS manual: small leaks can be managed with anastomitic drainage +/- repair and diversion. If managed with Hartmann’s, probably will never be able to reconnect as anast is so low already.
- Patients with a free leak should be taken to the operating room after fluid resuscitation and intravenous antibiotics are administered.
- After a thorough washout, the treatment is dictated by the findings.
- Most colorectal anastomosis will require anastomotic takedown and an end colostomy.
- To minimize the effects of a friable rectal stump (that cannot be closed with staples or sutures nor brought to the skin surface as a mucous fi stula), placement of transabdominal and transanal drains is indicated.
- Selective small bowel or ileocolic anastomotic defects can be repaired. However, resection of the anastomosis with creation of a new anastomosis or stoma is the most conservative option. Placement of the repaired anastomosis under the surgical incision will result in an enterocutaneous fistula instead of a second bout of peritonitis should a second leak occur.
- Any concern regarding viability of the bowel ends necessitates takedown of the anastomosis and creation of a stoma.
- Small defects in a colorectal anastomosis, in select circumstances, may be repaired and a proximal ileostomy created. This should be avoided when there is a large fecal load between the ileostomy and the repaired anastomosis.
- A contained anastomotic leak is walled off and typically located in the pelvis presenting as an abscess.
- If the abscess is small and contrast flows freely into the bowel, the patient can be treated with intravenous antibiotics, bowel rest, and observation.
- Larger abscesses or those removed from the site of the anastomosis may require radiologically guided drainage.
- A contained leak rarely requires immediate operative intervention, but surgery may eventually be required if the patient develops a cutaneous fistula, anastomotic stricture, or chronic presacral cavity.
50ish female, 3 years post LAR for rectal Ca with isolated greater omental met seen on imaging. Management
A. Palliative chemo
B. Isolated resection
C. Chemoreductive surgery with HIPEC
C
Sounds like the best candidate for CRS; long interval, young, limited disease. Despite HIPEC/CRS not yet being standard of care, it is supported by RCTs.
T2N0 pre-op staging rectal Ca, undergoes OR, final path T2N1. What next A. Chemo and RT B. Chemo C. Radiation D. Observe
A (this is an old answer)
New ESMO guidelines July 2017
The European Society for Medical Oncology (ESMO) has updated their guidelines for treatment of rectal cancer [1]. Among the many changes from the 2013 guidelines, they suggest a selective approach to postoperative chemoradiotherapy in patients with resected stage II and III disease (table 1), recommending it only for patients with certain high-risk features identified at the time of surgery (table 2).
Sufficient and necessary CRM ≤1 mm pT4b pN2 extracapsular spread close to MRF Extranodal deposits (N1c) pN2 if poor mesorectal quality/defects
Sufficient
pN2 low tumors within 4 cm of anal verge (risk of involved LPLN)
Extensive extramural vascular invasion/perineural invasion close to MRF
Borderline sufficient
pN2 in mid/upper rectum if good mesorectal quality
CRM 1 to 2 mm
Circumferential obstructing tumours
Insufficient and unnecessary pT1/pT2 pT3 CRM >2 mm pT4a above peritoneal reflection pN1 If good-quality smooth intact mesorectum
Lady in her 50s with resection of a rectal cancer. T2N1. 5 years later has an elevated CEA (17 then 50 a month later). full work up negative (CT, PET, colonoscopy) A. MRI B. Repeat the CT in 3 months C. Diagnostic laparoscopy D. Chemo
B
Rectal neuroendocrine 2 cm in size invading muscularis propria which is 1 cm above anal verge A. TEMS B. APR C. LAR D. Follow with colonoscopy
B
T2, >2cm means radical resection required. As 1cm above anal verge, APR.
Rectal NET: <1cm, confined to mucosa or submucosa, endoscopic resection adequate. >2cm need radical resection (APR/LAR) Intermediate tumours (1-1.9cm) controversial. Generally, if <1.5cm and no high risk features (LVI, mitotic rate, etc), local excision adequate. If high risk, formal resection.
Patient had colonoscopy and found to have mass/polyp in rectum, polypectomy was performed. Turned out to be neuroendocrine tumour with positive margin. Lesion was 1cm big. A. APR B. LAR C. Transanal excision D. Observe
C
Small NET 1cm, positive margins, requires local excision NOT radical resection. If >2cm or high-risk features, then formal resection.
71 year old male with who received neoadjuvant chemoradiotherapy for a T3 adenocarcinoma 1cm from the dentate line not involving the sphincter muscles. On repeat endoscopy, the lesion is no longer visible at the previously tattooed site. What is the BEST management?
A. Repeat endoscopy in 6 months
B. TEMS
C. LAR with handsewn coloanal anastomosis
D. APR
D
Observation of rectal cancer with complete clinical response is investigational and should not be done outside of a clinical trial. For exam purposes, need to obtain a 2cm distal margin; in this case 2cm would be below dentate so not feasible.
2.5cm pedunculated rectal polyp, well differentiated ca, only in mucosa, no invasion to vessels or lymphatics or stalk. Follow up: A. Anterior resection B. Colotomy and resection of stalk C. Colonoscopy and fulguration of stalk D. Colonoscopy in one year E. Colonoscopy in 4-6 months
E
67 yo male otherwise healthy, has been found to have a villous adenoma of the rectum. It is 6cm above the anal verge, has firm areas but is not fixed. Biopsies reveal dysplasia, as well as ca in situ. What should be done: A. Low anterior resection B. APR C. Piecemeal excision D. Transanal resection E. Trans sacral resection
D
3cm mobile sessile polyp at 4cm above dentate line. Biopsy proven foci of ca. What is the best management:
A. APR
B. Low anterior resection
C. Trans-anal resection
C
What is not an indication for transanal excision of rectal ca A. Tumor <4cm B. <40% or circumference C. T2/N0 D. 12cms from anal verge E. Moderately differentiated
C (most wrong answer)
Uptodate:
Local excision should be limited to the following groups
-Superficial T1 cancer, limited to the submucosa
-No radiographic evidence of metastatic disease to the regional nodes
-Tumor <3 cm in diameter
-Well-differentiated histology, no lymphovascular or perineural invasion
-Mobile, non-fixed
-Margin clear (>3 mm)
-Involving <30 percent of the bowel lumen circumference
-Patient is able to comply with frequent postoperative surveillance
What is the most important prognostic feature of rectal ca: A. Depth B. Nodal involvement C. Tumor aneuploidy D. Type of surgical resection E. POP radiotherapy
B
Which is true regarding the use of NdYAG laser for rectal ca:
A. It may eliminate the need for staged surgical procedure
B. It can not be used above the peritoneal reflection
C. It is useful for tenesmus
D. Use improves cure rates
E. Response is a useful staging tool
B in answer key
Neodymium-YAG laser therapy. Used mainly for palliation or in patients who are not surgical candidates
Endoscopic Nd:YAG laser treatment of inoperable lower gastrointestinal cancer.
“It requires no anaesthesia and is the only non-surgical procedure that can be safely carried out above the peritoneal reflection. “
Local control of rectal cancer with the Nd-YAG laser. - NCBI
Three patients with locally recurrent rectal cancer were treated using the Neodymium YAG laser to palliate the symptoms of tenesmus, discharge and bleeding.
What is the commonest complication occurring in a male after APR: A. Urinary retention B. Urinary stress incontinence C. Urethral-perineal fistulae D. Bladder neck obstruction E. Distal ureter injury
A
Most common pathology on ca of the anal canal: A. Adenoca B. Melanoma C. Bowen’s disease D. Paget’s E. Epidermoid
E
Which is not a risk factor for development of anal ca: A. Smoking B. Alcohol use C. Lymphogranuloma venereum D. Chlamydia infection E. Anal intercourse F. Condyloma acuminata G. HSV
B
Anal canal 3cm epidermoid ca. What is the best treatment: A. APR B. Local excision C. RX and chemo D. RX E. Chemo
C
Basaloid, epidermoid, mucoepidermoid are all subtypes of SCC, but do not influence treatment choice.
Reason for post-op radiation for rectal cancer as opposed to preop. Which is correct?
A. Decreased incidence of neorectal radiation injury
B. Decreased incidence of bladder radiation injury
C. Decreased sb radiation enteritis
D. Avoids over treatment of lesions of stage lower than t3no
E. Increased survival
D
A 20 yo male with multiple rectal polyps. All of the following are part of treatment except:
A. Ileo anal pouch
B. Ileo rectal anastamosis after colectomy
C. Sulindac
D. Endoscopic surveillance until dysplasia
E. Screen for extra colonic cancer
B
Most common cause of anal canal cancer: A. Squamous cell carcinoma B. Basal cell ca C. Melanoma D. Adenocarcinoma
A
Previous rectal cancer resection with recurrence. Which finding would make him unresectable A. Bilat hydronephrosis B. Pelvic pain C. Invading base of bladder D. Incontinence
A
DVT prophylaxis for rectal cancer procedure in patient with renal failure, previous history of DVT post hernia repair A. Heparin 5000u sc bid B. Heparin 5000u sc TID for one month C. LMWH D. SCDs until ambulating
B
Patient post-LAR for rectal cancer currently undergoing chemoradiation. Develops peripheral neuropathy and foot drop. What is the most likely etiology? A. Radiation B. Nerve injury during surgery C. Chemotherapy D. Disease recurrence
D
Most common cause is pelvic recurrence, followed by radiation.
FOLFOX –neurotoxicity is common, but is sensory only.
Obstructing rectosigmoid cancer. Intraop invading bladder, side wall etc. Mgmt A. Major en bloc resection B. Loop ileostomy C. Loop colostomy D. Close abdo
C
Best indication for TEM. A. T1 at 1 cm above dentate B. T1 proximal rectum C. T2 midrectum D. T3 mid rectum
B
Hemorrhoidectomy, path comes back as invasive SCC with negative margins. What should you do?
A. Close observation
B. Modified Nigro
C. Re-excise
A
Need to discuss at multidisciplinary case conference
Nigro is treatment for all anal SCC
Scaly perianal lesion, 6cm, circumferential, bx intraepithelial (intradermal) SCC
A. WLE
B. Imiquimod
C. APR
B
Bowen’s or HSIL. <10% will progress to invasive in immunocompetent patients, but can’t predict so treatment favoured. Standard treatment is WLE, although topical therapy (imiquimod) may used in unfit patients OR when surgery would leave a difficult wound
Neoplasms of Anal Canal and Perianal Skin. Clinics in Colon and Rectal Surgery, 2010.
The standard treatment is wide surgical excision.6 To ensure clear resection margins, a systematic four-quadrant biopsy technique, with intraoperative frozen sections has been advocated. The frozen sections should include intra-anal biopsies. Despite use of this technique, recurrence rates up to 30% have been reported. The major disadvantage of wide local excision is the difficulty to primarily close the wound and skin flaps may be necessary. The rotational v-y skin flap has been most frequently described in this setting.When surgery is not feasible or refused, other options are available such as topical chemotherapy (5-FU), immunomodulation (imiquimod), and phototherapy, although the latest guidelines favor radiotherapy.
Female patient went for short course radiation for rectal cancer.
A. Resection 1 week after radiation
B. Resection 6 weeks after radiation
C. Resection after 12 weeks
D. Observe
A
Patient with grade III hemorrhoids, banding in office immediate pain. Stable.
A. Remove band
B. OR debride
C. Observe
A
Band applied below dentate line.
Patient with anal fistula low lying with Crohns on routine exam. Asymptomatic.
A. Remicade
B. fistulotomy
C. Observe
C
Treat underlying CD
48hr pain to perineum with 1.5cm perianal nodule below the dentate line.
A. Excise
B. Observation
C. Incision/drainage
A
I&D of thrombosed external hemorrhoid is inadequate; excision is required. Excise up to 72 hours.
What decreases urinary retention post hemorrhoidectomy
A. Closed hemorrhoidectomy
B. Prone Jack knife
C. Limit IV fluids operatively
C
Schwartz: urinary retention is most common complication, limit perioperative fluids to reduce.
Anal fissure not responsive to medical treatments, fissure on lateral anal verge. Management? A. Botox B. Lateral sphincterotomy C. Topical CCB D. Biopsy
D
Atypical fissure should be biopsed or excised. Muscle relaxing treatments not effective in atypical lateral fissures.
25y M two weeks ago had a knee surgery. comes in with 1 week history of a posterior midline fissure best treatment A. Sitz bath with a stool bulking agent B. Topical CCB C. Lateral internal sphincterotomy D. Botox
A
Conservative measures first line for acute fissures.
Brachytherapy for cervical cancer present with stool per vagina with a 2cm fistula 4cm from the verge
A. Endorectal advancement flap
B. Omental interposition
C. Diverting ostomy
C
Complex fistula as likely in high location (near/at cervix) and radiation-related; should be diverted first as poor tissue quality.
Surgical Clinics (radiation-related RVF) In the absence of recurrent cancer, radiation-induced fistulas can be approached abdominally, locally, or with diversion. There are several variants of each, with little evidence to support 1 method over the next, but the location and extent of radiation injury usually determine the most prudent approach. Before surgery, the extent of radiation injury, including the compliance of the rectum, needs to be addressed. Compliance can be addressed with manometry and subjectively with attempted insulation during endoscopy. Considering the poor quality of the rectum and concomitant inflammation and edema of tissue planes, these repairs are typically performed in conjunction with a diverting stoma. The diverting stoma can be performed simultaneously or several months before the repair, depending on the amount of contamination and tissue integrity. If the vaginal mucosa is uninvolved with radiation and if the fistula is not higher than the apex of the vaginal vault, a vaginal flap can be raised.
Cameron, John L.; Cameron, Andrew M (2013-11-20). Current Surgical Therapy: Expert Consult - Online (Current Therapy)
With the increased use of both brachytherapy and external-beam radiation in the treatment of pelvic malignancies, radiation-induced complications are likely to increase. The first step in management of radiation-induced rectovaginal fistulas is to rule out the presence of residual or recurrent malignancy. This requires detailed imaging and an examination with the patient under anesthesia with multiple biopsies of areas of irregularity or random biopsies if no irregularity exists. Once the presence of malignancy has been ruled out, the condition of the rectum, vagina, and surrounding perineal tissues needs to be evaluated. It is mandatory to wait at least 6 months after the completion of radiation treatment before any repair is attempted. This allows for the full effect of radiation to be realized and for the surrounding tissue to recover. If the local tissues are healthy, a rectal or vaginal advancement flap can be attempted. However, it should be appreciated that because the repair is being performed with radiated tissue, it is less likely to succeed. If one attempt at local repair fails, subsequent attempts will most likely be futile. Interposition flaps with nonradiated tissue (e.g., gracilis flap) or a resection of the involved rectum with a coloanal anastomosis and omental interposition then remains the best available option and is preferable to the classic Bricker procedure.
Colitis cystica profunda with difficulty with passing stool. Defacography shows internal intussusception, on scope she has an ulcer at 6cm anteriorly.
A. Resect with rectopexy
B. Altmeier
C. Biofeedback
C
The diagnosis is made on the basis of histologic finding of fibromuscular obliteration of the lamina propria. We suggest observation alone or treatment with bulk laxatives and biofeedback in patients who are asymptomatic or minimally symptomatic (Grade 2B). We suggest surgery (typically abdominal rectopexy) in symptomatic patients with rectal prolapse rather than conservative therapy (Grade 2C). Surgery may also help relieve symptoms in patients with severe symptoms that are unresponsive to conservative management.
Grade 4 tear with partial involvement of internal and external anal sphincters during delivery (assuming this means just delivered) A. Debride B. Biofeedback C. Primary repair now D. Diverting ostomy
C
Primary repair up to 48 hours; if longer delay, wait for 6 months
Urinary retention after hemorrhoidectomy, most likely associated with A. Spinal B. Fluid C. Operative time D. Use of foley catheter
B
Uptodate:
Urinary retention following hemorrhoidectomy is observed in as many as 30 percent of patients [56]. Spinal anesthesia tends to be associated with higher rates of urinary retention [5]. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study) [57]. Warm sitz baths and pain medication also may lessen the incidence of urinary retention and reduce the need for catheterization. Some patients will require urinary catheterization, although some remain relatively asymptomatic.
Guy starts Aldara (imiquimod) for condyloma. Gets pain/redness/swelling in area. Why? A. Cellulitis B. Normal reaction to drug C. Allergic reaction D. Fungal infection
B
Occurs in 58-100%
23 year old male, hx of constipation, dilated sigmoid, narrowed rectum, poor rectoanal inhibitory reflex
A. Proctectomy with coloanal anastomosis
B. Lateral internal sphincterotomy
C. Total abdominal colectomy and coloanal anastomosis
D. Laxative and bulking agents
A
Adult diagnosis of Hirschsprungs disease. The rectoanal inhibitory reflex (RAIR) is an involuntary IAS relaxation in response to rectal distension, allowing some rectal contents to descend into the anal canal where it is brought into contact with specialized sensory mucosa to detect consistency
Cameron:
Presence of this reflex effectively rules out Hirschsprung’s disease.
Posterior anal fissure, needs sphincterotomy, why not do it posteriorly
A. Because its near the fissure
B. Because you don’t was to get into external sphincter
C. Fecal seepage
C
From Sabiston – Cochrane review showed that posterior sphincterotomy less effective and more incontinence
Male going for completion proctectomy, what to avoid to not affect both urinary and sexual dysfunction
A. Presacral nerves
B. Nervi ergenti
C. Prostatic plexus
C
Presacral nerves (sympathetic: shoot) (hypogastric plexus): ejaculatory difficulties/ retrograde ejaculation. Nervi erigenti (parasympathetic: point) at the lateral stalks, injured if dissection too wide: erectile dysfunction Prostatic plexus – mixed urinary and sexual dysfcn
The nervi erigentes are located in the posterolateral aspect of the pelvis and at the point of fusion with the sympathetic nerves are closely related to the middle hemorrhoidal artery. Injury to these nerves will completely abolish erectile function.
Finally, dissection near the seminal vesicles and prostate may damage the periprostatic plexus, leading to a mixed parasympathetic and sympathetic injury. This can result in erectile impotence as well as a fl accid, neurogenic bladder.
Crohns pt, has mildly symptomatic hemmorhoids with mild bleeding. Grade II hemorrhoids. What to do? A. Nothing/conservative B. Band C. Hemmorhoidectomy D. Stapled hemmorhoidectomy
A
Lady with PBC and BRBPR – prior previous episodes. Stable . On exam has rectal varices and grade I hemorrhoids. What to do?
A. TIPS and angioembolize
B. Argon beam coagulation
C. Hemorrhoidectomy
A
Incidence of rectal varices in Childs C is up to 70%; endoscopic therapy (banding/sclerotherapy) is 1st line. 2nd line is retrograde balloon occlusion or TIPS. Surgical therapy is last-resort, can include surgical shunts, IMV ligation, or transanal oversewing of varix.
Bleeding ectopic varices – TIPS is useful for acute hemorrhage (Up to Date). This patient is stable and TIPS/embolization seems like too much, although might be getting at prophylaxis. APC is not described anywhere, sclerotherapy is. Hemorrhoidectomy is not necessary for grade I disease. TIPS/embolization is described, so of these options is probably the best.
Old lady with strangulated rectal prolapse A. Delorme B. Perineal proctosigmoidectomy C. Laparotomy and sigmoid resection D. Laparotomy and pexy
B
Delorme and pexy are not options as does not resect the strangulates bowel. Even gangrenous prolapse can be managed with perineal procedures.
Surgical Management of Rectal Prolapse. JAMA Surgery, Jan1 2005. Wexner, S.
Perineal rectosigmoidectomy is well suited for male patients; patients with incarcerated, strangulated, or even gangrenous prolapsed rectal segment; and patients who have had recurrence after another transperineal repair.
Young guy with chlamydia proctitis. How to treat? A. Doxycycline B. Flagyl C. Steroids D. Cortifoam enema
A
Up to Date:
Empiric therapy for both chlamydia and gonorrhea is indicated for the treatment of patients with acute proctitis. An empiric regimen of doxycycline (100 mg twice daily) plus a single intramuscular dose of ceftriaxone (250 mg) is active against both [3]. The duration of doxycycline therapy will depend on the severity of symptoms. For patients with mild proctitis, seven days of therapy is adequate. Patients with severe proctitis may have lymphogranuloma venereum infection, which requires a full three-week course of doxycycline.
Chlamydial proctitis, defined as inflammation of the distal rectal mucosa that can cause anorectal pain, rectal discharge, or tenesmus [19], is relatively uncommon and occurs almost exclusively in men who have sex with men (MSM) who have had receptive rectal intercourse [20,21]. However, anal intercourse is not uncommon among heterosexuals [22], and symptomatic proctitis has been reported in women [23]. Chlamydial proctitis may be caused by either the common genital strains of C. trachomatis (serovars D-K) that typically cause uncomplicated genital infection in men and women or the lymphogranuloma venereum (LGV) strains (serovars L1, L2, L3), which can cause severe disease (eg, abundant bloody or mucopurulent discharge, severe pain with defecation, fever)
Untreated can progress to rectal ulceration and stricturing.
Pt has amyloidosis and the fat pad biopsy is not helpful. What is the next best place to biopsy? A. Rectum B. Penis C. Skin D. Lung
A
1st line is FNA of fat pad; 2nd line rectal biopsy since 1964. And in Up to Date. Kidney or liver has highest overall sensitivity if those organs are involved.
Profuse bleeding PR after LAR. Anastomosis at 12 cm. POD#1. Patient unstable despite resuscitation. A. Endoscopy with Clips and Epinephrine B. Revise anastomosis C. Angioembolization D. Trans-anal suture ligation
A
Real life would attempt endoscopic control 1st; too high for transanal and wouldn’t embolize an anastomosis. This patient is unstable and anast is high enough to revise. Plan: take to OR, attempt endoscopic, revise if fails.
SCNA – Complications of Colorectal Anastomoses
In most cases, the patient remains hemodynamically stable, and no intervention is required. The rate of transfusion requirement is routinely less than 5%. In the review by Martinez-Serrano and colleagues, bleeding in 6 of the 7 patients resolved with conservative treatment including endoscopy. Only 1 patient required surgical treatment, and there was no mortality and no anastomotic leaks in these 7 patients. Cirocco and Golub reported nonoperative therapy to be successful in 14 of 17 patients (82%), using endoscopic electrocoagulation in 6 patients (43%) and blood transfusion alone in another 6 patients (43%). The investigators concluded that endoscopic electrocoagulation can be safely and effectively used on a newly created anastomosis to control unremitting anastomotic hemorrhage. Alternative endoscopic techniques include the use of submucosal injection of 10 mL adrenaline (1:200 000) in saline at the bleeding point, with good results. The use of the endoscopic hemoclip has been well described in upper gastrointestinal procedures and in colonic diverticular bleeding; however, its application in postoperative anastomotic bleeding for colon or rectal anastomosis is lacking. Anecdotally, the author (DR) has successfully used the endoscopic hemoclip to control bleeding at a colorectal anastomosis in the postoperative period. Finally, although rarely required, surgical exploration with oversewing of the anastomosis or resection may be needed for select recalcitrant cases.
Bleeding is a rare event after intestinal anastomosis, and endoscopic techniques have largely replaced the need for laparotomy or other surgical interventions. It is advisable that the operative surgeon performs or be present when endoscopic manipulation of a newly created anastomosis is required.
During sigmoidoscopy for volvulus, perforation of the anterior rectum occured. You should:
A. Hartmann’s
B. Laparotomy primary repair, presacral drainage
C. Laparotomy, resection, primary repair , defuntioning colostomy
D. Laparotomy, exteriorize colon
A
Bowel will be dilated, with fecal contamination, so no anastomosis. If can devolved and decompress to achieve better calibre match, primary anastomosis ok.
Which best describes the etiology of rectal prolapse:
A. Diastesis of levator ani muscles
B. Laxity of endopelvic fascia
C. Stretching of pudendal nerve
D. Loss of horizontal rectal position
E. Full thickness intussusception of the rectum beginning at 5 to 7 cms from the anal verge
E
24 male undergoes hemorrhoidal banding. Later that night he presented with rectal pain and fever of 38.9. He has difficulty in passing urine and his WCC of 18,000. You should: A. Insert a foley catheter B. Abx and EUA C. Incise and drain D. Remove rubber band E. Abx and bed rest
B
What is the muscle expose in an hemorrhoidectomy: A. Internal anal sphincter B. Transverse perinei C. Gluteus maximus D. Subcutaneous external sphinter E. Deep external sphinter
A
Anal stricture may occur from: A. Crohn’s B. Radiation C. Lymphagranuloma venereum D. Hemorrhoidectomy
D in answer key
World J Gastroenterol. 2009 Apr 28; 15(16): 1921–1928.
Surgical treatment of anal stenosis
The causes of anal stenosis include surgery of the anal canal, trauma, inflammatory bowel disease, radiation therapy, venereal disease, tubercolosis, and chronic laxative abuse.
LGV causes rectal stricture
Which of the following statements regarding ischiorectal abscess is most correct:
A. The best treatment is Ab
B. Drainage is indicated as soon as the diagnosis is made
C. Drain when fluctuant
D. Drain into rectum
B
Sabiston – drain when the diagnosis is made
Regarding the treatment of condyloma acuminata with the CO2 laser, one of the following is true:
A. The laser is less painful than coagulation
B. The smoke plume has live virus particles
C. Use of laser avoids recurrence
D. The laser is faster than electrocautery
B
Pruritus ani may be secondary to which of the following:
A. Hemorrhoids
B. Key whole deformity
C. Perianal creams
A
Fistula in ano, most commonly arise from:
A. Intersphinteric abscess secondary to perianal abscess
B. Subcutaneous abscess following anal fissure
C. Horseshoe abscess
D. Ischioresctal abscess
A
Factors predisposing to fistulae in ano: A. Crohn’s B. Cryptitis C. Perianal intersphinteric abscess D. Diverticulitis
C
Most fistulas are thought to arise as a result of cryptoglandular infection with resultant perirectal abscess.
Treatment of a recurrent fistulae in ano includes all of the following except: A. Full fistulotomy B. Staged opening fistulotomy C. Seton suture D. Open half and clear
D
What forms the superior border of the ischiorectal fossae: A. Obturador internus B. Gluteus major C. Endopelvic fascia D. Levator muscle complex E. Internal anal sphinter
D
Injury to the rectum is possible with all except: A. Penetrating injury to the buttock B. Penetrating injury to the abdomen C. Central fracture to the acetabulum D. High thigh injuries E. Pelvic fractures
C
Central fracture to the acetabulum – this is actually possible but less likely
Long term complications of ileoanal anastomosis: A. Stricture B. Inflammation of mucosa C. Diarrhea D. Bleeding
B
Inflammation of mucosa (cuff remnant mucositis)
The reason to resect a sacrococcygeal teratoma early: A. Cosmetic B. Propensity for malignancy C. To improve walking D. To prevent paralysis
B
ASCRS Textbook:
Presacral tumours: 2/3 congenital, 2/3 benign. Can be categorized by congenital, neurogenic, osseous, or miscellaneous categories. Usually present late. More common in females (cystic), solid tumours (chordoma) more common in males.
Dermoid or epidermoid cysts, enteric duplication cysts.
Teratomas are neoplastic, derived from all 3 germ layers. Malignant degeneration in 40-50%. (and in Schwartz)
Neurogenic: meningoceles, chordoma, neurogenic tumours.
Osseous tumours: chondroma, osteochondroma, Ewings, myeloma
What is most likely cause of urinary retention after APR: A. Damage of bladder muscle nerves B. Damage to bladder neck angle C. Damage to bladder sphincter nerves D. Benign prostatic hypertrophy
A
Damage to pelvic autonomic/hypogastric plexus, nervi erigentes results in flaccid retention
Most common part of bowel that is injured by radiotherapy: A. Proximal jejunum B. Terminal ileum C. Rectum D. Sigmoid colon E. Duodenum
C
Rectum is overall most common, TI most common portion of SB
Ileum most commonly involved – 73%
Many authors argue for always doing an ileocecal resection when operating for CRE as it has lower anastomotic complications and less reoperation in future.
Operative and long term results after surgery for chronic radiation enteritis. Am J Surg, Sept 2001.
Small bowel was involved in 93 (85%) patients: ileum in 68, jejunum and ileum in 23, and jejunum in 2 patients.
42 year old man, hemorrhoids x 2 banded. Presents 36 hours later with rectal pain, perianal tenderness, fever and leukocytosis. Most appropriate management?
A. Antibiotics and EUA
B. I & D
C. Foley Catheter
D. Remove bands
E. Pain killers, sitz baths, stool softeners
A
58 year old man presents 1 month after APR for cancer with persistent, small volume purulent drainage from perineal wound. 1 cm wound extending to sacrum, 8 cm in length. Best treatment
A. Conservative management for at least 2 further months
B. Open, excise granulation tissue, pack open
C. Open, excise granulation tissue, suture closed over a drain
D. Open, excise coccyx, lower part of sacrum, pack open
E. Open, excise coccyx, suture closed over a drain
A
Causes of faecal incontinence after fistula-in-ano surgery
A. Post op infection
B. Division of puborectalis
C. Division of inferior rectal nerves
D. Division of part of internal sphincter
E, Failure to drain horseshoe abscess
D
Most frequent finding in peri-anal Crohn’s disease A. Fistula-in-ano B. Perianal abscess C. Skin tag D. Anal fissure
C
Up to Date: Abscess: 50% Fistula: 20-30% Fissure: 20% Skin tag: not mentioned
Schwartz 1038: most common is anal skin tag
AGA technical review on perianal Crohn’s disease. Nov 2003.
Skin tag: 37%
Fistula: 26%
Abscess: 16%
Fissure: 19%
Very high overall incidence of skin tags; the sources that compare directly all have anal skin tag incidence the highest.
Most cephalad border of ischiorectal fossa? A. Puborectalis B. Pubic tubercle C. Levator ani D. External sphincter E. Pubic ramus
C
Boundaries of ischiorectal fossa
Anterior : Perineal membrane (and superficial transverse perineal muscle)
Lateral : Obturator internus muscle (& fascia) on ischial tuberosity
Supero-medial : Levator ani muscle
Posterior :Gluteus maximus (& sacrotuberous ligament)
26 year old male, acute onset of pain at anus after straining for stool. On exam, small tender blue swelling. Diagnosis? A. Sentinel pile (Anal fissure) B. Perianal abscess C. Prolapsed external haemorrhoid D. Strangulated internal haemorrhoid E. Thrombosed external haemorrhoid
E
Which of the following is an indication for 1 stage fistulotomy:
A. Anterior transphincteric fistula in a female
B. Extrasphincteric fistula in a crohn’s patient
C. Lateral suprasphincteric fistula in a male
D. Posterior transphincteric fistula in anyone
E. Fistula secondary to radiation
D
What is the most frequent problem with abdominal repair of rectal prolapse A. Urinary retention B. Constipation C. Rectal incontinence D. Rectal bleeding
B
Can worsen constipation, incontinence improves only 50% of time
With respect to chronic anal fissure, which is true? A. Sublingual nitro is proven B. Lat external sphincterotomy is proven C. Botox and topical nitro are effective D. Fissurectomy is treatment of choice
C
Botox and topical nitro are effective (50-60%)
Sx tx is lateral internal sphincterotomy
Woman with incontinence to gas and liquid since birth of last child 10 yrs ago. Decreased squeeze and palp anterior defect. Best treatment: A. Artificial sphincter B. Gracillis repair C. Overlapping sphincteroplasty D. Parks post repair E. Colostomy
C
Most common longterm complication of ileo-anal pouch:
A. Stenosis
B. Leak
C. Mucosal inflammation
C
Pouchitis 23-59%
Best treatment for grade II and III hemorroids A. Hemorroidectomy B. Banding C. Sclerosis D. Coagulation
B
Superficial inguinal lymph nodes drain: A. Spongy urethra B. Clitoris C. Vulva D. Testicle E. Ovaries
C
POD10 transvaginal hysterectomy, stool coming from vagina. Best initial management A. Loop ileo B Transvaginal repair C. Anorectal flap D. LAR
A
Lap LAR. Sick 5 days later. Mild tenderness. CT shows 1 cm contained leak. A. ABx and observe B. Laparotomy with Hartman’s C. Loop ileo D. Laparoscopy with drainage
A
LAR, sick, CT shows 2 cm leak
A. Hartman’s
B. Repair anastomosis
C. Repair anastomosis with diversion
A
Pouchitis A. Broad spectrum abx B. 5 asa enemas C. Probiotics D. Steroid enemas
A
30 y male, diarrhea, weight loss and crampy pain, comes to see you because of bothersome anal skin tags. On exam, bluish hemorrhoids, anal skin tags. Mgmt
A. Excise tags
B. Biopsy tags
C. Colonoscopy
C
Young guy with 48 hours of pain with small blue tender nodule distal to dentate.
A. Sitz baths
B. Incision and drainage
C. Excision
C
Woman with Crohn’s bleeding PR, feeling of something going in and out, colonoscopy shows combined internal and external hemorrhoids
A. Conservative management (then band ligation)
B. Hemorrhoidectomy
C. Banding
A
Desperately try to avoid hemorrhoidectomy in CD: high rate of wound failure.
AGA technical review on perianal Crohn’s disease. Nov 2003.
Simple hemorrhoidectomy, the newer procedures for prolapsing hemorrhoids, and banding of hemorrhoids in patients with Crohn’s disease are usually contraindicated due to the frequent occurrence of postoperative complications, including poor wound healing, anorectal stenosis, and a high rate of proctectomy,12, 151and152 notwithstanding one recent report suggesting that simple hemorrhoidectomy can be safely performed in selected patients.153 When symptomatic prolapsing or bleeding hemorrhoids fail to respond to conservative measures, in the absence of active anorectal Crohn’s disease, elastic band ligation may be used with great effect (Victor Fazio, unpublished experience, May 2003). It should also be noted that in patients without a preceding history/diagnosis of Crohn’s disease who have a nonhealed hemorrhoidectomy wound 2–3 months postoperatively, investigation including colonoscopy is warranted to rule out occult Crohn’s disease.
Crohn’s disease post proctectomy and end colostomy for stricture comes in with dehiscence of perineal wound. Elevated WBC and perineal wound draining pus from an 8cm cavity. A. Antibiotic and daily packing B. VAC C. Debridement and primary closure D. Gracillus flap E. Abx and secondary closure
A
Male had radiation for prostate cancer, now with radiation proctitis and requiring multiple transfusion for bleeding. Has tried topical and oral steroids. Still bleeding. Mx?
A. Angio
B. Laser
C. Plasma beam coagulator
C
39yo man presents with five days of perianal pain, improving in the last 24 hours. Exam shows prolapsed thrombosed internal hemorrhoids. Best management? A. Sitz baths & laxatives B. Banding C. Hemorrhoidectomy D. Incision & drainage
A
Alcoholic male presents with retrosternal pain after vomiting. Imaging shows small contained leak in mid esophagus. Stable. Improves on conservative mgmt. A. Observe B. Stent C. Thoracotomy and primary repair D. Laparotomy and drain mediastinum
A
Surgery is not indicated for every patient with a perforation of the esophagus and management is dependent on several variables—stability of the patient, extent of contamination, degree of inflammation, underlying esophageal disease, and location of perforation.
Scope screening for Barrett’s, distal esophageal perforation seen in distal mediastinum. Worsens with conservative management A. Continue antibiotics B. Stent C. L thoracotomy D. Laparotomy
C
Patient with paraesoph. Hiatus hernia with evidence of pain. Taken to the OR with contents reduced, no necrotic stomach. Mgmt?
A. Crural repair
B. Crural repair with prosthetic mesh and fundo
A
Roux en Y esophageal-jejunostomy, CXR post-operatively reveals large pleural Lt effusion. Best initial management.
A. Upper GI series, water soluble
B. Barium swallow
C. Endoscopy
A
Gastrograffin followed by thin barium if no leak seen.
Patient with submucosal lesion of esophagus, best management?
A. Endoscopic biopsy
B. Thoracic enucleation
C. Esophagectomy
B
Likley benign esophageal leiomyoma
Biopsy not required. Diagnosis best on barium swallow.
Resect if symptoms, >2cm, or cannot r/o GIST. EUS is recommended by some, biopsy is useful but makes eventual surgery more difficult.
Sabiston
Leiomyomas are slow-growing tumors with rare malignant potential that continue to grow and become progressively symptomatic over time. Although observation is acceptable in patients with small (<2 cm) asymptomatic tumors or other significant comorbid conditions, surgical resection is advocated for most leiomyomas; however, imatinib (a tyrosine kinase inhibitor), as targeted therapy used on other GIST tumors, may have some benefit for esophageal leiomyomas. Surgical enucleation of the tumor remains the standard of care and is performed through a thoracotomy or with video or robotic assistance. Lesions of the proximal and midesophagus are removed through the right chest; those of distal origin are removed through the left chest.
Pearson’s Thoracic and Esophageal Surgery:
However, biopsy of intramural tumors (e.g., leiomyoma) is contraindicated because adequate pathologic material to exclude malignancy is impossible to obtain and violation of the mucosal layer may complicate subsequent surgical resection. Esophageal endoscopic ultrasonography (EUS) may further help in the diagnosis, planning of surgery, and follow-up of these tumors.
Endoscopy with biopsy for barretts. Develops retrosternal CP in recovery. On imaging see a small contained leak in the distal mediastinum. Start abx and resuscitate and continues to have temp of 38.2 and chest pain. Plan? A. Continue resuscitation B. Transabdominal repair with fundo C. Left thoractomy and repair D. Endoscopic stent
C
Requires source control and control of contamination (stent and drain is a potential option)
35y M going for hellers for achalasia with a toupet. 1mm perforation 6cm proximal to GEJxn.
A. Open repair with Thal
B. Stent
C. Lap repair and continue planned surgery
D. Lap repair and Dor
A in answer key but that’s crazy
D according to Botkin but C would provide some coverage.
Dor 180-200° anterior fundoplication.
Thal 270° anterior fundoplication.
80 yr male POD #5 Total gastrectomy for ca with esophagojejunostomy. WBC elevated, dyspneic, febrile. Imaging shows large left pleural effusion. Drains 1600mL foul-smelling clear, Gram +ve organisms. Likely etiology of this presentation? A. Empyema B. Pneumonia C. Anastomotic leak D. Subphrenic abscess
C
Open fundo years ago with complete SBO. No radiologic improvement after 24 hours, symptoms improved with NG A. Laparotomy and LOA B. Continue non-operative management C. Long intestinal tube D. Lap LOA
B
When doing Fundo what do you avoid when going through lesser omentum A. Vagus branch to the liver B. Left vagus C. Right vagus D. Left gastric artery
A
Effect of preserving the hepatic vagal nerve during laparoscopic Nissen fundoplication on postoperative biliary functions.
Ozdogan M et al
The patients (n = 40) were prospectively randomized into two groups. The HB-AVn was preserved during the dissection of the lesser omentum in the first group. The nerve was cut in the second group. Postoperative fasting gallbladder volumes were calculated by ultrasonography. Postoperative gallbladder ejection fraction (GEF) and gallbladder emptying time (GET) were determined by calculating intestinal transit time scintigraphically.
Sacrificing the hepatic branch causes prolongation in the GET. This change in the motor functions of the gallbladder does not cause any symptomatic effect during the early postoperative period. However, the delay in the GET may increase the risk of gallbladder stone formation in the long term.
EGD for dysphagia. Biopies of distal esophagus show eosinophilic esophagitis
A. Fluticasone proprionate
B. Oral prednisone
C. Repeat EGD in 3-6 months
A
Commonly used treatments include:
- Elimination and elemental diets to decrease allergen exposure.
- Acid suppression to treat gastroesophageal reflux disease, which may mimic or contribute to eosinophilic esophagitis. In addition, a subset of patients respond clinically and histologically to proton pump inhibitors. Such patients have been referred to as having proton pump inhibitor responsive esophageal eosinophilia.
- Topical glucocorticoids to decrease esophageal inflammation. (Fluticasone, budesonide, ciciesonide)
- Esophageal dilation to treat strictures.
Stricture in distal esophagus in patient with reflux and esophagitis, already on PPI. Rest of work up normal A. Collis B. Esophageal stricturoplasty C. Dilate and perform Fundo D. Dilate
C
Sabiston
All strictures should
be biopsied to rule out malignant processes and can frequently be
managed with dilation if they are benign. Metaplastic changes (Barrett esophagus) should be biopsied in four quadrants every centimeter to evaluate for dysplasia and cancer. Fundoplication
procedures can still be performed in this setting, but surveillance must continue at regular intervals because regression is rare
Submucosal lesion ?GIST in mid-esophagus A. Segmental resection B. Endoscopic resection C. EUS biopsy D. VATS resection
D
Enucleate. Don’t biopsy, makes eventual surgery much more difficult.
Esophageal perf/Boerhaave's with small contained perforation in mediastinum. Mild temp of 37.9. No other vitals given. Given Abx, NPO, etc. A. Observe B. Stent C. Repair though left thoracotomy D. Repair though right thoractomy
A
Another post-vomitting retrosternal chest pain and pneumomediastinum. This time has a temp of 38.4 or so.
A. Left thoracotomy
B. CT with contrast
C. EGD
B
Should do some sort of imaging to localize perforation, assess for collections, and plan management. Contrast swallow or CT with oral contrast should be done.
Patient with dysphagia, motility study shows high amplitude nonsynchronous contractions
A. Botox
B. Myotomy
C. Calcium Channel Blockers
C
Patient has Diffuse esophageal spasm
Long esophagomyotomy with Dor if fails medical management.
Patient has dysphagia. Upper GI swallow shows “corkscrew esophagus.” Manometry shows uncoordinated contractions. What is the best management? A. Calcium channel blockers B. Botox C. Dilation D. Myotomy
A
Guy with Ivor Lewis esophagectomy, presents with a small leak, contained in mediastinum, not septic
A. Observe
B. Stent
C. Thoracotomy for T tube through anastomosis
D. Thoracotomy for external drain
B in answer key
In the Ivor Lewis esphagectomy, the esophageal tumor is removed through an abdominal incision and a right thoracotomy (a surgical incision of the chest wall). The esophagogastric anastomosis (reconnection between the stomach and remaining esophagus) is located in the upper chest. For this reason, the Ivor Lewis esophagectomy is suitable for patients with resectable tumor of the middle to lower third of the esophagus and gastroesophageal junction.
Uptodate:
Thoracic anastomotic leaks are more likely to require re-exploration for appropriate control [61], although endoscopic stenting or transluminal vacuum therapy may provide acceptable outcomes in selected circumstances [62]. As an example, 49 patients were treated endoscopically for esophageal anastomotic leaks after cancer surgery [63]. Thirty-one patients had a covered stent placed across the leaks; three patients had the leaks closed with clips. After a median follow-up of 83 days, 88 percent of patients achieved healing of their leaks. Of the 23 patients who received more than one endoscopic intervention, 96 percent healed their leaks. However, stent migration remains a challenge, especially in the thoracic anastomotic position. Furthermore, there remains concern that the radial forces exerted by expandable stents could worsen regional ischemia and thus cause more significant tissue loss. Finally, stent erosion into surrounding structures such as the aorta and airway remains a risk with prolonged use of this technology [64].
Old guy, previous lung resection for cancer, has dysphagia. Barretts esophagus with high grade dysplasia and a 0.7 cm nodule
A. Esophagectomy
B. EMR
C. Photodynamic therapy
D. Aggressive medical management with repeat scope in 3 months
B
EMR for tissue; high likelihood nodule has invasive component, so surveillance is not appropriate. Esophagectomy contraindicated, not fit for surgery. PDT acceptable but contraindicated by nodule.
ACG Guidelines BE 2015
In patients with nonnodular BE, the utility of ablative therapy is becoming clearer. In patients with BE and HGD, ablative therapy should be preferred over either esophagectomy or intensive endoscopic surveillance because of its proven efficacy ( 63 ) and a side-effect profile superior to surgery ( 147 ). Recent data demonstrate that in patients with BE and LGD confirmed by a second pathologist, ablative therapy results in a statistically and clinically significant reduction in progression to the combined end point of HGD or EAC, or to EAC alone ( 142 ).
Best initial management of patient presenting with esophageal varices A. Octreotide B. Vasopressin C. Banding D. Beta blocker
A
For acute variceal hemorrhage, pharmacotherapy is indicated at the time of diagnosis while awaiting endoscopy. Octreotide is preferred over vasopressin (higher bleeding control, no side effects). Terlipressin used in Europe as first line. Antibiotic prophylaxis indicated as high rate of septic complications with AVH.
Endoscopic BL or sclerotherapy is succesful in 90%., EVL is 1st line
Portal decompressive procedures if fails endoscopic/pharmacologic. TIPS 1st, surgical shunt as last resort, very effective but 50% mortality.
Hemospray, SEMS, esophageal transection also described
Esophageal ca, what would make this resectable? A. Involvement of crura B. Virchow’s node C. Celiac node D. Mediastinal node
A
Previous lap fundo, recurrence of symptoms not responding to medical manamgnet. EGD normal.
A. ph and manometry
B. Redo fundo
A
Must do motility studies before redo.
Esophageal cancer, lower third. Which is resectable? A. Positive virchow’s node B. Positive paraaortic node C. Diaphragm invasion D. Positive cervical node
C
Male, barrett’s 10 cm. Nodule on EGD and high grade dysplasia. Mgmt: A. Repeat endoscopy in 3 month B. High dose PPI C. Photoablation D. EMR
D
Nodule requires resection
Epiphrenic diverticulum with chest pain. Mgmt.
A. Diverticulectomy, myotomy
B. Diverticulectomy
C. Diverticulectomy, myotomy, fundoplication
C
Pearson’s Thoracic and Esophageal Surgery:
Epiphrenic diverticula comprise approximately 20% of all esophageal body diverticula. They are frequently alluded to as separate pathologic entities from other pulsion diverticula. There is, however, sufficient evidence to show that the same underlying mechanisms as in midthoracic pulsion diverticula are present. Hypertensive lower esophageal sphincter and increased tone within the esophagus create a high-pressure area above the sphincter, resulting in outpouching of the mucosa through what is thought to be a weak area of muscle.
Epiphrenic diverticula are often seen in association with achalasiaas well as with diffuse esophageal spasm. The natural history, complications, and principles of treatment are, therefore, the same as for midesophageal diverticula, and a concomitant nonobstructing partial fundoplication is therefore advised.
Surgical Treatment of Epiphrenic Diverticula: A 30-Year Experience, The Annals of Thoracic Surgery, Volume 84, Issue 6, December 2007
Traditional transthoracic resection, long esophagomyotomy, and an antireflux procedure provide excellent long-term functional results with relatively low postoperative morbidity in patients with epiphrenic diverticula.
Post fundo, recurrent symptoms. No evidence of recurrent hiatal hernia. Mgmt
A. Manometry and pH study
B. PPI
C. Redo surgery
A
Treatment for eosinophilic esophagitis?
A. Endoscopic dilation
B. Oral prednisone
C. Fluticasone proprionate
C
Male smoker with enlarged jugulodigastric node. Biopsy showed adenocarcinoma. A. Lung cancer B. Salivary cancer C. Laryngeal cancer D. Nasopharyngeal cancer
B
Lung cancer – Level 2B node too high for lung primary.
Salivary cancer – only H&N malignancy that is adenocarcinoma.
Distal esophageal adenoCa, involving crura and enlarged nodes around L gastric. No distant mets. Management A. Total gastrectomy B. Esophagectomy with resection of crura C. Chemotherapy D. Radiation
B in answer key
Neoadjuvant seems more appropriate given enlarged LNs
Sabiston
For esophageal adenocarcinoma, mostly located in the distal esophagus or GEJ, we consider nodal disease located in the area from the celiac axis up to the paratracheal region to represent regional disease; nodal disease located outside of these boundaries
is regarded as distant disease.
Surgical resection of the esophagus was the mainstay of esophageal cancer treatment in the past. However, we have learned that even the most radical resections with extensive lymph node dissections
are not adequate to cure locoregionally advanced disease in the majority of cases.
The most notable and frequently quoted trial
that compared chemoradiation followed by surgery with surgery
alone for esophageal and EGJ cancer was the Chemoradiotherapy
for Oesophageal Cancer Followed by Surgery Study (CROSS).57 This trial enrolled an impressive 368 patients during a 4-year period, and 366 patients were included in the final analysis. The
surgery-alone group consisted of 188 patients, whereas 178 underwent
chemoradiation followed by surgery. The majority (75%) of
the patients had adenocarcinoma, and 22% had SCC. The chemoradiation
regimen consisted of a 5-week course of carboplatin and paclitaxel administered concurrently with radiation therapy at a dose of 41.4 Gy given in 23 fractions 5 days a week. Esophagectomy
was performed within 4 to 6 weeks in the treatment group
and immediately after randomization in the control group. The completeness (R0) of resection was higher in the trimodality group
than in the surgery-alone group (92% versus 69%; P < .001). Patients with SCC experienced complete pathologic response
(ypT0N0M0) significantly more than patients with adenocarcinoma
(49% versus 29%; P < .001). Expectedly, nodal positivity
was higher in patients with surgery alone compared with the trimodality group (75% versus 31%; P < .001). At a median follow-up duration of 45 months, patients receiving the trimodality therapy had significantly longer median overall survival. duration (49.4 months) than did patients undergoing surgery
alone (24 months; hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.49-0.87; P = .003). The estimated 5-year survival rate in the trimodality therapy group was 47% compared with
34% (HR, 0.65; 95% CI, 0.49-0.87; P = .003) in the surgery
group. Interestingly, trimodality therapy did not significantly benefit patients with adenocarcinoma histology (HR, 0.74; 95%
CI, 0.53-1.02; P = .07), and inexplicably it benefited patients with clinically node-negative disease (HR, 0.42; 95% CI, 0.23- 0.74; P = .003) but not those with node-positive disease (HR,
0.80; 95% CI, 0.57-1.13; P = .21).
Patient post-Lap fundo with dysphagia with solids, lost 8kg. Repeated 24pH and manometry without any abN findings. Barium swallow shows lumen that’s 4mm at GEJ or close to the wrap. A. Redo fundo B. Nasogastric feeding tube C. Prokinetic and liquid diet D. Endoscopic dilation
B then D after wt improved?
SAGES:
Early postoperative dysphagia rates are up to 50% and the general recommendation is for slow advancement of diet from liquids to solids. Attention should be paid to adequate caloric and nutritional intake in the postoperative period. Expert opinion suggests that most patients will lose 10-15 pounds (4.5 – 7 kg) with laparoscopic fundoplication and hernia repair followed by a graduated diet from liquids to soft solids. If dysphagia persists or weight loss occurs of 20 or more pounds (9 kg) evaluation and intervention for the dysphagia should be considered.
Depends on time. If early (<12 weeks), prokinetic and liquid diet, if >12 weeks, dilation.
Uptodate:
Patients with dysphagia in whom the 13 mm barium tablet passes slowly through the esophagus and who had normal motility preoperatively should be considered candidates for dilation after 12 weeks. Approximately 6 to 12 percent of patients with fundoplication required dilation in various reports.
Patients who have a 360 degree fundoplication may be candidates for revision to a partial fundoplication if dysphagia persists and effective barium tablet passage cannot be established.
Old guy, smoker, COPD, restricted functional activity. Doesn’t sound like a good OR candidate. Has dysphagia and found to have 3cm segment of Barrett’s on scope with LGD on biopsy of this raised area confirmed by 2 pathologists. Management A. Photodynamic therapy B. EMR C. Esophagectomy D. Maximize medical therapy
B
EMR – histology, short segment makes it appropriate – also describes nodule
SCNA:
PDT is falling out of favour; can have buried glands, and has high (40%) stricture rate. RFA is actually treatment of choice. EMR is most useful when there is a visible nodule or short segment BE.
RFA is treatment of choice for HGD and should be considered for LGD.
Old guy w/ poor performance status was found to have 3cm Barrett’s esophagus. Biopsy w/ confirmation path showing HGD. What to do
A. Intense medical Tx
B. Photo dynamic therapy
C. Esophagectomy
D. EMR
D
Sabiston:
Endoscopic mucosal resection (EMR) has gained favor for the treatment of Barrett’s esophagus with low-grade dysplasia. Also, it has been used as a diagnostic tool to rule out cancer in a focus of Barrett’s esophagus with high-grade dysplasia. Because of an increase in stricture rate with larger resections, it is not advocated for long-segment Barrett’s esophagus. It is acceptable for patients with high-grade dysplasia who are not acceptable candidates for esophageal resection and useful for patients who have an isolated focus of Barrett’s esophagus with dysplasia.
Young guy post blunt trauma w/ initial image shows pneumomediastinum. Found on PAD#4 with retrosternal chest pain, fever, CT contrast study show extravasation from distal esophagus into posterior mediastinum w/ severe inflammation. Tx?
A. Cervical esophagostomy, gastrostomy, jejunostomy
B. Esophageal stent
C. Primary esophageal repair w/ gastric fundoplication
A
Type 2 gastric varices, had profuse bleeding
A. Cyanoacrylate
B. Splenectomy
C. TIPS
Gastroesophageal varix (GOV) Type 1: Extension of esophageal varices along lesser Gastroesophageal varix type 2: Extension of esophageal varices along greater curve
Isolated gastric varix (IGV) type 1 near fundus of stomach and
Isolated gastric varix type 2: Varices in stomach or duodenum.
Gastric varices: Classification, endoscopic and ultrasonographic management
J Res Med Sci. 2015 Dec; 20(12): 1200–1207.
Gastroesophageal varix type 1 is the most common type, accounting for 74% of all GV. However, the incidence of bleeding is highest with IGV type 1, followed by GOV type 2. Overall, the most important predictor of hemorrhage is the size of varices, with the highest risk of first hemorrhage (15%/year) occurring in patients with large varices. Other predictors of hemorrhage are decompensated cirrhosis (Child B or C) and the endoscopic presence of red wale marks
The endoscopic sclerotherapy has been less effective in the treatment of gastric variceal bleeding and eradication of GV as against esophageal varices where endoscopic sclerotherapy is one of the effective modes of treatment.[12,18] Because of the high volume of blood flow through GV compared with EV, resulting in rapid flushing away of the sclerosant in the bloodstream. In acute GV bleeding, GVS has been reported to control bleeding in 60-100% of cases[20,21,22] but with unacceptably high rebleeding rates of up to 90%. Mucosal ulcers are also commonly seen, and cause rebleeding. Approximately, 50% of rebleeding is caused by sclerotherapy induced ulcers and is difficult to control, with a success rate between 9% and 44%.GVS appears to be least successful in controlling acute fundal variceal bleeding.[23,24]
Tissue adhesive such as N-butyl-2-cyanoacrylate, which is a monomer that rapidly undergoes exothermic polymerization on contact with the hydroxyl ions present in water, has been used for Gastric variceal obturation.
Patient with clean ulcer base, no active bleeding, clot removed, best management?
A. IV pantoloc
B. Epinephrine and heater probe
C. Clip
A
Acute hemorrhage
Forrest I a (Spurting hemorrhage)
Forrest I b (Oozing hemorrhage)
Signs of recent hemorrhage
Forrest II a (Non bleeding Visible vessel)
Forrest II b (Adherent clot)
Forrest II c (Flat pigmented haematin on ulcer base)
Lesions without active bleeding Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)
Uptodate
Stigmata of recent hemorrhage are present if anything other than a clean ulcer base is seen. However, only patients with active bleeding (spurting or oozing), a nonbleeding visible vessel, or an adherent clot are generally considered to be at high risk for recurrent bleeding. Most patients with high-risk stigmata require endoscopic therapy to decrease the risk of recurrent bleeding, whereas patients without these high-risk stigmata are considered low-risk and do not require endoscopic therapy.
Medscape
Endoscopic treatment is reserved for ulcers demonstrating signs of active or recent hemorrhage (i.e., spurting or oozing ulcers [Forrest Ia and Ib, respectively] and nonbleeding ulcers with visible blood vessels [Forrest IIa]). For-rest Ia, Ib, and IIa ulcers are high-risk lesions with a high probability of re-bleeding, despite achievement of initial hemostasis, and necessitate aggressive endoscopic and pharmacologic management. Nonbleeding ulcers with a clean base or dark spot at the base (Forrest III and IIc, respectively) do not require endoscopic therapy because the probability of rebleeding is low.[15] Management of ulcers covered by an adherent clot (Forrest IIb) is controversial. Most authorities believe that overlying clots should be removed and the underlying ulcer carefully examined. Endoscopic therapy is reserved for patients with high-risk lesions (Forrest Ia, Ib, and IIa ulcers) and withheld in the presence of low-risk lesions (Forrest IIc and III ulcers).[7]
Patient with clean ulcer base, no active bleeding, clot removed, best management? A. IV pantoloc B. Epinephrine and heater probe C. Clip D. Antrectomy
A
Forrest IIB since there was a clot
Acute hemorrhage
Forrest I a (Spurting hemorrhage)
Forrest I b (Oozing hemorrhage)
Signs of recent hemorrhage
Forrest II a (Non bleeding Visible vessel)
Forrest II b (Adherent clot)
Forrest II c (Flat pigmented haematin on ulcer base)
Lesions without active bleeding Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)
Uptodate
Stigmata of recent hemorrhage are present if anything other than a clean ulcer base is seen. However, only patients with active bleeding (spurting or oozing), a nonbleeding visible vessel, or an adherent clot are generally considered to be at high risk for recurrent bleeding. Most patients with high-risk stigmata require endoscopic therapy to decrease the risk of recurrent bleeding, whereas patients without these high-risk stigmata are considered low-risk and do not require endoscopic therapy.
Medscape
Endoscopic treatment is reserved for ulcers demonstrating signs of active or recent hemorrhage (i.e., spurting or oozing ulcers [Forrest Ia and Ib, respectively] and nonbleeding ulcers with visible blood vessels [Forrest IIa]). For-rest Ia, Ib, and IIa ulcers are high-risk lesions with a high probability of re-bleeding, despite achievement of initial hemostasis, and necessitate aggressive endoscopic and pharmacologic management. Nonbleeding ulcers with a clean base or dark spot at the base (Forrest III and IIc, respectively) do not require endoscopic therapy because the probability of rebleeding is low.[15] Management of ulcers covered by an adherent clot (Forrest IIb) is controversial. Most authorities believe that overlying clots should be removed and the underlying ulcer carefully examined. Endoscopic therapy is reserved for patients with high-risk lesions (Forrest Ia, Ib, and IIa ulcers) and withheld in the presence of low-risk lesions (Forrest IIc and III ulcers).[7]
Am J Gastroenterology
Those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion.
Patient with Crohn’s stricture to 3rd part of duodenum, dilated stomach on CT scan, best management?
A. Gastrojej
B. Strictureplasty
C. Endoscopy dilation
A
Difficult location, strictureplasty not effective, G-J best (per Kanthan).
SCNA: Surgical Management of CD
For gastroduodenal Crohn’s disease, bypass is often the optimal treatment. In patients with obstructing duodenal disease, resection has a fourfold increased risk of major morbidity when compared with gastrojejunal bypass. Some investigators advocate for strictureplasty in the case of duodenal disease. To accomplish this, the duodenum must be mobilized, which can be challenging in the setting of inflammatory changes. Gastroduodenal strictureplasty frequently fails, has a high rate of reoperation, and confers little advantage over gastrojejunal bypass. Strictureplasty is best used for selected, proximal duodenal lesions near the pylorus.
Patient visible vessel on endoscopy, posterior duodenum, no bleeding, management?
A. Epinephrine and heater probe and clips
B. Pantoloc infusion
C. Operative management
A
Forrest IIA
85y with a perforated duodenal ulcer with 5 days of pain. Comorbidities include chronic renal insufficiency, asthma, HTN. contrast study shows an a leak that is largely but contained but flows out into subhepatic space. stable with a fever. A. Perc drain B. Abx C. OR D. Endoscopic stent
C
Old, comorbid, uncontained leak, delayed presentation are all indications to operate.
UTD: nonoperative management less successful in >70 yrs
Patients chosen for nonoperative management are those with contained perforation, gastrointestinal fistula formation, or limited contamination as judged by imaging, in those who have no signs of systemic sepsis . Not surprisingly, since patients chosen for conservative management in contemporary series are generally less ill, conservative management is often associated with lower rates of morbidity and mortality compared with surgical management.
A conservative approach including antibiotic therapy combined with drainage (effusion, abscess), provision for nutritional support (eg, gastrostomy, feeding jejunostomy), or stent placement may be an appropriate initial management strategy
68y M UGIB found antral ulcer on mid lesser curve. heavy smoker on PPI. Initially unstable, but then stabilizes A. Oversew B. Wedge C. Antrectomy to include the ulcer D. V+D
C.
Type I ulcer; ulcer excision is preferred, particularly to rule out malignancy. If unstable, oversew; if stable, excise.
Lesser curve wedge is problematic due to vascular arcades, more likely to deform stomach and cause obstruction.
70M with dilated mucosal veins emanating from antrum, no active bleeding. Had been scoped for hx of iron deficiency anemia with positive FOBT. Management? A. Endoscopic coagulation B. Endoscopic banding C. Antrectomy D. Address portal hypertension
A
GAVE, or watermelon stomach, is an uncommon cause of UGIB that is often confused with Portal HTN Gastropathy, both of which can occur in patients with cirrhosis
The term “watermelon stomach” is derived from the characteristic endoscopic appearance of longitudinal rows of flat, reddish stripes radiating from the pylorus into the antrum that resemble the stripes on a watermelon. The red stripes represent ectatic and sacculated mucosal vessels. A punctate form (in which the red stripes are not apparent) has also been described and appears to be more common in patients with underlying cirrhosis. While acute bleeding may occur, low-grade GI bleeding is more common, often with iron deficiency anemia. It is uncommon for patients to present with acute and massive bleeding.
GAVE is usually an isolated problem but has been associated with cirrhosis and systemic sclerosis. In one series of 744 consecutive patients with nonvariceal UGIB, bleeding was due to GAVE in 4 percent. Portal hypertension was present in 31 percent of the patients with GAVE in this cohort. The most common clinical profile of a patient with GAVE is an older (>70 years old) woman. In the series described above, for example, the median age was 74 years, and 80 percent of the patients were women.
Patients may also present with acute bleeding. The clinical presentation is similar whether portal hypertension is present or not, except that those with portal hypertension may have diffuse antral angiomas rather than the classic linear pattern.
The diagnosis is based on the classic endoscopic appearance. It may be confirmed with endoscopic biopsy, endoscopic ultrasound, tagged red blood cell scan, or computed tomography (CT) scan [66]. Histopathologically, GAVE is characterized by vascular ectasia, spindle cell proliferation, and fibrohyalinosis (picture 8) [63].
Episodic transfusions are required in some patients. Endoscopic coagulation with a heater probe, bipolar probe, argon plasma coagulator, laser therapy, or radiofrequency ablation obliterates the vascular ectasia and decreases the degree of bleeding. Endoscopic band ligation has also been used successfully [68]. (See “Argon plasma coagulation in the management of gastrointestinal hemorrhage”.)
Portal decompression with TIPS does not reliably reduce bleeding, underscoring the uncertain relationship of GAVE to portal hypertension [69,70]. Antrectomy prevents recurrent bleeding but is usually reserved for patients who fail endoscopic therapies. Combination estrogen/progesterone therapy may decrease bleeding, although the ectatic vessels appear to persist [71].
70s male with prev BII with nausea, bloating relieved by emesis, Unable to intubate afferent limb on EGD, HIDA shows delayed empyting afferent limb
A. Roux-en-y
B. Balloon dilation of anastomosis
C. Prokinetics
A
Afferent limb syndrome is an intermittent partial or complete mechanical obstruction of the afferent limb of a gastrojejunostomy.
The syndrome classically refers to obstruction of the upstream limb of a side-to-side gastrojejunostomy, but has also been used to refer to the biliopancreatic limb of a Roux-en-Y gastrojejunostomy.
Afferent loop syndrome is not an uncommon postoperative complication, and one study has estimated that it occurs in 13% of post-pancreaticoduodenectomy patients. Patients usually present with epigastric pain, abdominal distention, nausea, and potentially bilious vomiting. It has been classified as acute (<7 days postoperative) or chronic (>7 days postoperative). Bilious vomiting is presumed to occur from regurgitation of bilious contents in the afferent limb into the stomach after release from intermittent obstruction.
Post PEG, patient has abdo pain and some subQ emphysema near entry gastrostomy site. What to do A. Lap B. Interventional PEG tube C. Urgent CT D. Observe and Feed
D? Although C may be reasonable if lot of pain
Uptodate
Subcutaneous air has also been described after PEG tube placement. It occurs from air being introduced between the
cutaneous and subcutaneous tissues [35]. In the absence of other findings, it is inconsequential and should not preclude
feeding [35].
45 F one year after lap gastric bypass. Now presents with nausea, vomiting. Amylase and lipase three times normal. AXR shows bowel in RUQ. No stones in GB What is the most likely diagnosis?
A. Internal hernia
B. GS Pancreatitis
C. Obstruction of J-J anastomosis
B in answer key but A more likely the answer
But gas in RUQ makes it suspicious for Petersen’s hernia
CT showing whorling of small bowel mesentery, presence of cecum and TI in RUQ and existence of majority of small bowel loops on one side of the abdo cavity as triad of CT findings pathognomonic for internal hernia
In RYGB, there is an assoc between SBO and an elevated amylase or lipase. Acute obstruction of biliopancreatic limb can be difficult to dx and in these pts, sensitivity of elevated amylase or lipase is high. It is important to recognize that an elevation of these enzymes is not likely a result of acute pancreatitis
To distinguish BP limb obstruction from pacnreatitis, the latter condition would have lipase elevated in the 1000s.
Recurrent bleeds from a posterior duodenal ulcer while on PPI, resolved. Not actively bleeding now.
A. Gastrin level
B. V+D
C. Endoscopic injection
A
Duodenal GIST 3 cm which is 5 mm from ampulla. In a guy who has had a bout of acute pancreatitis that is now resolved.
A. Local resection primary transverse closure
B. Local resection duodeno-jejunostomy
C. Whipple
D. Neoadjuvant Gleevec
D
Try to increase margin to ampulla to allow localized resection.
EGD reveals 2 one cm gastric adenomas, removed by polypectomy A. Wedge Gastrectomy B. Biopsy for H.Pylori C. Repeat EGD in 2 years D. PPI
B
Sabiston:
Adenomatous polyps carry a distinct risk for the development of malignancy in the polyp. Mucosal atypia is frequent,and progression from dysplasia to carcinoma in situ has been observed. The risk for the development of carcinoma is approximately 10% to 20% and increases with increasing size of the polyp. Endoscopic removal is indicated for pedunculated lesions and is sufficient if the polyp is completely removed and there are no foci of invasive cancer on histologic examination. If the polyp is larger than 2 cm, is sessile, or has a proven focus of invasive carcinoma, operative excision is warranted.
Up to Date:
Gastric adenomas typically occur in a background of chronic atrophic gastritis. Gastric adenomas are much less common than fundic gland polyps in patients with FAP; they are typically isolated and located in the antrum and are associated with a relatively low but real risk of progression to cancer.
Adenomas may be flat or polypoid, and are usually <2 cm in size. Adenomas are usually solitary. Most are found in the antrum, but some occur in the corpus and cardia.
It is estimated that 8 to 59 percent of adenomas are associated with synchronous gastric carcinomas [53]. The presence of invasive carcinoma in an adenoma correlates with increasing size, villous contour, and the degree of dysplasia [23,54]. The risk of malignancy is lower in flat adenomas [55]. High-grade dysplasia has been identified in close proximity to a high proportion (40 to 100 percent) of early gastric cancers.
In addition, as adenomatous polyps are associated with atrophic gastritis, the normal-appearing antral and corpus mucosa should be sampled to assess the stage of gastritis and, thus, cancer risk. All patients should be tested for active H. pylori infection and, if present, the infection should be treated
Pyloric stenosis, patient dehydrated. Best fluid to maintain a 3 kg child after giving NS bolus at 20cc/kg A. RL at 15 cc/hr B. D10W + 0.45 NS at 12 cc/hr C. D something + 5 KCL at 18 cc/hr D. D5W + 0.45 NS + 20 KCL at 20 cc/
D
Pyloric stenosis results in hypochloremic, hypokalemic metabolic alkalosis
Need 20 KCL or more; rehydrate at 150%.
Gastric biopsy of a 1cm mass showing Mucosal associated lymphocytes. Pathologist then calls to say H.P. also seen on specimen. (??maybe a MALT not sure) What is the best Management? A. H. Pylori eradication B. Chemo C. ChemoRad D. Antrectomy
A
HP eradication is first line. In the rare HP negative patient, RT is very effective with low recurrence. Complete response to eradication can take 12-18 months, so usually defer RT til after that. MALT with t(11:18) is unlikely to respond to eradication and is treated with RT
DLBC lymphoma (high-grade MALT) is treated with upfront chemo (R-CHOP).
Duodenal sessile polyp 2.1 cm located 5mm from ampulla. Biopsy shows sporadic (not related to FAP) duodenal adenoma with low grade dysplasia…treatment?
A. Whipple
B. Endoscopic resection
C. Transduodenal resection
D. Observation
C
Up to 2cm can consider endoscopic resection, but sessile is more difficult. Given size >2cm, sessile, and close to ampulla, transduodenal polypectomy would be best.
Schwartz
Tumors located in the duodenum, including asymptomatic lesions incidentally found during EGD, can pose the greatest therapeutic challenges. These lesions should be biopsied; symptomatic tumors and adenomas, because of their malignant potential, should be removed. In general, duodenal tumors less than 1 cm in diameter are amenable to endoscopic polypectomy. Lesions greater than 2 cm in diameter are technically difficult to remove endoscopically and may need to be removed surgically. Surgical options include transduodenal polypectomy and segmental duodenal resection. Tumors located in the second portion of the duodenum near the ampulla of Vater may require pancreaticoduodenectomy. EUS may offer utility for duodenal tumors ranging in size between 1 and 2 cm in diameter
Recent studies have shown that endoscopic resection of biopsy-proven benign duodenal periampullary adenomas leads to equivalent efficacy to surgery but with lower morbidity. Adenomas can recur; therefore, surveillance endoscopy is required after these procedures.
Fe deficiency anemia. EGD shows radial dilation of venous channels at antrum, no active bleeding A. TIPS B. Thermocoagulation C. Banding D. Antrectomy
B
Lady with occult GIB, endoscopy, CT, angio, RBC scan, all negative, next step
A. Capsule endoscopy
B. Enteroclysis
C. Surgery, with intraoperative endoscopy
D. Push enteroscopy
A
Old guy with perforated ulcer. Found to have 5 cm splenic artery aneurysm incidentally. How to manage aneurysm
A. Ligate proximal and distal to aneurysm
B. Angioembolize
C. Stent
D. Splenectomy
A
Sabiston:
Patients with splenic aneurysms may report a history of left upper quadrant or epigastric pain. The term double rupture has been used to describe these aneurysms, but is relatively rare. There is initial contained bleeding in the lesser sac, followed by free hemorrhage into the peritoneal cavity, causing hypovolemic shock. Treatment should be considered in aneurysms larger than 2 cm in diameter. Because of the high mortality rate, treatment is warranted for pregnant women and those of childbearing age. Simple ligation or excision of the aneurysm is preferred to splenectomy. Endovascular repair is emerging as the treatment of choice.
Dieulafoy lesion, bleeding not controlled with endoscopy A. Wedge resection B. Subtotal gastrectomy C. Gastrotomy with oversewing D. Angio
D
Sabiston: endo, then angio, then wedge
Dieulafoy’s lesion: current trends in diagnosis and management. Ann R Coll Surg Engl. 2010 Oct; 92(7): 548–554.
There is no consensus on the treatment of Dieulafoy’s lesions. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as a valuable alternative to endoscopy for inaccessible lesions. Currently, surgical intervention is kept for failure of therapeutic endoscopic or angiographic interventions and it should be guided by pre-operative localisation
Young guy, gastric ulcer, bleeding, intractable to medical therapy A. Wedge resection B. Subtotal gastrectomy C. Subtotal with vagotomy D. Angio
B in answer key though D seems like a reasonable choice.
If type I, no vagotomy required
Aortoenteric fistula. Huge hole in D2 (involving 60%). How to repair duodenum after extraanatomic bypass
A. Resection with distal jejunum to stomach
B. Primary repair
C. Resection with side to side duodenojejunostomy
C
Primary repair if small (usual case), otherwise resect portion and do D-J.
Patient awaiting surgery for brain tumor, having OR for perforated duodenal ulcer. Post op hypotensive, what must be given to patient in his immediate treatment of shock
A. Levophed
B. Activated protein C
C. IV hydrocortisone
A
C if previously had been on steroids
Visible vessel not actively bleeding on scope for UGIB A. Injection epi and thermocoag B. Inject epi C. Observe D. Oversew
A
Forrest IIa; dual methods of control is superior.
Healthy 65m, mgmt of organoaxial gastric volvulus. A. Gastropexy B. Repair hiatal hernia C. Gastrectomy D. PEG
B
Etiology is hiatus hernia. Organoaxial associated with HH; mesoaxial is not, so treatment for mesoaxial volvulus is gastropexy.
Third episode of hematemesis and melena. Non healing posterior wall duodenal ulcer. On EGD, non bleeding, no visible vessel, no clot. On max medical mgmt, quit smoking. H. pylori has always been negative, culture and serology. Stable. Mgmt.
A. Serum gastrin
B. TV and antrectomy
C. Gastrectomy
A
UGIB, hypotensive. Responds to fluids. On EGD 3 mm mucosal defect with surrounding normal mucosa. Minimal oozing from area. Mgmt. A. Endoscopic injection or coagulation B. Suture ligation C. Angio and embolize D. Treat H.pylori
A
Dieulafoy’s lesion. 1st line is endoscopic management.
First trimester pregnant woman with vomiting then hematemesis. Mucosal tear on EGD, can’t stop bleeding. Mgmt.
A. Angio and embolize
B. Gastrotomy and ligate
C. Gastrectomy
B
Sabiston:
If these maneuvers fail, high gastrotomy and suturing of the mucosal tear is indicated. It is
important to rule out the diagnosis of variceal bleeding in cases of failed endoscopic therapy by a thorough examination of the gastroesophageal junction.
Postop RYGB with abdo pain and large gastric air bubble. Mgmt.
A. Percutaneous gastrostomy
B. NG
C. Laparotomy
A
Acute gastric remnant distension.
- Usually after RYGB
- Due to edema or obstruction of enteroenterostomy site.
- Dx within first few days post op.
- N/V, LUQ pain, bloating, hiccups
- Tx– perc decompression or reoperation
- NG tube controversial and will not decompress the remnant stomach
Patient 2 years post Billroth 2, antecolic, for T2N0 gastric cancer. Complains of postprandial abdo pain, forceful bilious vomiting, does not vomit food. Mgmt. A. Revise to retrocolic gastojejunostomy B. Braun enteroenterostomy C. Prokinetic D. PPI
B
Afferent limb syndrome; revise to R-Y or Braun
Sabiston:
Upper endoscopy demonstrates friable, beefy red mucosa. Most patients suffering from alkaline reflux gastritis have had gastric resection performed with a Billroth II anastomosis. Although bile reflux appears to be the inciting event, a number of issues remain unanswered with respect to the role of bile in its pathogenesis. For example, many patients have reflux of bile into the stomach following gastrectomy without any symptoms. Moreover, there is no clear correlation between the volume or composition of bile and the subsequent development of alkaline reflux gastritis. Although it is clear the syndrome does exist, caution needs to be exercised to ensure that it is not overdiagnosed. After a diagnosis is made, therapy is directed at relief of symptoms. Unfortunately, most medical therapies that have been tried to treat alkaline reflux gastritis have not shown any consistent benefit. Thus, for patients with intractable symptoms, the surgical procedure of choice is conversion of the Billroth II anastomosis into a Roux-en-Y gastrojejunostomy, in which the Roux limb has been lengthened to more than 40 cm.
SCNA (Postgastrectomy Syndromes)
Another possible solution to afferent loop syndrome is an afferent to efferent loop bypass. This bypass procedure, originally described by Braun, is particularly useful when dissection of the original gastrojejunal anastomosis is not required or technically difficult.
Post Billroth 2 with bile reflux. EGD mucosa is friable, beefy red, ulcerated. Mgmt. A. PPI B. Prokinetic C. Convert to Billroth 1 D. Convert to RY gastro J
D
SCNA (Postgastrectomy Syndromes)
Although bile reflux and gastritis are more common after B-I and B-II reconstruction than after Roux-Y, debilitating symptoms are infrequent. For the few patients with severe bile reflux gastritis after partial or subtotal distal gastrectomy with B-I or B-II reconstruction, the best solution is to reoperate and convert to Roux-Y anatomy.
Patient post billroth II with abdo pain, EGD shows alkaline reflux (they give you the diagnosis) and biopsies show chronic inflammation with intestinal metaplasia. What should you do?
A. Promotility agent
B. Convert to Billroth I
C. R-en-Y gastrojejunostomy
C
Intestinal metaplasia is a risk factor for adenocarcinoma, but we don’t really know how to follow or treat these patients.
Up to Date says surveillance is recommended, eradicate H. pylori, and no data to support chemoprevention.
D1 ulcer eroding through into CBD seen on endoscopy. Not bleeding, patient stable. A. HJ B. IV pantoloc C. Endoscopic stent D. Choledochoduodenostomy
B
Shaw – no operation unless obstructing or cholangitic.
Older male with multiple comorbidities, needs some sort of gastrectomy for ulcer and also found to have 3.5cm splenic artery aneurysm, what to do?
A. Gastrectomy + splenectomy
B. Gastrectomy + ligate prox/distal aneurysm
C. Gastrectomy + endovascular
B
Most sources say treat when>2cm. If you’re already there for the ulcer, just ligate the thing and spare him the contrast.
Familial polyposis, found to have 2 polyps in duodenum during screening. Both about 1cm, away from papilla, tubular villous, no LVI. Management?
A. Whipples
B. Endoscopic resection
C. Open polypectomy
D. Observe
B
Endoscopic resection – 1st line; if recurrence then open polypectomy
Uptodate
Endoscopically visible duodenal adenomas are identified in more than half of FAP patients. Approximately half of duodenal cancers are ampullary or periampullary. Complete polypectomy or sampling of duodenal polyps should be performed at the time of initial discovery and on each subsequent examination. An abnormal-appearing papilla should be biopsied. Adenomas identified at the ampulla of Vater should be removed endoscopically if possible. Management of high-grade dysplasia in the periampullary region (surgery/ablative therapy versus more frequent surveillance) is controversial and should be individualized based on the patient’s age and the number of duodenal adenomas. The resection margins should be free of neoplastic tissue. A study that included 26 FAP patients who underwent endoscopic ampullectomy demonstrated the procedure can be performed safely, but ongoing surveillance is required because recurrences were common.
The severity of duodenal polyposis, as determined by the Spigelman stage (0 to IV), is used to guide subsequent surveillance (table 1). Surgery (duodenectomy) is reserved for patients with stage IV polyposis.
Crohns patient 2 prev SB resections, now with 12cm long SB stricture with obstructive symptoms. What is the management? A. Resection strictured segment B. Finney stricturoplasty C. Heineke Mukilicz stricturoplasty D. Isoperistaltic stricturoplasty
B in answer key
<12cm, HM; 12-25cm Finney appropriate. Maybe this patient is at risk for short bowel syndrome. Don’t do if longer than 25cm as creates a blind loop diverticulum.
But A is also a reasonable choice if no concerns about short gut cause there is a risk of malignancy with stricture
Best way to treat active bleed from Mallory Weiss tear? A. Endoscopic control B. OR gastrostomy and oversewing C. Angiography D. Balloon tamponade
A
Female epigastric/upper AP. Hx of medications for osteoarthritis. Hemodynically stable. Laparoscopy showed bile, and perf DU. How to management? A. Suture reapir B. Open omental patch C. MIS omental patch D. Drain
C
Depends on age. If >70, increased M&M with laparoscopic repair, so do open.
Patient with history of celiac disease. Fatigue, weakness, weight loss. Imaging shows small bowel mass w/ SBO. Most likely diagnosis? A. AdenoCa B. Crohns C. Lymphoma D. Melanoma
C
Enteropathy Assoc T cell Lymphoma
Perforated gastric ulcer 5cm from GEJ on lesser curve. EtOH user. Stable. What is best management
A. Omental patch and vagotomy
B. Omental patch
C. Pauchet gastrectomy
C
If stable, resect b/c of risk of malignancy. If unstable, oversew but needs repeat scopes.
Patient post LRYGB with SBO taken to OR found to have intussusception at jejunoileal anastomosis. Management
A. Reduce intussusception
B. Open anastomosis to look for lead point
C. Resect and reconstruct anastomosis
C
Patient post LRYGB POD1, not feeling great but hemodynically stable no fever as I recall but has shoulder pain and hiccups. XR done showing large gastric bubble. Management?
A. NG
B. OR
C. Gastrostomy
C
Gastric remnant distension—Gastric remnant distension is a rare but potentially lethal complication following gastric bypass [12,13]. The gastric remnant is a blind pouch and may become distended if paralytic ileus or distal mechanical obstruction occurs postoperatively. Iatrogenic injury to vagal fibers along the lesser curvature may also contribute, possibly by leading to impaired emptying of the bypassed stomach. Progressive distension can ultimately lead to rupture, spillage of massive gastric contents, and subsequent severe peritonitis [14]. The combination of the large size of inoculum (liters) and the injurious contents (acid, bile, pancreatic enzymes, and bacteria) makes this complication much more serious than leakage occurring at the gastrojejunostomy.
Clinical features include pain, hiccups, left upper quadrant tympany, shoulder pain, abdominal distension, tachycardia, or shortness of breath. Radiographic assessment may demonstrate a large gastric air bubble.
Treatment consists of emergent operative decompression with a gastrostomy tube or percutaneous gastrostomy [15]. Immediate oative exploration and decompression are required if percutaneous drainage is not feasible, or if perforation is suspected. Although gastrostomy is not performed routinely by most surgeons at the initial gastric bypass operation, drainage of the gastric remnant can prevent this rare but sometimes fatal complication. Routine gastrostomy should be considered in the elderly, super-obese patients, patients with diabetic gastropathy and as part of revisional surgeries where gastric emptying may be delayed.
Patient post sleeve gastrectomy, febrile, tachy, increase respiratory rate. Hemodynamically stable. U/O 200cc over last 4 hours. Ab tender but no peritonitis. Management
A. CT PE
B. Endoscopy
C. UGI contrast swallow
C
UGI contrast swallow – leak, also to assess distal stomach for outflow obstruction
Several points (based on ASMBS paper):
1) Unstable patients should not have imaging studies but go to the OR for exploration
2) CT with oral and IV contrast is more sensitive
3) For GB, early exploration and repair of leak with remnant gastrostomy
4) For GS, early leaks (within 48 hrs) can be managed with operative repair, drainage, and feeding access, but beyond 48 hrs don’t try to repair the leak, just drain and feed.
Infant history consistent with pyloric stenosis, patient is hypoK, hypoCl and in metabolic alkolosis, what is the next most appropriate step A. Rehydrate B. Open pyloromyotomy C. Lap pyloromyotomy D. TPN
A
2cm gastric AdenoCa limited to mucosa on biopsy and EUS. No nodes seen. No ulceration. Does not invade muscularis propria
A. EMR
B. Lap wedge
C. Distal gastrectomy with D1
D. Neoadj chemo and distal gastrectomy with D2
A
<2cm, not ulcerated, clinically node negative is candidate for EMR.
Up to Date:
Standard and expanded criteria for endoscopic resection—The general guidelines for the selection of patients with EGC who are appropriate for endoscopic resection with EMR or ESD are outlined below [1-4]:
●High probability of en bloc resection ●Tumor histology •Intestinal type adenocarcinoma •Tumor confined to the mucosa •Absence of venous or lymphatic invasion ●Tumor size and morphology •Less than 20 mm in diameter, without ulceration •Less than 10 mm in diameter if Paris classification IIb or Iic
Studies have shown high survival and cure rates in patients with EGC who undergo EMR:
Sabiston
Endoscopic therapy for gastric cancer is well established in Eastern countries. Endoscopic resection is a safe and effective technique for patients who meet the criteria and will continue to play an increasing role in the treatment of this disease. As a matter of standard practice, patients with tumors larger than 2 cm, with ulceration or with any submucosal invasion, should be referred for gastrectomy with lymph node dissection if not part of a clinical trial.
Subtotal gastrectomy for adeno, fozen margins neg, final path with positive proximal margin A. Total gastrectomy B. Chemotherapy C. Radiation D. Endoscopically watch q3months
A
Controversial; NCCN says chemorads, but surgeons say in fit patient, R0 resection is only chance for cure and can get wider margins so re-resect to negative margins. Different if esophageal margin is positive. If there is metastatic or N2 disease, probably little benefit from re-resection and treatment should be chemorads (or chemo), but if N0 or N1 in a young person, there is survival advantage. Some evidence that positive margins re-resected is equivalent to initially negative margins.
Staging laparoscopy most indicated for which lesion in gastric cancer A. T1 with no mets B. T2 with liver met C. Obstructing T3 D. T3 with normal CT
D
Standard textbook answer, although Toronto manual 2015 says staging laparoscopy for T2 and higher.
New diagnosis of gastric cancer in male 45 yo. Father died of gastric cancer, mother wants to know about screening for her child. What is the best way to do this?
A. Look for pernicious anemia
B. Eradicate H. pylori
C. Gastroscopy q5-10 years surveillance
D. Test for E-cadherin and if positive gastrectomy
D
Up to Date:
Many families with HDGC have germline mutations in the E-cadherin (CDH1) gene that are inherited in an autosomal dominant pattern. The lifetime cumulative risk for clinically significant gastric cancer in individuals from these families is >80 percent in both men and women by age 80; the median age at diagnosis is 38. Because these early gastric cancers are located beneath an intact mucosal surface, early detection is extremely difficult, and prophylactic total gastrectomy is usually advised after age 20, and before the age of 40.
Modified criteria for selection of patients for genetic testing for HDGC have been proposed based upon the experience of the British Columbia Cancer Agency Hereditary Diffuse Gastric Cancer Program:
●Families with two or more documented cases of gastric cancer in first or second degree relatives, with at least one diffuse gastric cancer diagnosed before age 50 years
●Families with multiple lobular breast cancers with or without diffuse gastric cancer in first or second degree relatives
●Individual diagnosed with diffuse gastric cancer before 35 years of age from a low incidence population
●Potential additional criteria which need additional validation in clinical studies include:
•Three or more cases of gastric cancer in first or second degree relatives, diagnosed at any age, one or more of which is a documented case of diffuse gastric cancer (3 percent mutation rate; 1 positive/30 tested)
•Family with one or more cases of both diffuse gastric cancer and signet ring colon cancer (33 percent mutation rate; 1 positive/3 tested).
•Personal history but no family history of diffuse gastric cancer or lobular breast cancer (mutation rate unknown)
Old guy GOO long standing reflux,vomiting, biopsy shows LGD with fibrosis and inflammation A. Antrectomy B. Gastrojejunostomy C. Endoscopic stent D. Endoscopic dilation
D
Antrectomy – diagnosis, therapy, risk of CA, deals with obstruction
Endoscopic dilation – also reasonable, but doesn’t mention deeper biopsy; need to exclude deeper invasive
Dilate, PPI, rescope and rebiopsy. LGD has low rate of progression to invasive, and given age just dilate.
Gastric Preneoplastic Lesions and Epithelial Dysplasia,Gastroenterology Clinics of NA (2007)
Given the low rate of malignant transformation of low-grade dysplasia, annual endoscopic surveillance with rebiopsy typically is performed, and surgical resection is usually not necessary [99]and[100]. It also must be emphasized that low-grade dysplasia occurring in a background of extensive intestinal metaplasia may be associated with a higher risk of malignancy [101]. Patients who have high-grade dysplasia, large adenomatous polyps, or well-differentiated adenocarcinomas no more than 2 cm should undergo definitive therapy. Complete excision of mucosal-based lesions may be performed by endoscopic mucosal resection, obviating the need for surgical resection in many cases [102]. Mucosal lesions that are not amenable to endoscopic resection, and those with a submucosal component, are managed best with surgical resection.
22 yo F. CDH-1 discovered after D2 distal gastrectomy for T2N0 Gastric Cancer
A. Chemo then oopherectomy
B. Chemo them hysterectomy
C. Serial endoscopy and Bilateral Mammograms
D. Completion Gastrectomy and Bilateral Mastectomy
D
Prophylactic gastrectomy between ages 20-40 (peak incidence age 38).
Mammography is not useful as young and dense breasts, and lobular carcinoma not detected on mammo. MRI would be good option.
EGD reveals 2 one cm gastric adenomas, removed by polypectomy A. Wedge Gastrectomy B. Biopsy for H.Pylori C. Repeat EGD in 2 years D. PPI
B
Sabiston:
Adenomatous polyps carry a distinct risk for the development of malignancy in the polyp. Mucosal atypia is frequent,and progression from dysplasia to carcinoma in situ has been observed. The risk for the development of carcinoma is approximately 10% to 20% and increases with increasing size of the polyp. Endoscopic removal is indicated for pedunculated lesions and is sufficient if the polyp is completely removed and there are no foci of invasive cancer on histologic examination. If the polyp is larger than 2 cm, is sessile, or has a proven focus of invasive carcinoma, operative excision is warranted.
50ish male who has gastric cancer resected with a distal gastrectomy and LN resection. Presents with a N/V and partial SBO. Imaging shows ascities and recurrent gastric cancer at the midline wound and in the pelvis and a distal partial SBO. What is the best management? A. IV Steroids and octreotide B. Loop jejunostomy C. Palliative Chemo D. Jejuno-Transverse Colostomy
A
SBO is contraindication to chemo. This patient has very short life expectanct (weeks) so medical management is optimal, as even with surgery likely wont survive to discharge. Surgery for MBO is contraindicated with ascites. NCCN specifically included steroids and octreotide for medical management of MBO.
Multifocal recurrence, incomplete SBO. May be a role for palliative surgery, but overall is not clear exactly what that is. Midline recurrence would require abdominal wall resection otherwise would not heal. Don’t operate for MSBO if generalized carcinomatosis or ascites.
Gastric outlet thickening 1 cm over a distance of 5 cm in patient with dyspepsia on PPI. Biopsy shows mucosal inflammation A. H. Pylori eradication B. Deeper biopsy C. Continue PPI D. Antrectomy
Both A and B in answer key
Deeper biopsy – reasonable -exclude lymphoma
Proven cancer 3 cm from GE junction on lesser curve
A. Wedge resection
B. Subtotal gastrectomy to include include ulcer
C. Total gastrectomy
D. Esophagogastrectomy
C
Not Siewerts III as does not invade EGJ, but even if it were:
Patients with Siewert type II and III tumors should undergo a total gastrectomy with a transhiatal resection of the distal esophagus with lymphadenectomy of the lower mediastinum and an extended lymph node dissection including nodes along the hepatic, left gastric, celiac, and splenic arteries as well as those in the splenic hilum. (UTD)
Man, 2 cm carcinoid of stomach. No evidence of gastritis. H. pylori negative. Mgmt A. Wedge B. Endoscopic resection C. Observation D. D1 gastrectomy
D
TYPE III , so resection and lymphadenectomy. Regardless, resect all 2cm or greater.
Up to Date: Type 3 (sporadic) gastric carcinoids are treated by partial or total gastrectomy with local lymph node resection. The risk of nodal metastases is dependent on tumor size and depth, and some have suggested that endoscopic resection alone may represent adequate therapy for intraepithelial tumors <2 cm and perhaps for tumors <1 cm invading the lamina propria or submucosa. However, this is not a standard approach. For type 1 and 2 gastric carcinoids smaller than 1 to 2 cm, endoscopic resection represents adequate therapy. Subsequent endoscopic surveillance is needed every 6 to 12 months since these patients continue to exhibit mucosal changes and hyperplasia of enterochromaffin-like cells (ECL) due to sustained hypergastrinemia.
Lesser curve ulcer, non healing, multiple biopsies negative for malignancy. Mgmt.
A. Subtotal gastrectomy to include the ulcer and TV
B. Total gastrectomy
C. 90% subtotal gastrectomy
D. Wedge
D in answer key but maybe A based on uptodate
UTD
Type I gastric ulcer — Type I gastric ulcers are the most common type of gastric ulcer. These occur along the lesser curvature near the junction of fundic and antral mucosa and occur in the setting of acid hyposecretion.
For most patients with type I gastric ulcer, distal gastrectomy with Billroth I or Billroth II reconstruction is recommended since this approach removes the ulcer and the diseased antrum. It also treats an occult malignancy.
Although type I gastric ulcer has classically been considered the consequence of inadequate gastric mucosal defense, as opposed to increased acid secretion, many advocate the addition of some form of vagotomy to the gastric resection.
Although most prefer distal gastrectomy, highly selective vagotomy has been used for type I gastric ulcer. The value of highly selective vagotomy in gastric ulcer may derive from its ability to decrease acid secretion while maintaining adequate gastric emptying and minimizing postoperative duodenogastric reflux. The procedure is performed as for duodenal ulcer, with the addition of a gastrotomy to resect or biopsy the ulcer bed.
Gastric cancer 4 cm from GE junction. Full thickness. Mgmt.
A. Esophagogastrectomy
B. Subtotal gastrectomy
C. Proximal gastrectomy
A
Siewert classification — subclassification scheme for EGJ adenocarcinomas
- Type I tumor (located between 5 and 1 cm proximal to the anatomical squamocolumnar junction or Z-line (figure 2)) [16] – Adenocarcinoma of the distal esophagus that usually arises from an area with specialized intestinal metaplasia of the esophagus (ie, Barrett’s esophagus) and that may infiltrate the EGJ from above.
- Type II tumor (located between 1 cm proximal and 2 cm distal to the anatomical Z-line) – True carcinoma of the cardia arising from the cardiac epithelium or short segments with intestinal metaplasia at the EGJ; this entity is also often referred to as “junctional carcinoma.”
- Type III tumor (located between 2 and 5 cm distal to the anatomical Z-line) – Subcardial gastric carcinoma that infiltrates the EGJ and distal esophagus from below.
In general, type I cancers more frequently involve lymph nodes in the upper mediastinum (tracheal bifurcation and above) [28]. Patients with type I tumors are not appropriate candidates for a purely transabdominal approach to resection. The standard surgical approach is a transthoracic en bloc esophagectomy combined with resection of the upper part of the stomach and two-field lymphadenectomy.
On the other hand, for type II and III carcinomas, nodal metastases are more frequently found in the lower mediastinum and around the celiac trunk (table 4) [29]. The standard surgical approach is a transhiatally extended total gastrectomy with distal esophageal resection and systemic lymphadenectomy of nodes that drain the stomach.
Gastric cancer invading tail of panc, spleen, multiple nodes. Mgmt.
A. Chemorads
B. Perioperative chemo
C. En bloc resection
B
Perioperative chemo for T3 and higher, N1 and higher.
UTD
For most patients with potentially resectable, histologically proven noncardia gastric adenocarcinoma with invasion beyond the submucosa (clinical stage T2N0 or higher (table 1)) on preoperative staging evaluation, we recommend combined modality therapy over surgery alone.
We generally prefer neoadjuvant therapy over initial surgery, especially for those with a high likelihood of developing distant metastases (ie, those with bulky T3/T4 tumors, visible perigastric nodes by preoperative imaging studies, a linitis plastica appearance, or positive peritoneal cytology in the absence of visible peritoneal disease). There are no randomized trials demonstrating better outcomes from neoadjuvant therapy versus initial surgery followed by any form of adjuvant therapy. However, given the greater chance of delivering therapy in the preoperative setting and the fact that patients who are at high risk of developing distant metastases may be spared the morbidity of unnecessary gastrectomy if evidence of distant metastases emerges after chemotherapy, we favor this approach. However, upfront surgery remains an accepted approach, especially for patients with clinically staged, nonbulky, T2 or T3 tumors with no visible perigastric nodes.
Gastric cancer, submucosal. Laparoscopy negative, no nodes. Mgmt.
A. Subtotal gastrectomy to negative margins with perigastric node dissection
B.Subtotal gastrectomy with splenectomy, celiac nodes
C. Subtotal gastrectomy, distal panc, splenectomy with celiac nodes
A
D1 vs D2, Dutch and British trials did not show survival benefit to D2. Morbidity is related to pancreatectomy and splenectomy, so don’t do it. Current standard of care in Canada is D2
Bleeding gastric cancer, not stopped with EGD. Intraop, distal gastric Ca, distal stomach is mobile, single met to left lobe liver. Mgmt. A. Distal gastrectomy liver resection B. Distal gastrectomy wedge of liver C. Close D. Distal gastrectomy, no liver surgery
D
Palliative resection for bleeding, do not resect met!
2cm mid body stomach lesion, EUS says involving mucosa only, no lymph nodes, CT shows it’s not invading muscle layer
A. EMR
B. Antrectomy with D1
C. Perioperative chemo, gsatrectomy and D2
A
Old man with GOO, endoscopy shows ulcerating tumour in the antrum, laparoscopy has positive cytology. A. Gastrojej B. Distal gastrectomy C. Total gastrectomy D. Total gastrectomy w D2
A
Old man with large ulcerated lesion in body of stomach, looks like T3, in the OR you see it’s involving the root of the celiac axis and the pancreas.
A. En bloc resection
B. Palliative chemotherapy
C. Total gastrectomy
B
EGD shows 3cm submucosal mass, biopsies are normal mucosa…
A. Open wedge
B. Laparoscopic wedge
C. Subtotal Gastrectomy
B
Patient presents w/ distal gastric CA, no distant mets, good status, laparoscopy is N. What is the best treatment.
A. Total gastrectomy
B. Subtotal gastrectomy w/ D1
C. Periop chemo + Subtotal Gastrectomy + D2
D. Subtotal Gastrectomy + Postop ChemoRT
C
MAGIC: perioperative ECF for stage II-IVa; improved 5-yr survival, DFS, recurrence rates.
Up to Date:
Lymphadenectomy:
The Dutch trial has been updated with 15-year follow-up [64]. The survival curves have continued to separate, although the difference in overall survival is still not statistically significant (22 versus 28 percent in the D1 and D2 arms, respectively, p = 0.34). However, the gastric cancer-related death rate is significantly higher in the D1 arm (48 versus 37 percent) while death rates due to other causes were not different. This supports the concept that if the D2 dissection can be done with low operative mortality, similar to that of a D1 dissection (as occurs in high volume centers), there will be a positive survival impact. This mirrors the conclusion of the latest Dutch trial paper, which is that D2 dissection is recommended in patients with potentially curable gastric cancer.
Given the apparent impact of D2 lymphadenectomy on disease-specific survival, most major cancer centers are performing a D2 as compared to a D1 dissection. Treatment guidelines published by the National Comprehensive Cancer Network (NCCN) recommend that D2 lymph node dissection is preferred over a D1 dissection. However, in view of the higher reported rates of operative mortality when this procedure has been performed in randomized trials, this recommendation this should be tempered by where and by whom the operation is being performed
Perioperative Chemotherapy:
A meta-analysis of these three trials [3,22,23] plus two other trials comparing preoperative oral fluoropyrimidine versus surgery alone [24,25] and seven other smaller trials comparing a variety of preoperative chemotherapy regimens versus surgery alone concluded that neoadjuvant chemotherapy was associated with a statistically significant benefit in terms of both overall survival (odds ratio [OR] 1.32, 95% CI 1.07-1.64) and PFS (OR 1.85, 95% CI 1.39-2.46) [27]. Furthermore, neoadjuvant chemotherapy was associated with a significantly higher complete (R0) tumor resection rate (OR 1.38, 95% CI 1.08-1.78), and did not significantly worsen rates of operative complications, perioperative mortality, or grade 3 or 4 adverse effects.
In terms of patient selection for this approach, it is reasonable to utilize the eligibility criteria for the MAGIC trial (patients of any age with a performance status of 0 or 1, a histologically proven adenocarcinoma of the stomach that was considered to invade through the submucosa [stage T2 or higher, with no evidence of distant metastases or locally advanced inoperable disease, as evaluated by CT, ultrasonography, or laparoscopy)
SCNA:
In summary, based on the trials mentioned earlier, the retrospective studies suggest improved survival in patients undergoing ELND, but this is not confirmed in prospective studies. With an experienced surgeon, a D2 lymphadenectomy can be performed safely and provides more accurate staging information
BII for gastric cancer. In recovery room, found to have fresh sang from NG tube. This persisted and he continued to bleeding with output of 400cc over a few hours.
A. Take back to OR, gastrotomy and oversew bleeder at anastomosis
B. Take back to OR and revise anastomosis
C. Endoscopic hemostasis
C
Endoscopic therapy as 1st line is reasonable, even if unstable. We routinely scope unstable UGIB patients for hemostasis.
Mastery (6th ed, p 993). Postoperative intragastric hemorrhage should always be managed first with endoscopy. If bleeding is ongoing after 4U of blood in 24hrs and it is not possible to control endoscopically, reoperation is needed. At relook, should make transverse gastrostomy 3-5cm above the anastomosis and obtain hemostasis. Closure is in horizontal direction
Patient with large gastric mass then invades into adrenal and pancreas. Biopsy shows spindle cells, C-kit +. Best next step? A. Gastrectomy B. Enbloc resection C. Enbloc resection then Gleevec D. Neoadjuvant Gleevec then resection
D
- What is TRUE about achalasia?
A. Dilatation has a perforation risk of 20%
B. Need to dilate for 5 minutes
C. Surgical treatment has a poor prognosis
D. Treatment does not change risk of cancer
D
A 50 year old man is diagnosed with Barrett’s with a short 2.0 cm segment. Biopsy also shows low grade dysplasia. What would your follow-up be?
A. Repeat endoscopy in 6 months for 2 times then yearly
B. Repeat endoscopy every 3 months for one year then yearly
C. Aggressive medical management only
A
What is the MOST significant prognostic factor in instrumental esophageal perforation? A. Location of injury B. Size of the perforation C. Underlying disease D. Delay in diagnosis
D
Perforation of the esophagus is a surgical emergency. Early detection and surgical repair within the first 24 hours results in 80% to 90% survival; after 24 hours, survival decreases to less than 50%.
What is correct with respect to Schatzki ring? A. Dysphagia if < 13 mm B. Needs surgery C. Transmural fibrosis will be present D. Located anywhere in esophagus E. Marker for GERD and hiatus hernia
E
Common cause of intermittent dysphagia, associated with HH, treatment is dilation or endoscopic forcep disruption of mucosal ring.
65 yo male with dysphagia to solids+liquids for 10 months. Cine-esophagram shows dilated esophagus with bird’s beak suggestive of achalasia. Most appropriate initial step?
A. Refer for OGD and biopsy of GEJ
B. Refer for radiological balloon dilation
C. Refer for esophageal myotomy
D. Start Ca antagonists
E. Start anticholinergics
A
What is an increased risk for SCC Ca of the esophagus? A. Barrett’s B. Celiac C. Food with fungus in it D. Achalasia
D
57 yo male on UGI endoscopy shows Barretts. What is true?
A. Barretts develops in 5-8% of patients with GERD.
B. Patients with Barretts are at risk for developing SCC 0.5% per year
C. Patients with low grade dysplasia should have screening every 3-5 yrs
D. Patients with high grade dysplasia should have screening every 5 yrs
A
Young hockey player cant play because of pain due to 6cm splenic calcified cyst, unilocular. What to do? A. Splenectomy B. Partial splenectomy C. Aspirate and check for O&P D. Perc drain
B
Splenic cysts are categorized as parasitic, usually from Echinococcus infection, or nonparasitic. Nonparasitic cysts, can be further subdivided into primary (congenital) or secondary (pseudocysts). Primary cysts are relatively rare entities. Symptoms are generally vague left upper-quadrant discomfort, although many cysts are completely asymptomatic and are discovered when imaging is done for other purposes.
Indications for surgical intervention include symptoms and cysts larger than 5 cm (figure 1). Percutaneous aspiration of the cyst contents leads to poor results, with reaccumulation of the cystic fluid being the norm. Therefore, a variety of sclerosing agents added to percutaneous aspiration are used. Although success rates for eradicating the cyst have improved, recurrence rates remain high. Unroofing of the cyst still leaves behind a portion of the cyst lining on the spleen. Therefore, recurrences are still possible.
Splenectomy would be an effective treatment of the cyst, and, in fact, was previously considered the standard of care. However, with splenectomy, all of the functioning splenic parenchyma is removed, with the subsequent short- and long-term complication associated with the asplenic state. The newer technique of partial splenectomy offers the best management option of eliminating the entire cyst wall, thereby minimizing recurrences, yet maximizing the remaining functional splenic parenchyma. This can be done either through an open laparotomy incision or laparoscopically. It is also less technically demanding if the cyst is located at a splenic pole.
Patient with infective endocarditis with solitary splenic abscess, large. Best mgmt?
A. IV abx
B. Perc drain
C. Splenectomy
C
Although uncommon, splenic abscesses can be lethal if not treated appropriately. The most common etiology of a splenic abscess is hematogenous spread to the spleen from another septic focus, such as endocarditis, diverticulitis, or directly from intravenous drug abuse. Trauma to the spleen can make the organ more susceptible to infection if there is a devascularized segment of splenic parenchyma. Patients present with fever, elevated white blood cell count, and left upper-quadrant pain. Diagnosis is made by CT scan
Intravenous antibiotics and splenectomy provide the best means of source control. Aspiration or percutaneous drainage may occasionally be successful; they are associated with increased rates of abscess recurrence (50–60. Park AE, Godinez CD Jr. Spleen. In: Brunicardi FC, Andersen DK, Billiar TR, eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill;2010:1245–1265.
UTD:
Splenic abscess is usually managed by a combination of antibiotic therapy and splenectomy [44-46,49]. CT-guided percutaneous aspiration is occasionally successful, but this approach has not replaced splenectomy as the standard of care.
Splenectomy for ITP, Platelets 35, what do you do pre-op A. Vaccination B. IVIG C. High Dose Steroids D. Transfuse platelets if count < 10
A
UTD:
Optimizing the preoperative platelet count – If the platelet count needs to be increased for splenectomy, intravenous immune globulin (IVIG) is often administered several days to a week prior to the procedure (table 2). We prefer to perform splenectomy with a platelet count of ≥50,000/microL; however, some patients with ITP are able to undergo splenectomy safely in the setting of more severe thrombocytopenia with platelets available for transfusion if urgently needed because of intraoperative bleeding
4cm splenic cyst, non parasitic, in an asymptomatic in a 35 yr male construction worker. A. Observe B. Splenectomy C. Partial splenectomy D. Perc drain
A
Observe if asymptomatic, <5cm.
25 year old male involved in a trauma. Stable, but admitted for mechanism. On tertiary survey found a 3 cm solid homogeneous adrenal lesion. What is the best management for the adrenal lesion?
a. CT guided biopsy
b. Plasma aldosterone to plasma renin ratio
c. 24 hour Dexamethasone suppression test
d. Repeat CT in 6 months
B and D
First determine functionality. If nonfunctional, observe if <5cm.
Tests
-Pheo: 24-hour urine fractionated metanephrines
and catecholamines
-For patients with symptoms of Cushing’s syndrome:
24-hour urinary free cortisol
-For patients lacking symptoms of Cushing’s syndrome:
1 mg overnight dexamethasone suppression test
-Primary Aldosteronism: Plasma aldosterone concentration, plasma renin activity
-For adrenocortical carcinoma: Serum DHEAS
Patient referred for splenectomy who is an alcoholic cirrhosis with splenomegaly. Platelets 30. WBC 2.5. Hgb about 100. A. Lap spleen B. Open spleen C. Medical management D. Splenic embolization
C
Splenectomy may be useful in cirrhotics with thrombocytopenia preventing antiviral therapy. IFN 2-a is effective antiviral but can cause thrombocytopenia precluding use.
UTD: splenectomy almost never necessary for thrombocytopenia in cirrhosis unless <10 which is extremely rare.
Clear evidence of portal hypertension; not an indication for splenectomy.
Guy returns 3 weeks after highly selective splenic embolization with left shoulder pain and a hematoma 12 cm around spleen with fluid into paracolic gutter. Management?
A. Proximal embolization
B. Splenectomy
C. Observe
A and B both highlighted in answer key
Patient went through splenectomy for ITP, responded well with increase platelets, but now recurrent ITP one year later. Why? A. Splenosis B. Ectopic spleen C. Wrong diagnosis D. Bone marrow failure
B
Ectopic spleen (accessory spleen)- more common in ITP than splenosis
Female plt 60, on steroids for ITP, still bleeding from mucosal and gingival. What is the best management?
A. IVIG
B. Splenectomy
C. Observation
B
Mucous membrane bleeding is considered significant bleeding., so 2nd line therapy is indicated. Splenectomy is the preferred 2nd line therapy, as IVIG only transiently improves counts. Question is odd, however, as clinical bleeding with plts >50 is exceptionally uncommon.
Sabiston
Splenectomy is also the treatment of choice for patients with incomplete response to glucocorticoid treatment and for pregnant women in the second trimester of pregnancy who have also failed steroid treatment or IV Ig therapy with platelet counts less than 10,000/mm3 without symptoms or less than 30,000/mm3 with bleeding problems. It is not necessary to proceed to splenectomy for patients who have platelet counts higher than 50,000/mm3, have had ITP for longer than 6 months, are not experiencing bleeding symptoms, and who are not engaged in high-risk activities. A recent review of short-term and long-term failure of laparoscopic splenectomy has reported an overall approximate failure rate of 28% at 5 years after splenectomy.9
UTD
The goal of ITP therapy is to provide a safe platelet count to prevent clinically important bleeding, rather than to normalize the platelet count [1-4]. We often initiate second-line therapy at a slightly lower platelet count than used for initiating initial therapy (ie, <20,000/microL rather than 30,000/microL that is used for initial therapy)
We consider intravenous immune globulin (IVIG) to be rescue treatment in ITP rather than routine therapy. It is important for patients with clinically important bleeding and for patients in whom a more rapid response is required [5].
Second-line therapy is generally reserved for patients with thrombocytopenia that is associated with significant bleeding symptoms (eg, mucosal purpura, more serious bleeding) or for severe, persistent or recurrent thrombocytopenia (eg, platelet count <20,000/microL), following glucocorticoid-based treatments. For second-line therapies, we recommend splenectomy or rituximab rather than observation or chronic glucocorticoids
For patients who require additional treatment beyond initial therapy with glucocorticoids, we suggest splenectomy, provided the patient can tolerate surgery. This practice is based on greater response rates and longer sustained responses to splenectomy compared with rituximab
If the platelet count needs to be increased for splenectomy, intravenous immune globulin (IVIG) is often administered several days to a week prior to the procedure (table 2). We prefer to perform splenectomy with a platelet count of ≥50,000/microL; however, some patients with ITP are able to undergo splenectomy safely in the setting of more severe thrombocytopenia with platelets available for transfusion if urgently needed because of intraoperative bleeding
Perf diverticulitis, peritonitis in female and also 3cm hypoattenuating adrenal mass on imaging.
A. Urine metanephrine
B. Alpha block and sigmoid resection
C. Sigmoid resection and observe adrenal lesion
C
Patient needs urgent OR for diverticulitis due to peritonitis.
Male with history of melanoma. Had CT for diverticulitis, incidental finding of mass in adrenal. Plasma metanephrine normal. What do you do next
a. urine cortisol
b. FNA
c. adrenalectomy
B
Another guy HTN, on beta blocker and ACEI, mild CRF. Found to have adrenal mass. Plasma metaneprhine midly elevated, Cr slightl elevated, what investigation do you do next? A. FNA B. MRI C. CT D. MIBG
B
Mild elevation in metanephrines expected with antihypertensives, TCA’s, antipsychotics. CT if first line, non-contrast to evaluate densite (obviously can’t assess washout). MRI would be indicated d/t CT being contraindicated. MIBG non-contributory as a routine test, used if pt has pheo and concern for multifocality.
●With CT, there is some exposure to radiation but no risk of exacerbation of hypertension if current radiographic contrast agents are given. CT with low-osmolar contrast is safe for patients with pheochromocytoma even without alpha or beta blocker pretreatment, as illustrated in a report of 22 such patients [56]. After intravenous (IV) low-osmolar contrast administration for CT scan, there was a significant increase in diastolic blood pressure but no increase in plasma catecholamine levels or episodes of hypertensive crises.
●With MRI, there is neither radiation nor dye. This more expensive test can distinguish pheochromocytoma from other adrenal masses; on T2-weighted images, pheochromocytomas appear hyperintense and other adrenal tumors isointense, as compared with the liver (image 1) [18]. However, MRI lacks the superior spatial resolution of CT.
• If abdominal and pelvic CT or MRI is negative in the presence of clinical and biochemical evidence of pheochromocytoma, one ought first to reconsider the diagnosis. If it is still considered likely, then iodine-123 (123-I) metaiodobenzylguanidine (MIBG) scintigraphy may be done. MIBG is a compound resembling norepinephrine that is taken up by adrenergic tissue. A MIBG scan can detect tumors not detected by CT or MRI or multiple tumors when CT or MRI is positive [6].
●MIBG scintigraphy is superfluous in patients with sporadic solitary adrenal pheochromocytoma identified on CT/MRI [57].
●MIBG scintigraphy is indicated in patients with large (eg, >10 cm) adrenal pheochromocytomas (increased risk of malignancy) or paraganglioma (increased risk of multiple tumors and malignancy) (image 2) [25]
Another guy HTN, on beta blocker and ACEI, mild CRF. Found to have adrenal mass. Plasma metaneprhine midly elevated, Cr slightl elevated, what investigation do you do next? A. FNA B. MRI C. CT D. MIBG
B
Mild elevation in metanephrines expected with antihypertensives, TCA’s, antipsychotics. CT if first line, non-contrast to evaluate densite (obviously can’t assess washout). MRI would be indicated d/t CT being contraindicated. MIBG non-contributory as a routine test, used if pt has pheo and concern for multifocality.
CT and MRI are equivalent; MRI better for extraadrenal; IV contrast can also precipitate catecholamine crisis.
Non-contrast CT would be best.
●With CT, there is some exposure to radiation but no risk of exacerbation of hypertension if current radiographic contrast agents are given. CT with low-osmolar contrast is safe for patients with pheochromocytoma even without alpha or beta blocker pretreatment, as illustrated in a report of 22 such patients [56]. After intravenous (IV) low-osmolar contrast administration for CT scan, there was a significant increase in diastolic blood pressure but no increase in plasma catecholamine levels or episodes of hypertensive crises.
●With MRI, there is neither radiation nor dye. This more expensive test can distinguish pheochromocytoma from other adrenal masses; on T2-weighted images, pheochromocytomas appear hyperintense and other adrenal tumors isointense, as compared with the liver (image 1) [18]. However, MRI lacks the superior spatial resolution of CT.
• If abdominal and pelvic CT or MRI is negative in the presence of clinical and biochemical evidence of pheochromocytoma, one ought first to reconsider the diagnosis. If it is still considered likely, then iodine-123 (123-I) metaiodobenzylguanidine (MIBG) scintigraphy may be done. MIBG is a compound resembling norepinephrine that is taken up by adrenergic tissue. A MIBG scan can detect tumors not detected by CT or MRI or multiple tumors when CT or MRI is positive [6].
●MIBG scintigraphy is superfluous in patients with sporadic solitary adrenal pheochromocytoma identified on CT/MRI [57].
●MIBG scintigraphy is indicated in patients with large (eg, >10 cm) adrenal pheochromocytomas (increased risk of malignancy) or paraganglioma (increased risk of multiple tumors and malignancy) (image 2) [25]
When doing a splenectomy for severe ITP, when do you give the platelets?
A. 24 hrs preop
B. Immediately preop
C. Just after the incision is made
D. After the splenic artery has been ligated
E. After the spleen has been removed at the end of the case
D
Regarding splenic artery aneurisms all are true except.
A. More common in women.
B. Most common visceral aneurysm.
C. Occur at bifurcation and are saccular.
D. Double rupture phenomenon
E. Cause splenic infarcts.
E
Treatment of splenic abscess - antibiotics plus A. Splenectomy B. Percutaneous drainage C. Open drainage D. Drain via 12th rib
A
Treatment of splenic abscesses depends on whether the abscess is unilocular or multilocular. In one third of adult patients, the abscess is multilocular. In one third of children, the abscess is unilocular. Unilocular abscesses are often amenable to percutaneous drainage, along with antibiotics, with success rates reported at 75% to 90% for unilocular lesions. Multilocular lesions, however, are usually treated with splenectomy, drainage of the left upper quadrant, and antibiotics. Laparoscopic splenectomy for abscess has been reported.3
Gold standard is actually splenectomy, but better efficacy of perc drain if unilocular.
Blood supply to adrenal A. Ao, Renal artery, Inf phrenic artery B. Ao, Renal artery, Sup phrenic C. Lumbar, renal, aorta D. lumbar, renal, Inf phrenic E. lumbar, renal, sup phrenic
A
When must accessory spleens be removed? A. Severe congenital hemolytic anemia B. Trauma C. Staging for lymphoma D. Myeloid metaplasia
A
Severe congenital hemolytic anemia – antibody mediated; must removal all splenic tissue
Myeloid metaplasia – only for relieving mass effect
2.5 cm incidental adrenal mass on CT for Pancreatitis. What next? A. Adrenalectomy B. Biochemical workup C. Iodocholesterol scan D. Repeat CT in 3-4 months E. Perc bx
B
Transfusion of platlelets indicated for:
A. After 7 U prbcs in trauma
B. Platelets 23 in TTP
C. Preop in ITP
D. In patient with VonWillebrand’s disease
E. After transfusion of 10U PRBCs during a Whipple with microvascular bleeding
Both A and E
All of the following are features of ITP EXCEPT A. Considered an autoimmune phenomenon B. Antibodies to platelets C. Spleen is enlarged D. Prednisone is helpful
C
All of the following regarding splenic artery aneurysms are true EXCEPT:
A. “Double rupture” phenomenon
B. Tend to be saccular and located at arterial branchings
C. Cause splenic infarcts
D. More common in women
E. Occur in association with splenomegaly
C
Splenic Arterial Interventions: Anatomy, Indications, Technical Considerations, and Potential Complications, 2005.
Splenic artery aneurysms are the most common visceral artery aneurysms, with a reported prevalence of 0.8% at arteriography and 0.04%–0.10% at autopsy. Most aneurysms are small (<2 cm in diameter), saccular, and located at a bifurcation in a middle or distal segment of the splenic artery. Splenic artery aneurysms are multiple in 20% of cases. Splenic artery aneurysms are found most often in multiparous women:
Double rupture phenomenon: aneurysm first ruptures into the lesser sac with mild clinical symptoms then the blood overflows into peritoneal cavity through the Winslow foramen with hemorrhagic shock.
Child with left flank injury: Stable. CT shows free fluid and splenic hilum injury A. Splenorrhaphy B. Splenectomy C. ICU D. Embolize
D
Grade IV injury, embolization improves succes of NOM. Stable patient.
Post-splenectomy, all except: A. Decreased red cell life span B. Howell-Jolly bodies C. Decreased properdin D. Decreased tuftsin
A
Decreased red cell life span – lengthened RBC life span
Properdin and tuftsin are opsonins produced in spleen, Howell-Jolly bodies present post-splenectomy. RBC life span is increased.
After splenectomy which one is not true: A. Decreased IgM (IgG stays normal) B. Decreased WCC C. Decreased RBC span D. Decreased properdin E. Decreased opsonization
C
Decr IgM but IgG stays same
Decr WCC
Incr RBC lifespan, especially in HS
Child with ruptured spleen. Best way to diagnose: A. CT B. Angio C. Spleen scan D. US E. MRI
A
Which would not be and indication for splenectomy: A. CLL B. Autoimmune hemolytic anemia C. SLE with hypersplenism D. Feltys syndrome E. SC anemia F. Hereditary spherocytosis G. Cirrhosis with splenomegaly H. Trauma I. Hairy cell leukemia J. Polycytemia rubra vera
G and now H based on recent literature
a. CLL – yes, maybe
b. autoimmune hemolytic anemia – yes, if warm
c. SLE with hypersplenism
d. Feltys syndrome – yes, good response to splenectomy
e. SC anemia
f. hereditary spherocytosis
g. cirrhosis with splenomegaly
h. trauma
i. Hairy cell leukemia – SESAP: used to be an indication, but newer medical treatment obviated splenectomy
j. Polycytemia rubra vera (yes, if painful or splenic infarctions)
Basically, splenectomy useful if symptomatic splenomegaly.
The following are true regarding partial splenectomy, except: A. Indicated in trauma B Indicated for a splenic cyst C. Indicated in ITP D. Need full mobilization of the spleen
C
Splenomegaly is associated with all except: A. Acquired hemolytic anemia B. CML C. ereditary spherocytosis D. ITP
D
What is the most common organism identified in splenic abscess in immunocompromised patients: A. Candida B. Staph C. Strep D. Bacteroides E. Aspergillus
A
Staph, Salmonella, E. coli (Clinical Infectious Disease)
Sabiston: Staph, Strep, Salmonella, Enterococcus
Candida possible in neutropenic/immunosuppressed, but seems like still less common than bacterial.
Fungal in 25% of immunosuppressed splenic abscescc patients. (Shackleford’s)
Candida – more common then in immunocompetent, but still < staph.
What is the most cost effective single test to diagnose the presence of a subphrenic abscess suspected after splenectomy: A. CT B. US C. Nuclear scan D. 3 views abdo E. MRI
A
Splenectomy is most likely to be difficult to to adhesions in which condition:
A. Septic infarcts
B. ITP
C. Splenomegaly
D. Trauma
E. Hypersplenism secondary to portal hypertension
A
What poses the greatest risk after splenectomy: A. Anemia B. Thrombocytopenia C. Thrombocytosis D. Sepsis E. Splenic vein thrombosis
D
Sepsis 1-5%
After a bx for lymphoma all of the following are acceptable but: A. Quick section B. Culture C. EM D. Immunohistochemistry E. Light microscopy
A
Laparotomy reveals additional splenic tissue. Cause:
A. Previous splenic trauma
B. Congenital anomaly
C. Accessory spleens
C
Accessory spleens – actually quite common, probably more than trauma
Left adrenal vein drains into: A. Left renal vein B. L gonadal vein C. Inferior vena cava D. L phrenic vein E. Portal vein
A
CT abdo for trauma. Incidental 2cm adrenal mass: A. Pheo B. Adenoma C. Adrenocortical ca D. Myelolipoma
B
Which is not a feature of primary hyperaldosteronism: A. Hypertension B. Hypokalemia C. Acidosis D. Muscle weakness E. Polydipsia
C
Hypertension, +/- hypokalemia, hypernatremia, metabolic alkalosis, muscle weakness, hypomagnesemia, CV risk
Key features of hyperaldosteronism are: A. Hypokalemia B. Urine with low sg and resistant to ADH C. Alkalosis D. Hypochloremia
A
Urine with low sg and resistant to ADH (should be high SG)
Alkalosis – not a key feature but may be present
40 yo female, obese, sudden onset of diastolic hypertension, polydipsia, polyuria, weakness, Na=150, K=2.5. A. Cushing B. Primary hyperaldosteronism C. Pheo D. Renal vascular hypetension
B
Which of the following is not associated with hyperaldosteronism: A. Hypertension B. Liver failure with ascites C. Adrenal adenoma D. Adrenal hyperplasia
B
Cushing syndrome is most commonly due to:
A. Pituitary Adenoma
B. Ca
C. Bilateral cortical hyperplasia
D. Ectopic ACTH
E. Bilateral cortical and central hyperplasia
F. Adrenal Adenoma
A
Sabiston – 75% caused by pituitary adenoma.
UTD:
1) iatrogenic 2) ectopic ACTH (SCLC) 3) Cushings disease 4) adrenal tumours
SESAP says pituitary source in 80-85%, ectopic in 15%. UTD says ectopic, but qualifies that it is “probably” the 2nd most common (after iatrogenic) although often undiagnosed.
Traditional answer is adenoma (pituitary) so Cushing’s disease.
Which of the following are not considered APUDOMAS: A. Folicullar adenoma B. Parathyroid adenoma C. Gastrinoma D. Carcinoid E. Pheo
A
The best test for neuroblastoma is:
A. VMA in urine
B. Epinephrine
C. Nor-epinephrine
A
The most common reason for missing Conn’s sydrome:
A. Not adequately repleting K prior to renin test
B. Not adequately repleting Na prior to renin test
C. Missing the tumor on the CT scan
D. Missing the tumor on iodocholesterol test
A
Man w/ ITP. On 60 mg prednisone x 6 weeks. Not bleeding but plt remain at 50,000. Best treatment. A. Splenectomy B. IVIG C. Increase prednisone to 120 D. Nothing
C or D in answer key
IVIG is 2nd line, provides temp support if pts <5 or bleeding. IVIG lasts for days to weeks.
Indications for splenectomy: Duration 3-6 months, ongoing thrombocytopenia,
Splenectomy only for plts <30, or 30-50 and inability to wean from steroids; steroid dosing is 1-1.5mg/kg/d/ 6 weeks is too early to consider splenectomy; should wait 6 months as possibility of spontaneous regression.
Goal is 50,000, so should start to taper. Splenectomy only after 6 months and if unable to maintain plts 50 or higher.
UTD:
In practice, we often wait at least six months from diagnosis of ITP to splenectomy, to allow for late spontaneous remissions; this practice is consistent with a 2010 consensus report [6]. However, many patients with persistently severe and symptomatic thrombocytopenia in spite of first-line therapy may require splenectomy much sooner (eg, within weeks).
A patient undergoes splenectomy for ITP. 3 days post op develops thrombocytosis of 750,000. What is your medication of choice? A. ASA 325 mg PO OD B. Plavix C. Nothing D. SC Heparin
C
In well selected patients undergoing cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy, or HIPEC, for colorectal carcinomatosis, which of the following is TRUE?
A. Survival is improved in patients with distant disease
B. Methods are standardized in developed countries
C. R0 resections are required
D. Complication rates are high
E. Disease-specific survival is equivalent to standard systemic therapy options
D
HIPEC is not offered to pts with distant mets. Methods for HIPEC vary between centres. Difficult to standardize surgical technique between surgeons. Other variables include timing of intraperitoneal therapy with regard to surgical anast; thoroughness of extirpation; and the doses, timing and choice of chemo. R0 resections may not be possible. Disease specific survival compared with standard systemic therapy options is improved. Improvement is on the order of months or occasionally years. Trade off is mortality rates approaching 20% in worst cases but closer to 6% in high volume centres. Major morbidity ranges from 12-52% in high volume centres and can lead to prolongs hosp stays and high costs
Regarding the effect of aspirin in the prevention of CRC, which of the following statements is TRUE?
A. There is modest reduction in polyps and cancers
B. The incidence of other cancers is reduced
C. Effect is seen mostly in women
D. High dose therapy is required
E. Concurrent statin therapy decreases the protective effects
A
Low or high dose aspirin reduces both polyps and advanced lesions in men and women. At least 4 RCTs provided evidence in at risk pts, with good colonoscopy FU regimens. Adverse events were uncommon with no difference between groups for death, MI, bleeding or invasive cancers. Incidence of invasive cancer of the colon was low with this level of surveillance but high risk lesions (e.g. High grade dysplasia, a known precursor to cancer) were seen less freq with aspirin in some studies. Others showed a decr in invasive cancer risk. Latency period from aspirin prevention to benefit appears to be approx 10 yrs; apparent only after at least 5 yrs of therapy. Concurrent statin therapy does not appear to have an effect on polyp or cancer prevention
In a patient with a hx of colon resection for CRC now discovered to have liver mets, which of the following is a contraindication to liver resection for cure?
A. At least 4 hepatic mets B. Extrahepatic disease C. Node positive primary tumor D. Prev hepatic resection for CRC mets E. Inability to completely resect all disease in the liver
E
CRC liver mets can be resected for long term survival and even cure. Approx 5-10% of 50,000 cases of CRC liver mets each yrs in US are candidates for curative resection. Long term survival can occur in up to 50% of pts.
5 preop factors most affecting outcomes in pts presenting for liver resection of CRC mets: 1) Size >5 cm, 2) disease free interval <1 year, 3) Node positive primary, 4) Greater than 1 tumor, 5) CEA >200
Traditional contradindications to hepatectomy for met CRC were presence of extrahepatic diseases at least 4 hepatic mets, close margins and inability to resect all disease.
Hepatectomy for at least 4 mets is assoc with a 5 yr survival rate of 33% and recurrence rate of 80%. Pts w/ close or involved margins have long term survival, and resection of extrahepatic mets presenting concomitantly with liver mets results in long term survival of selected pts. Extrahep met sites most favourable for resection are lung mets, local recurrence of original tumor, and portal LNs. After resection for hepatic CRC mets, recurrence rates at least 80%, with half of recurrences isolated to the liver. Pts whose disease is amenable and who undergo second liver resection for removal of all disease have 5 yr survival for 30-40%
14 year old presents with 1 week hx of SOB and night sweats. CXR and CT obtained showing compression of at least half the diameter of trachea in some views. No peripheral adenopathy. CT guided bx is non diagnostic. Unable to lie flat. Which of the following is the next best step?
A. Chest radiotherapy
B. Chamberlain procedure using local anesthesia
C. Chamberlain procedure under light sedation
D. Chamberlain procedure under GA
E. Standard chemo regimen for lymphoma
B
Pt has large mediastinal mass. Radio growth of mediastinal masses, such as lymphomas, may distort airway, causing resp distress, wheezing and orthopnea. Imaging depicts enlargement of mediastinum with involvement of airway. At times, pleural or pericardial fluid can be obtained for cytologic analysis. If neither peripheral LNs nor fluids are available for bx or puncture, CT guided needle bx for cytologic analysis is generally next step. If this is still not diagnostic, bx by thoracoscopy or anterior Chamberlain may be necessary. Chamberlain procedure is an anterior mediastinoscopy used to bx a mass or LNs in the center of the chest, which is done through a small transverse incision in an intercostal space.
Mediastinal disease compressing the airway poses a significant risk. In pts with tracheal compression, sedation and anesthesia should be avoided. These pts may prove impossible to ventilate, even with intubation, b/c of distal tracheal or bronchial obstruction. For pts with severe airway obstruction, dx by alternate methods needs to be considered. In this pt, a Chamberlain procedure using local anesth is the safest approach. Radiotherapy or chemo is inappropriate until a dx is made.
Which of the following is TRUE regarding bevacizumab?
A. Currently indicated for breast cancer
B. Anaphylactic/anaphylactoid reactions are not reported
C. It is an epidermal growth factor
D. It can cause gastrointestinal perforation
E. It improves wound healing
D
Anti vascular growth factors (VEGF) recombinant humanized monoclonal antibody. New blood vessel formation is a fundamental event in the process of tumor growth and met dissemination. VEGF and its receptors play a role in tumor proliferation. Approaches to limit VEGF activity include monoclonal antibodies and small molecules, incl the corresponding receptor tyrosine kinase activity.
FDA removed met breast ca indication from bevacizumab labelling, citing a lack of demonstrated safety and efficacy in breast cancer. Does not prolong OS and does not provide sufficient benefit in slowing disease progression to outweigh significant risks assoc with treatment.
Indications include colon, kidney, brain and lung cancers.
Assoc with incr incidence of hypersensitivity reactions in combo with chemo compared with chemo alone. Incidence of anaphylactic/anaphylactoid reactions was 5% in clinical trials.
Patients have significantly incr risk of GI perf with a positive correlation with higher doses of bevacizumab and CRC. Extended used can incr long term risk of wound healing complications for up to 6 mos after cessation
22F undergoes an uncomplicated lap appy for perf appendicitis. Final pathology reveals carcinoid tumor of the tip of the appendix measuring 3 cm. What is the most appropriate next step?
A. Observation B. Chemotherapy C. Cecectomy D. R Hemi E. Radiation
D
Most common tumor of appendix is carcinoid, a neuroendocrine tumor that is found in 0.3-0.9% of pts who undergo appy. Appendiceal tumors including carcinoid, are usually found incidentally on pathologic exam of an inflamed appendix. Size of tumor determines tx and ppx with tumors >2 cm having the greatest met potential. Formal R hemi is indicated. Other indications for R hemi include mesoappendiceal invasion, tumors at base of appendix with positive margins, high grade malignant tumors with a high mitotic index, and goblet cell adenocarcinoid tumors. R hemi also may be considered for 1-2 cm tumors at the base of appendix; however this remains controversial. Simple appy reserved for tumors <1.5 cm in diameter, b/c chance of lymphatic or distant mets is minimal. Observation and radiation have no role and chemo may be considered in mgmt of met tumors, although it has limited efficacy.
53F undergoes an EGD for dyspepsia. During the procedure, she has evidence of chronic gastritis. In addition, a small mass is identified in the body of the stomach. Specimens are taken and return a dx of H pylori infection and an extranodal marginal zone lymphoma of mucosa assoc lymphoid tissue (MALT lymphoma). Which of the following is the next step in tx of this patient?
A. H pylori eradication therapy B. Chemo C. Chemo and radiation D. Radiation E. Partial gastrectomy
A
MALT lymphoma aka extranodal marginal zone lymphomas MALT type. Indolent B cell lymphomas that develop secondary to chronic inflamm from either infection or autoimmune process. Any tissue that has mucosa assoc lymphoid tissue can develop this tumor, including salivary glands, resp tract, bladder and small intestine. Most commonly seen in stomach. Gastric MALT lymphomas are typically identified during endoscopy being performed for non specific gastric symptoms. Discrete masses are rare, with the most common endoscopic finding beating erythema, ulcer or erosions. Most are seen in the Antrum and multifocal disease is common. Dx made by bx of area
All patients with gastric MALT need to be evaluated for H pylori. Regardless of H pylori status, all pts with local disease should be tx with eradication therapy b/c of risk of false neg test. Of pts with local disease positive for H pylori, 50-70% will have a favourable response to tx. Complete response can take a several months, and serial endoscopy is needed to evaluate tx response.
Once gastric MALT lymphoma is identified, a staging evaluation is undertaken to determine whether more than mucosal involvement is present. Gastric staging is done with endoscopic U/S. Further staging includes CT chest/abdo/pelvis, bone marrow evaluation and a PET CT scan. Unique to MALT lymphoma is the evaluation of other potential sites of disease including bronchoscopy, colonoscopy and small bowel evaluation
If the patient fails to response, follow up radiation can be used. Chemo is not used if only local disease is present. Resectional therapy is rarely necessary and quality of life is better with gastric preservation. Disseminated disease is tx as any other lymphoma with chemo or antibody based approaches. However, b/c these are indolent tumors, watchful waiting is also reasonable.
Regarding pulmonary mets assoc with soft tissue sarcomas
A. Surgical resection follows neoadjuvant therapy
B. Recurrent pulmonary mets are tx by surgery
C. Multiple unilateral mets are a contraindication to resection
D. Bilateral mets are a contraindication to resection
E. Lobectomy and lymphadenectomy are required.
B
Lung is most common site of mets for soft tissue sarcoma. Similar to the primary tumor, resection of pulm mets is performed to control local diseases. Resection confers a survival advantage and should be performed, if possible, before considering any other tx modality.
Criteria need to be applied to planned resection: Minimal amt of lung should be removed with each specimen. Stapled metastasectomy is procedure of choice. Multiple unilateral resections can be performed, again with lung preservation being of utmost importance. If multiple lesions are present in a single lobe, precluding separate excision, especially if thoracoscopic approach is undertaken. If a patient has recurrent pulmonary disease that can be resected safely, sx should be undertaken using the these same principles.
Soft tissue sarcomas do not met to LNs. Lymphadenectomy would not be part of sx. Neoadjuvant therapy before surgical resection has no benefit.
An otherwise healthy 70F with painless rectal bleeding at defecation. DRE reveals a 1 cm firm anal mass. Colonoscopy 1 yr ago was N except for diverticulosis. Anoscopic exam shows a mass in anal canal. What would you recommend to this patient?
A. Reassurance and observation B. I & D C. Excisional bx D. Rubber band ligation E. Laser ablation
C
Firm symptomatic anal lesions require path exam to exclude malignancy. Reassurance and observation are contraindicated. Laser ablation does not provide tissue for dx. B/c of anatomical position of this lesion, seen only through the anoscope, office excision would be technically difficult and likely very uncomfortable for the pt. Transanal excision in the OR allows for complete excision with margins under optimal conditions.
This lesion is an anal melanoma. By contrast, with cutaneous melanoma, anal melanomas are often amelanotic
Level I data support the avoidance of which of the following to reduce and prevent lymphedema after LN dissection?
A. Needle sticks B. BP measurements C. Wt gain D. Extreme heat and burns E. Exercise
C
Lymphedema is accumulation of protein rich fluid in regions where lympahtic system cannot transport interstitial fluid. Occurs most often as a complication of LN dissection for cancer tx. Most commonly assoc with breast cancer mgmt, overall 16% incidence in pts tx for melanoma; sarcoma; H&N; urologic and gyne cancer.
Tx remains suboptimal and usually palliative, focus is on several measures to prevent it, although many measures are anecdotal and no evidence based. Conflicting lower level data regarding needle stick avoidance, no data to support bp measurement avoidance, and level 1 data refuting the notions of avoiding extremes of temp or vigourous exercise. RCT of wt loss after LN surgery shows less lymphedema in intervention group. Findings support a large amt of evidence linking obesity to the development of cancer related lymphedema.
67F presents 2 yrs after distal gastrectomy for a c-kit (CD 117) positive GIST. Pt has an abdo wall soft tissue mass, and bx reveals recurrent tumor. CT reveals multiple intra-abdo masses and abdo wall masses. Pt is started on imatinib mesylate 400 mg/day. Which of the following statements regarding this tx is TRUE?
A. The most common side effects are HTN and thrombocytopenia
B. Most response occur soon after starting tx
C. Most pts are rendered resectable
D. Tx can be continues up until time of sx
E. Tx incr the risk of post op complications
D
GIST, the most common sarcoma of the GI tract, arises from interstitial cells of cajal and possesses unique kinase mutations that can serve as targets for medical therapy, either in the adjuvant setting or when gross tumor is present. Most common mutations at exon 11 of c kit (CD117), a tyrosine kinase. Imatinib is a tyrosine kinase inhibitor specific for such mutations is commonly used as medical therapy for GIST.
Drug stopped right before planned operation does not increase complications over the expected rate. OS at 2 yrs was 91-93%. Given to pts with advanced but possible operable disease, approx 25% converted to resectable tumors and long term survival was documented.
Whether given in the adjuvant, neoadjuvant or palliative setting, imatinib, an oral agent is generally well tolerated. Major side effects include fever, H/A, fluid retention, GI side effects, anemia and elevated LFTs
One of the hallmarks of imatinib therapy of measurable tumors is delayed response. Avg time of overall response in the multi center trial was 13 weeks. Centres using imatinib for advanced GIST in hope of rendering pts resectable generally follow reponding patients for at least 6 months before considering surgical exploration. Soon after starting therapy, some tumors actually swell, giving the false impression of CT that the tumors are progressing. Dynamic studies such as MRI, contrast enhanced CT or PET/CT may show decr intensity in these swollen tumors, indicating a metabolic response. Accordingly the Choi criteria, which include a dynamic measure of response, may be more accurate for assessing response to imatinib than the standard guidelines that rely on size alone.
50 y.o. Otherwise healthy man undergoes exp lap for a presumed ruptured appendix. At OR, the abdo is filled with gelatinous material adherent to all the peritoneal surfaces and intestinal surfaces. Frozen section of this material is read as “mucinous neoplasm”. Which of the following is the best therapy for this pt’s condition?
A. R Hemi, followed by observation
B. Debulking of all gross disease, followed by observation
C. Systemic chemo
D. Cytoreductive surgery and intraperitoneal chemo
E. Palliative surgery
D
Systemic chemo is palliative and generally provides only limited improvement in survival. Over past few decades, CRS and HIPEC were developed for pts with mucin producing peritoneal surface malignancies. Studies have shown survival advantages for these approaches.
CRS is an extensive procedure and incl greater omentectomy, splenectomy,. R and LUQ peritonectomy, chole, less omentectomy, pelvic peritonectomy, amd resection of the most involved parts of the bowel–often R colon, rectosigmoid and sometimes gastric antrum. Completeness of resections is scored on a standard grading scale, with the score correlating with survival.
Tx plan and prognosis hinge on specific histology, which usually can’t be determined by frozen section. PMP is the more rare type of mucinous intraperitoneal neoplasm, characterized by mucinous ascites, low grade neoplasm (often of appendiceal origin) and a better prognosis. PMP has almost no ability to spread by via lymphatics or hematogenous routes. Generally stays limited to peritoneal cavity where it spreads by fluid current and gravity. Repeated CRS can palliation the disease for yrs but rarely yields cure. However, the addition of appropriately timed (before adhesion formation) HIPEC has yielded 5 and 10 yr survival rates of 75-100% and 68%, respectively, although results are worse with higher grade tumors and incomplete resections.
Mucinous colorectal adenocarcinoma (MCA) is essentially stage 4 colon cancer limited to the abdo. MCA is assoc with the ability to spread to lymphatics and a poorer outcome. In selected patients with MCA limited to the peritoneal cavity, CRS and HIPEC can 5 yr survival rates of 27-31%. Role of systemic therapy and bio therapy for MCA remains under study
Although CRS and HIPEC are therefore considered the next step in the otherwise healthy pt presented; such pts may be best tx at centres of expertise and only after exact histology has been determined on permanent pathology. Even a recent report of CRS and HIPEC done at nonspecialized hospitals involved surgeons with special expertise operating at carefully chosen institutions.
After complete excisional bx of an anal melanoma with neg margins, what is the next step?
A. Nigro protocol B. Inguinal LN dissection C. Radiation therapy D. APR E. Observation
E
Regardless of disease stage at presentation and extent of sx, prognosis for anal melanoma is poor, with overall 5 yr survival rates of 10-20%. Although 20% of pts have inguinal node met disease at presentation, it is unclear that groin dissection has any effect on mgmt or prognosis. Survival after WLE is similar to APR, which has prompted recommendation of transanal excision over radical sx in most cases. Results of systemic therapy are disappointing. Radiation alone provides the options of sphincter preservation but does not incr survival. Chemorads with Nigro protocol is 1st line tx for scc of the anus not melanoma. For a pt whose anal melanoma has already been completely excised, observation is best recommendation.
25F undergoes emergent appy. Pathology reveals presence of a 1.5 cm well differentiated carcinoid tumor at the tip of the appendix with clear margins. Which of the following should be the next step in mgmt of this pt?
A. CT Abdo B. Colonoscopy C. R hemi D. Octreotide scan E. 24 hr urine 5-HIAA
A
Carcinoid of the appendix is the most commonly type of primary malignant lesion of the appendix. Often asymp and found incidentally during appy. Incidence 0.3-0.9% undergoing appy and they are commonly located at the tip of the appendix
Major of incidental carcinoid cured by appy. Current recommendations of additional sx include inadequate resection margins, tumor >2 cm, goblet type morphology. Complete R hemi is required. In tumors >2 cm, 30-60% will have met spread. Met rate for tumors <2 cm is no higher than 3%. Controversy regarding tx of lesions in 1-2 cm range. In such cases, evidence of mesoappendiceal invasion, vasc invasion, incr mitosis, or presence of proliferation markers must be evaluated and careful pt risk assessment undertaken. Goblet cell carcinoids have features resembling both carcinoid and adenoca and they all require R hemi.
In this pt, tumor size 1.5 cm at the tip with clear margins, surveillance by CT abdo is indicated. Nether has evaluation by colonoscopy nor R hemi is indicated. Octreotide scan is useful for making a dx b/c it can image carcinoids expressing somatostatin receptors, particularly those with receptor subtypes 2 and 5 for which octreotide has high affinity. Urine 5 HIAA is a useful lab marker to make the dx of carcinoid, b/c it provides a summation of tumor secretory activity. Neither of these studies are indicated in this pt, however, b/c a pathologic dx has been made.
Match the correct lettered answer with the numbered statement
A. Basal cell carcinoma
B. Melanoma
C. Both
D. Neither
- UV radiation constitutes a risk factor
- Interferon alpha 2b is used for therapy
- Minimal 1 cm excision margin is required
- Depth of invasion is a prognostic indicator
- Smoking constitutes a risk factor
- C 2. B 3. B 4. C 5. D
20% of Americans over lifetime will develop some type of skin cancer. Divided into nonmelanoma skin cancers and cutaneous melanoma. Nonmelanoma skin cancers account for ~90% of all cutaneous malignancies. Of these tumors, BCC is the most common (75% of all nonmelanoma lesions), followed by SCC (20%) and rare skin lesions (fibrohistiocytic and adnexal cancer 5%). Cutaneous melanoma is the deadliest skin cancer, accounting for 75% of all skin cancer related deaths.
UV radiation from sun exposure is a major RF for all skin cancers, accounting for 90% of all nonmelanoma skin cancers and 65% of all CM. Both UVA (320-400 nm) and UVB (280-320 nm) radiation lead to skin cancer formation. UVA radiation approx 95% of all UV exposure to the skin, causes indirect cutaneous damage via oxygen radical formation and depletion of Langerhands cells in the skin. UVB, the remaining 5% of UV exposure, directly damages DNA within the skin cell. For both BCC and CM, fair complexion, blond or red hair, and blue eyes constitute risk factors. Whereas cumulative UV exposure incr risk of SCC, intermittent UV exposure is assoc with CM and BCC. Hx of sunburn at an early age incr CM risk. Although smoking is not a RF in either BCC or CM, it does incr risk of developed SCC by 3x.
BCC typically raised, pearl color nodule; SCC tends to be a small, scaly, white or red lesion with friable base; CM is characterized by ABCDEs. Care must be taken b/c pigmented BCCs can exist and nonpigmented CM does occur.
Depth of invasion is an important prognostic factor in both CM and SCC due to strong assoc between mets and tumors >1 mm thick. CM tends to met to regional LNs first. Distant mets can arise throughout the body, incl the liver, brain, bone, lung, skin and GI tract. Although rare (<0.03%), BCC can met as well and its risk is assoc with depth of invasion. Other RF for BCC mets include large/recurrent tumor, prev irradiated tumors and immunosuppression. Common sites of mets for BCC are bone and lung.
For lesions requiring surgical excision, recommended margin is predicted on lesion and in certain cases, its size. For CM, 1 cm margin is required for lesions 1 mm or less in depth, whereas 2 cm margin is needed for lesions >1 mm. In BCC, surgical excision with 0.5-1 cm margins is often adequate. SCC lesions usually require margins of at least 2 cm. Other tx options include topical chemo with imiquimod (BCC or CM) or 5FU (SCC), photodynamic therapy (BCC and SCC), radiotherapy (BCC, SCC, and met CM), immunotherapy (interferon alpha 2b or IL2 in met CM), curettage and dissection (BCC), MOHs (BCC) and systemic chemo (BCC, SCC, CM)
Match the correct lettered answer with the numbered statement
A. Vemurafenib
B. Ipilimumab
C. Both
D. Neither
- Approved for stage IV melanoma
- Targets specific mutation
- Common side effects include skin cancers
- C 2. A 3. A
Resection of mets may provide a small but real disease free survival. Further, new agents that tx met melanoma may render more pts resectable. Some of the newer agents target either the pt’s T cell receptors or a specific tumor mutation
Ipilimumab is a fully human monoclonal antibody against cytotoxic T lymphocyte antigen 4 (CTLA 4). Causes activated T cells to survive and incr the pool of anti tumor T cells. Adverse events assoc with the drug are mostly immune related and include colitis, rash and elevated LFTs. RCT phase III study of stage IV melanoma pts tx with ipilimumab vs a peptide vaccine showed 3 yr survival rates of 21% and 12%, respectively, and led to FDA approval
Approx 40-60% of CM carry mutations in tyrosine kinase protein BRAF and 90% of those mutations are a substitution of glutamic acid for valine at codon 600 (V600E). Vemurafenib is an inhibitory molecule selective for the V600E mutation. In a large RCT phase III study of stage IV melanoma pts tx with either vemurafenib or dacarbazine, responses rates were 48% and 5% respectively. Led to FDA approval of vemurafenib for stage IV melanoma in pts with V600E mutation. Adverse effects are mostly cutaneous and include appearance of SCC and kerathoacanthomas. Exact mechanism is undergoing study. May be related to activation of alternative pathways, such as mitogen activated protein kinase pathway, and thus it may be assoc with drug resistance.
Match the correct lettered answer with the numbered statement
A. Hepatic resection B. RFA C. TACE D. Orthotopic Liver Transplant (OLT) E. Systemic chemo
- Primary therapy for 60M Hep C positive, Child B cirrhotic with two 1 cm foci of HCC in confined segments I and II of the liver
- Primary therapy for 65M with three 3 cm met CRC lesions involves segments IV, V, and VIII of the liver
- Primary therapy for 75F with COPD who has a solitary 3 cm CRC lesion bridging segments IV and V of the liver abutting the L portal vein
- D 2. A 3. B
Several modalities exist and therapy chose depends on type of lesion, number present, anatomical locations, size, patient comorbidities, degree of liver dysfunction (i.e. Cirrhosis, portal HTN), and presence of extrahepatic disease. Accurate preop radiologic and functional assessment of liver is essential. Multidetectoy CT with 3D reconstruction and MRI with MRCP are recommended to determine morphologic characteristics of tumor, vascular or biliary involvement, presence of satellite lesions, and presence of chronic liver disease. Determine liver functional status with Child Pugh or MELD score. Liver volumetry can also be performed.
Complete surgical removal of tumor remains mainstay for acheving cure in pts with hepatic involvement. Type of resection (anatomical vs wedge) and width of margin required is based on lesion type. Major vasc resection when necessary and regional lymphadenectomy should be undertaken. Criteria for resectability vary with type of malignancy. In HCC, pts with early cirrhosis (CP A/early B) meeting Milan criteria (1 lesion =5 cm or 3 or fewer lesions with larger = 3 cm) and this without cirrhosis are candidates. In CRC liver met, criteria include =4 lesions, favourable anatomy for resection (ie. proximity to vasc structures, ability to obtain adequate margin), and lack of extrahepatic disease.
Both RFA and TACE are tx options in the setting of unresectable disease. Successfully used to downstage tumors, allowing their resection. In addition,they can serve as bridging therapies in pts who are transplant candidates. RFA uses direct application of high freq alternating current to cause thermally induced coagulation necrosis of tumor cells. Depending on temp generated, this necrosis occurs over a short time interval (50-52) or is immediate (>60). For large tumors, multiple applications are necessary. An advantage of RFA is that it may be used in near large vascular structures b/c they can serve as a heat sink to prevent endothelial damage. Pts with multiple bilateral lesions, central lesions not amenable to anatomic resection, contralat nodules after undergoing hemihepatectomy, and severe liver disease/comorbidities are candidates for RFA.
TACE involves administration of cytotoxic drugs via hepatic artery with subsequent embolization. Direct intra-arterial infusion of chemo drugs is more effective than IV infusion and maximizes local effects while minimizing systemic complications. Often used in the setting of unresectable HCC. In CRC liver met, direct hepatic artery infusion can be used by means of a surgically placed pump. Contraindications to TACE include Child C cirrhosis, severe leukopenia/thrombocytopenia, cardiac/renal insufficiency, ascites, PV occlusion, and atypical hepatic artery anatomy.
Orthotopic liver transplant is preferred therapy for Child Pugh B and C pts with HCC satisfying Milan criteria. In this setting, OLT results are similar to those found in OLT for other cases. 4 yr survival approaches 75% and recurrence free survival 83%
In CRC liver met, new chemo agents such as oxaliplatin, iron ore an and bevacizumab have improves response rates compared with traditional 5FU/leucovorin therapy, allowing for neoadj downstaging of prev unresectable met lesions
75F pt with central CRC liver met abutting portal vein is candidate for RFA b/c she is a poor surgical candidate for major hepatic resection
Match the correct lettered answer with the numbered statement
A. Osteosarcoma B. Giant cell tumor C. Burkitt lymphoma D. AML E. Ewing sarcoma
- Onion skin appearance on plain XR
- Starburst appearance on plain XR
- EBV
- E 2. A 3. C
Classic appearance of Ewing sarcoma on XR is an onion skin appearance. Osteosarcoma has an appearance of a starburst.
Most common cytogenetic changes in Ewing sarcoma is a translocation (11:22). Burkitt lymphoma has cytogenetic change, translocation <8:14). EBV is implicated in multiple types of cancers, including Burkitt lymphoma. Giant cell tumors are usually lyric lucent lesions that are rarely malignant. Account for approx 20% of benign tumors.
AML is assoc with bone pain caused by buildup of leukaemia cells and is sometimes assoc with pathologic #s. It is assoc with translocations that are different from Ewing sarcoma and Burkitt lymphoma.
Match the correct lettered answer with the numbered statement
A. 45F with T2N1M0 ductal carcinoma of the breast being considered for therapy with trastuzumab (Herceptin)
B. 40M with T3N0M0 adenoca of the R colon and no polyps
C. Daughter of a 50 y.o. Ashkenazi Jewish descent with invasive carcinoma of breast
D. 50 y.o. With 5 cm stromatolites tumor in the stomach
E. 70F with stage III bronchoalveolar carcinoma of the lung being considered for gefitnib
- B 2. A 3. D 4. C 5. E
Familial susceptibility to breast ca accounts for <25% of all breast ca cases. BRCA 1 and BRCA 2 are high penetrance breast cancer predisposition genes identified by genetic studies. Germaine mutations found in all cells within the body; peripheral monocytes are used for testing. Clinical criteria for referral for BRCA testing include 1) at least 3 breast or ovarian cancer cases, at least 1 in the same family when the pts is <50 yrs, 2) breast can cases when pt is <40 yrs in same family, 3) male breast ca and family member with either ovarian cancer early or early onset female breast ca, 4) pt <60 yrs with breast ca in a family of Ashkenazi Jewish descent, 5) pt < 40 yrs with bilat breast ca, and 6) breast ca and ovarian ca in same pt.
Historically GISTs were through to be of smooth muscle or neural origin. Mid 1990s KIT was recognized to play a key role in development of interstitial cells of Cajal and cells of origin for GISTs. KIT is commonly expressed in GISTs and is a tyrosine kinase whose activity is normally regulated by binding of endogenous ligand, stem cell factor. Binding of stem cell factor to KIT results in receptor homodimerization and activation of its tyrosine kinase activity. In >80% of GISTs, mutation in KIT gene occurs, leading to constitutive activation. Imatinib is a small molecule that is a specific inhibitor of a number of tyrosine kinase enzymes, including c-kit. It inhibits c-kit by occupying the TK active site, leading to decr in activity.
HNPCC is a common, autosomal dominant syndrome characterized by early onset of cancer (avg age <45 y.o.), development of neoplasticism lesions in a variety of tissues (e.g. Endometrial, gastric, renal, ovarian, and skin) and microsatellite instability (MSI). Tumors should be tested for MSI in the following situations: 1) CRC dx in pt <50 yrs, 2) presence of synchronous, metachronous CRC or other HNPCC assoc tumors regardless of age, 3) aCRC with MSI-H histology dx in of <60 yrs old 4) CRC dx in at least 1 first degree relative with an HNPCC related tumor, with 1 of the cancer being dx at <50 y.o, 5) CRC dx in at least 2 first or second degree relatives with HNPCC related tumors, regardless of age
ERBB encodes a tyrosine kinase inhibitor involved in growth signaling and belongs to the epidermal growth factor receptor family. Overexpression secondary to gene amplification is the most common mechanism or ERBB2 (HER2/neu) protein overexpression and can lead to oncogenic transformation. Overexpression in 18-20% of invasive breast carcinomas and is an independent marker for poor clinical outcome in newly dx pts, who usually have ER neg phenotype. From a therapeutic point of view, pts with breast ca and incr Her2 have a good therapeutic response to traztuzumab, a human monoclonal antibody. Patients also have relative resistance to endocrine therapies, especially SERMs (e.g. Tamoxifen)
EGFR encodes a cell membrane receptors with protein tyrosine kinase activity and downstream mitogenic effects. Nearly 90% of lung ca specific EGFR mutations consist of point mutations that lead to constitutive action of protein tyrosine kinases. Testing for EGFR mutations in lung ca has become widespread b/c pts with non small cell lung cancer carrying mutations respond more often to PTK inhibitors such as gefitinib. Trials show mutation status to be an independent predictor of response, progression free survival and OS in pts with NSCLC tx with gefitinib. Mutations are more common in adenocas of female pts who never smoked and are of Asian descent
Match the correct lettered answer with the numbered statement
A. Papillary thyroid cancer B. Huerthle cell thyroid cancer C. Medullary thyroid cancer D. Anaplastic thyroid cancer E. Follicular thyroid cancer
- Amyloid
- Nuclear grooves and inclusions
- Oxyphilic cells
- Calcitonin
- C 2. A. 3. B 4. C
Papillary thyroid cancer can be accurately dx by FNA based on presence of hyper cellular aspirate containing nuclear overcrowding, grooves or inclusions. Total thyroidectomy is tx of choice for papillary thyroid cancers >1 cm in diameter. RET gene trans locations are present in some as somatic genetic changes. Should not be confused with RET gene codon mutations, which are assoc with medullary thyroid cancer
Follicular thyroid cancer cannot be dx by FNA. Follicular cancer can be distinguished from benign follicular Adenoma by capsular or vascular invasion, which can be determines reliably only on permanent histology. Follicular cancers or adenomas have an identical appearance on FNA and are collectively called follicular neoplasms. Definitive tx is total thyroidectomy
Huerthle cell cancers consist of oxyphilic cells that appear pink and are filled with mitochondria. Cannot be dx by FNA. Can be distinguished from benign Huerthle cell Adenoma by capsular or vascular invasion., which can be determined reliably only on permanent histology. Huerthle cell cancers and adenomas have identical appearance on FNA and are collectively called Huertle cell neoplasms. Definitive tx is total thyroidectomy
Medullary thyroid cancer is characterized by presence of stromatolites amyloid and absence of thyroid follicles; can be dx by FNA. Amyloid stains strongly with Congo red staining. FNA can’t always distinguish MTC on bases of appearance of cells alone, immunohistochemistry staining of FNA sample for chromogranin A, CEA or calcitonin can confirm neuroendocrine origin of MTC from parafollicluar C cells. Serum calcitonin of CEA elevations also confirm dx. Total thyroidectomy and bill central neck dissection is OR of choice for pts with clinically evidence disease. Ipsilateral lateral neck dissection is indicated for pts who have large primary tumors or who have enlarged LNs in the lateral compartment
FNA is typically sufficient to dx anaplastic thyroid cancer. Immunohistochem can be used to verify cytologic dx. Mgmt is difficult b/c of rapid progression of disease and uniformly fatal outcome. Although surgical resection with aggressive adjuvant chemorads may be considered for rare small tumors confined to the thyroid, almost all pts with anaplastic thyroid cancer will have unresectable disease and should be offered non surgical tx under investigation
Morbidly obese patient with blunt trauma. Unstable. Negative fast. Normal cxr. Still unstable post fluids, best manage. A. Ct abdo B. Peritoneal aspiration diagnostic C. Laparotomy D. Pericardiocentesis
C
Lady w 3.5 cm pash. Mng? A. Excise B. Excise 1 cm margin C. Radiate D. Observe
D
Pseudoangiomatous stromal hyperplasia (PASH) is a benign stromal proliferation that simulates a vascular lesion. PASH may present as a mass or thickening on physical examination. The most common appearance on mammography and ultrasound is a solid, well-defined, noncalcified mass.
The characteristic histologic appearance is a pattern of slit-like spaces in the stroma between glandular units. PASH can be confused with mammary angiosarcoma.
If there are any suspicious features on imaging, the diagnosis of PASH on a core biopsy should not be accepted as a final diagnosis, and excisional biopsy should be performed. However, in the absence of suspicious imaging characteristics, a diagnosis of PASH at core biopsy is considered sufficient, and surgical excision is not always necessary. There is no increased risk of subsequent breast cancer associated with PASH.
Mvc blunt trauma. Closed head. Grade 4 spleen with active bleeding. Stable. Mgmt? A. Splenectomy B. Serial hgb C. Splenic embolization D. Observe
A
From feliciano trauma, head injury is a relative reason to operate
Young lady. 3 cm lesion that has doubled in size over 2 years, prev core showed fibroadenoma. Manage. A. Excise 2 cm margin B. Excisonal biopsy C. Observe, fu us 6 mo D. Core biopsy
B
Old lady w 4 cm phyllodes. A. Lumpectomy B. Simple mastectomy C. Simple mastectomy and slnb D. Mrm
A
Lady w er positive, her2 neu negative ductal carcinoma. Type? A. Luminal type a B. Luminal type b C. Basal D. Her2 enriched
A
Young guy presents 2 weeks after embolization of spleen. Febrile. Tachycardia. Ct shows 12cm subcapsular splenic hematoma. Mng A. Splenectomy B. Perc drain C. Embolize main artery D. IV ABx
A
Gsw left abdo. Pain distended and has pain. Diminished left femoral pulse. Stable. Ct shows bullet on right pelvis. Mng?
A. Exploratory lap and explore retroperitoneum
B. Lap first then angio later
C. Angio
D. Observe
A
Location of superior parathyroid A. Medial to superior thyroid vein B. Dorsal to RLN C. Ventral to RLN D. Medial to RLN
B
Posterior and superior to nerve
Dorsal and lateral to the RLN.
Lady with elevated calcium serum, urine, and elevated PTH. Approach with the highest chance of success?
A. Four gland exlploration with intraop frozen section
B. Local exploration with venous sampling
C. Local exploration with intraop PTH
D. Local exploration with gamma probe
A
3.4 cm papillary thyroid cancer in person with no history radiation or famhx of thyroid cancer. Mgn? A. Total thyroid and central compartment B. Hemithyroidectomy C. Total thyroid D. RAIU
C? (B/c old question?)
NCCN says consider total vs lobectomy if no prior rads, no distant mets, no cervical LN mets, no extrathyroidal extension or tumor <4 cm
Self inflicted injury to anterior neck. At exploration has 1.5 cm laceration in 3rd tracheal ring. Mgn?
A. Tracheostomy through wound
B. Primary repair, no trach
C. Primary repair and trach thru cricothyroid membrane
D. Leave et tube in 48 hours
B
Feliciano recommends primary repair for injuries less than 50% of the airway with minimal devitalization.
Patient 48 hours after trach. Bleeding around tracheostomy. Mng? A. Pack with hemostatic B.Go back to OR and revise C. Pull trach out and intubate D. Ct and bronch
D
Rule out tracheoinominate fistula is bleeding >48 hrs.
If bleeding <48 hrs likely skin bleed and can do A.
Middle age guy, with tumor in stomach. Biopsy shows adeno. EUS shows submucosal invasion. No nodes on CT. Peritoneal washings negative. A. D1 gastrectomy B. D2 with spleen C. Total gastrectomy D. Neoadj
D?
Old answer key says A.
This is a T1b tumor. NCCN says surgery alone vs neoadjuvant then surgery
Guy with bleeding antral tumor with liver met on ct.
A. Wedge stomach
B. Antrectomy with wedge liver
C.Antrectomy
D. Antrectomy with anatomic liver resection
A?
Terrible question. Patient has metastatic gastric cancer. In real life, would try endoscopy or IR to stop bleeding
Lady epigastric pain, bile on scope. Had BII for gastric ca 1 year ago. No evidence of disease on ct. Mng? A. Revise to retrocolic BII B. Prokinetic C. Roux en Y D. BI
C
R en Y is treatment for bile reflux and afferent loop syndrome
Lady with BII for something. Forceful bilious emesis post prandial without food in it. Ct with oral shows patent GJ with distended DU. Mgn? A. Revise to retrocolic BII B. Prokinetic C. Braun D. Steroids
C
Alkaline Reflux Gastritis: patient dosent feel better after vomiting, usuall fails to respond to medical therapy although Urosdeoxycholic acid might be promising.
Surgical Options are: Braun(enteroenterostomy),distal enteroenterostomy , Roux-en-Y , Henley Loop. (C)
Gastric carcinoid in antrum 1.5 cm. No gastritis and no fam hx and negative gastrin. A. PPI B. D1 antrectomy C. Endoscopic polypectomy D. Surveillance
B
Type 1, which represent 70 to 80 percent of all gastric carcinoids, are associated with chronic atrophic gastritis. In this condition, serum gastrin rises in response to gastric achlorhydria. The elevated gastrin, in turn, simulates neuroendocrine cell hyperplasia in the stomach and development of multifocal polypoid carcinoid tumors. The clinical behavior of these tumors is usually indolent.
Type 2, which represent approximately 5 percent of gastric carcinoid tumors, also occur as a result of elevated serum gastrin levels stimulating multifocal gastric carcinoid tumors. The underlying cause of type 2 gastric carcinoids is a pancreatic or duodenal gastrinoma (Zollinger-Ellison syndrome). The clinical behavior is usually indolent.
Type 3 gastric carcinoids (sporadic carcinoids) occur in the absence of atrophic gastritis or the Zollinger-Ellison syndrome. They account for 20 percent of gastric carcinoids and are the most aggressive; local or hepatic metastases are present in up to 65 percent of patients who come to resection.
Type 3 (sporadic) gastric carcinoids are treated by partial or total gastrectomy with local lymph node resection. The risk of nodal metastases is dependent on tumor size and depth, and some have suggested that endoscopic resection alone may represent adequate therapy for intraepithelial tumors <2 cm and perhaps for tumors <1 cm invading the lamina propria or submucosa. However, this is not a standard approach.
For type 1 and 2 gastric carcinoids smaller than 1 to 2 cm, endoscopic resection represents adequate therapy. Subsequent endoscopic surveillance is needed every 6 to 12 months since these patients continue to exhibit mucosal changes and hyperplasia of enterochromaffin-like cells (ECL) due to sustained hypergastrinemia.
Progression to a malignant phenotype or disease-related death is rare with small tumors. Metastases occur in less than 10 percent of tumors ≤2 cm.
Antrectomy is a reasonable option for type 1 gastric carcinoids if there are numerous progressive tumors. Antrectomy reduces hypergastrinemia by reducing the gastrin-producing cell mass in the antrum of the stomach; in most cases, this leads to tumor regression. The success of this approach was shown in a series of 51 patients with type I carcinoids, 10 of whom had antrectomy (eight in conjunction with endoscopic removal of the largest tumor)]. Seven of the eight with residual disease became endoscopically tumor-free, and one progressed and died of metastatic disease. In all, 9 of the 10 patients treated with antrectomy remained tumor-free for an average of 65 months.
More aggressive surgical therapy is rarely needed for type 1 gastric carcinoids, unless there is extensive tumor involvement of the gastric wall (which increases the risk for a coexisting adenocarcinoma, tumor size >2 cm (which increases the risk for metastases, poorly differentiated histology, or for emergent bleeding .
Guy pod 3 for roux en Y gastric bypass. Has sudden severe abdominal pain. Contrast swallow shows dilated gastric pouch, and no leak. A. ppi B. Surgical exploration C. PEG tube D. CT PE
C
Guy pod 1 for rou en Y. HR 140. needs 7 l of fluid to maintain UO. Tachypnea. Mgn? A. Ct B. Scope C. Contrast swallow D. Surgical exploration
D
Lady comes 6 months after lap band. Sudden onset epigastric pain, radiating to back. Unable to tolerate fluids or PO. Best management? (really it says best management) A. Deflate band B. Remove band C. Contrast swallow D. Scope
B
79 yr old guy prev lung resection for cancer. Has gerd. Scope shows 10 cm segment of barret’s with polyp. Biopsy from polyp shows HGD. Mgn? A. Esophagectomy B. Ablation C. EMR D. Repeat scope 3 months
C
Patient with epiphrenic diverticulum. 3 cm. Mgn?
A. Resect
B. Resect and myotomy
C. Resect and myotomy with anti reflux procedure
D. Myotomy and anti reflux procedure
C
Small (<2 cm) diverticula can be suspended from the vertebral fascia and need not be excised. In patients with severe chest pain, dysphagia, or a documented motor abnormality, a long esophagomyotomy is indicated. If a diverticulopexy is performed, the myotomy is begun at the neck of the diverticulum and extended onto the LES. If a diverticulectomy is pursued, a vertical stapling device is placed across the neck, and the diverticulum is excised. The muscle is closed over the excision site, and a long myotomy is performed on the opposite esophageal wall, extending from the level of the diverticulum onto the LES. If a large hiatal hernia is also present, the diverticulum is excised, a myotomy performed, and the hiatal hernia repaired. Failure to repair the hernia results in a high incidence of postoperative reflux.
Schwartz: In patients selected for surgery, preoperative manometry is essential to determine the proximal extent of the esophageal myotomy. Most surgeons extend the myotomy distally across the LES to reduce outflow resistance. Consequently, some form of antireflux protection is needed to avoid gastroesophageal reflux.
Which of these patients can have curative resection in distal esophageal cancer? A. Virchow node B. Celiac node C. Invading crus D. Mediastinal node
B
cervical goes to cervical nodes; mid esoph to mediastinal; distal to abd. Crus is a T4a lesion. Bad nodes are defined as beyond one nodal station, therefore for a distal cancer, b is ok. (B)
Guy with fundo in past. Still having reflux symptoms, not controlled by PPIs. Ct shows fundo in good position. Scope shows normal fundo, no signs of reflux. Mng? A. Redo fundo B. ph and manometry C. Gastrograffin D. Continue PPIs
B
