QE Flashcards

1
Q

Pheo w/up:

A
  1. Spot plasma or urine metanephrine (sensitive)
  2. 24-urine metanephrine (specific)
  3. CT (> MRI)
  4. MIBG (if suspect multi-focal)
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2
Q

Mucinous cystic neoplasm - dx and tx

A
  • dx: EUS-FNA w/ high CEA (>190), low Amylase
  • tx: resect
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3
Q

Tx pelvic fx

A
  1. Binder
  2. Angio OR packing w/ fixation (especially if IR n/a)
  3. Early external fixation
    - refractory bleed after angio → packing + fixation

**MC source is presacral venous plexus

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4
Q

Dx and Localize a gastrinoma

A

Dx:
1. Off PPI: G > 1000 or >200 w/ secretin stimlation
2. Can’t get off PPI: SS Scintigraphy

Localize:
1. Triphasic CT/MRI
2. SS Scintography (Dotatate PET/CT)
3. Endoscopic US
4. Selective intra arterial Ca
5. OR: Intra-Op US, transduodenal palpation, duodenotomy, palpate HOP

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5
Q

Tx pseudocyst/WON

A

Dx: US or CT
- if can’t r/o cystic neoplasm on imaging must get EUS-FNA

Tx: drain if persistent sxs. Wait 4-6 weeks for the wall to mature
- near stomach/duo, > 6cm: endoscopic cystogastrostomy/duodenostomy
- open or lap cysto-enterostomy (usually jejunostomy if not abutting duo or stomach)

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6
Q

Tx of pancreatitis masses
1. WON sterile
2. WON infected
3. Pseudocyst
4. Infected pseudocyst

A
  1. WON sterile: conservatively
  2. WON infected: step-up approach
  3. Pseudocyst: tx if sxs (infxn, obstruction, pain)
    - 4-6w → internal drain → cyst-enterostomy
  4. Infected pseudocyst: drainage (internal, external, endoscopic). Endoscopic preferred.
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7
Q

Indications to tx ICA stenosis and sxs

A
  1. Asx: > 60%
  2. Sxs: > 50% (>125 cm/s)
    - Sxs: contralateral motor/sensory sxs, ipsi vision sxs
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8
Q

Bethesda criteria for thyroid

A

**1 cm is cutoff to get an FNA

  1. Non-diagnostic → repeat FNA
  2. Benign → follow-up
  3. Undetermined significance → repeat FNA or lobectomy
  4. Follicular neoplasm → lobectomy
  5. Suspicious for malignancy → lobectomy vs. thyroidectomy
  6. Malignant → thyroidectomy
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9
Q

Achalasia - Px, Dx, Path and Tx

A

Px: dysphagia (to solid and liquid) is MC sx

Dx:
- no peristalsis
- high LES pressure > 15 (vs. scleroderma, low)
- incomplete relaxation

Path: injured ganglion cells

Tx: only motility disorder w/ upfront surgery
- myotomy (6 eso, 2 stomch) is 1st line (avoid Nissen).
- botox or dilation if high risk.

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10
Q

Tx Medullary thyroid cancer

A
  1. TOTAL thyroidectomy
  2. > 1 cm or bilobar: bilateral central/level 6 dissection
  3. Lateral neck dissection on that side if central+
  4. Start T4 postop. Monitor w/ calcitonin AND CEA
    - RAI is c/i! (C cell origin)
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11
Q

Radial scar- Dx and Tx

A
  1. Dx: aka comlpex sclerosing lesion
    - Mammo: spiculated mass with central sclerosis (lucency) and surrounding distortion
    - Histo: fibroelastic core w/ entrapped ducts
    Gross: white center (central scar)
  2. Tx: core bx ➡ excisional bx (to r/o ca)
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12
Q

Tx for ectopic pregnancy

A
  1. Stable ➡ methotrexate or salpingotomy
    - MTX: absolute c/i if the patient is breast-feeding
  2. Unstable, free fluid, ongoing pain/bleeding ➡ salpingectomy
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13
Q

Hyperkalemia EKG
Hypokalemia EKG

A
  • hyperK: peaked T wave, eventual SINE
  • hypoK: flat T waves, U waves
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14
Q

HS reactions

A
  1. IgE allergic rxn; anaphylaxis; tx w/ epi
  2. Ab rxn; AIHA
  3. immune cx; serum sickness, hep’s
  4. delayed; t-cell; dermatitis, PPD
  5. auto-immune
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15
Q

Tx of thyroid ca in pregnancy

A
  • Well differentiated: surgery post-partum
  • Postpone until 2T if advanced (MTC, nodes, mets)
  • Anaplastic requires immediate surgery in any trimester
  • RAI is c/i (during pregnancy and w/ breastfeeding)
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16
Q

Mastodynia tx

A
  1. Cyclic: OCP/NSAIDS
    - sxs improve after menses
  2. non-cyclic and >30 OR cyclic + mass ➡ mammo
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17
Q

Tx mucinous neoplasm of the appendix

A
  1. Confined to appendix: appe only (no LADN’y)
    - must have negative margin
    - scope in 6w to r/o sync lesions
  2. Involving base, ruptured, or +margin: R hemi +/- LADN
  3. Peritoneal dissemination: perc bx
    - if appendicitis: remove ruptured segment + directed peritoneal bx
    - no appendicitis: postpone appe until cytoreductive surgery
    - no hipec/cancer operation until staged

**need post-op scope to r/o synchronous lesions

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18
Q

GCS eye opening

A

4- spon
3- to voice
2- to pain
1- none

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19
Q

Torsades

A
  • “polymorphic ventricular tachycardia”
  • 2/2 hypoK, hypoCa, hypoMg, macrolides
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20
Q

Normal values: CVP, WP, SVR, CI

A
  • CVP 2-6
  • WP 4-12
  • SVR 700-1500
  • CI 2.5-4
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21
Q

When to excise burns

A
  • < 72 hours but not until after appropriate fluid resuscitation
  • Used for deep 2nd-, 3rd-, and some 4th-degree burns
  • Viability is based on punctate bleeding (#1), color, and texture after removal (use dermatome)
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22
Q

TTP - Path, Px, Tx

A

Path- def in ADAMtS13
Px- fever, anemia, TCP purpura, renal dz, neuro sx (FATRN)
Tx- plasmapheresis ➡ steroids ➡ splenectomy

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23
Q

LE angio

A

AT comes off first and goes lateral
TP trunk- PT behind tibia, peroneal behind fibula

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24
Q

Liver lesions on arterial phase:
HCC
Mets
Adenoma
Hemangioma
FNH

A
  • HCC: rapid enhancement. rapid w/out. “hot” on nuclear imaging
  • Mets: Hypoattenuation
  • Adenoma: rapid enhancement. rapid w/out. “cold” on nuclear imaging. gado/eovist not retained
  • Hemangioma: peripheral nodular enhancement. delay: centripetal fill-in (no early washout!)
  • FNH: Centrifugal enhancing. w/out except for scar enhancement. take up sulfer colloid and gado/eovist
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25
Q

Methanol and Ethylene glycol toxicity - Px and Tx

A

Px: profound AG metabolic acidosis
- oxalate stones → renal failure

Tx: NaB + fomipazole (ADH inhibitor)
- consider iHD

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26
Q

Ureter anatomy

A

Runs under the vas/uterine arteries
Runs over the iliacs

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27
Q

Elective surgery after stent

A
  1. ASA lifelong
  2. Plavix
    - BMS: 1 month
    - DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)
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28
Q

UE Injuries:
1. supracondylar humerus
2. DRF
3. Mid shaft
4. ant shoulder disloc
5. post shoulder disloc

A
  1. supracondylar humerus- brachial artery
  2. DRF- median nerve
  3. Mid shaft- radial nerve
  4. ant shoulder disloc- ax. nerve
  5. post shoulder disloc- ax. artery
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29
Q

Teg interpretation:
R time
K time
a angle
MA
LY 30

A

R time- FFP
K time- cryo
a angle- cryo
MA- PLTs
LY 30- TXA

Rule of 6’s:
R > 6 minutes
alpha angle > 60 degrees
MA < 60 mm
LY30 > 6%

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30
Q

DeMeester score

A

Score: pH <4 , changes in position, duration, # of episodes
> 14.7 is positive

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31
Q

Standard Deviations

A

1, 2, and 3 SD = 67%, 95%, and 99.7% of the data

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32
Q

s/e of ileal conduit

A

Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)

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33
Q

Angiodysplasia of the colon - Dx and Tx

A

Dx: usually found in cecum and ascending colon
-2nd MC CO gi bleed (vs. div’s)
- MC CO right colon bleeding
- MC CO bleeding > 65 yo

Tx: if bleeding or iron deficiency
1. Endoscopic
2. Surgery if refractory

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34
Q

Stewart-Treves syndrome - px, dx, tx

A

Px: post-mastectomy lymphangiosarcoma (bruises)
- 2/2 chronic lymphedema; 10 years from surgery

Dx: incisional bx

Tx: wide local excision w/ 3-6 cm margin + chemotherapy
- often requires arm amputation
- don’t need to stage nodes (hematog spread)

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35
Q

Tx for gallstone ileus

A

Stable and healthy- stone removal and take down fistula
Unstable, old/frail- stone removal only!

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36
Q

Sorafenib

A

Tyrosine kinase inhibitor
Tx of HCC

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37
Q

Stricturoplasties
- Heineke s’plasty
- Finney s’plasty
- Side2Side isoperistaltic s’plasty

A
  1. Heineke: <10cm; open long and close transversely
  2. Finney: > 10cm; segment folded on itself and common wall created
  3. Side2Side isoperistaltic (Michellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together

**Bleeding is MC complication

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38
Q

Dx and tx of gastroparesis

A

Dx: Scintigraphy gastric emptying

Tx:
- Metoclopramide (Reglan): dopa antagonist
- gastric pacemaker or pyloroplasty
- feeding tube
- TPN

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39
Q

Burn degrees

A

1D: epidermis

2D superficial: pap dermis, painful, hair follicles intact; blanches
- don’t need grafting

2D deep: retic dermis, decreased sensation; loss of hair follicles, no blanch
- need skin grafts

3D burn: subcutaneous fat, leathery

4D: fat/muscle/bone; surg

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40
Q

Tx and Survival Benefit of ARDS

A
  • TV at 4-6 ml/kg
  • Permissive hypercapnia
  • Proven benefit: prone, lung protection, paralyze
    -P/F < 100 = severe
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41
Q

Interleukins 1, 2, 4, 5, 10
C5-9

A

IL1: fever, wound healing
IL2: T cell proliferation
IL4: B cell proliferation. abxs allergic rxs
IL5: eosinophil growth, asthma, allergic rxns
IL 10: anti-inflammatory
C5-9: MAC ➡ cell lysis

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42
Q

Glucagonoma - loc, px, dx, tx

A

Loc: distal (a cells)

Px: dermatitis, DRH, DM, nec mig erythema
- most malignant
- no stones (vs. SS’oma)

Dx: gluc > 1000

Tx: distal panc + splenectomy + LADN’y + CC’y

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43
Q

Aminocaproic acid vs. streptokinase

A

ACA: Plasmin inhibitor
- Use: DIC, excess tpa

Streptokinase/Urokinase/TPA: plasmin activator
- bust clot

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44
Q

s/e of carb, protein, and lipid

A
  1. carb: immunosuppression, resp failure
  2. lipid: pro inflammatory
  3. protein: false neurotransmitters, rise in ammonia/urea
    - can worsen hepatic encephalopathy (use branched chain AA instead of aromatic AA)
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45
Q

Dx, Bx, and Tx actinic keratosis

A
  • Dx: red, crusty, weeping lesion
  • Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
  • Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)
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46
Q

Hirschsprung surgeries
- Duhamel
- Soave
- Swenson

A
  • Duhamel: agang stump in place/gang colon pulled behind; end-to-side mosis; neo-rectum; lowest stricture rate
  • Soave: pull-through; “reverse alte”; remove M/SM; pull through within an aganglionic CUFF; least dissection
  • Swenson: original; aganglionic segment resected to sigmoid colon; pull-through with end-to-end anastomosis- colon x rectum.
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47
Q

z11 trial implications

A
  • If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK
  • if >70, t1, ER+ and SNLBx neg ➡ can consider no XRT after lumpectomy
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48
Q

Hard signs of vascular injury

A

shock
expanding hematoma
pulsatile bleed
thrill/bruit
absent pulse
ischemia

If negative ➡ ABI…if positive ➡ CTA (to localize)

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49
Q

Polyps that require surgery instead of endoscopic resection

A
  1. Submucosal invasion > 1mm
  2. Poorly differentiated
  3. <1 mm margin
  4. LV invasion
  5. Tumor budding
  6. Taken piecemeal
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50
Q

Iron deficiency sxs

A

anemia, glossitis, brittle nails, cardiomegaly

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51
Q

T staging indications for neoadjuvant
- eso
- stomach
- colon
- rectal
- lung

A
  • eso: T2 (MP)
  • stomach: t2 (MP)
  • colon: t4b (adjacent organs)
  • rectal: t3 (through MP)
  • lung: n2 nodes
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52
Q

Atlanta classification pancreatits

A
  1. Interstitial:
    <4w- acute peripanc collection
    >4w pseudocyst
  2. Necrotic:
    <4w- acute necrotic collection
    >4w- walled of necrosis
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53
Q

Fuel for:
- SB
- LB

A
  • SB: glutamine
  • LB: short-chain fatty acids (acetate, butyrate). Directly absorbed by intestinal epithelium w/out lipolysis
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54
Q

Motilin

A

Motilin – released by intestinal cells of gut; acts. on smooth muscle to↑ intestinal motility (erythromycin acts on this smooth muscle receptor)

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55
Q

Screening in IBD patients

A
  • Start 8 years after sx onset
  • 2-4 random bx every 10 cm throughout the colon + suspicious areas

Repeat schedule:
- normal: q1-3 years
- PSC, stricture, or dysplasia w/out colectomy: q1 year

Any dysplasia usually gets a colectomy
- if resectable can consider endoscopic resection with close surveillance

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56
Q

NEC - px and tx

A

Px: bloody stools after 1st feed
- prematurity is biggest RF

tx:
- resuscitation, ngt, abx (no surgery) x 7-10 day (50% success)
-surgery (50%): resect all non-viable segments. create stoma.

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57
Q

W/up of thyroid nodule found on exam or incidental imaging

A
  • U/S and TSH:

a. Nodule + Low TSH ➡ RAI uptake scan
- hot/functioning: toxic adenoma (no cancer) ➡ thionamide, b-block + lobectomy
- cold: FNA

b. Nodule + Normal/High TSH ➡ FNA

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58
Q

Tx male breast ca

A

Tx: simple mastectomy w/ SLNBx
- BCT usually can’t be done b/c not enough tissue
- if ER+: tamoxifen (Her2+ is rare). consider orchiectomy if metastatic.
- More likely ER/PR+ than females!
- Prognosis similar to W but delay in px
- a/w BRCA 2/Chromosome 13. Should BRCA test if family hx

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59
Q

Nutcracker eso - manometery and tx

A

Mano:
- high amplitude (> 180 mmHg)/long peristalsis (>6 sec)
- normal LES pressure
- normal relaxation

Tx: (identical to DES)
1. PPI, CCB, TCA
2. Long segment myotomy if refractory

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60
Q

General principles - repair of Bile Duct Injury

A
  1. Intro-op:
    - convert to open, intra-op cholangio, repair OR
    - widely drain and send to specialty center
  2. Post-op:
    - Perc cholangiography to define the anatomy
    - Control spillage: external drain +/- stent +/- PTC
    - Repair in 6-8 weeks
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61
Q

Eso dysplasia tx

A
  1. LGD: ablation OR scope q6-12m
    - OK for fundoplication
  2. HGD: ablation + Q3m scope
    - fundoplication c/i
  3. T1a: ablation
  4. t1b (or low risk T2): upfront esophagectomy

*Fundoplication does not decrease cancer risk

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62
Q

Superior epigastrics
Inferior epigastrics

A

SE: runs between rectus and posterior rectus sheath; branch of int mammary

IE: runs between rectus and transversalis fascia; branch of EI

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63
Q

When to intubate burn patients

A
  • hypoxia, hypercarbia, severe upper airway edema
  • If stable/GCS > 8 and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling
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64
Q

Tx hemobilia after trauma

A
  1. EGD → CTA (if stable)
  2. angio embolization (no surgery)
    - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA
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65
Q

Paget Von Schroetter syndrome - path, px, tx

A

Path: narrowing of SC/Ax vein 2/2 mech compression

Px: acute swelling

Tx: catheter-directed thrombolysis before anything else (NOT open thrombectomy)

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66
Q

Tx of AT3 def

A

Tx- recombinant at3 or FFP followed by heparin then warfarin

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67
Q

Vitamin C mechanism and deficiency

A

Mech:
- hydroxylation of lysine and proline
- type 3 collagen cross-linking

Def: Scurvy
- gingivitis, wound healing, rough skin

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68
Q

Indications for chemotherapy for rectal cancer

A
  1. Neoadjuvant:
    Stage 2 and above
    Stage 2: at least t3 (crossing muscularis prop) or any n (stage 3)
  2. Adjuvant chemo as well for Stage 3+ (nodes)

**XRT either pre or post-op (not both)
**Typical course: chemo-XRT ➡ surgery ➡ chemo

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69
Q

Periop anticoagulation - risks and tx

A

Risks:
- High risk pt: afib, MHV, recent TE event (3m)
- High risk surgery: nsurg, optho, cards

Tx:
- bridge for high-risk patients
- stop warfarin 5 days before surgery if not bridging, resume on day of surgery
- Hold Noac 2 days before surgery and resume 1 day after
- stop Plavix 5 days before
- resume AC within 24h for low risk surgery. 48-72h for high risk surgery.

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70
Q

What is not suppressed by high dose dexa

A

Adrenal mass
Ectopic mass (small cell cancer)

**dexa is strongest steroid (hydrocort is weakest)

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71
Q

Metabolic alkalosis - chloride responsiveness

A
  1. Cl responsive (Ur Cl < 20)
    - temporary loss, replaceable
    - vomiting
  2. Cl resistant (Ur Cl > 20)
    - hormonal, continuous loss
    - conn’s, steroids, hyperaldosterone
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72
Q

Heller myotomy margins and fibers

A

6 cm proximal, 2 cm distal
- Esophagus: vertical fibers first (outside), then circular (inside)

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73
Q

Margin for invasives cancer vs. dcis

A
  1. Invasive cancer- no tumor on ink
  2. DCIS- 2 mm

**if both in specimen, margin is no tumor on ink

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74
Q

ITP- path, dx and tx

A
  1. path: IgG against gp 2b/3a
  2. dx: of exclusion- increased megakaryocytes, petechia, TCPenia
    - smear: normal with low PLTs
  3. tx:only if PLT < 30K!
    steroids → IVIG 2nd line → splenectomy
    - spleen is source of Ab’s
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75
Q

Staph species causing graft infection

A

G+/aerobe/clusters

coag+ → staph aureus
- MC early graft infections

coag- → staph epidermidis
- MC late graft infection 2/2 biofim

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76
Q

Cryptorchidism tx

A
  • wait until 6 month old
  • if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma
  • risk of ca higher in both testes.
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77
Q

Sarcoma grade

A
  1. differentiation
  2. mitotic coun
  3. necrosis

** more important than size, nodal/distal mets for prognosis

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78
Q

Neuroblastoma dx and tx

A

dx:
- CT: displacement of renal parenchyma (vs. Wilm’s)
- Can also use MIBG and VMA levels (like pheo)
- Usually adrenal. Can also be neck, chest, spine
- neck can px w/ horner syndrome
- tissue bx to get n-myc status

tx:
1. S1-2 (low risk) → surg alone
2. S3+ or n-myc+ (high risk) → chemo/XRT then XRT
- need bx: chemo regimen determined by n-myc amplification

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79
Q

Gastrin - MOA and stimulation

A
  • MOA: G cells of antrum signal EC cells ➡ Histamine ➡ Parietal cell ➡ H/K exchange (ATP) ➡ HCl (+ intrinsic factor)
  • Stimulation: ACh, beta ago, AA
  • Inhibition: acid, SS, secretin, CCK
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80
Q

Esophagus blood supply

A
  1. Cervical- inf thyroid
  2. Thoracic- aortic branches (bronchial arteries)
  3. Abd- left gastric/inferior phrenic
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81
Q
  • CBD and PD on ERCP
  • Blood supply of CBD
A
  • CBD at 11’. PD at 2’
  • Ampulla is between them (they both feed into it)
  • Blood supply 9’ and 3’.
  • perform sphincterotomy by cutting from 11’ to 2’
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82
Q

Tx urethral injury

A

Grade:
1/2- contusion/stretch ➡ foley
3- part disruption ➡ foley +/- cystostomy/repair
4/5-complete disruption ➡ cystostomy + delayed repair

  • can try urethral cath with cysto assistance
  • must get a CTAP to r/o concomitant injuries that would require delayed repair
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83
Q

TEF - MC types. dx and tx

A
  1. Type C - MC, 85%
    - Proximal esophageal atresia (blind pouch) and distal TE fistula
    - dx: AXR ➡ distended, gas-filled stomach, coiling tube
    - no UGI needed!
  2. Type A: second most common, 5%
    - Esophageal atresia and no fistula
    - dx: XR: gasless abdomen, coiling tube
    - no UGI needed!

Tx:
1. Resuscitate w/ repogle tube
2. Echo: VACTERL cardiac w/up
3. G-tube placement to decompress and feed
4. Delayed RIGHT extra-pleural thoracotomy
5. Distal ligation of TEF (if gas in abdomen, type C)

**long term r/o dysphagia and GERD in almost ALL patients

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84
Q

Tx of Ogilvie’s

A
  1. CT or scope to confirm dx. R/o obstruction.

2 supportive, dc narcotics, ng tube, neostigmine

  1. if > 10cm ➡ scope decompression and neostigmine
  2. failure ➡ OR
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85
Q

Px and Tx of prolactinoma

A

Px: bitemporal hemianopsia, galactorrhea, amenorrhea, ED, osteopenia

Tx:
1. Bromocriptine or carbegoline (both dopa agonists)
- bromo is safe in pregnancy
2. Surgery only if tx failure

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86
Q

Pros/Cons:
- Sevoflurane
- Isoflurane
- Halothane
- NO

A
  • Sevo: rapid induction, less pungent. Good for kids.
  • Isoflurane: good for neurosurgery; no increase in ICP
  • Halothane: slow onset/offset, cards depression, hepatitis.
  • NO: least cardiac depression b/c sympathomimetic. c/i in SBO. Highest MAC.
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87
Q

Atropine MOA

A
  • competitive inhibitor of ACh at muscarinic receptor
  • liver metabolism
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88
Q

FMD- Dx, Path and Tx

A

Dx: string of beads on angiogram

Path: fibroplasia, thickened media, collagen formation

Tx: angio + balloon (no stent)

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89
Q

MEN1/MEN2 genes

A

MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene

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90
Q

Birads score

A

0- redo imaging
1- negative, NTD
2- benign, NTD
3- benign, repeat q6m
4- suspicious, bx
5- highly suspicious, bx
6- confirmed, excise

**discordance: perform repeat bx w/ surgical excision or core bx (if there was a correctable error)

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91
Q

MOA, use, s/e of antifungals:
Fluconazole
Voriconazole
Micafungin
Amphotericin

A
  1. Fluconazole: ergosterol synth inhibitor
    - Non-systemic candida (yeast infection, c. albicans)
    - s/e: liver toxic, GI upset
  2. Voriconazole: ergosterol synth inhibitor
    - aspergillosis
    - s/e: visual changes, psychosis
  3. Micafungin: echinocandin; inhibit glucan
    - invasive/disseminated candidiasis
    - s/e: TCPenia
  4. Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access)
    - invasive mucor, cryptococcal meningitis
    - s/e: nephrotoxic, electrolytes (hypoK)
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92
Q

Recurrent laryngeal nerve + aberrant anatomy

A
  • motor: larynx except cricothyroid
  • sensory: larynx below the cords
  • injury: hoarseness, airway compromise, permanent ADduction —> bilateral may need a trach

Aberrant anatomy:
- NR right a/w: arteria lusoria ➡ absent innominate + right SC takes off from left aortic arch
- NR left a/w R sided arch

  • inferior PT is anterior to RLN. Superior PT is posterior to RLN
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93
Q

PFTs for lung resection

A
  1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing
    - >.8L wedge, >1.5L lobe, >2L pneumo
    - < 80% ➡ lung scan for PPO FEV1, DLCO
  2. PPO FEV1, DLCO > 60% ➡ no further testing
    - < 60% ➡ exercise test
  3. VO2 > 10 ml/min/kg ➡ OK for surgery
    - < 10 ➡ high risk for surgery
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94
Q

Origins of medullary thyroid cancer

A
  • 4th pharyngeal arch releases NCC which form parafollicular C cells
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95
Q

Gastrinoma - loc, px, dx, tx

A

Loc: gastrinoma triangle (CBD, panc neck, 3D)

Px: refractory PUD
- Mostly malignant

Dx: G > 1000 (off PPI) or >200 w/ secretin (off PPI)
- SS Scintigraphy (dotatate scan) if can’t get off PPI
- MRI for regional disease

Tx: Screen for MEN1
- <2 cm: enucleate w/ LADN’y
- > 2cm: resect w/ LADN’y

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96
Q

qSOFA score

A
  1. AMS (<15)
  2. RR > 22
  3. SBP < 100
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97
Q

MC Benign and Malignant H/N tumors - tx

A
  1. Benign: Pleomorphic adenoma
    - Tx: superficial parotidectomy even if asx
  2. Malignant: mucoepidermoid carcinoma tx
    - Tx: total parotidectomy (facial nerve preservation) + MRND + XRT
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98
Q

Tx frostbite

A
  • Frostnip: rapid moist/pool re-warming
  • 2d: clear/milky blister- drain
  • 3d: HMHG blister- leave intact
  • 4d: bone- prostacyclin/TPA, amputate
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99
Q

Tx of Pilonidal cyst

A
  1. ASx: NTD
  2. Acute abscess: drain only
  3. Chronic cyst: offer surgery if effecting QOL
    - marsupialization and leave open: lower recurrence
    - primary closure: faster healing. Off midline- less complication (preferred)
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100
Q

Tx TCPenia

A

<10k if asx
<20k if septic, chemo/rads, RF’s
<50K if elective surgery

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101
Q

Dx and Tx annular pancreas

A

Dx: UGI with double bubble at 2D

Tx:
- neonates: duo-duo (mobile duo)
- adults: duo-jej

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102
Q

Production and function:
- TNFa
- IF-gamma

A

TNF-a: produced by PMNs, mphages
-cachexia, inflammation

IF-gamma: produced by T lymphos
- activate PMNs, mphages

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103
Q

W/up of pancreatic cystic neoplasms:
Pseudocyst
Serous cystadenoma
MCN
IPMN

A
  1. MRI
  2. EUS w/ FNA (If unclear):

-Pseudocyst: high Am, low CEA
-Serous cystadenoma: low Am, low CEA
-MCN: low Am, high CEA (>200)
-IPMN: high Am, high CEA (>200)

***High CEA > 190

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104
Q

Propofol - MOA, pros and cons

A

MOA: GABA-A agonist

Pros
- rapid distribution and on/off
- decreases ICP, anti-emetic

Cons
- s/e: hypotension, resp depression, meta acid
- no analgesia
- liver metabolism
- prop infusion syndrome: metabolic acid + rhabdo

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105
Q

Enterohepatic circulation

A

Primary bile salts
- cholic acid, cheno-cholic acid (C’s) → hepatocytes → conjugated BS:

  1. 80% conjugated ➡ active ileum absorbed
  2. 20% deconjugated by bacteria ➡ passive colon absorbed
  3. 5% out in stool
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106
Q

Dx and Tx CO poisoning

A
  • Suspect in burn patient with neuro/cards sxs

Tx:
1. 100% O2 w/ facemask or intubation (not hi flo)
- Hyperbaric O2 if C-Hb > 25%

  1. Intubate if comatose, severe acidosis
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107
Q

Indication for APR

A
  1. Rigid proctoscopy: w/ in 2cm of anal verge (levators)
  2. PE: baseline sphincter dysfxn
  3. Recurrent SqCC (s/p Nigro)
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108
Q

Cancer associations:
- CEA
- AFP
- CA 19-9
- CA 125
- Beta-HCG
- PSA
- NSE
- BRCA I and II
- Chromogranin A
- Ret oncogene
- KRAS

A
  • CEA: colon CA
  • AFP: liver CA
  • CA 19-9: pancreatic CA
  • CA 125: ovarian CA
  • Beta-HCG: testicular CA, choriocarcinoma
  • PSA: prostate CA
  • NSE: small cell lung CA, neuroblastoma
  • BRCA I and II: breast CA
  • Chromogranin A: carcinoid tumor
  • Ret oncogene: medullary thyroid CA
  • KRAS: pancreatic CA (MC genetic mutation)
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109
Q

Types of esophagectomy compared

A
  1. Ivor-Lewis (Trans-thoracic): abdominal + R thoracotomy
    - anastomosis: thoracic
    - theoretically more thorough oncologic resection
    - less overall leak rate
    - may be better in more fit patients
  2. Transhiatal: abdominal + L neck
    - anastomosis: cervical
    - theoretically less chance of mediastinal leak, shorter operation BUT more overall leak rate
    - may be better if old/frail and distal esophagus tumors
  3. McKeown: abdominal + L neck
    - anastomosis: cervical

***Gastric conduit supply- R gastroepiploic (off GDA/CHA)

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110
Q

Somatostatinoma - loc, px, dx, tx

A

Loc: head

Px: DM, GALLSTONES (> glucagonoma), steatorrhea, block exo/endo pancreas
- most malignant

Dx: sx’s + high fast SS

Tx: resect + LADN’y + CC’y

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111
Q

Etomidate - Pros and Cons

A

Induction agent

Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e
Cons- adrenocortical suppression

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112
Q

W/up and Tx testicular mass:
- Seminoma
- Non-seminomatous

A
  1. PE
  2. Ultrasound
  3. AFP, HCG, LDH
    - Seminoma: no AFP! (most common)
    - Non-seminoma: high AFP, HCG, LDH
  4. Inguinal orchiectomy: any patient with solid testicular mass
  5. Based on path/tumor markers decide:
    - Seminoma: XRT or chemo
    - Non-seminomatous: retroperitoneal node dissection

**ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection

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113
Q

Liver collection dx and tx:
1. Pyo
2. Amoebic
3. Echino
4. Fungal

A
  1. Pyogenic: after cholangitis (MC) or div’s (via portal vein);
    - drain and abx (+mica if fungal)
  2. Amoebic: after mexico trip (or aMazon).
    - dx w/ serology/hemagglutination 1st
    - metronidazole (no drain)
  3. Echinococcal: wall Ca+ and sub-cysts
    - albendazole and resect/PAIR
  4. Fungal: 2/2 chemo/neutropenia
    - perc drain + micafungin
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114
Q

EVAR specs:
- Proximal landing
- Common iliac (distal landing)
- Neck angulation
- External Iliac

A

Proximal landing: > 1.5 cm
- diameter < 3cm

Common iliac (distal landing): > 1 cm
- diameter > 8 mm

Neck angulation < 60 degrees

External Iliac diameter> 7mm

**smoking is stronger RF for AAA
**extensive calc is a c/i

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115
Q

Tx of anal fissure

A
  1. Sitz bath, fiber
  2. topical nifedipine/nitroglycerin
    - nitro causes headache
  3. Surgery (or botox)
    - Good sphincter tone: LATERAL, INTERNAL sphincterotomy
    - Poor tone: botox

**If 2/2 crohn’s dz: optimize medical management

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116
Q

Lynch genes and gene funtions

A

Genes:
- MLH1
- MSH2, MSH6
- PMS2
- EPCAM

Fxn:
DNA MM repair gene causing microsatellite instability

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117
Q

Condyloma types

A
  1. acuminatum- HPV (6, 11- warts; 16, 18- Cancer)
  2. lata- syphilis
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118
Q

Tx of liver lesions:
1. Hemangioma
2. FNH
3. Adenoma

A
  1. Hemangioma: only if sxatic or KM syndrome
    - enucleate (or resect); angioembo if active bleed
  2. FNH: NTD
  3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing
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119
Q

Dx and Tx congential DPGM hernia

A

-Dx: prenatal dx on US ➡ must confirm with MRI

-Tx:
1. intubate (in delivery room)
- goal O2 > 60, CO2 < 60
2. NGT +/- ECM
3. delay OR when stable

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120
Q

Stages of empyema formation

A
  1. Exudative ➡ drainage or VATS (1-7 days)
  2. Fibrinopurulent ➡ VATS (7-21 days)
  3. Organizing ➡ thoracotomy (21+)

**VATS between days 3-7
- Preferred over 2nd CT placement or fibrinolytic therapy

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121
Q

Vertebral artery occlusion px

A

posterior circulation
sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia

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122
Q

5T’s of cyanosis

A
  1. TOF
  2. Transposition of GVs
  3. Truncus art
  4. Tricuspid atresia
  5. TAPVC
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123
Q

DES - Manno and Tx

A

Manno:
- unorganized peristalisis
- normal LES pressure
- normal relaxation

Tx:
1. CCB (+TCA if chest pain)
2. Botox injection (endoscopic)
3. Last resort: long segment myotomy

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124
Q

Supraceliac aortic control

A
  1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram
  2. Stable: left medial visceral rotation is preferred
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125
Q

Mondor disease - px and tx

A

px- tender, “cord-like” structure
tx- NSAIDs

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126
Q

Dx and Tx Phyllodes

A

Bx: stromal overgrowth, atypia, high MI, “leaf-like”
- aggressive fibroepithelial lesion
- non aggressive is fibroadenoma

Tx: WLE w/ 1 cm margin + XRT (if > 5cm)
- can spread hematogenous to lung (more than ax nodes)

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127
Q

Replaced Rand L hepatic

A

Right:
- SMA (behind pancreas and CBD)
- found behind CD during a chole

Left: left gastric (in gastrohepatic ligament)
- found medial to portal triad
- injured during paraeso hernia

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128
Q

Effective for enteroccous

A

Ampicillin/Amoxacillin
Vancomycin
Zosyn
(Resistant to all cephalosporins)

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129
Q

Loss in excess weight for each surgery

A

REYGB- 75%
SG- 60%
Lap band- 50%

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130
Q

Acid/Base of Ng suctioning

A

HypoCl, HypoK metabolic alk
- Mech: Loose HCl and fluid ➡ turn on RAA system
Retain Na/Excrete acid (paradoxic acidurea)

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131
Q

Indications for total thyroidectomy (pap and follicular)

A

Indications for total thyroidectomy:
- Tumor > 4cm
- Tumor 1-4cm and patient preference
- Distant mets or extra-thyroid disease
- Nodal disease
- Poorly differentiated
- Prior radiation

*micro-mets do not count as distant disease
**if thyroid lobectomy only: tx with thyroid hormone to suppress TSH, get serial U/S to monitor

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132
Q

Soft tissue sarcoma - dx and tx

A

dx:
- < 3cm: excisional bx
- > 3 cm: core needle (preferred) or incisional

tx:
- resect w/ 2 cm marg
- neoadj: rhabdomyo, Ewing, high grade, > 10 cm
- adj XRT: > 5cm, high grade, recurrence, close marg
- adj chemo: never

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133
Q

Step up approach

A

Infected pancreatic necrosis (WBC + gas on CT)

  1. CT with gas
  2. Carbapenem
  3. FNA + Perc drain OR endo drain (if stomach is close to pancreas)
  4. Upsize drain
  5. MIS retrop necrosectomy (VARD)
  6. Open necrosectomy
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134
Q

CN11 - nerve, location, muscle/injury

A
  • nerve: spinal accessory nerve
  • location: exit jugular foramen (post triangle)
  • injury: SCM and trapezius. no shoulder shrug, winged scap!
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135
Q
  1. Central cord syndrome
  2. Anterior cord syndrome
A
  1. Central cord: loss of pain, temp, motor
    - motor UE> LE loss (vs. anterior syndrome)
    - hyperextension in the setting of SS
  2. Anterior cord: loss of pain, temp, motor
    - below the level of the lesion
    - ASA injury or anterior cord compression
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136
Q

Types and Tx SVT

A

types: af, aflutter, paroxysmal SVT, WPW

  1. vagal → adenosine
    - may unmask afib/flutter
  2. HDS: BB, CCB ➡ sync cardioversion
  3. HDUS ➡ sync cardioversion
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137
Q

Von Hippel Lindau - mechanism and surveillance

A

VHL gene - upreg. of VEGF
1. Brain/retinal hemangioblastoma- q2y brain MRI
2. Clear cell RCC- q1y US/MRI of abdomen
3. Pheochromocytoma- yearly metanephrines

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138
Q

Melanoma w/up and tx

A
  1. Punch bx or excisional bx (if < 2cm, non-sensitive area)
    - MIS- 5mm margin
    - <1mm- 1cm
    - 1-2mm- 1-2cm
    - >2mm- 2cm
  2. Clinical positive nodes (stage 3) require FNA for confirmation
    - negative: SLNBx
    - positive: completion LN dissection
  3. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
  4. If SLNBx+ (stage 3): q4m US surveillance OR completion LN dissection
  • LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes

**MOHS can be used for in-situ disease. Need 5 mm margin.

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139
Q

Steps of rapid sequence intubation

A

c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine

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140
Q

PSC vs. PBC - assocaited and tx

A

PSC: Male; intra/extra hepatic; onion fibrosis; chain of lakes
- a/w Ulcerative colitis, cholangioca

PBC: Female; intra hepatic; granulomas; +AMA
- a/w Sjogren, RA

tx: trx, cholesty., UDCA
- meds generally don’t help

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141
Q

CPP

A

MAP - ICP
normal CPP > 60
Normal ICP < 20

  • would prefer low MAP with CPP of 60 then higher MAP for brain bleed
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142
Q

Draining peri-rectal abscess

A
  1. Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles)
  2. Supralevator abscesses need to be drained trans-rectally
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143
Q

Px, Dx and Tx malrotation

A

Px: bilious emesis

Dx: UGI duodenum does not cross midline
- should be done in all infants with bilious emesis

Tx: urgent OR (risk of malro)
1. resect Ladd’s bands
2. widen the mesentery (resect central bands)
3. counterclockwise rotation
4. place cecum in LLQ (cecopexy), duodenum in RUQ
5. appendectomy

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144
Q

Epidural hematoma - shape, vessels, px

A

Shape: Biconvex. DOES NOT suture lines

Vessel: MMA

Px: lucid interval. Ipsilateral blown pupil is early sign
- (vs. subarachnoid thunderclap, worst HA)

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145
Q

MEN syndromes

A

1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD

2a- Parathyroid (PTC),MTC, Pheo (catecholamines); ret; AD

2b- Pheo, MTC, marfanoid/neuroma; ret; AD

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146
Q

Nitrogen balance

A

Protein intake (grams)/6.25 - (UUN + 4 grams)

UUN =grams of nitrogen excreted in the urine over a 24 hour period
4 = stool and insensible losses

Recommended protein = 1.5g/kg/day
Nitrogen = protein intake/6.25

**muscle is greatest site of protein turnover

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147
Q

Periop Warfarin

A

stop 5 days before
Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6+

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148
Q

Management of PE

A
  1. no RH strain → acoag
  2. RH strain → IR catheter
  3. RH strain + HDUS → systemic tPA
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149
Q

Methemoglobinemia - px, dx and tx

A

Px: nitrites, Hurricane spray, fertilizers, g6PD def, serotonergic drugs, benzocaine spray
- Fe2+ to Fe3+ impairing O2 binding

Dx: blood gas measurement and pulse ox says 85%
- MethHb level > 20%

Tx: methylene blue or vitamin C (for g6pd or ser)

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150
Q

Layers of colon/rectum

A
  1. mucosa
  2. sub-mucosa (strength layer)
  3. muscularis propria
  4. serosa
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151
Q

LE vascular trauma

A
  • small: patch plasty
  • large: contralateral GSV (must maintain venous system b/c deep vein may be injured)
  • limited time/unstable: shunt
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152
Q

Tx for DVT

A
  1. unprovoked: malignancy, inherited ➡ indefinite
  2. provoked: surgery, travel, preg, OCP, immbility ➡ 3m

Special cases:
- ileofemoral: cather directed thrombolysis
- open thrombectomy ➡ extensive (ileofemoral) DVT OR phlegmasia
- Superficial femoral vein is a DVT
- Pregnant ➡ use Lovenox. NOAC and Coumadin are c/i

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153
Q

Loop diuretics vs. Ca sparing diuretics

A
  • loop: furosemide
  • Ca sparing: thiazides (can cause gynecomastia)
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154
Q

MALT lymphoma dx and tx

A

Dx: EGD + bx
- usually in the stomach
- CD20+, lympho infiltration
- associated w/ h. Pylori.
- non-hogkins (worse prognosis)

Tx:
- Low grade: triple therapy (eradicate HP)
- High grade: chemo and XRT (CHOP) +/- rituximab (CD20)

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155
Q

lower extremity bypass graft failure depends on temporal relation to the surgery.

A
  • <30d: technical error
  • 1m-2y: intimal hyperplasia, (at the distal anastomosis)
  • > 2y: progressive atherosclerotic disease
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156
Q

Dx and Tx Parathyroid ca

A

Dx: palpable neck mass + Ca > 14 is presumptive dx. Otherwise, dx intra-op based on gross features.
- FNA is not recommended
- Treat based on intra-operative gross invasion. Frozen section is not helpful.

Tx:
1. Control hypercalcemia: usually > 14
- IV fluids 1st! Then bisphosphonates
- cinacalcet (sensipar - ca mimetic)

  1. Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT)
    - no chemo
    - usually don’t perform any node dissection unless palpable nodes
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157
Q

Tx infected pseudocyst

A

aspirate/gram stain to dx → drainage (internal, external, endoscopic)

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158
Q

Tx melanoma of anal canal

A

Tx:
- WLE (1 cm). No SLNBx
- APR if sphincter involved, LADN, or > 4mm
- No chemo-XRT

**5y-S is 20% w/ R0
**WLE = APR

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159
Q

Kaposi’s sarcoma - cause and px

A
  • Case: HSV8
  • Px: Violet/brown papules
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160
Q

Mechanism and Tx of thyroid dz:
1. Graves
2. TMN
3. Hashimoto’s
4. DeQuervains/Subacute
5. Reidels

A
  1. Graves: IgG stimulates TSHr ➡ hyperT
    - BB, PTU, RAI ➡ thyroidectomy
  2. TMN: chronic TSH stimulation ➡ hyperT
    - BB, PTU, RAI ➡ total/subtotal thyroidectomy
  3. Hashimoto’s: antiTPO/TG Ab ➡ hypoT
    - thyroxine ➡ partial thyroidectomy
  4. DeQuervains/Subacute: viral URI
    - path: giant cells, leukocytes
    - NSAIDS/ASA ➡ steroids
  5. Reidels: autoimmune inflammation
    - steroid, thyroxine ➡ surgery for compression
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161
Q

Sonograph FNA recs

A
  • cystic: no bx

-isoech/hyperech: FNA if > 2cm

-hypoech (high sus): FNA if > 1cm

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162
Q

Tx anal incontinence

A
  1. 1st line: fiber/bulking, exercises
  2. Refractory: endoanal U/S
    - defect: overlapping sphincteroplasty
    - no defect or refractory: sacral modulator
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163
Q

s/e of burn topical treatments:
- silver nitrate
- silver sulfadiazene
- mafenide
- bacitracin

A
  • Silver nitrate: electrolytes disturbance (no sulfa)
  • Silver sulfa: neutropenia, sulfa (covers pseudo)
  • Mafenide: met acidosis (CA inhibitor), sulfa (covers pseudo and eschar)
  • Bacitracin: G+; nephrotoxic
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164
Q

Triple therapy

A

PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks

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165
Q

APC gene

A
  • chromosome 5
  • 1st mutn in adenoma to carcinoma
  • mc mutation in colon ca
  • a/w FAP
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166
Q

Contents of post triangle

A
  1. CN 11
  2. subclavian artery
  3. EJV
  4. brachial plexus trunks
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167
Q

Gail model

A
  1. age
  2. age 1st period (earlier is worse)
  3. age 1st birth (earlier is better)
  4. 1d relative
  5. previous bx
  6. race
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168
Q

Associated orthopedic injuries:
1. post hip disloc’n
2. post knee disloc’n
3. DRF
4. Supracondylar humerus fx
5. Anterior shoulder disloc’n

A
  1. post hip disloc’n: sciatic nerve (peroneal branch)
  2. post knee disloc’n: popliteal atery
  3. DRF: median nerve
  4. Supracondylar humerus fx: brachial artery
  5. Anterior shoulder disloc’n: axillary nerve
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169
Q

Dobutamine

A

B1 at low dose
- inotropy

B2 at high dose
- vasodilation

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170
Q

types of endoleak and tx

A
  1. proximal/distal seal: immediate balloon expansion of distal/proximal attachments + stent
    - 1a: proximal leak
    - 1b: distal leak
  2. back bleeding: observe. coil embolization if enlarging
  3. graft defect (tear or junctional leak): immediate additional graft coverage
  4. porosity- reverse anticoagulation
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171
Q

Carcinoid vs. GIST vs. Desmoid- cells and tx

A
  1. Carcinoid- Kulchinsky cells (enterochromaffin-like)
    tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable
  2. GIST- cajal cells
    tx- resection (MC stomach), imantinib
  3. Desmoid- spindle cells
    tx- resect if extra-abdominal. NSAID/estrogen if intra
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172
Q

Meckel’s Diverticulum Pathophys

A
  • Anti-mesenteric border of SB
  • 2/2 peristant viteline duct
  • pancreatic and gastric tissue
  • 2 feet from IC valve
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173
Q

VRE coverage

A

Linezolid, Dapto
- Amp if not amp resistant

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174
Q

MOA:
- Milrinone
- Midodrine

A

Milrinine- PD inhibitor, contractility with vasodilation
- c/i in renal failure

Midodrine- a1 agonist

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175
Q

Hyperaldosterone w/up

A

Px: resistant HTN and hypokalemia

  1. AM plasma aldo/renin
    - A/R < 20: 2nd hyperaldo
    - A/R > 20: primary hyperaldo ➡
  2. Confirmatory test: salt load suppression test
    - give salt load ➡ 24h urine aldo remains elevated
  3. Discern laterality: CT scan! (>MRI)
    A. Unilateral: lap adrenal (consider adrenal vein sampling 1st if > 35 to r/o BAH)

B. Bilateral or negative ➡ adrenal vein sampling
- Lateralization: lap adrenal
- No lateralization: idiopathic hyperplasia ➡ tx medically

**tx HTN with spironolactone

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176
Q

Dx and Tx of SBP

A

dx: ↑ascitic PMN ANC > 250 (Se) and
- don’t require culture (Sp)
- e. coli is MC (usually single organism)

tx:
1. paracentesis for cx
2. abxs:
- <48h/community acquired: 3GC
- >48h/hospital acquired: carbapenem + MRSA coverge (dapto)
3. Albumin (survival benefit)

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177
Q

HLA test

A
  • Tissue typing
  • Donor organ: carries Ag (on WBC)
  • Recipient body: carried Ab
  • Recipient serum with donor wbc
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178
Q

Tx acute variceal HMHG

A
  1. Resuscitate, ensure airway
  2. Octreotide + antibiotics
  3. Endoscopic intervention (ligation/sclerotherapy)
  4. Blakemore
  5. TIPS (temporized with Blakemore)
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179
Q

Tx SVC syndrome tx

A
  1. Elevate HOB
  2. Chest CT with IV contrast (can skip CXR)
  3. Consider bronch
  4. Assess sxs
    A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting
    B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo
    - no chemo/XRT unless its 2/2 cancer
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180
Q

Crystalloid and colloid for trauma kids

A

Crystalloid: 20cc/kg
PRBC: 10cc/kg

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181
Q

Melanoma characteristics:
- superficial spreading
- lentigo
- nodular
- acral

A
  • superficial spreading: MC
  • lentigo: sun exposed, best prog
  • nodular: worst prog
  • acral: AA

**thickness is most indicative of prognosis

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182
Q

Tx appendicitis

A
  1. Uncomplicated: lap appe
  2. Septic/Unstable: immediate lap appe
  3. Stable w/ abscess
    - < 3cm: lap appe
    - > 3cm: IR drain ➡ interval appe, offer scope
  4. Crohn’s ileitis
    - intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty
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183
Q

Tx MEN2A/B

A
  1. urine metanephrine to r/o pheo 1st
  2. tx pheo 1st w/ adrenalectomy
  3. Address thyroid
    - 2A: total thyroid + bilateral central neck by 5y
    - 2B: total thyroid + bilateral central neck by 1y
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184
Q

Tx MEN1

A
  1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
  2. Asses other lesions
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185
Q

Prog and Tx anaplastic thyroid ca

A

Prognosis:
- aggressive, undiff
- mort ~ 100%; no tx

Tx: XRT improves short-term survival +/- surg
- BRAF inhibitor for chemo

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186
Q

GI Hormone Release and action:
- Glucagon
- Insulin

A

Glucagon: alpha cells of pancreas
- glycogenolysis, gluconeogenesis

Insulin – beta cells of the pancreas
- cellular glucose uptake; promotes protein synthesis

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187
Q

Criteria for transanal excision of adenocarcinoma

A
  1. T0 or T1 (submucosa)
  2. < 3 cm
  3. < 30% circumference
  4. Palpable on DRE (<8cm from anal verge)
  5. No high-risk features (poorly diff, LV invasion)

**local recurrence rate is higher

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188
Q

Merkel cell ca - dx, histo, and tx

A

Dx:
-rare neuroendocrine tumor of the skin
-purple raised; looks like BCC w/out rolled edge
- CK20+. TTF- (vs. small cell ca of the lung, TTF+)

Tx:
-Tx: surgical excision + SLNBx! + XRT (very sensitive)

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189
Q

Breast abscess tx

A
  • US aspiration BEFORE I/D if refractory
  • Bx if > 2 weeks to r/o ca
  • abxs to cover staph if systemic sxs. Consider MRSA coverage if RFs
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190
Q

5 steps to LADDS procedure

A
  1. Resect Ladd’s bands
  2. Widen the mesentery
  3. Counterclockwise rotation
  4. Cecum in LLQ (cecopexy), place duodenum in RUQ
  5. Appendectomy
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191
Q

HNPCC screening and treatment

A
  1. CRC: scope q1-2y starting at 20-25
    - Surgery if:CRC or endoscopically unresectable lesions
    - TAC with IRA w/ q1y rectum surveillance
  2. Endometrial ca
    - childbearing: endometrial sampling q1y
    - after children: TAH-BSO
  3. Ovarian ca: annual pelvic exam and TVUS
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192
Q

Dx and Tx choledochal cyst

A

Dx: U/S or HIDA

Tx:
1. fusiform dilation: REY-HJ
2. diverticulum: simple excision
3. choledococele: transduo excision vs. sphincteroplasty
4a. intra + extra dilation: hepatic resection + recon
4b. extra only: excision + recon
5. intra only: transplant

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193
Q

Vit D vs. PTH

A

Vit D: increase Ca and Ph
PTH: increase Ca and decrease Ph

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194
Q

Arterial content

A

(1.34 x Hb x Sa02) + (.003 x PaO2)

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195
Q

Px, Dx, and Tx:

Duo atresia
TEF
Pyloric stenosis
Intussusception
Malro

A

Duo atresia: newborn; bilious emesis directly after birth
- a/w down syndrome
-dx: AXR- double bubble with no gas distally. don’t need UGI
-tx: duodenoduodenostomy

TEF: newborn, spit ups. can’t place NG. resp sxs
- dx: AXR- gasless (A), gas (C)
- tx: right extra-pleural thoracotomy

Pyloric stenosis: 1-3 months; NB projectile vomiting
-dx: U/S- 4mm thick, 14 mm long. String sign on UGI
-tx: pyloromyotomy (1-2 from duo to antrum)

Intussusception: 3m-3y; currant jelly stool
- dx: U/S w/ bull’s eye
- tx: air contrast enema

Malro: 1y-5y; sudden onset bilious emesis
- dx; UGI- no duo sweep (any child w/ bilious emesis)
- tx: ladd’s procedure

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196
Q

Cori cycle

A
  • recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production
  • requires alanine
  • provides 40% of glu when starving
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197
Q

Tx of GB cancer

A

1a: LC only
- lap chole only
- excise to negative CD margin
1b: muscle involved
- OPEN chole + seg 4b and 5 + portal LADN
- CD margin positive: REY-HJ

**high suspicion for GB Ca should also get an open chole (polyp > 2cm)

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198
Q

Layers of mucosa

A

Epithelium
Lamino Propria
Muscularis mucosa

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199
Q

Stage 3 breast cancer and tx

A

3a: 4 to 9 nodes ➡ +/- neoadj
3b: chest wall (not pec wall) or breast skin ➡ +/- neoadj
3c: supra clavicular nodes ➡ neoadj required

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200
Q

Tx of CBD stone intra-operatively

A
  1. Flush ➡ glucagon x 2
  2. Lap exploration
    A. Transcystic: stone < 1 cm, <8 stones, no CHD stones
    B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones
  3. Open exploration: if lap exploration failed
    - CBD < 2 cm: trans-duo sphincteroplasty
    - multiple stones, CBD > 2 cm: biliary-enteric drainage.
    - Leave T-tube

**thin CD can be dilated

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201
Q

W/up Hurthle Cell Cancer

A
  1. FNA- hurthle cells (can be seen in other conditions)
  2. Lobectomy 1st for diagnosis
  3. If malig: total thyroidectomy +/- L6 nodes
  4. If palpable nodes: MRND

No RAI

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202
Q

Conduit after esophagectomy

A

Stomach and Right gastroepiploic
- if out abort and discuss conduit options at a later time (don’t go for colon or jejunum b/c needs to be prepped)

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203
Q

Cancer Markers:
Ca 125
bHCG
AFP
Inhibin

A

Ca 125- epithelial
bHCG- choriocarcinoma
AFP- germ cell/endodermal/yolk sac
Inhibin- granulosa/sex-cord

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204
Q

Tx of High grade AIN/bowen’s disease of anal margin

A
  1. Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin
    - otherwse: cryo, curettage, 5-FU, laser
  2. Lifetime surveillance even if tx!
  • Bowen disease = SqCC in situ = high grade AIN
  • Actinic keratosis is precursor

*vs. pagets disease- excision

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205
Q

Types of rejection - px, path, and tx

A
  1. hyper-acute: w/in 1 hour
    - path: ABO Ab (t2 HS)
    - px: mottled organ
    - tx: remove organ
  2. acute cellular: days-weeks; change in organ function
    - path: B or T (t4 HS)
    - px kidney: lymphocytic infiltration, tubulitis
    - px liver: endothelitis, portal triad lymphocytosis
    - tx: increase IS or pulse steroids ➡ IVIG
  3. chronic: months-years
    - path: B or T (t4 HS)
    - px kidney: interstitial fibrosis, tubular atrophy
    - px liver: bile duct atrophy
    - px heart: vasculopathy and atherosclerosis; 1/2 @ 10y
    - px lung: bronchiolitis obliterans; 1/2 @ 5y
    - tx: increase IS or re-trx (no good options)
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206
Q

Dx and Tx DPGM injury

A

Dx: CXR ➡ CT ➡ diagnostic scope if inconclusive

Tx: repair is always recommended
- Abdominal approach
- Debride devitlized tissue
- Repair with non-absorbable suture
- If too large can close primarily can use mesh or tissue flap (if contamination)

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207
Q

Hypocalcemia vs. Hypercalcemia - sxs and ekg

A
  1. HypoCa: tingling, chvostek/trousseau sign
    - EKG: qt prolongation
  2. HyperCa: stones, bones, groans, overtones, DI
    - EKG: shortened QT
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208
Q

Calcitonin

A

Parafollicular C cells
Inhibits osteoclast resorption
Increases Ph excretion

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209
Q

Crohn’s drugs MOA:
- Azathioprine/6-MP
- Sulfasalazine/5-ASA
- Infliximab

A
  • Azathioprine/6-MP: inhibit DNA synthesis
  • Sulfasalazine/5-ASA: COX/LOX inhibitor
  • Infliximab: monoclonal Ab to TNF; moderate Crohns, recurrent perianal fistula!
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210
Q

GI Hormone Release and action:
Gastrin
Somatostatin
CCK
Secretin
VIP

A
  1. Gastrin - G cells in antrum
    - ↑ HCl, IF, and pepsinogen
  2. Somatostatin – D cells in pancreas
    - inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output
  3. CCK – I cells of duodenum
    - gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells)
  4. Secretin – S cells of duodenum
    - ↑ pancreatic/GB bi release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release
  5. VIP – pancreas and gut
    - ↑ intestinal secretion (water and electrolytes) and motility
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211
Q

Anal canal
Dentate line
Anal verge
Anal margin

A

Anal canal- from levators to verge
Dentate line- w/in the canal; columnar/sq. jxn
Anal verge- sqamous/myoc. jxn
Anal Margin- 5-6 cm from the anal verge

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212
Q

Px, Dx, Tx Galactocele

A

Px: breast mass that looks like abscess w/ no infectious signs

Dx/tx: u/s ➡ aspiration shows milky debris
- continue bfeeding
- no abxs (unless infected)!

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213
Q

Stages of graft healing

A
  1. imbibition (direct diffusion)
  2. inosculation (cap beds meet)
  3. revascularization
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214
Q

Hernia repairs:
Bassini
McVay
Lichtenstein
Shouldice

A

Bassini: conjoint tendon to inguinal ligament (from pubic tubercle medially to internal ring laterally)
- may need relaxing incision in anterior rectus sheath

McVay: open the floor to ➡ conjoint tendon to cooper’s/pectineal ligament.
- transitional stitch from conjoint, cooper’s, and femoral sheath at medial aspect of femoral vein
- re-approximate the rest of the inguinal floor by suturing the conjoint tendon to the inguinal ligament
- may need relaxing incision

Lichtenstein: mesh to inguinal ligament and conjoint tenown

Shouldice: divide the floor ➡ 4-layer tissue closure

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215
Q

EBUS accesible nodes:

A

2, 3, 4, 7, 10, 11, 12
- innominate seperates level 3, 4
- 4: carinal
- 7: sub-carinal
- 10: R/L hilar
-n2 nodes: 1-9
-n1 nodes: 10-14

  • cannot sample 5, 6 (sub-aortic/AP window) ➡ chamberlain procedure (Parasternal mediastinotomy)
  • 8 (para-eso), 9 (IPL) ➡ EUS or VATS
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216
Q

Order of cells in healing

A
  1. Hemostasis: PMNs
    - 24-48h
    - PMNs: remove necrotic tissue
  2. Inflammatory: monocytes/macrophages
    - 48-96h
    - mphage: growth factors, angiogenesis, cell proliferation
    - chronic wounds
  3. Proliferative: fibroblasts
    - 3 days+
    - fblasts: collagen production
  4. Maturation: fibroblasts
    -10 days+
    - myofibroblasts for wound contraction

PMN (24-48h) ➡ MPhages (48-96h) ➡ Fblast (3d) ➡ MFblast

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217
Q

Hemophilia A

A

f8 deficiency, SLR
MC inherited disorder
tx- DDAVP (mild), f8 concentrate (severe)

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218
Q

Adenoid cystic carcinoma - px and tx

A

Px: MC minor salivary gland tumor (Sub-Mand gland @ Palate)
- Spread along nerves
- Remains quiescent for years then metastasizes

Tx: Total parotidectomy w/ facial nerve preservation + MRND + XRT
- don’t aggressively resect b/c very XRT responsive

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219
Q

Tx for cholangiocarcinoma

A

Tx:
1. Resectable if:
- contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor
- no distant mets or organ invasion

  1. Consider location
    - Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
    - Middle ⅓: hepaticojejunostomy
    - Lower ⅓: Whipple
  2. Chemo + transplant if unresectable
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220
Q

acid and alkali burns - px

A
  1. Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis
  2. Acid burns (battery acid) produce coagulation necrosis
    - copious water irrigation as soon as possible
    - cagluc if HF acid
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221
Q

IPMN - dx and tx

A

dx: MRI 1st! then EUS/FNA; high CEA, high amylase
tx:
1. Branched
- resect if >3 cm, sxs, or signs of malig (nodule)
- Otherwise surveillance
2. Main duct
- resect if > 1 cm or sxs (60% chance of Ca)
- 5-9 mm EUS/FNA. Resect if SOMalig
- < 5mm, surveillance MRIs

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222
Q

Tx PDA

A

to close- indomethacin
to open- PGE1

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223
Q

Airway management anatomy

A

Anatomy:
1. Elective trach: between 2nd and 3rd trach rings
2. Crich: CT membrane between thyroid cart and cric
- Thyroid ➡ cricoid ➡ rings

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224
Q

Dopamine dosing and s/e

A

low: d1/2-ago (renal dose)
medium: B-ago (heart)
high: A-ago (vaso)

**s/e: high UOP. difficult to titrate. tachyarrythmias

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225
Q

Parkland formula

A
  • 4 x weight x TBSA
  • Use 2 for “modified Brooke formula”
  • 1st 1/2 in 1st 8h
  • 2nd half next 16

arm = 9, leg = 18, each torso = 18, head = 9, each hand = 1, genitals = 1

UOP: .5-1 cc/hr. 1-2 cc/hr if child < 30 kg

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226
Q

Who needs stress dose steroids and how to dose

A

> 20 mg of steroids for > 3 weeks

Surgery: continue regular dose the day of surgery +
1. Low risk (inguinal hernia): just continue regular dose day of surgery
2. Moderate risk: 50 mg HC pre-proc. Then 25q8 x 3
3. High risk: 100 mg HC pre-proc. Then 50q8 x 3

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227
Q

Path, Dx and Tx of Zenkers

A

Path: outpouching SUPERIOR to cricopharyngeous

Dx: UGI (don’t do EGD) ➡ manometry (r/o dysmotility)

Tx: open or scope approach:

<2cm : myotomy alone
>2cm: multiple options
- consider endoscopic stapling +/- myotomy
- 2-5 cm: myotomy with suspension or inversion
- larger: diverticulectomy with myotomy

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228
Q

Tx SIADH

A

Acute – vaptan, demeclocycline
Chronic – fluid restriction, diuresis

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229
Q

Spinal vs. Epidural

A

Spinal- below l1/l2; SA space; fast; n/m block
Epidural- any level; epidural space; slow; no block

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230
Q

VIPoma - loc, px, dx, tx

A

Loc: distal

Px: watery DRH- hypoK, met acid. achlorhydria, inhibits gastrin
- DRH ➡ bicarb sexn ➡ met acid
- most malignant

Dx: high VIP

Tx: distal panc + splenectomy + LADN’y + CC’y

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231
Q

Gastric CA tx - chemo, margins, nodes

A
  • neo-adj chemo for T2+ or N
  • proximal- total gastrectomy
  • distal- partial
  • 5 cm margin; 15 nodes
  • Can consider endoscopic mucosal resection: if < 2cm, well-differentiated, mucoa only, no LV invasion
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232
Q

DDAVP/Vasopressin - production and effect

A
  • Made in SON of HT. Stored PP
  • Cause endothelium to release f8 and vWF
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233
Q

Milan criteria

A

indications for trx w/ HCC
- Single tumor < 5cm
- No more than 3 tumors each < 3 cm

**Hepatectomy if compensated cirrhosis (no portal HTN), low MELD, and solitary mass < 3 cm is still preferred

**5-year transplant pt survival is 65-90%

indications for trx of cholangioca
- cant be intrahepatic
- must be unresectable, perihilar, < 3cm
- no distant mets

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234
Q

Posterior and anterior vagal trunk branches
Vagotomies

A

Right ➡ Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet

Left ➡ Anterior trunk- Liver (hepatic branch) and ant Laterjet (L’s)

  1. Truncal vagotomy: transect ant/post @ distal eso
    - removes lesser curve and pylorus nerve
    - selective: resect at ant/post Laterjet
    - need pyloroplasty. high r/o dumping syndrome
  2. Highly selective: transect @ crow’s ft, preserve laterjet
    - removes innervation to lesser curvature
    - preserves pylorus → no drainage procedure
    - lowest morbidity
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235
Q

Insulinoma - loc, px, dx, tx

A

Loc: throughout (B cells)

Px: whipple’s triad. Most benign.

Dx: I/G > .4 and high C-pep
- dx w/ fasting test 1st!
- endoscopic U/S most sensitive for detection

Tx: < 2cm encucleate, >2cm resect.
- High carb diet 1st
- Diazoxide if can’t tolerate surgery
- LADN’y if suspect malignancy

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236
Q

Dx and Tx fat necrosis

A
  1. dx: breast oil cyst w/ Ca+ rim
    - smooth, circumscribed lesion outlined in white (course, egg-shell calcs)
    - suspect post-op
  2. tx:
    no trauma- bx
    trauma- watch
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237
Q

Px, Dx and Tx Pancreatic divisum

A

Px: child with chronic pancreatitis episodes

Dx: secretin-enhanced MRCP

Tx:
- Only tx if sxs
- ERCP sph’otomy of MINOR papilla (Santorini/Superior)
- Refractory: resect HOP (duo preserving)

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238
Q

Indications for neoadjuvant therapy eso cancer

A
  • high grade t1b or T2 and above OR any nodal involvement
  • Also get XRT
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239
Q

Marfans vs. Ehlers-Danlos

A
  1. Marfans- Fibrillin-1 defect (elastin);
    - AD; mitral regurg, aortic root dilation, lens defect, arachnodactyly
  2. Ehlers Danlos- t3 collagen defect
    - hyper elastic skin, hypermobile joints, aortic root dilation

**Both need CTA of aorta to r/o aortic root``

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240
Q

Bladder ca - dx and tx

A

px- hematuria in a smoker
dx- CT urogram 1st (bladder, kidney, or ureter ca)

  1. T1a- no muscle/including LP
    tx- transuretehral resexn (TURBT) + mitoM + BCG
  2. T2a- muscle/beyond LP
    tx- cystectomy + LND + chemo
  3. T3- fat/nodes
    tx- neoadjuvant
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241
Q

Tx tracheal inj

A

Small ➡ absorbable in 1 LAYER w/ strap buttress
- 2 layer leads to tracheal stenosis
- primary repair up to 5-6 rings
- bilateral injury ➡ bilateral SCM incisions and join (“U” incision)

Large and above 3rd ring → tracheostomy through the defect
- avoid below 3rd ring (TI fistula)

Access: distal 1/3, right main, proximal L main ➡ right postero-lateral thoracotomy

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242
Q

Specific to Crohn’s and UC

A
  1. Crohn’s:
    - Creeping fat
    - Skip lesions
    - Transmural
    - Cobblestoning
    - Granulomas
    - Fistulas
  2. UC:
    - Crypt abscess
    - Pseudopolyps
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243
Q

Uremic PLT dysfunction - px, dx, tx

A

Px- 2/2 renal disease.
dx- normal coags. elevated BT only.
tx- ddavp

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244
Q

Escharotomy indications

A
  • Circumferential deep burns
  • Neuro-vascular sxs
  • Problems ventilating torso burns
  • Go down to fascia but don’t divide the fascia

**Perform within 4–6 hours
**Usually bedside
**May need fasciotomy AFTER

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245
Q

Gastric ulcers: elective classification and management

A

Dx- EGD and Bx (Bx needed to r/o ca!)
Tx-only tx if refractory to max medical management after 12 weeks.

  1. lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2
  2. gastric + duo; high acid ➡ antrectomy + vagotomy
  3. pre pyloric: high acid ➡ antrectomy + vagotomy
  4. GE junction: normal acid ➡ sub-total gastrectomy + REY
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246
Q

Emergent vs. Elective UC Tx

A

Emergent:
1. Steroids +/- abxs
2. Infliximab, Cyclosporine
3. No response, megacolon (> 6 cm), HDUS, or perf ➡ TAC with end-ileostomy
- When stabilized can perform proctectomy and IPAA
- Don’t do proctectomy in emergent situations

Elective:
- Indications: dysplasia, cancer, refractory disease
- PC w/ IPAA

** Surgery reduces: erythema nodosum, arthritis
– no effect on PSC or ank spondy

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247
Q

Kasabach-Merritt Syndrome

A
  • hemangioma + thrombocytopenia
  • usually infants
  • resect!
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248
Q

Peutz-Jeghers - px and screening

A

Px- intestinal hamartomas (intususpeption), pigmented oral mucosa, polyposis
- Cancers: GI tract, breast, pancreatic
- AD, STK11 mutation

Screening
- Scope @ 25y then q2 years b/c high r/o GI/pancreas ca

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249
Q

Omphalocele

A
  • 2/2 failure of umbo ring closure
  • 11th week gut returns to abdominal cavity
  • normal bowel (protected)
  • Other congenital defect are more common
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250
Q

Cryo contents and uses

A
  • Contents: VWF, f8, fibrinogen
  • Uses:
    1. VWD
    2. Fibrinogen def
    3. Hemophilia A
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251
Q

Zone injuries and management

A
  1. penetrating:
    - zone 1-3 –> explore
  2. blunt:
    - zone1 –> explore
    - zone 2-3 –> do not explore
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252
Q

TOS tx

A
  1. neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
  2. venous- catheter-directed thrombolysis → surgical decompression
  3. arterial- C7/1r resection, subc artery resection/reconstruction
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253
Q

FAP - Dx and Tx

A

Dx: > 100 adenoma or < 100 w/ fam hx
- AD; APC mutation
- CA by 40
- desmoid tumors (slow growing abdominal wall mass)

Tx:
- sigmoidoscopy q1y at 10 (don’t need colonoscopy)
- EGD @ 20 or when polyps start- SB polyposis
- TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen)
- q1y EGD post op for duodenal cancer (MC COD after colectomy)
- q1y c’scope if TAC
- polyposis/high grade dysplasia @ stump → proctectomy +/- pouch
- desmoid: resect. Anti-E if intra-abdominal

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254
Q

BRCA risks and tx

A

female breast, ovarian, male breast
I (ch17)- 60, 40, 1
II (ch13)- 60, 10, 10

Tx:
-pre-meno: offer bilateral mastectomy OR q1 MRI starting @ 25
- @ 30 annual MRI w/ mammo
-post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH)

**SOO decrease r/o OVARIAN Ca (80%) for BRCA1/2
AND breast Ca for BRCA2 only (50%)
**No TAH!

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255
Q

When to operate on adrenal mass

A
  1. all functioning tumors
  2. all > 6 cm ➡ open resection
  3. if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection

**DO NOT biopsy first

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256
Q

Adjuvent chemo for breast ca

A
  1. Adjuvent chemo: tumor > 1cm, nodal dz, triple neg
    - echo before for cardiotox
  2. Tamoxifen/Anastrazole: 5y for HR+ tumors
    - Tamox for men
  3. Trastuzumab- 1y for Her2/neu+ tumors
    - echo before for cardiotox
  4. Olaparib- 1 year for triple negative/BRCA+ tumors
    - PARP inhibitor

**Oncotype recurrence score > 26 requires adjuvant chemotherapy

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257
Q

FNH - path, dx and tx

A

path- CENTRAL STELLATE SCAR!
dx- bright on arterial phase homogenous
tx- resect if sxatic. no malignant potential.

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258
Q

Secretin vs. CCK

A

Both released by duo
S cells ➡ Secretin- duct cells ➡ bicarb
I cells ➡ CCK- acinar cells ➡ enzymes

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259
Q

Pancreas drainage procedures

A
  1. duct > 7mm- Peustow, pancreaticojej (for large duct)
  2. duct > 7mm and large head- Frey, pancreasticojej + core out head
  3. duct < 7mm and large head- Berger, pancreatic head resection
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260
Q

Tx papillary/follicar thyroid cancer

A
  1. Indications for total thyroidectomy:
    - Tumor > 4cm
    - Distant mets or extra-thyroid disease
    - Poorly differentiated
    - Prior radiation
  2. Nodes dissection:
    A. Lateral neck dissection: of involved compartments if palpable or bx+ nodes
    B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes.
    - Usually not performed for follicular
  3. Radio iodine indications (6w post op, want TSH high)
    - Only after total thyroidectomy to be effective
    - For high risk tumors: tumor > 1 cm, extra-thyroidal disease
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261
Q

Heparin - MOA and measurement

A

MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin

Measurement:
- PTT
- ACT: better intra-op if high doses of hep given

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262
Q

Screening guidelines for breast ca

A

Mammogram every 2–3 years after age 40
then yearly after 50

High-risk screening
- mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative

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263
Q

Tx SDH

A
  1. Nonop: HDS, <10 mm, <5 mm shift
  2. Evacuate: > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP
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264
Q

Central venous O2 vs. mixed venous O2

A

Mixed venous: from PA
Central venous: from SVC only (estimation of mixed)

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265
Q

Reversals:
- BB
- CCB
- Tylenol
- Benzos
- CN/Nitroprusside
- Vecuronium/Rocuronium
- Ethylene glycol
- Methemoglobinemia

A
  • BB overdose: fluids/atropine → glucagon
  • CCB: Ca + Insulin + Atropine + Pressor
  • Tylenol: NAC
  • Benzos: flumazenil (.2mg IV)
  • CN/Nitroprusside: sodium thiosulfate, amyl nitrite
  • Vecuronium/Rocuronium: sugammadex
  • Ethylene glycol: femopizole and bicarb OR ethanol; iHD
  • Methemoglobinemia: methylene blue
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266
Q

Orientation of portal triad

A

Bile duct lateral
Hepatic artery medial
Portal vein posterior

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267
Q

Px an tx:

Cryoptococcus
Coccidiomycosis
Histoplasmosis
Mucormycosis

A
  1. Crypto- CNS sxs in AIDs pt
    tx- amphotericin
  2. Coccidio- pulm sxs in the southwest
    tx-amphotericin
  3. Histo- pulm sxs in ohio river valley
    tx- itraconazole → ampho B (only if sxs)
  4. Mucormycosis- burns/trauma w/ bloody cough
    tx- emergent debride, ampho
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268
Q

LN harvest/margin
eso
stomach
colon
rectum

A

eso- 15/7cm
stomach- 15/5cm
colon-12/5 cm
rectum- 12/5 cm

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269
Q

Succinylcholine - MOA, s/e, c/i

A

MOA: ONLY depolarizing. degraded by plasma CE
- Short half-life and rapid onset (RSI)
- Used for “full stomach”

s/e: rhabdo, hyperK, M/H, bradycardia
c/i: spinal cord injury, renal failure, large burns

tx of M/H: stop drug, dantrolene, Bicarb, cooling, tylenol

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270
Q

Breast nerve - muscle and actions:
- Thoracodorsal
- Intercosto-brachial
- Lateral petoral
- Medial pectoral
- Long thoracic (medial)

A
  • Thoracodorsal (lateral): Lat Dorsi, ADduct/extension/IR
  • Intercosto-brachial: hypesthesia
  • Lateral petoral: p major, arm flexion
  • Medial pectoral: p major/minor, ADduct/extension/IR
  • Long thoracic (medial): SA, wing scap

**Wing scap: LTN or spinal accessory nerve

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271
Q

Cohort study vs. Case control

A

Cohort: prosepective; exposed vs. non-exposed
RR- [a/a+b]/[c/c+d]

Case control: retrospective; diseased vs. non-diseased
OR- (a/b)/(c/d)
- good initial study to show an association

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272
Q

Tx acute limb ischemia

A

Tx: Rutherford

1: no deficits ➡ hep gtt. imaging. eventual revasc

2a: motor intact ➡ imaging. hep gtt (motor intact, sensation). eventual revasc
- if early post-op case skip the imaging

2b: any weakness, rest pain ➡ hep gtt and immediate revasc (don’t image if delay in tx)
- if present in prior graft perform thrombectomy

3: paralysis ➡ amputation

Revasc options:
1. Endovascular: short segment, single lesion
2. Open: long segment, multiple lesions

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273
Q

Papillary cystadenoma (Warthin tumor) - px, tx

A

Px: benign tumor of salivary gland
- often BILATERAL and 2/2 smoking
- Slow growing

Tx: complete resection with uninvolved margins even if ASx

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274
Q

Hemangioma - path, px, and tx

A

path- PERIPHERAL ENHANCEMENT with continued late filling

px- young women

tx- if rupture, size change, or KM syndrome

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275
Q

Pancreatic ducts

A

Wirsung- major, lies inferior
Santorini- minor, lies superior

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276
Q

Gluconeogenesis precursors

A

lactate , pyruvate, AA (alanine, glutamine)

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277
Q

Sirolimus - MOA, s/e

A

MOA: mTOR (rapamycin) inhibitor
- Less nephrotoxic
- Alternative to tacro intolerance

s/e:
- lymphocele (w/ obstruction)
- wound complications/poor wound healing: held or switched to tacro before hernia repairs

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278
Q

Tx of rectal prolpase

A
  • Not past the verge: biofeedback, fiber

-Many comorbidities or acute presentation: Altemeir (perineal rectosigmoid’y)

-Prolpase < 50cm with comorbidities: Delorme (muscle plication)

-Young/healthy and elective: rectopexy +/- resection

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279
Q

Li Fraumeni - gene, mechanism, and px

A
  • gene: p53 mutation; TSG on Ch17; AD inheritance
  • mech: cell cycle regulation at G1/S to promote apoptosis in DNA damaged cells
  • px: breast ca + sarcoma b4 45
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280
Q

Chylothorax dx and tx

A
  1. dx: fluid TG > 110
  2. tx: chest tube and NPO
    - < 1L/day: MCT diet, octreotide, TPN → 7d: thoracic duct lig (Open R chest or IR)
    - > 1L/day: thoracic duct ligation (Open R chest or IR)

**for cancer patients: pleurodesis > ligation

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281
Q

Tumor lysis syndrome - px, path and tx

A

Px: Common 2/2 B cell lymphoma
- hyperU, K, Ph w/ hypoCa

Path: CaPh crystal ➡ renal failure + hypoCa

tx: IV hydration ➡ iHD

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282
Q

CRC T and N stages

A

t1- SM
t2- MP
t3- xMP/subserosa
t4- invade
n1- 1-3, n2- >=4

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283
Q

Rectovaginal fistula tx

A

wait 3-6m
low- endorectal advancement flap
high- abdominal approach

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284
Q

Schiatzki’s Ring - Path and Tx

A

Path:
- Associated with hiatal hernia. 2/2 GERD.
- Usually distal eso
- Mucosal process. No muscle involved
- Protective against Barret’s

Tx: only if sxatic.
1. Bx first to r/o eosino esoph’s
- if esosino esoph’s: medical therapy first
2. Dilation and PPI
3. Steroids, endoscopic resection

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285
Q

NNT

A

NNT = 1/absolute risk reduction (ARR)
- ARR = event rate in intervention group - rate in control group
- RR = event rate in intervention / rate in null group
- RRR = (rate control - rate experimental) / rate control

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286
Q

Tx childhood GI disease:
- Pyloric stenosis
- Intussusception
- Duo atresia
- TEF
- Malro

A
  • Pyloric stenosis: pyloromyotomy
  • Intussusception: air contrast enema (air > water)
  • Duo atresia: DD or DJ
  • TEF: right extrapleural thoracotomy
  • Malro: LADDS proc
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287
Q

Pancreatic fistula - dx and tx

A

dx: drain amylase 3x serum amylase at 3 weeks
- considered a “biochemical leak” if leakage is cx insignificant
- amylase clears faster than lipase

tx:
- NPO, TPN or N-J feeding x 4-6 wks
- octreotide if high output (>200/day). Does not increase healing rate or closure. Does decrease output.
- consider ERCP w/ stent after 6 weeks (vs. biloma which can be ERCP/stented early)

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288
Q

Max dose of lido and bupiv and tx of OD

A

lido = 5mg/kg (7 w/ epi)
bupiv = 2.5 mg/kg (3 w/ epi)

tx- lipid emulsion

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289
Q

Epi, Dx and Tx Aspergillosis

A

Epi:
- MC fungal infection in IC patient
- Histoplasmosis is MC fungal infection overall (itraconazole)

Dx: +gallactomannan Ab/Ag detection, PCR, microscopy, cx or path
- can cause pneumonioa, lung abscess, brain abscess

Tx:
- aspergilloma: resect
- aspergillosis: voriconazole (inhibits ergosterol)

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290
Q

Dx and Tx of GIST

A
  1. Dx: MC GI Sarcoma
    - EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC.
    - Bx: cajal cells. c-KIT+
    - don’t require bx if high suspicion
  2. Tx: wedge resection (gross margin)
    - can be R0 or R1 resection
    - Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf
    - mitosis/hpf is most predictive of prognosis (>mets)
    - neoadjuvant if need to down-stage for resection
    - adjuvant for 3 years
291
Q

Vitamin K - MOA and def

A

MOA: gamma CARBOXYLATION (not decarb) ofGLUTAMATE on 2, 7, 9, 10, c, s

Px of def: coagulopathy, suspect if obstructive jaundice

292
Q

Rectum:
1. Arterial supply
2. Venous drainage

A
  1. Arterial supply:
    - IMA to superior rectal a.
    - II to middle rectal a
    - II to internal pudendal a. to inferior rectal a.
  2. Venous drainage-
    - SRV ➡ IMV ➡ PV (portal)
    - MRV/IRV ➡ internal pudendal ➡ internal iliac (systemic)
293
Q

Kcal per macronutrient
Total kcal req

A
  1. protein = 4 kcal/g
  2. dextrose = 3.4 kcal/g
  3. lipid = 9kcal/g
  4. carb = 4 kcal/g

total req = 25-30 kcal/kg
- use ideal body weight if BMI > 25
- 50% carb, 30% fat, 20% protein

294
Q

Hinchey

A

1- pericolic abscess
2- pelvic abscess
3- purulent
4- feculent

295
Q

Contents of ant triangle of neck

A
  • Carotid sheath, anca cervicalis, CN 12 (hypoglossal)
  • Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular
  • Facial vein is the gateway
296
Q

Px and Tx for Leriche syndrome

A

px: diminished femoral pulse, butt claudication, ED
- younger than infra-inguinal vascular dz patient

tx: aortobifemoral bypass

297
Q

Benign lesions that require excisional bx

A

Core needle returns ➡
- Atypical (25% of malignancy)
- DH/LH
- LCIS/DCIS
- radial scar
- papillary lesion
- any atypia

**lesions generally have a 15-30% chance of carcinoma in situ or invasive cancer

298
Q

Future Liver Remnant requirements and indications for PVE

A
  1. minimum 20% if normal liver
  2. pre-op chemo/some dysfxn = 30%
  3. cirrhosis = 40%

-Otherwise should undergo PVE
-Overt PH is a c/i to PVE

299
Q

type 1 vs. type 2 error

A

type 1: false positive
- say something is true (reject the null) when it’s not
- alpha = prob of type 1 error. Set at .05
- minimize by decreasing stat significance

type 2: false negative
- say something is false (do not reject the null, accept H0) when it’s true
- beta = prob of type 2 error. Set at .2
- minimize by increasing sample size/power

**power = 1 - type 2
**reject the null = “a difference exists”

300
Q

hepatic adenoma - imaging, tx, and risks

A

path- EARLY enhancement on arterial phase w/ rapid washout. well-circumscribed.
**vs hemangioma: peripheral enhancement over time

tx- stop OCP use.
resect immediately if > 5cm, sxatic, male gender

risks:
1. rupture MC
2. malig transformation

301
Q

Types of mastectomy

A
  1. Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin (no nodes)
  2. MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes
  3. BCT: partial mastectomy + XRT
302
Q

Pyoderma gangrenosum and erythema nodosum - px and tx

A
  • Pyoderma: pre-tibial ulcer
  • Erythema Nodosum: pre-tibial erythematous plauque
  • both associated w/ IBD
  • both RESOLVE after resection
  • tx: steroids
303
Q

anion gap - equation and causes

Cases of NAGMA

A

Na - (Cl+Bic)
NaCl = non-AG, increased Cl, metabolic acidosis

AGMA: Methanol, Uremia, Diabetes, Paraldehyde, Iron/INH, LA, Ethanol/Glycol, Salicylates

NAGMA: normal saline, DRH, fistula, ureteral conduit, RTA

304
Q

MOA reglan and erythromcyin

A
  • reglan: dopamine antagonist
  • erythromycin: motlin receptor agonist causing SM contraction
305
Q

Modality and staging for eso cancer (T and N)

A

If CT and PET: no distance disease ➡

Endoscopic U/S for T and N:
t1a- LP and MM
t1b- SM (where it spreads)
t2- MP
t3- adventitia
t4a- resectable structures
t4b- unresectable structures

n1: 1-2 nodes, n2: 3-6 node, sn3: 7+

306
Q

Barrett’s eso surveillance (progress to cancer)

A

Bx: Goblet cells and columnar cells

  1. No dysplasia: 4 quad every 2 cm q 3-5y
    - 1 cm if mucosal irregularities
    - Ca .1%/y
  2. LGD: 4 quad every 1 cm q6m. Consider ablation.
    - Ca .5%/year
  3. HGD: ablation/endoscopic resection. 4 quad every 1 cm q3m
    - Ca 5%/year

*Fundoplication is only c/i in HGD
*No screening if asx

307
Q

HNPCC vs. Lynch S
Dx and Screening

A

HNPCC: fulfill amsterdam criteria
- 3+ relatives with Lynch syndrome-associated cancers (CRC, endometrium, small bowel, ureter, renal)
- 2 generations
- 1 ca dx < 50 yo

Lynch syndrome: refers to mutation in DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) or the EPCAM gene.
- should test in all with new onset CRC

308
Q

Serum osmolarity

A

Osm = 2xNa + Glu/18 + urea/2.8

309
Q

Superior laryngeal nerve (external branch) - fxn, injury, and tx

A

fxn: motor to cricothyroid

injury: trouble w/ high pitch, voice remins clear
- cord looks normal on laryngoscopy

tx: none

**MC nerve injury w/ a total thyroid

310
Q

GCS motor

A

6- obeys commands
5- localized
4- w/draws
3- flexion (decort) - ‘flex your core’
2- extension (decErebrate)
1- none

311
Q

LeFort fxs

A

I- palate
II- nose and palate
III- entire face

312
Q

Human bite tx and organism

A

tx: amox/clavulanate (augmentin)
- requires I&D if joint appears septic (pain w/ passive motion)

**MC for human bites- eikenella

313
Q

MCCO healthcare infection:
- HAP/VAP
- central line infection
- SSI
- UTI
- GI infection
- SBP
- Cholangitis
- NSTI
- ICU infection
- Fungal infection
- Graft infection
- Lymphangitis

A
  • HAP/VAP: staph aureus (pseudomonas #2)
  • central line infection: coag negative staph (staph epi)
  • SSI: staph aureus
  • UTI: e. coli
  • GI infection: c. diff
  • SBP: e. coli
  • Cholangitis: e. coli
  • NSTI: polymicrobial
  • ICU infection: VAP
  • Fungal infection: hitsto (asperg if I/C)
  • Graft infection: staph aureus (early), staph epi (late)
  • Lymphangitis: strep pyogenes
314
Q

Tx of trx of great vessels

A

1st give PGE1 → ballon atrial septostomy

315
Q

RF, Dx and Tx SqCC of anal canal

A

RF: HPV 16/18, STI, HIV
- test for cervical ca too

Dx:
- Anoscopy + FNA/core bx
- HIV test all patients

Tx:
- Nigro protocol: XRT (ing/pelvic nodes) + 5FU + MitoC
- Recurrence (10-20%): q6 months to diagnose ➡ APR
- Lateral to I/S groove (anal margin): tx like skin cancer

316
Q

TOF - defects and tx

A

Most common cyanotic defect
1. VSD
2. Pulmonary outflow obstruction
3. Over-riding aorta
4. RVH (2/2 RV outflow obstruction w/ harsh murmur)

tx- beta blocker; surgery at 3-6m

317
Q

Cutoff for low risk lung nodules not requiring follow-up

A
  1. 6mm ➡ NTD
  2. 6-8 mm ➡ q6-12m CT
  3. > 8mm
    - low risk pt- q3m CT
    - high risk pt- bx or resection
318
Q

Light’s criteria

A

Exudate if:
PLprotein/serum Pr >.5
PLLDH/serum LDH > .6
PL LDH > 2/3 ULN

  • Exudate: capillary damage from inflammation, neoplasm, trauma
  • Transudate: change in oncotic pressure;
319
Q

Treatment of colo-cutaenous fistula

A
  1. Start with conservative tx
  2. Quantify output:
    - High output: > 500 cc/day ➡ likely OR. Start with NPO/TPN.
    - Low output: < 200 cc/day ➡ likely conservative. OK for PO intake.
  3. If input increased with PO intake ➡ NPO and TPN
  4. OR if failed after about 6 weeks
320
Q

Most abundant bacteria in the colon

A

Bacteroides fragiles (anaerobe)

321
Q

T staging for esophageal cancer

A

t1a: muscularis mucosa: endo resection

t1b: SM: upfront esophagectomy (or low grade t2)

t2: muscularis propria: neoadjuvant
- low risk: upfront esophagectomy

t3: adventitia: neoadjuvant
*no serosa. Ca spread through SM lymphatics

322
Q

Exposing the pancreas: head, body, tail and order of operations in trauma

A

Head: kocherize
Body: incise gastrocolic ligament ➡ lesser sac
Tail: mobilize spleen

Trauma:
1. R medial visceral rotation
2. Kocher
3. Divide GC ligament/enter LS
4. Complete Kattel
5. Mobilize LOT

323
Q

Thoracic duct course

A
  1. originates at L1-L2 @ c. chyli
  2. cross from R to L at T4-5
  3. empties into L SC/IJ jxn

**Carries chylomicrons and LCFA

324
Q

Stomach vs. Duo ulcer px

A
  1. Stomach ulcer: pain right after meal
    - 75% H. pylori, 25% NSAIDS/ASA
  2. Duo ulcer: pain 2-3h after meal
    - 90% H. pylori, 10% NSAIDS/ASA

**NSAID/ASA: decrease mucosal mucus secretion and bicarb secretion

325
Q

Effective for Pseudomonas

A
  1. Zosyn
  2. 3/4G cephalosporin (ceftriaxone, cefepime)
  3. Aminoglycodies (genta, tobra)
  4. Flouroquinolones (cipro)
  5. Meropenem/Imipenem

**Not linezolid (good for G+/MRSA)

326
Q

most common organism in burn wound infection
most common viral burn wound infection

A
  • Pseudomonas (< 10^5 organisms – not a burn wound infection)
  • HSV
327
Q

Cuff size for kids

A

age/4 + 4

328
Q

Grading and tx of BCVI

A

1- <25% narrowing ➡ ASA
2- > 25% narrowing ➡ ASA
3- PsA ➡ ASA + IR stent
4- complete occlusion ➡ ASA only
5- transection ➡ OR if accessible. Otherwise IR.

*most are not surgically accessible

329
Q

Ectopic parathyroids

A
  1. Superior parathyroids: from 4th pouch
    - usual location: posterior to RLN.
    - Not found: explore retro-esophogeal and para-esophogeal space ➡ open carotid sheath.
    - TE groove is MC ectopic location
  2. Inferior parathyroids: from 3rd pouch (with thymus)
    - usual location: anterior to RLN.
    - Not found: explore thymus and thyroid ➡ consider thymectomy or ipsi thyroidectomy even if no palpable mass
    - thyrothymic ligament is MC ectopic location
    - more commonly ectopic b/c longer travel
  3. 4 normal appearing galnds
    - supranumary PT in the thymus

**Overall, thymus is MC location or ectopic gland

330
Q

Trauma to the pancreas

A
  1. Head
    - main duct: drain + post-op ERCP + staged resection
    - no duct: drain
  2. Tail
    - main duct (grade 3+): resect w/ splenectomy (unless CHILD and HDS)
    - no duct (grade 1-2): drain
331
Q

MOA and s/e of trx meds
- Tacro
- Cyclosporine
- Sirolimus

A

Tacro: calcineurin inhibitor; bind fK ➡ calcineurin ➡ block IL2
- 100x more potent than cyclosporine
- neuro sxs (tremor), GI sxs
- nephrotox, hepatotoxic
- DM
- alopecia

Cyclosporine: calcineurin inhibitor; bind cyclophillin ➡ calcineurin ➡ block IL2
- nephrotox, hepatotox, neuro sxs
- gingival hyperplasia, hypertrichosis
- cycled in bile, gallstones

Sirolimus: bind fK ➡ mTor inhibitor (IL2 inhibitor)
- impaired wound healing
- interstitial lung disease
- lymphocele

332
Q

Interossei and lumbrical innervation

A

palmar- ulnar n, adduct
dorsal- ulnar n, abduct
lumbricals- median (1-2)/ulnar (3-4)

333
Q

MOA and S/e of tamoxifen

A

MOA: competitive E inhibitor in breast; weak agonist in uterus/liver

S/e:
- dvt/pe
- endometrial cancer
- cant take with SSRI (CYP inhibitors)

334
Q

DCIS mammo and tx

A

Mammo: clustered calcs

Tx: like ca
- BCT: lumpectomy (2mm) + XRT +/- boost +/- endocrine
- no SLNBx (does not metastesize)
- no chemotherapy
- if XRT c/i → mastectomy AND SLNBx (b/c 20% have invasive ca)

335
Q

DCIS SLNBx

A
  • does not metastasize
  • not w/ l’omy unless >4cm, multicentric, palpable, high grade
  • required w/ mastectomy b/c 20% have invasive ca
336
Q

Dx and Tx of Cystadenoma

A

low CEA, low Amylase
tx- resect if sxs

337
Q

Post polypectomy screening

A

-2-6m: piecemeal removal

-1 year: > 10 adenomas

-3 years: 3+ adenomas, HGD, > 1cm, villous elements

-5 years: 1-2 tubular adenomas (< 1cm)

-10 years: hyperplastic polyps (<20)

338
Q

Encapsulate organisms and empiric tx

A

-Organism: “Shin”
1. Strep pneumo (MC)
2. Neisseria
3. Haemophilus

  • Empiric tx: vanc + 3GC
339
Q

Casues of increased ET CO2

A

Increased muscle activity (shivering)
Increased metabolism (sepsis, fever, malignany hyperT)
Increased CO
Decreased minute ventilation

340
Q

Dx and Tx of Meckels

A

dx: suspect if recurrent intususpeption, GI bleeds
- Meckel’s scan (Tc-99) is best test. Increase Se by giving pentagastrin, glucagon, h2 blocker. Not as Se in adults (atrophic gastric cells)
- only detects gastric tissue (not panc)
- if negative but high suspicion ➡ repeat scan
- if inconclusive then proceed with abdominal exploration (not CT)

tx: resection if sxs
- base < 2 cm → diverticulectomy
- > 2 cm or wide base → seg resection
- appendectomy as well if exploratory surgery for presumed appe ended up being meckels
- If incidental: resect meckel’s in kids, leave in adults.

341
Q

Products of posterior pituitary

A

“PAO in the POST”
ADH, Oxytocin
2/2 direct stem from neurosecretory cell

342
Q

Hereditary pancreatitis - dx and tx

A

dx
- PRSS1 trypsinogen mut’n
- AD

tx: none
- smoking cessation is important

**different from AI pancreatitis (IgG+)

343
Q

Cilostazol - MOA and use

A

MOA- PDi, inhibits PLT aggregation
tx for periph claudication
- c/i in any degree of HF (PDi)

344
Q

Esophagus and Trachea access

A

Proximal eso- L cervical
Mid eso/prox thoracic eso- R P/L thoracotomy
Distal eso- L thoractomy

Cervical trachea: collar incision
Carina/Either main-stem bronch: RIGHT P/L thoracotomy

Aorta: L thoracotomy

**for trauma do A/L thoracotomy b/c decub is not safe in unstable patient and want access to the heart

345
Q

Ureter injuries

A
  1. proximal ⅓ (U/P jxn and above) → primary uretero-urostomy.
    Other options: ileal transposition, nephrostomy
  2. middle ⅓ → primary u-u (preferred)
    - Other options: tran uretero-urosotomy, Boari flap
  3. lower ⅓ (distal to iliacs) → re-implanation +/- hitch
  4. early: w/in 5 days- stent, explore, or repair
    - HDUS intra-op: ligate, perc neph, delayed repair (3m)
  5. late: > 10 days- perc nephro and delayed repair (3m)
346
Q

Vitamin D processing

A

7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3

347
Q

Tx papillary/follicar thyroid ca

A

Start with lobectomy

Indications for total thyroidectomy:
- Tumor > 4 cm (1-4 cm, close observation or total)
- Extra-thyroidal disease
- Multi-centric or bilateral lesions
- Previous XRT

Consider ppx level 6 for high risk

If thyroid lobectomy only:
- Tx with thyroid hormone to suppress TSH
- Get serial U/S to monitor

Indications for MRND
- extra thyroid extension

Radio iodine indications (6w post op, want TSH high)
- Consider for 1-4 cm, definitely > 4cm
- Extra-thyroidal disease
- Need total thyroidectomy to be effective

348
Q

Tx Odontoid fx

A

1: upper D, stable, non-op

2: base of D, unstable, worst, +/- surg
- may require intubation

3: c2 vert, usually no OR

349
Q

GCS verbal

A

5- normal
4- confused
3- inappropriate words
2- incomprehensible
1- none

350
Q

MELD vs. CTP

A

Meld:
1. Bili
2. INR
3. Creatinine
- designed for mortality over 3 months after TIPS
- At least 15 for trx
- HCC gets automatic score of 22

CTP: Billirubin, Albumin, INR, Ascites, Encephalopathy

351
Q

Intraductal papilloma dx and tx

A

dx: dx mammo 1st ➡ U/S is enough or contrast ductogram
- MCCO bloody nipple dc
- only use ductogram if all other imaging is equivocal

tx: excisional biopsy including the ductal segment
- do central duct excision if can’t ID the duct

352
Q

Tx Umbo and Inguinal hernia in child

A

most close by 2
<3cm- primary repair
>3cm- mesh
repair by 5

Inguinal- repair by 2 weeks if reducible
- otherwise, OR then

353
Q

Gastroschisis - px and tx

A

Px:
- GastRoschisis to the Right of midline
- rare defects…EXCEPTION- instestinal atResia

Tx:
- cover bowel after delivery
- stabilize and attempt primary closure (80%)
- for larger defects, place silo for delayed closure
- post op: ICU, TPN, assess for short gut

354
Q

Mineral def:
-Zn
-Sel
-Chromium
-Copper
-B1
-B3

A

-Zn: wound heal/skin, night blind
-Sel: cardiomyopathy
-Chromium: hyperglycemia
-Copper: micro anemia
-B1 (thiamine): wernicke’s encephalopathy, p. Neuropathy, gap acidosis (lactate)
-B3 (niacin): pellagra (DRH, dementia, dermatitis)

355
Q

UES vs LES muscles

A

UES- cricopharyngeus; higher resting pressure (70)
LES- lower resting pressure (15)

356
Q

Stiewert-Stein Class and Tx

A

Relation to GEJ:
1. 1-5 cm above: eso ca
- esophagectomy and prox gastrectomy (Ivor lewis)

  1. 1 cm above-2 cm below: eso ca
    - esophagectomy and prox gastrectomy (Ivor lewis)
  2. 2-5 cm below GEJ: gastric ca
    - total gastrectomy

*Require 5 cm eso margin, 4 cm gastric margin, 15 nodes for eso CA

357
Q

Esophageal CA tx

A
  1. HGD, TIS, T1a: endoscopic ablation/resection
  2. T1b: upfront esophagectomy or endo ablation (if low risk)
  3. T2 or N: neoadjuvant then esophagectomy
    - Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso
  4. T4b or M: definitive chemo-XRT

< 5cm from cricoP: definitive chemo-XRT
> 5 cm from cricoP: esophagectomy

358
Q

Indications and C/I to anti-reflux surgery

A

Indications:
1. Extra-eso complications: cough, aspiration, CP
2. Persistant sxs
3. C/I to antireflux meds
4. Barrett’s w/out HGD
5. Strictures
6. Esophagitis

C/I:
1. Cancer
2. Barrett’s w/ HGD

359
Q

Classic and Alarm sxs for GERD

A

Classic sxs: heart burn + regurg

Alarm:
1. dysphagia (not regurgitation)
2. odynophagia (pain)
3. bleeding
4. weight loss
5. anemia
*Require EGD

360
Q

Tx of Leiomyoma

A
  1. sxs or > 4cm- enucleate
  2. < 4cm- observe
  3. > 8cm or circumferential- esophagectomy

Approach:
Cervical- L
Mid eso- R
Distal eso- L

361
Q

Required for staging esophageal CA

A
  1. CT of chest, abdomen- M
  2. Whole-body PET scan- M
  3. EUS- T and N stage
362
Q

Caustic injury w/up

A
  1. Avoid NGT. No neutralizing agents
  2. CT scan if stable
  3. Early endoscopy (AFTER CT)
  4. OR if unstable. Otherwise, restart orals in 48h.

*alkali- liquefaction necrosis. worse outcome
*acid- coagulation necrosis

363
Q

Steps of Heller myotomy

A
  1. Divide G-H ligament
  2. ID R crus and posterior vagus
  3. ID L crus and anterior vagus
  4. Divid short gastric vessels
  5. Expose GEJ (excise eso fat pad)
  6. Myotomy (6 eso, 2 stomach)
    - outer long 1st
    - inner circular 2nd
  7. Partial wrap
364
Q

How to mobilize the stomach for intra-thoracic anastamosis

A
  1. Divide G-H ligament
  2. Transect the L gastric. Keep the R gastric.
    —- Lesser Curve Mobilized—-
  3. Transect gastro-colic until prox duo. Avoid R gastro-epiploic!
  4. Extend gastro-colic to take the L gastro-epiploic, short gastric vessels, and gastrophrenic vessels
    —- Grater Curve Mobilized —-

To gain extra length:
1. Kocher maneuver
2. Divide the R gastric artery

Greater omentum = gastro-colic + gastroc-splenic + gastro-phrenic ligaments

365
Q

Epiphrenic divertciulum

A

Loc: distal eso. R > L. Pulsion
Tx: only if sxs.
- L diverticulectomy w/ contra myotomy

366
Q

Dx and Tx of Eso perf

A

Dx: XR then contrast esophogography (GG then Ba)
- EGD if UGI is negative but still high suspicious
- don’t require CT

Tx-
1. abxs (fungus)
2. Cervical: open neck and place drains
3. Thoracic: L thoracotomy, extended myotomy, cover w/ 2 layers
- if achalsia: contra myotomy
4. Buttress with IC muscle
NG, chest tube
5. Very unstable: exclusion and diversion

Selective non-op:
1. Contained perf w/ minimal signs of sepsis
OR
2. Very poor operative candidate

Stenting: contained perf or minimal extrav after EGD

367
Q

FeNa equation and interpretation

A

(U Na/S Na) / (U Cr / S Cr) * 100

<1% = Pre-renal
>1% = Intrinsic
>4% = Post-renal

368
Q

Refeeding Syndrome - mech and px

A
  • Mech: fat to carb metabolism ➡ resumption of ATP production and Insulin surg ➡ Ph influx into cells ➡ hypoPh
  • Px: HypoMg, Ph, K; paresthesia, confusions, RD
  • COD is cardiac failure
369
Q

pH relation to pCO2

A

10 mmHg increase in pCO2 = .08 decrease in pH

370
Q

Tx of DI

A
  1. Central- DDAVP
  2. Peripheral- tx underlying causes (stop Li), amiloride, HCTZ
371
Q

W/up and Tx of endometrial CA

A

W/up: Post-meno w/ bleeding ➡ TVUS ➡ endo bx

Tx: Hysterectomy, bilateral SO, peritoneal w/out, LN sampling
- Required for Tx AND staging!
- XRT if high risk
- Chemo if mets

372
Q

Pregnant lap appe

A

Left lateral decubitus position
Entry port:
- take into account fundal height (6cm above)
- P/S @ 12 wks, half-way @ 16 weeks, umbo @ 20 weeks
- 2T-3T: supra-umbo if possible otherwise LUQ or RUQ

373
Q

Px, Dx and Tx of ovarian torsion

A

Px: Sudden pain + adnexal mass w/out bleeding
- prior similar episdoes

Dx: pelvic US with doppler

Tx:
- Lap detorsion
- Oopherectomy only if- necrosis, cancer, recurrent

374
Q

Monitor and reverse TPA

A

Fibrinogen level (<100 = r/o bleeding)
Reverse: a-CA

375
Q

Cause and Tx of Warfarin skin necrosis

A

Cause: protein C def (not S!)
Tx:
Stop Coumadin
Give vitamin K
Start hep gtt or argatroban

376
Q

Intrinsic vs. Extrinsic Pathways

A

Intrinsic: 8, 9, 11, 12
Extrinsic: 7 (shortest t 1/2), Tissue factor
Common: 1, 2, 5, 10

377
Q

Reversal of NOACs:
Apixaban
Rivoroxaban
Dabigatran

A

Apixaban: andexanet
Rivoroxaban: andexanet
Dabigatran: idarucizumab (+iHD)

378
Q

VWD dx and tx

A

dx: normal PLTs. Abnormal BT, PTT
- ristocetin test or measure vWF level

tx:
1. type 1: not enough; ddavp ➡ cryo
- MC congenital bleeding disorder

  1. type 2: qualitative; VWF/f8 concentrate, cryo
    - DDAVP for some subtypes
  2. type 3: VWF/f8 concentrate, cryo

**only type 1 (and some type 2 subtypes) can use DDAVP

379
Q

Tx of hepatic encephalopathy

A
  1. Correct precipitating cause
  2. Lactulose (goal 2-3 stools/day)
  3. Rifaximin
  4. Neomycin
380
Q

PEP:
1. HIV
2. HBV
3. HCV

A
  1. HIV: 4wks of anti-retroviral combo
  2. HBV: HBIG + Vaccine
  3. HCV: No recommendations.
381
Q

Segmental liver anatomy

A

7 - 8 - 4a - 2
6 - 5 - 4b - 3

382
Q

Dx and Tx of Budd-Chiari Syndrome

A

Dx: doppler (usually 2/2 to p. vera)
Tx:
1. Lifelong AC
2. < 4 weeks: thrombolytics
3. > 4 weeks: angioplasty/stenting
4. Refractory: TIPS, transplant, surgical shunt

383
Q

Tx of Isolated Gastric Varices

A

2/2 chronic pancreatitis induced splenic vein thrombosis
tx- Splenectomy

384
Q

Effects of pneumoperitoneum

A

Increase preload initially, then decrease
Increase afterload. Decrease CO
Increased PCO2. Decrease FRC
Decrease renal function

385
Q

Pancreas blood supply and anatomy

A

Head- Superior PD (Off GDA, off CHA, off CeT) and Inferior PD (off SMA)
Body/Tail- Branches of the splenic artery

Head- right of SMA (SMV is right of SMA also)
Uncinate- hugs the SMV and SMA
Neck- over the SMA
Body/tail- left of SMA

386
Q

Indication for ERCP w/ GB dz

A
  1. Bili > 4
  2. CBD stone on U/S
  3. CBD > 6 mm and Billi > 2
  4. Ascending cholangitis
387
Q

Autoimmune pancreatitis - px, dx, tx

A

Px: pancreatitis w/ normal Lipase and LFTs
Dx: IgG+, biopsy to prove.
- CT: dilated w/ no Calcs. “sausage” appearance.
- Brush biliary tree if concern for malignancy
- different from hereditary pancreatitis (PRSS1 mut’n)
Tx:
0. Bx first!
1. ERCP if stricutre: r/o ca, relieve obstruction
2. Steroids

388
Q

W/up of pancreatic cancer

A
  1. Pancreatic protocol CT
  2. EUS: if questionable LN or vessel involvement
  3. ERCP: if jaundice or dx uncertainty
    - 90% sensitive for dx
  4. PET/CT: selectively if suspicion for malignancy.
  5. Staging scope: if suspect disseminated dz
    - > 3cm, high Ca 19-9, tail tumor, high weight loss/malnutrition
  6. Bx: Not if resectable. Only if neo-adj chemo
389
Q

Tx of acute mesenteric ischemia

A

Thrombotic: at origin of SMA; prox. jejunum to transverse colon
- smokers

Embolic: distal SMA; jejunal sparring
- embolism (usually from left atrial appendage)

  1. IVF, abxs, AC
  2. Emergent revascularization
    - peritonitis: ex lap to evaluate bowel, open embolectomy
    - consider endovascular if specialized center, no peritonitis, and low suspicioun for necrotic bowel
390
Q

Dx and Tx of chronic mesenteric ischemia

A
  • Dx:
    1. duplex (Celiac > 200, SMA > 275) is 1st line for screening
    2. CTA (>70%) for definitive dx (best test)
  • Tx: Sxs + stenosis of > 70%
    1. Endovascular plasty/stent is 1st line. 1V SMA stenting is enough even if both celiac/SMA are inovlved
    2. Open surgery: if can’t tolerate endovascular
  • aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation
391
Q

Tx of renovascular stenosis

A
  1. BB
  2. ACEi: unless 1 kidney or bilateral dz
    - efferent dil’n can worsen kidney dz
  3. PTA: perc trans-luminal angio +/- stent (or open revascularization)
    - only if refractory to meds!
  4. Nephrectomy

**CORAL trial: PTA is not better than maximum medical therapy

392
Q

Open SMA embolectomy

A
  1. Lift transverse mesocolon
  2. Trace MCA. Palpate the SMA at root of mesentery along inferior margin of pancreas
  3. Incise peritoneum and dissect down to the artery (left of the SMV)
  4. Therapeutic heparinize
  5. Proximal and distal control
  6. Transverse arteriotomy PROXIMAL to middle colic origin
  7. 2 or 3 Fogarty balloon passed proximal and distal
  8. Close arteriotomy with interrupted proline
393
Q

Tx of air embolism

A
  1. LEFT lateral decubitus and Trendelenburg (trap air in the RV)
  2. Aspirate central line
394
Q

Timing of endarterectomy after a stroke

A
  1. Non-disabling stroke or TIA: 2d-2w
  2. Big stroke: no consensus
395
Q

When to consider ppx fasciotomy + steps

A

6+ hours of warm ischemia

Steps:
- lateral incision: between tibia and fibula ➡ open anterior and lateral compartment
- medial incision: 1 finger posterior to tibia ➡ open fascia over the gastric ➡ peel soleus off of the tibia ➡ open deep posterior fascia

396
Q

Femoral embolectomy

A
  • Longitudinal incision over the groin
  • Expose femoral common, SFA, and profunda
  • Control with vessel loops
  • Ensure ACT > 250
  • 4-5F fogarty proximal, then distal to SFA and profunda (2x clean pass for each)
  • Infuse hep saline
  • Close arteriotomy w/ interuppted prolene
397
Q

Exposure of LE arteries:
1. Femoral
2. AK Pop
3. BK Pop
4. TP Trunk

A
  1. Femoral: vertical incision over the artery from inguinal ligament
  2. AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus lateralis. I
  3. BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment.
    4, TP trunk: MEDIAL incision below the tibia. Divide soleus origin of the tibia
398
Q

Preference for peripheral fistula

A

Location:
1. Rad/Ceph
2. Rad/Bas
3. Bra/Ceph
4. Bra/Bas
5. Prosthetic peripheral
6. Prosthetic ax-brachial
7. Prosthetic femoral

**Upper extremity preferred to LE

Rule of 6’s:
- flow > 600/min
- diameter > 3mm before placement. > 6mm after placement
- depth of 6mm

**artery at least 2 mm

399
Q

SC Steal syndrome - path and tx

A

Path- Prox SC stenosis. Reversal of flow through ipsilateral vertebral to SC

Tx: if V/B sxs (diplopia, vertigo, dysphagia, ataxia)
1. PTA w/ stent to SC artery
2. Carotid to SC bypass

400
Q

Tx of type B dissection

A
  1. Uncomplicated: b-blocker for impulse control, elective repair
    - Surveillance q3, 6, 12m. TEVAR if progression
  2. Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR
    - Need at least 2 cm landing zone distal to L SC
401
Q

Tx of splenic aneurysm

A
  1. > 2cm, sxatic, or fertile age female
    - embolize distal AND proximal (back bleeding from short gastric)
    - trauma/rupture situation may require splenectomy
  2. Otherwise, monitor
402
Q

Tx of aneurysms
- splenic
- renal
- iliac
- femoral
- pop

A
  • splenic: > 2cm or sxs ➡ embolize
  • iliac: > 3 cm ➡ covered stent
  • femoral: > 2.5 cm ➡ covered stent
  • pop: > 2 cm ➡ exclusion and bypass
403
Q

Tx of psuedoaneurysm

A

tx:
< 2cm observe
> 2cm:
- skinny neck: thrombin injection
- wide neck: operative intervention

Surgery for complicated disease:
- infxn (cellulitis)
- skin necrosis, skin changes
- neuro deficit, AMS
- HDUS, pulsatile,

404
Q

Nerve injuries during CEA:
- Recurrent laryngeal
- Marginal mandibular
- Hypoglossal nerve
- G/Ph nerve
- Superior laryngeal
- Accessory

A
  • Recurrent laryngeal: MC cranial nerve; 2/2 clamping; hoarseness
  • Marginal mandibular: excessive retraction and angle of jaw; Ipsilateral lip palsy
  • Hypoglossal nerve: ipsilateral tongue deviation
  • G/Ph nerve: from high dissection; difficult swallowing
  • Superior laryngeal: high-pitch
  • Accessory: failure to shrug shoulders
405
Q

Tx of Type A dissection

A
  • Treat with immediate surgery
  • Put patient on bypass
  • Median sternotomy
406
Q

May-Thurner Syndrome

A

Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine

tx- venogram, thrombolysis and stenting

407
Q

W/up of non-variceal UGI bleed (M/W tear)

A
  1. NGT+ ➡ EGD w/in 24h- clips, coags, banding, sclerose
  2. NGT-:
    - HDUS: IR angio (must be brisk)
    - HDS- C’scope/consider RBC scan, surgery
408
Q

Surgical indications for acid reduction surgery

A

Elective indications:
- refractory to medical management
- suspicion of a malignancy within an ulcer

Acute indications: HDS, minimal contamination AND:
1. PUD w/ unknown h. pylori status (if known can just be tx medically) OR
2. Unable to stop NSAID therapy (NSAID ulcer)

409
Q

Acute surgical options for duodenal ulcer disease

A

Indications: bleeding, perforation, obstruction

  1. Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed
    - can tie off the GDA if continues to bleed
    - no vagotomy
  2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment (90% H.pylori related)
    - If close to pylorus: pyloroplasty (+/- truncal vagotomy)
    - If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy
  3. Obstruction: NGT, resuscitation, anti-secretory ➡ EGD w/ balloon dilation ➡ antrectomy
  • Only do acid surgery acutely (vagotomy/drainage) if:
    1. HDS, minimal contamination AND
    2. PUD w /h. pylori status negative, unknown, refractory OR unable to stop NSAID therapy (NSAID ulcer)

**EGD does not require bx for duodenal ulcers

410
Q

Tx of gastric ulcer disease

A

Indications for surgery: bleeding, perforation, refractory
- 8-12w of PPI + H. pylori eradication
- must bx at 8 spots

Approach:
1. GC, antrum, body: wedge resection
2. Lesser curve: distal gastrectomy w/ bili
3. GEJ:
- bleeding: anterior gastrotomy, over-sew, send biopsy
- perf: sub-total gastrectomy w/ REY reconstruction

**Can’t wedge lesser curve b/c prominent L gastric arcade and deformed stomach

411
Q

Tx of Complications after Billroth 2:
- Afferent limb obstruction
- Dumping syndrome
- Alk reflux
- Post-vag DRH

A
  1. Afferent limb obstruction: prevent with afferent limb < 20 cm
    - acute: convert Bil 1 or REY (STAT!)
    - chronic: Bacterial overgrowth: try abxs 1st (Rifaximin)
    . convert to REY
  2. Dumping syndrome: small meals, no sugar ➡ octreotide
  3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm.
    - pro-kinetics, bile-acid binding ➡ convert to REY with long roux
  4. Post vagotomy DRH: cholestyramine (dx of exclusion) ➡ reversed jejunal segment
412
Q

How to confirm H. pylori eradication

A

4-weeks after triple therapy:

  1. Urea breath test: preferred 1st line
  2. EGD + Bx: preferred if known gastric ulcer (r/o CA)
  3. Fecal Ag test

**Gram-, spiral-shaped

413
Q

Primary fuel source in fasting state

A
  1. 1st 4 hours: exogenous glucose
  2. 4h-1d: Liver glycogen
  3. 1d-1w: gluconeogenesis phase (alanine from muscle)
  4. 1w+: protein-sparing phase
    - FA/Ketones are used everywhere
    - RBCs use glucose only
414
Q

Dx and Tx of rectus sheath hematoma

A

Dx- mass unchanged with contraction
Tx- CTA if HDS. OR if unstable:
1. Observation- no active bleed
2. IR- if active bleeding or T3 (pre-vesicle space)
3. OR- if HDUS or skin necrosis

**can also consider IR if HDUS

415
Q

Removal of perc chole tube

A
  1. Remain in place for 3-6 weeks for tract to form
  2. Cholangiogram to assess CD patency
  3. Clamp tube or elective chole if surgical candidate
416
Q

Essential fatty acids and deficiency px

A
  1. Linoleic acid- omega-6 (Cis, Unsturated)
    - inflammatory
  2. α-linolenic acid- omega-3 (Cis, Unsturated)
    - anti-inflammatory

Deficiency: waxy skin, dermatitis, hair loss, TCP

417
Q

RQ interpretation (metabolic cart)

A

CO2/O2

< .7 = underfeeding/starving
.7 = pure fat
.8 = pure protein
.8-.9 = desired
1 = pure carb
>1 = overfeeding

418
Q

BSC vs. SqCC - dx and tx

A

BSC: most common malignancy in USA; pearly, rolled borders, peripheral palisading; MC upper lip ca

SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca
- MC ca after trx

Tx:
- 4 mm for unaggressive: well differentiated and < 2 cm
- 8 mm for aggressive: poorly differentiated, > 2cm, or Marjolin
- 1 mm for MOHS
- MOHS for aggressive subtypes
- LADN’y for clinical positive nodes
- Can consider SLNBx for high risk SqCC
- Limited role for chemo/XRT

419
Q

Dx and Tx of Nec Fac

A

Dx:
- LRINEC score: Na. glucose, WBC, CRP, Hb, Cr; >8 = 95% PPV
- CT: gas, thick fascia

Bacteria profile:
- MC polymicrobial
-if monomicrobial, MC GAS/strep pyogenes: M protein virulence

Tx:
- abxs: carbapenem OR broad spectrum w/ clinda (anti-toxin effect) and MRSA coverage
- surgery

420
Q

Dx and Tx of pancoast tumor

A

Dx:
- Perc bx: usually sqcc
- Mediastinoscopy (or EBUS)

Tx:
- Induction chemo-XRT
- surgical evaluation
- c/i to surgery: extra-thoracic mets, n2 disease, brachial plexus above T1, >50% vertebral body, eso/trachea involvement
- vascular involvement is not c/i

421
Q

Types of hyperPTH

A

1- High Ca/Low Ph: over-secretion

2- Low Ca/High Ph: CKD or VitD def (physiologic)

3- High Ca/High Ph: hyperplasia 2/2 kidney transplant

**VitD def: compensatory hyperPTH 2/2 to low Ca and Ph

422
Q

Dx and Tx of Ewing Sarcoma

A

Dx: “onion skin” in diaphysis
- pelvis is MC location

Tx: chemotherapy (1st line) + surgery or XRT

423
Q

Pulmonary sequestration

A

No bronchial commmunication
1. Intra-lobar: MC; blood from aorta; pulmonary veins
2. Extra-lobar: systemic arteries and veins

Tx- lobectomy or segmentectomy

424
Q

Lung anatomy: R vs. L

A

Right:
- oblique/major fissure: separates lower from middle/upper
- horizontal/minor: separates middle from upper
- main bronchus 90-degrees; 2 bronchi

Left:
- oblique/major fissure; 1 bronchus

425
Q

RF and Tx of T/I fistua

A

RF- trach below 4th ring OR, high pressure cuff, high innominate cross

  1. Over-inflate the cuff
  2. Intubate from above
  3. Compress against the sternum
  4. Median sternotomy
  5. Ligation AND division of innominate artery
  6. Buttress tracheal hole w/ muscle

**aorto-enteric fistula should also be treated aggressively with operative takedown and extra-anatomic bypass

426
Q

Indications for pleurodesis

A
  • Air Leak > 5 days
  • Recurrent (even if contra-side)
  • High risk occupation (scuba, pilot)
427
Q

Px, dx and tx Lymphocele

A

Px: sudden decrease in UOP weeks after trx
-2/2 lymphatic leak from iliac dissection
-Sirolimus is a RF

Dx: US

Tx: perc drain (if sxs) ➡ peritoneal window

428
Q

Px, Dx, Tx of RAS and thrombosis after kidney transplant

A
  1. Thrombosis: sudden cessation of UOP immediately post op
    -Dx: U/S
    -Tx: nephrectomy unless small branch
  2. Stenosis: refractory HTN and elevated Cr
    - Dx: US (vel > 180, 70%)
    - Tx: perc angio/stent

**No pain with arterial issue (pain = venous issue)

429
Q

W/up and Causes of low UOP after kidney trx

A

w/up:
1. doppler U/S: check vasc/urteter mosis, bladder outlet obstruction
2. empiric fluid bolus

Causes
1. Immediate: arterial thrombosis- nephrectomy
2. Weeks: lymphocele- open/lap peritoneal window
3. Months: polymovirus (BK)- nephrostomy + reconstruction

430
Q

Inflow and outflow for pancreas transplant

A
  1. Inflow: iliac vessels (kidney- left, pancreas- right)
    –donor SMA and splenic artery are connected with donor iliac artery Y graft to be plugged into the right iliiac
  2. Outflow: iliac vessels
    –donor SMV/splenic vein are already connected. Plugged into R iliac vein (or SMV/PV)

**Duo can be connected to SB or bladder

431
Q

w/up of kidney graft dysfunction

A
  1. Elevated Cr. Low UOP.
  2. US: high RI is a non-specific finding
    - Vascular abnormality ➡ angio, stent, or surg
    - Lymphocele/Urinoma ➡ perc drain ➡ perit window
    - Negative: graft dysfunction ➡ Core needle bx
432
Q

Post transplant hepatic artery vs. PV thrombosis

A
  1. HA thrombosis: MC
    - Early: FHF ➡ thrombectomy OR re-trx
    - Late (months): abscess, strictures ➡ temporize, re-trx
    - Stenosis: angio and stent
  2. PV thrombosis: rare
    - Early: FHF ➡ thrombectomy or re-trx
    - Late (months): encephalopathy, varices ➡ AC
    - Stenosis: angio and stent
433
Q

GVHD - px, path, dx, tx

A

-Px: hepatitis, dermitis, GI sxs after stem-cell/marrow trx

-Path: DONOR T cells morph into Th cells; target host

-Dx: bx

-Tx: steroids + IS

434
Q

Tx of testicular torsion

A
  1. Surgical de-torsion of involved testes
    - If doubtful viability: <10 keep, >10yo orchiectomy
  2. Exploration and fixation of uninvolved testis as well!

**don’t delay OR for U/S if suspicion is high

435
Q

Dx and Tx of RCC

A

Dx: triple phase CT (don’t need tissue bx unless mets)
- do cystoscopy after CT

Tx: Upfront Radical nephrectomy + LND +/- chemo +/- XRT
- TK inhibitor is 1st line chemo
- Simultaneous thrombectomy if IVC thrombus

436
Q

Types of hydrocele and Tx

A
  1. Communicating: children. 2/2 patent processus
    - <2yo: conservative, observe
    - >2yo: surgical excision of processus
  2. Non-communicating: adults. 2/2 secretions not connected to peritoneum
    - dont tx if asx. tx w/ excision

**can dx on PE (transillumination). DO NOT need U/S

437
Q

Dx and Tx of LCIS

A

Dx
- usually incidental/bilateral
- pre-menopausal white women. mammo negative
-R/o breast ca is .5% per year

Tx
- Lumpectomy/Excisional bx (10-20% chance of DCIS/CA)
- Don’t need negative margins
- No SLNBx
- Can use tamoxifen to prevent hormone+ cancers (even if you don’t know hormone status)

PPx options
- Surgery
- Hormonal therapy
- Surveillance w/ MRI or mammo q6m

438
Q

Dx and Tx of inflammatory breast ca

A

Dx: clinical diagnosis
- rapid erythema with paeu de orange < 6 months
- mammo/US first!: must have path of invasive cancer
- bx: dermal lymphatic invasion is suggestive but not required

Tx:
1. Neo-adjuvant
- can give trastuzumab if HER2+
2. MRM
3. XRT
4. Endocrine tx

439
Q

Fibroadenoma - px, dx, tx

A

Px: painful/larger w/ periods or pregnancy

Dx:
- imaging: well-circumcribed, coarse ca+
- bx: fibro-epithileal lesions (“aggressive” = phyllodes)

Tx:
- obesrve if: mobile, concordant imaging/bx
- resect if: > 3cm, sxs, growth, anxiety, discordance, lesions “not further defined”

440
Q

Tx of breast ca in preg

A

Dx: mammo + U/S + bx
- mammo is safe

Tx:
1T (13w): mastectomy + SLNBx (radioactive sulfer) +/- chemo at 2T

2-3T: lumpectomy + SLNBx (radioactive sulfer) +/- chemo + post delivery XRT
- chemo is safe in 2nd/3rd trimesters. XRT is not
- XRT is c/i throughout preg

**No blue dye!

441
Q

Indications for post-mastectomy radiation

A
  1. > 5cm (T3+)
  2. 4+ nodes (N2)
    • margin
  3. skin involvement
  4. inflammatory BC

**if prefer recon must be delayed or used a tissue expander for immediate recon

442
Q

Bolus fluid and blood in children

A

Fluid: 20cc/kg
Blood: 10cc/kg

443
Q

Repair aortic trauma

A

Access usually with Mattox maneuver
If < 50% closure primary with polypropylene suture
If > 50% perform a PTFE patch

444
Q

Small bowel trauma

A
  1. Serosal tear: interrupted, non-absorbable
  2. <50%: 1 or 2 layer closure
  3. > 50%: resection and anastaoisis
  4. Multiple short segments: resection and anastamoisis
445
Q

Access to neck zones

A

Zone 1: thoracic inlet to cric ➡ median sternotomy with left neck incision

Zone 2: cric to angle of mand ➡ left neck incision

Zone 3: angle of mand to skull base ➡ IR

446
Q

Causes of R-shift/decrease affinity on Oxy-Hb curve

A

2,3 DPG
Elevated temp
Higher paCO2
Acidosis

447
Q

Shock class

A
  1. No VS changes
  2. Tachycardia
  3. Hypotension and combative
  4. No UOP and obtunded
448
Q

Ketamine MOA, s/e and c/i

A

MOA: NMDA glutamate ANTAgonist,

s/e: tachycardia, hallucinations

c/i:
- MI (b/c SNS activity/cardiac demand)
- Space occupying brain lesion

449
Q

SCIP Quality Measures

A
  1. abx 1h prior to incision (for approrpaite pts)
    - include G negative coverage for GI procedures
  2. abx dc w/in 24h
  3. appropriate hair removal
  4. controlled 6am glucose in cards pts
  5. dc foley on POD1-2
  6. normothermia
450
Q

Insulin peri-op

A

On morning of surgery:
- Don’t take oral hypo-glycemics
- Don’t take short-acting insulin
- Take 1/2 of long-acting insulin

**Insulin pump should be converted to insulin gtt for emergency surgery

451
Q

Frey Syndrome

A
  • Gustatory sweating
  • 2/2 auriculotemporal nerve
  • Suspect after parotidectomy for H/N tumor
  • tx with anti-persiperant
452
Q

Dx and Tx:
1. TG duct cyst
2. Brachial cleft cyst
3. Cystic hygroma

A
  1. TG duct: midline through hytoid bone; sistrunk procedure
    - if infected tx w/ abxs first
  2. Brachial cleft: anterior SCM; resection
    - 2nd cleft cyst MC (mid/lower neck)
  3. Cystic hygroma: posterior triangle; resection (avoid infection)
453
Q

STITCH trial

A

5 mm bites every 5 mm

454
Q

Tx of parastomal hernia

A
  1. ASx- can observe
  2. Sxs- sugarbaker is preferred
    - keyhole is alternative
    - do not relocate
  • Only repair for obstruction or strangulation
  • LB herniates more than SB
455
Q

Tx of hiatal hernia

A

Type 1- asx: NTD; sxatic: PPI; Surgery if refractory
Type 2-4: surgery even if asx

456
Q

Dx and Tx Ischemic Orchitis

A

dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5

tx- NSAID and pain meds. Orchiectomy is last resort.

457
Q

MCCO Cushing syndrome

A
  1. Exogenous steroids
  2. ACTH pituitary adenoma (Cushing disease)
  3. Cortisol secreting adrenal adenoma
  4. ACC
458
Q

Dx and Tx of Addison’s

A

Cause- AI attack of adrenal cx
Labs- hypoNa, hyperK
Dx: cosyntropin stim test - cortisol remains low
- deceased cortisol and aldo with high ACTH
Tx- steroids

459
Q

Px and W/up of Hypercortisolism (Cushing’s syndrome)

A

px: moon facies, striae

  1. Initial tests: choose 1-2
    - 24h urine free cortisol (most se)
    - late night salivary cortisol (when cortisol is lowest)
    - overnight 1 mg dexa suppression
  2. ACT Level
    A. ACTH normal/high - high dose dexa suppresion
    - no suppression: small cell lung ca
    - suppressed: pituitary adenoma (Cushing’s disease) (MC endogenous)

B. ACTH low
- CT positive: adrenal mass
- CT negative: exogenous (most common)

460
Q

Dx, Path and Px, and Tx of carcinoid tumors

A

Dx: neuroendocrine tumor
- 24H urine HIAA
- chromoA for progression (not specific, false + on PPI)
- Octreotide scan if can’t locate

Path: +chormogranin. desmoplastic mesentery.
- grade ~ Ki67 index

Px:
- Rectum > SI (ileum) > Appendix (MC tumor of appendix)
- GI tract > pulm > GU. Rectum MC
- Carcinoid Syndrome: 2/2 liver mets or large GI tumor

Tx:
- SS analogues (lanreotide) for sxs
- < 2 cm: local excision (transanal, appendectomy, segmental) ➡ no further w/up.
- > 2 cm: staging CT. formal cancer resection.
- all lung carcinoids get formal resection with MLND
- c/scope post-op b/c 15% have synch lesions

461
Q

Tx of mesenteric vein thrombosis

A
  1. AC
  2. Surgery if peritonitis or failure to improve
    - can also consider endovascular thrombolytics
  3. 2nd look operation 24-48 hours
462
Q

Tx of Grave’s disease

A
  1. Beta blocker
  2. Methimazole. PTU if preggo
  3. RAI once euthyroid: worsens opthalmopathy and c/i in pregnancy/breast-feeding
  4. Surgery if refractory, opthalmotaphy, compressive sxs, RAI and methimazole/PTU c/i
    - consider lugol’s solution pre-op (only for Grave’s)

**Preggo: beta blocker, PTU. Avoid RAI. Surgery if can’t tolerate PTU

463
Q

W/up of Hashimoto’s disease

A
  1. FNA- r/o ca
  2. Bloodwork- antiTPO/TG Ab
  3. Tx- thyroxine ➡ partial thyroid

**MCCO hypoT and goiter in the US

464
Q

Tetanus ppx

A
  1. Full immunized (>= 3 toxoid doses)
    - clean/minor: toxoid vaccine if dose >= 10 years
    - dirty or > 1cm: toxoid vaccine if dose >= 5 years
  2. Unknown or not fully immunized
    - clean/minor: toxoid vaccine
    - dirty or > 1 cm: toxoid vaccine + Ig
465
Q

Px, Dx and Tx of CMV colitis

A

Px: colitis, retinitis, hepatitis (can effect any organ system)

Dx:
- usual CD4 < 50
- PCR is unreliable b/c does not prove end-organ disease (can be falsely negative)
- must scope and bx: Cowdry bodies, punched out ulcers

Tx: gancylovir (valgan is oral form)
- initiate HAART
- opthalmic exam to r/o retinitis

466
Q

Standard w/up for lung ca

A
  1. PET/CT
  2. PFTs
  3. Bronchoscopy (can be intra-op)
  4. Mediastinal eval- EBUS or mediastinoscopy
467
Q

Bronchiolitis obliterans

A

MCCO long term lung trx failure
2/2 bronchiole inflammation
Px- serial decline in PFTs. Normal tacro. CT- ILD
Dx- of exclusion
Tx- steroids (inhibit COX2), IS, reTrx (very poor outcomes)

468
Q

Pressor for neurogenic shock

A
  1. Above T6: nor-epi (b/c HoTN and brady)
  2. Below T6: Phenylephrine (may worsen brady above T6)

**don’t normally get neuorgenic shock below T6

469
Q

Vitamin A

A
  • wound healing especially in steroid patients
  • def: night blindness, dry eyes
470
Q

PPV and NPV

A

PPV = of those who test + how many have the dz
NPV = of those who test - how many do not have the dz

Increasing prevalence = increase PPV and decrease NPV
Increasing survival = increasing prevalence

471
Q

Pearson’s R Value

A

Correlation coeff between -1 and 1

1 = very strong positive (direct proportion)
> .7 = strong positive
0 = no correlation
- .7 = strong negative

Do not determine causation

472
Q

Phases of clinical trail

A
  1. Safety in a small group of humans
  2. Effectiveness and side effects
  3. RCT compared to standard of care
  4. Long term safety and monitoring
473
Q

Subclavien exposures

A
  1. Median sternotomy: right
  2. Left Anterolateral thoracotomy: left subclavian
    - trap door supraclav incision for distal access
474
Q

Indications for hepatectomy instead of liver trx in HCC patient who meets Milan criteria

A

Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm
- hepatectomy is preferred to transplant if they are Childs A

475
Q

SMA embolus vs. thormbosis px

A

Embolus- lodges after the middle colic. Jejunal sparring
Thrombus- at ostium; pan-bowel

476
Q

Desmoid Tumor - associations, path and tx

A

A/w:
- FAP (after surgery, 2nd MCCO death), Gardner syndrome

Path: non calcified, fibrotic, low mit index, spindle cells

Tx:
- WLE for extra-abd; NSAID, anti-Estrogen (tamoxifen) if intra!
- XRT if sensitive area

477
Q

Serologic work-up for adrenocortical mass

A
  1. Dexa suppression (cortisol)
  2. Urine androgens (sex hormones)
  3. Plasma metanephrines (pheo)
  4. aldo/rennin ratio > 30 (salts)
478
Q

Px, Dx and Tx endometriosis

A

Px- cyclic pain, pain with sex

Dx- dx laparoscopy

Tx-
1. Medical therapy
2. Surgery if unresponsive. Ablation if young.

479
Q

MCCO primary hyper-aldosteronism and tx

A
  1. Idiopathic bilateral adrenal hyperplasia (60%)- medical
  2. Adrenal adenoma (Conn’s syndrome)- lap adrenal
  3. Adrenal adenoca- open adrenal + mitotane
    * Can use adrenal vein sampling to distinguish
480
Q

Respectability of pancreatic tumor and next step

A

Triple phase CT:

  1. Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV
    - EUS/FNA for tissue dx for neoadjuvant
  2. Borderline- <180 SMA/celiac, reconstructable PV/SMV
    - EUS/FNA for tissue dx for neoadjuvant
  3. Resectable
    - dx lap (to confirm resectability) + whipple
481
Q

Tx of horseshoe abscess

A

Hanley procedure:
- Midline drainage incision of deep posterior space (through ano-coccygeal ligament)
- Bilateral lateral counter-incisions for ischiorectal space
**all external drainage

482
Q

Tx of anorectal fistula

A

<30% sphincter- fistulotomy or cutting seton
>30% sphincter- draining setons THEN ARAF or LIFT

**Crohns patient: px w/ multiple fistulas
- avoid fistolotomy.
- draining setons.
Can try infliximab if active infection has resolved.

483
Q

Tx of Internal HMHDs

A

G1- bleeding, G2- spontaneous reduce, G3- manual reduce:

1st line: sitz, stool softener, bowel reg, fiber, fluids
2nd line (office): band, sclerotherapy, coagulation
- band is most effective
- sclerotherapy if on blood thinners

G4- can’t reduce
- surgical HMHD’ectomy (stapled has higher recurrence)

484
Q

Tx of External HMHDS

A

1st line: sitz, stool softener, bowel reg, fiber, fluids
2nd line: surgical HMHD’ectomy
Thrombosed: incise or excision if w/in 48h

485
Q

Paget’s disease of the anus (px and tx)

A

Px: intractable pruritis, eczematoid rash

Tx: scope (r/o malignancy)
- dc topical agents
- perianal punch bx + WLE

486
Q

Unresectable cholangiocarcinoma

A

Criteria
- bilateral HA or PV
- unilateral HA with extensive contra duct
Tx
- no extrahepatic dz ➡ neoadj chemo-XRT + liver trx
- extrahepatic dz ➡ chemo-XRT

487
Q

Bismuth classification and tx

A

For hilar cholangioca. Only t4 unresectable.
1: CH duct- REYHJ + LADN +/- lobectomy
2: bifurcation- REYHJ + LADN +/- lobectomy
3: R or L HD- REYHJ + LADN + lobectomy
4: Both ducts- chemo-XRT + liver trx

488
Q

Lap CBD exploration

A
  1. Dissect CD to the level of the duo
  2. Cholodochotomy distal to the CD/CBD junction
  3. Fush, basket, or fogarty balloon the stone out
  4. Close primarily, over a T-tube, or over a stent
489
Q

Px and Tx of Chalangitis

A

Dx: fever, RUQ, and jaundice
- stones > malignancy > stricture
Tx:
- signs of sepsis: resuscitate/abx then urgent ERCP
- no sick: US/MRCP

490
Q

Px and Tx of Sphincter of Oddi dysfunction

A

Px: Biliary pain with normal RUQ U/S after years lap chole
Dx: mannometry (no MRCP or CT 1st)
Tx: endoscopic sphincterotomy at 11’ (CCB usually ineffective)
- CBD at 11’, PD at 1-3’
- h/o REY: open transduo sphincterotomy

491
Q

Ideal setting for stone formation

A

Low bile salts
Low lecithin
High cholestersol

492
Q

Mirizzi syndrome tx

A

px- GB neck/CD stone compresses CHD
types:
1: no fistula- cholecystectomy
2: < 1/3 circ- CC’ectomy + CBD repair w/ T-T
3: < 2/3 circ- CC’ectomy + REY-HJ
4: full circ- CC’ectomy+ REY-HJ

493
Q

Types of GB polyp

A
  1. Cholesterolosis: MC; CE mphages in LP; benign
  2. Adenomyomatosis: benign
  3. Adenoma: malignant; >1cm is RF for CA (resect)
494
Q

Tx strategy for CBD transections

A
  1. Intra-op
    - <50%, not cautery: primary repair
    - >50%, or cautery: REY-HJ
  2. Late phase
    - Place drain
    - Define anatomy w/ ERCP, PTC, or MRCP
    - Place PTC tube
    - CTA to assess for R/L HA injury
    - Delayed reconstruction 6-8 weeks once optimized
495
Q

Management of GB polyps

A
  1. Sx: cc’ectomy
  2. For asx:
    - > 18 mm: tx as GB cancer
    - > 10 mm: CC’y
    - 6-10 mm: q6m U/S for 1 year. cc’ectomy if PSC
496
Q

PSC screening guidelines

A
  1. Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9
  2. GB CA: US q6-12m
  3. CRC: colonscopy q1-2 years (regardless of UC)
497
Q

Dx and Tx of Colovesicular Fistula

A
  1. CT w/ oral/rectal (no IV b/c will obscure bladder)
    (not cystoscopy, colonoscopy, or Ba enema)
  2. Colonoscopy to r/o malignancy
  3. Cystoscopy if suspect cancer. Retrograde cysto if CT is equivocal or operative planning

Tx- resect sigmoid even if asx; Don’t need to repair the bladder, just drain

498
Q

Colon cancer and arterial resection

A
  1. R hemi- IC, RC, RBMC
    - cecum/asc colon
  2. Extended R- IC, RC, MC
    - hepatic flex/prox t colon
  3. L hemi- LBMC, LC
    - Distal TV, splenic flex, prox descending
  4. Extended L- LBMC, origin of IMA
    - splenic flex
  5. Sigmoid- IMA (hi- b4 LC, low- after LC)
    - dist desc/sig
499
Q

Colon CA surveillance after curative resection

A
  1. Exam and CEA q3-6m x 3 years
  2. Colonoscopy @ q1, 3, and 5 years
    - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel)
  3. CT CAP q1y x 3 years
  • At 2 years: recurrence local or hepatic
  • after 2 years: hepatic more often
500
Q

Staging w/up of rectal cancer

A
  1. TRUS (avoid if > t2) or MRI- T/N stage
    - suspicious nodes on MRI count as clinical stage N (neo-adj)
  2. CT CAP- M stage
  3. C’Scope- for initial dx and sync lesion. not for T stage
  4. Rigid Sig’Scope- for distance from anal verge (required! even. if c’scope done)
501
Q

Tx of refractory Crohn’s pan-colitis

A
  1. Segmental colitis- partial colectomy
  2. Rectal sparing pan-colitis- TAC w/ IRA
  3. Pan-colitis w/ rectum- PC w/ end ileostomy
    - IPAA whether w/ or w/out loop should NOT be done on Crohn’s b/c r/o pouchitis
502
Q

Tx of cecal volvulus

A

Stable- R hemi and primary mosis (no pexy)
Unstable- R hemi with end ileostomy

503
Q

Dx of Juvenile polyposis

A

Dx: 5+ polyps or any polyps w/ family hx
- SMAD4+
Non-adenomatous polyps ~ hamartomas

504
Q

Tx of Lynch Syndrome

A
  1. CRC: MC
    - q1y C-scope @ 20-25
    - TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma
    - q1y scope post op
  2. Endometrial: 2nd MC
    - q1y endometrial sampling @ 30-35
    - ppx TAH-BSO after children
  3. Ovarian:
    - q1y TVUS and Ca-125 @ 30-35
    - ppx TAH-BSO after children
  4. Stomach:
    - EGD/Bx q2-3y @ 30-35
  5. Renal: transitional cell ca
    - q1y UA and US @ 30-35
505
Q

APR vs. LAR

A

Tumors that require APR:
1. < 5cm for anal verge
2. Tumor at dentate line w/ sphincter involved
3. Tumor that can’t get a 1 cm distal margin w/out sphincter
4. Poor pre-surgical anorectal function (history of DRH)
5. Locally recurrent low-lying cancer

**Generally follows pre-chemo location of tumor unless COMPLETE tumor response. If tumor initially involved the sphincter complex and now does not ➡ still require APR

506
Q

Polyposis syndromes:
-Muir-Torre
-Gardner
-Turcot
-P/J
-Cowden
-JuP

A

-Muir-Torre: MLH/MSH; sebaceous gland tumor
-Gardner: APC; desmoid tumors, osteomas, epidermal cysts/lipomas
-Turcot: APC; Malignant CNS tumors
-P/J: STK; myocutameous pigmentation
-Cowden: PTEN; Hamartoma polyps, endometrial/breast/thyroid CA
-JuP: SMAD4; epistaxis, AVM, telangiectasia

507
Q

Indications for colonic stent

A
  1. Bridge to surgery in acute obstruction (usually with metastatic cancer)
  2. Palliative measure
    * Usually for L-sided lesions
508
Q

Gram, Tx and Virulence of C. diff

A

Gram: G+ bacillus, anaerobic

Tx:
1. Primary: oral fidox
- oral vanc is 2nd line now

  1. Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus
    - no fidox
  2. Recurrence: PO fidox or vanco
  3. Multiple recurrence: tapered fidox or vanco
    - consider fecal transplant
  4. Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm)

Virulence:
- Toxin A: intestinal necrosis
- Toxin B: cytotoxin

509
Q

Dx and Tx of ischemic colitis

A

Dx- CT first to rule out non-ischemic colitis or infarction; C’scope to confirm
- suspect in low flow state, HoTN
- CTA can’t dx b/c its a microvascular disease
Tx- usually supportive; OR if perf, sepsis

510
Q

Dx and Sx of PNETs
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma

A

**All require bichemical testing before imaging!

  1. Glucagonoma: glucagon > 1k; NME, DM, DVT (no stones vs. SS’oma)
  2. Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad
  3. Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1
  4. VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH)
  5. SSoma: High fasting SS; DM, STONES, steatorrhea

*Do not perform imaging or go to the OR until biochemical diagnosis!

511
Q

Dx and Tx of Pancreatic cysts:
1. Serous cystadenoma
2. MCN
3. IPMN
4. Psuedocyst

A

-W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA
1. Serous cystadenoma: low M/CEA, low Am; resect if sxs
2. MCN: high M/CEA, low Am; resect
3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm
4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy

512
Q

Tx of PNETs:
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma
6. Non functional

A
  1. Glucagonoma: distal panc w/ splenectomy + cc’y
  2. Inuslinoma: enucleate
  3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple
  4. VIPoma: distal panc w/ splenectomy + cc’y
  5. SSoma: resect w/ cc’y
  6. Non functional: < 2cm observe or enucleate. > 2cm resect
513
Q

Perform splenectomy for distal panc PNET?

A

No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm

514
Q

Arterial anatomy of the celiac trunk

A
  1. CHA: gives off GDA then R gastric
    - GDA gives of SPDA and R gastroepi
  2. Splenic: gives off short gastrics and L gastroepi
515
Q

ECG findings of PE

A

Sinus tach is MC
S1Q3T3 pattern w/ TWI

516
Q

Dx and Tx of Pulmonary Blastoma

A

MC primary lung tumor in children
Dx- air/fluid filled cystic lesions. Looks like pneumo.
Tx- Surgical resection +/- chemo-XRT

517
Q

lead vs length time bias

A

Lead-time bias is due to early detection. Remember the “d” in lead is for early detection.

Length-time bias is due to slow cases being detected more often simply because they are slowly progressing/indolent. Remember the “g” in length is for slowly progressing.

518
Q

Brown-Sequard

A

Ipsi loss of motor
Contra loss of pain/temp

519
Q

Dx of biliary dyskinesia

A

Suspect if GB w/ normal US and EGD
Dx- HIDA scan w/ EF < 35% (c/i in pregnancy)
Good responders if classic sxs (n/v, RUQ pain, w/ fatty meals)

520
Q

Emergent ariway in a child

A
  1. Try ETT placement with a miller blade
  2. Needle cric is preferred over open if < 12 yo
  • use cuffed tubes for everyone except newborns
521
Q

Tx of peptic stricture 2/2 GERD

A
  1. Serial dilations
  2. PPI
  3. Consider stenting
    - Surgery is last resort (in contrast to achalasia)
522
Q

Exposure to bronchial tree in trauma

A

Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)

523
Q

CREST Trial

A
  • Carotid stenting has higher incidence of stroke
  • CEA has high incidence of MI
  • Composite end-point of stroke, death, MI was the same
524
Q

Px, Dx and Tx of Bacterial Overgrowth

A
  • px: 2/2 bill2 or REYGB
  • watery stools, bloating, b12 deficiency
  • dx: d-Xylose (carb test breath test)
  • tx: abxs (Rifaximin) ➡ surg 2nd line
525
Q

Inguinal hernia nerves + MC injuries

A
  1. Ilioinguinal: under to EO, anterior to cord
    - sensation to medial thigh
  2. Ilio-hypogastric: supero/medial to the ilio-inguinal. Between EO and IO
    - sensation to lower abdomen
  3. GB of GF: runs within the spermatic cord, posterior to the cord structures
    - sensation to scrotum

MC injuries:
- Open repair: II, GB of GF
- Lap repair: lateral femoral cutaneous, GF

**Iliac vein inured when sewing mesh to shelving edge

526
Q

HRS- Path, Px and Tx

A

Path: liver failure ➡ sinusoidal portal HTN ➡ increase CO and splanchnic dilation (compensatory)➡ HoTN ➡ turn on RAA system ➡ renal constriction

Px:
- albumin + vasoconstrictive agents (terlipressin)
- TIPS
- transplant

527
Q

Treatment of lung ca

A
  1. No N2 disease (stage 1-2) ➡ up-front surgery
    - lobectomy + MLNDx. Can consider segmentectomy.
    - can wedge if 2:1 margin ratio
  2. N2 disease or T4 ➡ chemo-XRT first

n1- ipsi bronchial/hilar nodes
n2- ipsi mediatinal/subcarinal (2-9)

t1- <3cm
t2- >3cm
t3- >5cm OR invading pleura, chest wall, phrenic n, pericardium OR nodule in same lobe
t4- >7cm OR invading DPGM, mediastinum, heart, great vessels, trachea, RLN, esophagus, vert body, carina. OR different lobe

528
Q

Lung ca w/up

A
  1. < 8mm ➡ surveillance
  2. > 8 mm ➡ PET-CT
    - FDG- ➡ surveillance
  3. FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy)
    - nodal disease –> EBUS
  4. No N2 dz –> Segmentectomy or lobectomy
    - n2 disease –> chemo
529
Q

Steps of hiatal hernia repair

A
  1. Complete dissection of hernia sac from mediastinum
    - look for replaced L hepatic and hepatic branch of vagus near pars flaccida
    - avoid vagus nerve
    - divide short gastrics to aid in mobilization
  2. At least 3 cm of esophagus into the abdomen!
    – Colis gastroplasty if insufficient
  3. Close the hiatus with sutures or mesh (posterior and inferior)
    – mesh has better short term outcomes only
    – RELAXING incision if can’t reapproximate
530
Q

Pre-op and intra-op regiments for aldosteronoma and pheo

A
  1. Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic
  2. Pheo: phenoxybenzamine then BB

Intra-op:
- HTN crisis: Nitro gtt
- Tachy arrythmia: Esmolol gtt

531
Q

Tx of HCC

A
  1. Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant
    - Consider portal vein embolization if remnant is insufficient
    - Consider pre-op TACE to as an adjunct
  2. Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant
    - Transplant if candidate: UNOS criteria
    - Otherwise: loco-regional therapy or systemic therapy
532
Q

When to re-implant the IMA in EVAR

A
  1. Back-pressure < 40
  2. Previous colon surgery
  3. SMA stenosis
  4. Inadequate left colon flow
533
Q

Lynch vs FAP Screening

A
  1. FAP- chromosomal; APC
    - > 100 polyps, including small bowel (duodenum)
    - Surveillance: start at 10
  2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM
    - <10 polyps in the colon
    - Surveillance: start at 20
534
Q

Surgical Tx of thyroid/PT cancers
1. Papillary/Follicular
2. MTC
3. Hurthle
4. Anaplastic
5. PT

A
  1. Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk
  2. MTC: total + bilateral L6 (usually) + T3 post op
    - RAI is c/i
  3. Hurthle: lobectomy then total + bilateral L6
  4. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes
  5. PT: hemi-thyroid +/- L6 (usually not)

**MRND if L6 is positive

535
Q

Confirmation of brain death

A
  1. Neuro exam:
    - absent brain stem reflexes
    - no response to stimuli
  2. Apnea test: CO2 > 60 after 10 minutes
    - if test aborted OR CO < 60 ➡
    - can’t perform test if confounding factors: unstable, hypercarbia, intoxication, paralytics (unable to wean), c-spine injury
  3. Confirmatory test: CTA, MRA or nuclear scan
536
Q

Bleeding during mesh fixation, inguinal hernia

A
  1. Open: sewing mesh onto EO –> femoral vein
  2. TEP: tacking mesh medially –> corona mortis (obturator branch)
537
Q

Tx of H/N tumors

  1. Mucoepidermoid
  2. Adenoid cystic
  3. Pleomorphic adenoma
  4. Warthin/Papillary cystadenoma
A
  1. Mucoepidermoid: MC malignant
    - total parotid + ppx MRND + XRT
  2. Adenoid cystic: malignant
    - total parotid + ppx MRND + XRT
  3. Pleomorphic adenoma: MC benign
    - superficial parotidectomy
  4. Warthin/Papillary cystadenoma
    - superficial parotidectomy

**Use modified Blair incision for these tumors

538
Q

W/up of UGI bleed/perf:
1. Boerhave
2. Traumatic esophogeal perf
2. UGI bleed

A
  1. Boerhave: XR suggestive ➡ UGI (CT controversial)
  2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI
  3. UGI bleed: +/- NGT ➡ EGD
539
Q

Tx of Cellular vs. Ab Rejection

A
  1. Cellular:
    - mild: steroids (inhibit COX2)
    - severe: TG
  2. Ab:
    - Plasmaphoresis (clear Ab)
    - IVIG (so body thinks there are still ab)
    - Rituximab (CD20 Ab)
540
Q

IS for transplant - induction and maintenance

A

Induction: choose 1
1. Thymoglobulin - polyclonal Ab (potent)
2. Basiliximab - IL2 inhibitor (mild)

Maintenance
1. Tacrolimus
2. MMF
3. Prednisone
4. Sirolimus

541
Q

Transplant ABX ppx

A
  1. Bactrim- PCP, toxo gondi, listeria, nocardia
  2. Diflucan- antifungal
  3. Valganciclovir- CMV
542
Q

Transplant cross-matching

A
  1. ABO Incompatibility
    - A, B, O Ab
  2. Cross-match: recipient serum X donor lymphocytes
    - preformed HLA Ab (A, B, DR). DR is most important.

**Livers don’t need a cross-match
**Can give A2 donors to O recipients

**Donor: Ags are important (WBC)
**Recipient: Abs are important

543
Q

MAC

A

MAC = minimum alveolar [] to prevent movement in 50% of people

Low MAC = lipid soluble
High MAC = water soluble
- NO has highest MAC

Factors that decrease MAC: older age, met acidosis, hypothermia, anemia, pregnancy
- require less anesthesia

544
Q

CDH1

A

High r/o gastric ca
ppx gastrectomy by age 40

545
Q

px, dx, and tx of meconium ileus

A

px- failure to pass meconium
dx- sweat chloride test, “soap bubble sign” on XR
tx- GG then NAC enemas
- surgery: ostomy for antegrade enema

**Cystic fibrosis is 2nd MCCO pancreatic insufficiency (after chronic pancreatitis)

546
Q

Congenital thoracic disorders - px and tx
1. Pulm sequestration
2. Cystic adenoid malformation
3. Congenital lobar emphysema
4. CDH

A
  1. Pulm sequestration: infection w/ abnormal CXR
    - tx: resection
  2. Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree
    - tx: lobectomy
  3. Congenital lobar emphysema: XR looks like tension PTX
    - tx: lobectomy
  4. CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior
    - a/w pulm HTN, NTD, malrotation
    - tx: intubate +/- ECMO. Delayed repair.
547
Q
  1. Ig crosses the placenta
  2. Ig in brast milk
  3. Ig first responder
A
  1. IgG (small, y-shape)
  2. IgA (two y’s with joined tails)
  3. IgM (pentad)
548
Q

Nutrition requirements per day
1. Protein
2. Fat
3. Carb

A

Nutritional requirements for average healthy adult male (70 kg)

  1. 20% protein calories: 1 g protein/kg/day
    - burn: 1g/kg/day + 3 g/day x % BURN…(usually 2-2.5g/kg/day)
  2. 30% fat calories
  3. 50% carbohydrate calories
549
Q

Wilcoxon test

A

Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed
- ex: patient satisfaction before and after an intervention (1-5)

550
Q

COX proportion hazard modeling

A

Like a regression model but for survival analysis
Allow you to control for different factors

551
Q

Changes to VS and labs with preggo

A
  • Increased HR, increased SV
  • Decreased SVR, Decreased BP
  • Dilutional anemia. More PRBC but also more water. Requires more blood loss for HoTN
552
Q

Afferent limb syndrome - cause, px, dx, tx

A
  1. Cause: affarent limb is too long from LOTz
  2. Px: acute or chronic
    - Acute: complete obstruction requiring emergent OR
    - Chronic: partial obstruction w/ bacterial overgrowth
    - steatorrhea, B12 deficiency. MC w/ antecolic Bili2
  3. Dx:
    - Acute: abdominal pain with dilated afferent limb in early post op
    - Chronic: d-xylose breath test
  4. Tx
    - stat OR for REY revision
    - Chronic: abxs –> REY/shorten the limb
553
Q

Medical tx for melanoma

A
  • Pd1 inhibitors: pembrozilumab, nivolumab
  • CTLA inhibitors: ipilmumab
  • If Braf+: braf inhibitor remains 2nd line
554
Q

MC benign/malignant thoracic tumors in adults/children

A

Adults
- benign: hamartoma (popcorn calcification)
- malignant: sqcc

Children
- benign: hemangioma
- malignant: carcinoid

555
Q

Tx of Rhabdomyosarcoma

A

MC soft tissue tumor in children
tx: surgery + SLNBx
- consider neo-adjuvent if unresectable
- post-op chemo-XRT (very radiosensitive)

556
Q

C/i to covering the left subclavian artery

A
  1. Aberrant or Dominant left vertebral a.
  2. Previous CABG using LIMA (cardiac ischemia)
  3. LUE AVF
557
Q

Mesothelioma - px, dx, tx

A

px- asbestos exposure (shipyard)
dx- CT then tissue dx
tx- surgery, XRT, systemic chemotherapy, HIPEC

558
Q

Marginal ulcer - dx and tx

A

S/p REY GB
On the jejunal side
Dx- EGD
Tx- PPI + sucralfate + stop smoking + avoid NSAID +/- tx H. pylori (if present)

559
Q

Hipec is most effective for which cancers? (5ys)

c/i

A
  1. Appendix (75%)
  2. Mesothelioma (45%)

**c/i: extra-peritoneal dz

560
Q

Tx of HPV precursors in the anus

A
  1. Condyloma in low risk patient: simple anoscopy (internal extent defined) and ablate
  2. High risk pt: homosexual, HIV, women w/ +pap ➡ anal cytology/anal pap ➡ high resolution anoscopy,
    - Condyloma: ablate
    - AIN1: observe/annual screen
    - High grade: AIN2, AIN3 ➡ ablate
    - All patients: give HPV vaccine
    - LSIL/HSIL ➡ high resolution anoscopy
561
Q

Tx of rectal carcinoid

A

<1 cm - endoscopic removal
1-2 cm- full thickness excision
> 2cm- LAR or APR

**Invasion into muscularis/LN involvement- require TME

562
Q

Polypectomy criteria that require formal resection

A
  1. Poor differentiation
  2. Vascular/Lymphatic invasion
  3. Invasion below the SM
  4. < 2mm of surgical margin
  5. Base involvement (Haggit 4)
563
Q

Cancer screening in FAP

A
  1. CRC- q1-2y c’scope starting at 10
  2. Duo/Stomach ca- EGD at 20 or when polyps occur
  3. Pap thyroid ca- thyroid U/S q2-5y at 18
  4. Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs
564
Q

Staging Melanoma and MC mets

A

Staging:
-Stage 1-2: Don’t need staging CT CAP
- Stage 3+: Consider CT CAP or PET/CT
- Stage 4: MRI brain + PET/CT

MC Mets:
1. Lungs
2. Small bowel!
- suspect if multiple isolated small bowel masses
3. Colon

565
Q

Perforated diverticulitis tx

A

Primary anastomosis with DLI (DIVERTI trial) or without DLI (LADIES trial) is safe except if:
- HDUS
- Acidosis
- Acute/Chronic organ failure
- I/S
- Very old
- Poor pre-op sphincter function

566
Q

Zenker location

A
  • Killian’s triangle
  • Inferior to pharyngeal constrictor (thyropharygneous)
  • Superior to cricopharyngeous
567
Q

Tx for reflux after heller

A

Lifetime PPI
DO NOT convert to a Nissen b/c baseline achalasia

568
Q

Narrowest portions of the eso

A
  1. Criciopharyngeous
  2. AA/Left mainstem bronchus
  3. Hiatus
569
Q

Sxs of vagus injury after hiatal repair

A
  • Gastroparesis
  • Delayed gastric emptying
  • Reflux
  • DRH
  • normal UGI!
570
Q

Required w/up before anti-reflux surgery

A
  1. EGD- r/o ca
  2. 24h pH- prove reflux
  3. Esophagram- r/o motility disorder (DES, eso web)
  4. Manometry- r/o other motility disorders
571
Q

Deficiency of fat soluble vitamins

A

A- xeropthalmia
D- hypoca, hypoPh
E- hemolytic anemia
K- elevated INR

**suspect with any fat malabsorption

572
Q

Na deficit

A

NAD - “no denominator”
(140 - current Na) * TBW
TBW = .6 or .5 x (weight in kg)

.9NS = 154 mEq per liter
3%NS = 514 mEq per liter

replete 6 mEq/24 hours

573
Q

Lung cancer paraneoplastic syndromes

A

Squamous cell- PTHrP
Adenoca- hypertrophic osteodystrophy
Small cell- SIADH

574
Q

Lithium toxicity

A

HyperCa, hypocalcuria
HyperMg
Elevated PTH, normal Ph

**gastric bypass can elevate Li levels

575
Q

Ferritin

A

Main storage protein of Iron
Low in iron def anemia
High in anemia of chronic dz (acute phase rxn)

576
Q

Sheehan syndrome

A

Hypopituitarism (anterior pit) 2/2 gland necrosis from HoTN
Usually px w/ hypoNa

577
Q

Tx for STI:
1. Chlamydia
2. Gonorrhea
3. Trich/BV

A
  1. Chlamydia: doxy
  2. Gonorrhea: CTX
  3. Trich/BV: flagyl
578
Q

HIT - path, dx, and tx

A

path: IgG to PF4

dx: 50% PLT fall ➡ Ser release assay

tx: stop SQH. start fondaparinox, argatroban
- use bivalirudin is liver/cirhotic patients

579
Q

Hormone and production:
- CCK
- Gastrin
- Glucagon
- Histamine
- Insulin
- Motilin
- Secretin
- SS

A
  • CCK: I cell, SI
  • Gastrin: G cells, antrum and duo
  • Glucagon: alpha cells, pancreas
  • Histamine: ECL cells, stomach
  • Insulin: beta cells, pancreas
  • Motilin: Mo cells, SI
  • Secretin: S cells, SI
  • SS: delta cells, pancreas
580
Q

Steps of hepatectomy

A
  1. Mobilize ligaments
  2. CC’y and cannulate CD
  3. Isolate vessels
  4. Ligate HA ➡ PV ➡ HV
  5. Divide parenchyma
581
Q

Tx of HCC

A
  1. Trx: tumor < 5cm or 3+ tumors < 3cm
  2. Resection: early stage, preserved liver function
  3. RFA: early-stage BUT poor OR candidate
  4. TACE: intermediate stage disease
  5. Sorafenib: advanced/Unresectable
582
Q

Indication and s/e for TIPS

A

2-3 paracentesis/month despite Na restriction and diuretics

s/e:
- increase r/o encephalopathy
- no change in overall survival

583
Q

kwashiorkor vs. marasmus

A

kwashiorkor
- moderate calorie intake; inadequate protein
- large belly. normal weight.

marasmus
- insufficient calorie and protein
- simian face. low weight.

584
Q

Absorption of glucose, galactose, fructose

A

glucose: Na-dependent secondary active transport
galactose: Na-dependent secondary active transport
fructose: Na-independent facilitated diffusion

585
Q

Tx of MCN

A
  • Dx: EUS/FNA ➡ high CEA, low amylase
  • Location: body/tail
  • Spleen Preserving Distal Pancreatectomy (usually can be spleen preserving)
  • No follow-up is needed (no increase r/o recurrence)
586
Q

S/e of protamine

A
  • Hypotension, Bradycardia
  • Administer slowly: 1 mg per 100 units of insulin
  • Has partial reversal on lovenox
  • No renal/liver adjustment required
587
Q

Dermatofibrosarcoma protuberans - px, histo, tx

A

px: flesh-colored sarcoma resembling a keloid
- inovles dermis and subcutaenous tissue. No epidermis.

dx:
- excisional bx if < 3 cm
- core/incision if > 3 cm
- histo: spindle cells, +cd34, +Vimentin

tx:
- imatinib to down-stage if needed
- en block resection w/ 2-4 cm margin`

588
Q

In transit melanoma tx

A

Lesions > 2cm from primary but not beyond regional tumor basin
- immunotherapy or BRAF inhibitor
- only excise if feasible (few lesions)

589
Q

Pressure wound staging

A

1- non-blanching erythema
2- dermis
3- full-thickness subcutaenous
4- muscle, bone fascia

590
Q

Post-splenectomy blood smear + best way to ID

A

H-J bodies and Target cells
- If absent: accessory spleen (usually in hilum or tail of the pancreas)
- HJ bodies: nuclear remnant (purple spot in cytoplasm)
- Target cells (codocyte): deformed RBC with excess membrane

ID accessory spleen: peripheral smear ➡ radionucleotide tech sulfur colloid scan

591
Q

Gastro-gastric fistula - px, dx, and tx

A

Px- weight gain, reflux years after a bypass
Dx- UGI or CT with oral contrast
Tx- observation, resection of the involved segment

592
Q

ERCP with REY anatomy

A
  1. Laparoscopic-assisted ERCP or ERCP through a gastrostomy
  2. Double balloon endoscopy
593
Q

Posterior Mediastinal Mass - dx and tx

A

dx: neurogenic- schwannoma, neurofibroma
- CT then MRI. Bx not needed

tx: all require resection (even if asx)

**lymphoma if middle
**thymoma if anterior

594
Q

Lung ca resectability

A
  • carina/contra trachea involvement is still resectable ➡ sleeve pneumonectomy
  • SVC involvement can still be resectable
  • c/i: N3 disease ➡ contralateral mediastinal LN involvement
595
Q

Internal thoracic (mammary) anatomy

A
  • 1st branch off the subcalvien
  • supplies anterior chest wall, breast
  • bifurcates to form superior epigastric and m/phrenic
  • gold standard for LAD bypass
  • can ID during clambshell thoracotomy
596
Q

Management of lung abscess

A
  1. Abxs 1st. No drain if < 4 cm
  2. Cath drainage: > 4 cm or failure of abxs
    - perc (peripheral) or bronch (central)
  3. Surgical resections

Indications for surgery:
- failed medical tx
- BP fistula
- hemoptysis
- suspect cancer
- empyema

597
Q

Prostate ca - px, dx

A

Px- asx or abnormal PSA

Dx:
- Transrectal U/S guided bx - 12 samples
- Gleason score 1-5

598
Q

CAH - px’s

A

“salt and sex”

21: most common; sex
- dx: high 17 levels
17: salt
11: salt and sex

599
Q

Amide vs. ester

A

amide- two “i’s”; plasma cholinesterase metab;
ester- one “i”; liver metab; PABA analogue –> allergic reactions

600
Q

Px, Mech, Tx of Malignant Hyperthermia

A

px: AD; ryanodine receptor type 1

mech: huge increase in INTRAcell Ca

tx: stop drug, dantrolene, Bicarb, cooling, tylenol
- dantrolene: ryanodine rec antagonist

601
Q

Dx adrenal insufficiency in the ICU

A
  1. Early morning salivary or serum cortisol (screen when cortisol is highest)
    - vs. cushing’s which requires PM cortisol (when cortisol is lowest)
  2. High dose cosyntropin (ACTH) stim: give 250 ug and measure serum cortisol (positive if < 18)

Tx- Resuscitation. IV dex 4 q24 or HC 100 q8

**dexa is strongest steroid (hydrocort is weakest)

602
Q

Breast cancer endocrine chemo: MOA, tx duration/indications, s/e:
1. Tamoxifen
2. Anastrazole
3. Trastuzumab

A
  1. Tamoxifen: ER partial agonist
    - for ER/PR positive and < 70
    - 5 years
    - s/e: dvt, endometrial ca
  2. Anastrazole: reversible aromatase inhibitor
    - for ER/PR positive and > 70
    - 5 years
    - s/e: MSK fractures
  3. Trastuzumab: monoclonal Ab to Her2/Neu rec
    - for HER2 positive
    - 2 years
    - s/e: cardiotoxic
603
Q

Paget’s disease of the breast

A

px: scaly, ulcerated crust of the areola

dx: nipple punch bx with epidermal cells w/ clear cytoplasm and oval nuclei

tx: total mastectomy (including NAC) and SLNBx
- don’t need ax dissection
- no breast conservation
- total mastectomy even if small underlying lesion

604
Q

Indications for transcutaneous pacing

A
  • Symptomatic sinus bradycarias
  • Mobitz II (2nd degree) AV block
  • 3rd degree AV block
  • New L or R BBB

**If transcutaneous is unsuccessful ➡ transvenous

605
Q

Types of AV block

A
  • 1d- PR > 200 ➡ no tx if asx
  • 2d Mobitz 1- progressive PR prolongation, then dropped beat ➡ no tx if asx
  • 2nd Mobitz 2- random dropped beat. normal PR ➡ atropine and pacing
  • 3rd degree- A and V pump independently ➡ atropine and pacing
606
Q

Digoxin - MOA and S/e

A

MOA: inhibits N/K ATPase. Stimulated PSNS
- increased contractility (Ca rushes in)
- slows AV node conduction

S/e:
- fatal arrythmia (especially in the setting of hypoK)
- beware of patients with n/v (hypoK met alk)
- keep K > 4

607
Q

Indications for emergent C-section in preggo trauma

A
  • Within 4 minutes of CPR for cardiac arrest
  • Fetus must be at least 24 weeks
  • Give O, Rh negative blood if needed
  • usually 2/2 abruption (vaginal bleeding)
608
Q

Management of penetrating coronary artery injury

A
  • LAD is MC
  • Primary repair is preferred
  • If too much loss of length then CABG
  • Do not ligate
609
Q

Tx of blunt cardiac injury

A
  1. EKG +/- trop
    - negative: can dc
    - positive: admit to tele (Sinus tach is abnormal)
  2. Persistant arrhythmia or HoTN ➡ echo
610
Q

Dx and Tx of rectal injuries

A

Dx: CT w/ rectal contrast is best

Tx:
1. Intraperitoneal ➡ colonic injury
2. Extraperitoneal ➡ primary repair w/ loop sig colostomy
- if inaccessible just leave open and divert
- avoid presacral drainage or distal washout

611
Q

Tx of gastric trauma

A
  • mobilize to see extent of injury
  • most commonly primary repair
  • if large along the greater curve can wedge staple
  • if very extensive can resect and reconstruct w/ REY or Billroth
612
Q

SC artery control

A

Right: median sternotomy

Left:
- anterior thoracotomy: proximal control
- supraclavicular incision: distal control
- can connect with sternotomy for “trap door”

613
Q

Central vs. Peripheral DI - cause and tx

A
  1. Central: disrupted ADH synthesis ➡ responds to DDAVP
  2. Peripheral: genetic or Li induced defective ADH receptor ➡ low salt diet, amiloride
614
Q

Px and Tx of Steal syndrome vs. IMN

A
  1. Steal: pain, diminished pulse, cold hand
    - Tx: DRIL (distal revasc interval ligation)
    - Ligate immediately distal to AVF. Bypass distal to the ligation site.
    - 2/2 to impaired compensatory mechanisms
  2. IMN: pain, normal pulse, warm hand
    - Tx: immediate ligation
    - 2/2 nerve ischemia
615
Q

Tx of superficial venous thrombosis

A

Thrombus is in GSV, SSV

  1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months
  2. No near the jxns ➡ prophylactic AC for 45 days
  3. Otherwise: surveillance

**Superficial femoral vein is a DEEP vein
**EHIT: heat induced thrombus after RFA
- tx with AC until resolution if it involves femoral jxn and > 50% occlusion
- < 50%: compress, NSAID, surveillance

616
Q

Tx of varicose veins

A
  • RFA or EVLA are 1st line
  • Indications for surgery instead: high ligation and vein stripping:
    1. proximal/dilated and tortuous GSV
    2. previous thrombophlebitis
    3. vein too large (RFA > 15mm, EVLA > 8 mm)
  • lower extremity telangiectasias, reticular veins, and small varicose veins ➡ sclerotherapy recommended
617
Q

Sensory nerves of the foot

A
  • Dosal: superfial peroneal n.
  • 1st webspace: deep peroneal n. (is deeper)
  • Medial: saphenous n.
  • Lateral: sural n.
618
Q

Tx of perforated colon ca

A
  • HDS: perform a cancer resection
  • HDUS: resect and divert
  • Scope in 3-6 months to r/o synch lesion

**Divert if unstable, contaminated, poor nutrition, etc.

619
Q

Contents of cord structures

A
  • Cremasterics (vessels, muscle, lymphatics)
  • GB of GF
  • Testicular artery and veins
  • Vas deferens
  • Processus vaginalis

**round ligament in women

620
Q

Levels of evidence

A

1- RCT or SR of RCT
2- Cohort study or SR of cohort studies
3- Case-control or SR of case-control
4- Case series
5- Expert opinion

621
Q

Tx and prognosticators of hepatoblastoma

A
  1. neoadjuvant 1st unless pure fetal histology and low mitotix index
  2. resection
  3. transplant if 4+ section involved/unresectable after chemo

Good prog: < 5 yo, AFP > 100

622
Q

VACTERL defects

A

Vertebral
Anal
Cardiac
TE fistula
Renal, Radial bone
Limb defects

623
Q

Biliary atresia - px, dx, and tx

A

px: infant with bilirubinemia

dx:
0. Rule out TORCH infections/neonatal hepatitis
1. HIDA with no contrast in the duo
2. Cholangiogram: look at what segments are strictured
3. perc bx (tissue dx)

tx: REY-HJ vs. REY-portoenterostomy (Kasai) ➡ transplant if unsuccessful

624
Q

Catelcholamine synthesis

A

Tyrosine ➡ L-dopa ➡ dopamine ➡ NE ➡ adrenal PNMT ➡ Epi

625
Q

BK Virus- rf, px, and tx

A

rf’s- high IS, pulse steroids

px- hematuria, nephritis after kidney trx

tx- decrease IS, cysto/possible stent

626
Q

Strategies to decrease SSI

A
  • stop smoking 4-6 weeks b4 surgery
  • mechanical and abx prep before elective colectomy
  • perioperative glucose < 200
  • clippers > razors
  • abxs 1h b4 incision; 2h for vanc or FQ
  • normothermia
  • closing tray for colorectal cases
627
Q

Aminoglycosides - MOA, coverage, s/e

A

MOA- inhibit 30s; bacteriocidal

Coverage- GNRS, pseudomonas

s/e- nephrotoxic, ototoxic

628
Q

Tx of thyroid storm

A
  1. PTU or methimazole
  2. Steroids

**No alpha/beta blockade

629
Q

Polypsos syndromes: px and gene mutations
- MutY
- FAP
- Peutz-Jeghers
- Juvenile polyposis
- Lynch/HNPCC
- Cowden

A
  • MutY: 10 R sided adenomas ➡ MUTYH
  • FAP: 100s of adenomas + desmoid ➡ APC
  • Peutz-Jeghers: hamartomas + skin lesions ➡ STK11
  • Juvenile polyposis: hamartomoas + telangiectasias ➡ SMAD4
  • Lynch/HNPCC: L sided adenomas ➡ MLH1, MSH2, MSH6, PMS2
  • Cowden: hamartomas + breast/thyroid ➡ PTEN
630
Q

Tx of dysplasia with IBD (UC and Crohn’s)

A
  • Screening scopes 8 years after onset. Scope q1-3 years thereafter.
  • Invisible HGD: confirm w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA
  • Visible HGD:
    1. Resectable: endoscopic resection + serial scopes
    2. Not-resectable: TC w/ IPAA
  • for Crohn’s can do segmental resection
631
Q

Indications for surgery of brain bleeds:
1. Epidural
2. SDH
3. Intraparenchymal

A

Indications for surgery of brain bleeds:
1. Epidural: > 1.5 cm or > 5 mm shift
2. SDH: > 1 cm or > 5 mm shift
3. Intra-parenchymal: > 5mm shift

632
Q

Indications for trx of cholangioca

A
  • cant be intrahepatic (prognosis is too poor)
  • must be unresectable, perihilar, < 3cm
  • no distant mets
633
Q

Short gut syndrome - risk/length + feeds

A
  • Adults risk starts at < 180 cm
  • Infants risk starts at < 75 cm
  • Feeds with elemental nutrition
634
Q

Tx of toxic megacolon

A
  • suspect when colon > 6cm
  • TAC w/ end ileostomy
  • Keep the ileocolic intact for future J pouch
  • Keep the SRA intact for good staple line flow
  • Divide rectum above the posterior peritoneal reflection at level of sacral promontory
635
Q

Repair of bile duct injuries based on Strasburg class

A

A- CD stump leak:
- Intraop: clip/ligate and leave drain
- Postop: perc drain + ERCP plasty/stent

B- Aberrant right hepatic ligation:
- Only if sxs ➡ REYHJ

C- Transect aberrant right hepatic:
- Only if sxs ➡ REYHJ

D- Lateral injury to CHD/CBD:
- No devascularization and small: 1’ T-tube closure
- Devascularized: REY-HJ

E- full transection of CHD/CBD
- < 1cm or distal w/out tension: 1’ T-tube closure
- > 1cm OR proximal injury: REY-HJ

e1- > 2cm, below confluence
e2- <2cm, below confluence
e3- at confluence (confluence intact)
e4- at confluence (confluence separated)
e5- aberrant RH duct injury w/ CBD stricture

636
Q

Indications for MRM

A
  1. Prior radiation
  2. Radiation therapy contraindicated by pregnancy
  3. Inflammatory breast cancer
  4. Diffuse suspicious or malignant-appearing microcalcifications
  5. Widespread disease that is multicentric
  6. A positive pathologic margin after repeat re-excision

MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes

637
Q

p450 inducers and inhibitors

A

CRAP GPs spend all day on SICKFACES.com.

Inducers:
Rifampicin
Alcohol
Phenytoin
Sulphonylureas

Inhibitors:
Sodium valproate
Isoniazid
Fluconazole
Grapefruit juice
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole

638
Q

Pseudomyxoma peritonei - dx and tx

A

dx: CT and histopathology
- mc at the appendix

tx:
- ex lap in acute setting to resolve obstruction
- cytoreductive surgery + HIPEC
- don’t do palliative feeding tube without tissue dx/staging

639
Q

Condyloma acuminata - tx

A
  1. Imiquimod, Podophyllotoxin, Sinecatechins
  2. Cryo, acetic acid, surgery, laser
  3. Podophylin, 5-FU
640
Q

Px and w/up of cholangioca

A
  1. Px: painless jaundice.
  2. W/up:
    - Ca 19-9
    - CT/MRI
    - Tissue:
  3. ERCP w/ stent: brushings + in 50% (preferred if obstuctive)
  4. EUS/FNA: negative bx does NOT rule out
641
Q

RF’s for cholangioca

A
  • PSC
  • UC
  • Choledochal cyst
  • Biliary tract infection
642
Q

Hypothermia classes

A

1.Mild: 90-94; mild MS change
2. Moderate: 84-89; afib, HoTN
3. Severe: 84-70; Osborne waves, coma
4. Profound: <70; no vitals

643
Q

Emergent management of lower GI bleed of unknown origin

A
  • If patient is hypotensive - TAC w/ end ileostomy
  • If stabilized- prep 1st with 4-6L of PEG. Scope w/in 24h.
644
Q

Haggit stage and management

A

Stage: extent of submucosal invasion!
0- superficial to MM (no SM)
1- invasion into head
2- invasion into neck
3- invasion into stalk
4- in SM. superficial to MP.

**all superficial. toMP

Mx:
- all sessile are 4 by definition
- 4 is an indication for resection
- < 4 cancer without high risk features ➡ polypectomy alone w/ follow-up scope in 3 months

645
Q

Path, Dx and Tx of rectocele

A

Path- bulging of rectum into vagina
Dx- bimanual exam reveal large bulge in posterior vagina
Tx- transvaginal plication of vaginal muscularis +/- mesh

646
Q

ERAS protocol of CRC

A
  1. CLD 2h preop
  2. Preop gabapentin and tylenol
  3. Thoracic epidural or TAP block
  4. Pre-op entereg + 7 days post-op
  5. Scope patch
  6. Non-opiate
  7. Normothermia, good O2, glycemic control, skin preop
  8. Net zero fluids
  9. Avoid draina nd prolonged foley
  10. Dc w/in 3 days
647
Q

Dx and Tx of slow transit constipation

A

Dx: nuclear study or radio-opaque marker

Tx:
1. Medical management
2. TAC with IRA is most effective
- pelvic floor dysfunction must be addressed prior to surgery

648
Q

Impediments to fistula closure

A
  1. Foreign body
  2. Radiation
  3. Inflammation/Infection
  4. Epithelialization
  5. Neoplasia
  6. Distal obstruction
649
Q

NCCM CRC screening

A
  • average risk: start at 45. Screen q 10 years.
    -1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.
650
Q

Tx of sigmoid volvulus

A
  1. Colonoscopic detorsion
  2. Sigmoid resection DURING the admission
651
Q

Colon/Rectum Transitions

A
  • Colon: has taenia/above reflection
  • Rectum: no taenia/below reflection
652
Q

Dx and Tx of contained esophageal perforation

A

dx: gg swallow then thin barium
tx:
- NPO, IV abxs
- consider stenting
- generally don’t need IR drain
- includes cervical and thoracic

653
Q

Tx of Barrett’s

A
  1. PPI or H2 block daily x 8 weeks
    - BID if severe sxs, HGD, or esophagitis
  2. Work-up for anti-reflux surgery
    - dysplasia should be eradicated prior to surgery
  3. Continue surveillance
    - no dysplasia: q5y
    - LGD: q6m. ablation.
    - HGD: q3m. ablation or endoscopic resection.
654
Q

Tx of TOA

A
  1. Abxs first
    - unless rupture or HDUS
  2. Drainage/Surgery if failure
655
Q

Types of collagen and life cycle

A
  • type 1: most abundant. scar tissue. predominate after 8 weeks of wound healing.
  • type 3: 1st 2-3 weeks of wounds healing. weaker.

**Collagen deposition peaks at 3 weeks. Degradation starts then

656
Q

Tx of eso varices

A
  1. > 5mm or < 5mm w/ red spots
    - Tx: beta blocker or banding ➡ TIPS
  2. < 5 mm: repeat scope in 1-2 years

**bleed rate 10%/year w/ 20% mortality

657
Q

Branched chain AA - importance and use

A
  • leucine, isoleucine, valine
  • metabolized by the muscle instead of liver
  • use to feed liver impaired patients
658
Q

Peroneal nerve injury

A
  1. Superficial: inability to evert. numbness at dorsum (except 1st web space)
  2. Deep: foot drop. numbness of first web space
659
Q

Px and Tx of Pancreatic Lymphoma

A

Px- pancreatic head mass with LADN. Normal Ca 19-9. Constitutional sxs

Tx- chemo only

660
Q

Indications for MOHS

A
  • Cancers: SqCC, BSC, melanoma in-situ
    Location: face, genitalia, hand/foot
  • Size: > 6mm on high-risk area
  • High risk subtype: morphaeform, dibrosing, sclerosing, infiltrating, micronodular
  • High risk features: Ill defined borders, peri-neural invasion, prior radiation, immunosuppression
661
Q

Indications for deep inguinal LN dissection for melanoma and operative considerations

A
  1. > 4 nodes on superficial dissection
  2. Positive cloquet’s node
  3. Enlarged ileo-obturator nodes on CT
  4. Clinically palpable femoral nodes
662
Q

Pernicious anemia - pathophysiology

A
  • IF secreted by parietal cells
  • improves absorption of b12 in the TI
  • post gastrectomy can get megaloblastic anemia
663
Q

Tx of Bronchial Carcinoid

A

Surgical resection with complete LADN
- usually lobectomy

664
Q

Immunotherapy agents and use by target:
- PD-1
- EGFR
- CTLA4
- RET
- Aromatase
- HER2

A
  • PD-1: pembrolizumab; melanoma (1st line); NSC lung ca,
  • EGFR: cetuximab; KRAS NEGATIVE colon ca
  • CTLA4: ipilimumab; melanoma (2nd option)
  • RET: selpercatinib; MTC (MEN)
  • Aromatase: anastrazole; ER+ breast ca
  • HER2: trastuzumab; HER2+ breast ca
665
Q

Histoplasmosis - px, dx, tx

A

Px: pulm sxs in ohio river valley
- MC mycosis in the overall
- SVC syndrome if fibrosis

CT: fibrosing mediastinitis

Bx: oval budding yeasts

Tx: only if sxs
- itraconazole → ampho B
- stent if fibrosis

666
Q

MOA and s/e of trx meds
- MMF
- Basiliximab
- Azathioprine

A

MMF: purine (T cell) inhibitor
- GI sxs, myelosuppression, anemia

Basilixamab: il2 inhibitor
- GI sxs

Azathioprine: purine (T cell) inhibitor
- myelosuppression, marrow suppression, pulm fibrosis

667
Q

Meperadine (demerol) - MOA and s/e

A

MOA: mu agonist

s/e: seizures
- 2/2 to metabolite normeperadine
- worse with renal impariment

668
Q

s/e of local anesthetic and opioid epidural

A

Bupivocaine: HoTN

Morphine: respiratory depression

669
Q

Absolute c/i to BCT

A
  1. Pregnancy
  2. Diffuse micro-calcs
  3. Positive pathologic margin
  4. Multi-quadrant disease
670
Q

Tx of Lymphedema s/p breast surgery

A

Stage 1: pitting edema, no fibrosis
- compression garment

Stage 2: fibrosis
- complete decongestive therapy

Stage 3: severe fibrosis, elephantiasis
- pneumatic compression

**venous insufficiency does NOT cause lymphedema

671
Q

Most common recon after mastectomy with blood supply

A

Pedicled:
- TRAM: superior epigastric. use rectus.
- Lat dorsi: thoracodorsal

Free:
- DIEP flap: deep IE vessels. lower abdominal skin. Rectus spared.

**delayed autologous flap is preferred over implant if XRT is expected

672
Q

Pressor receptors:
- NE
- Epi
- Phenyl
- Vaso

A
  • NE: alpha1 > beta1
  • Epi: beta1 > alpha 1, some beta 2
  • Phenyl: all alpha1
  • V1 stimualtor
673
Q

Effects of hypovolemia on RAA

A
  • constrict the efferent arteriole to promoted blood to kidney
  • increase ADH secretion
  • JG cells sense low Na and release renin
  • absorb water/na and excrete K/H
674
Q

Nerves in triangle of pain

A

medial-to-lateral:
1. GB of GF
2. FB of GF
3. Femoral
4. Anterior femoral cutaneous
5. Lateral femoral cutaneous (MC injured)

675
Q

Phase of cell cycle

A

G1: longest. self regulation. go to G0 if irregular.
- p53 regulated G1/S transition

S: DNA replication

G2: 2nd check-point

M: mitosis/cell division
- most XRT sensitive

676
Q

WAGR Syndrome - chrom anomaly and px

A

Chrom: deletion of short arm of chrome 11

Px:
Wilm’s tumor
Aniridia- absent iris
GU anomalies- cryptorchidism, hypospadia, streak ovary
Retardation

677
Q

Dx and Tx of pediatric Intussusception

A

Dx: U/S, current jelly stools, abdominal mass

Tx:
1. Air contrast enema (75% effective)
- surgery if unstable, perforation, mass, or completely unsuccessful on repeat U/S
2. Repeat enema
3. Observe for 4 hours if success
- only 5% recur

678
Q

Tx of duodenal ulcer

A
  1. 1-2 cm: simple closure
  2. 2+ cm: graham patch repair
  3. > 4 cm: resection and reconstruction
    - thal patch, pyloric exclusion, G-J
  4. > 4 cm unstable: controlled fistula via drain through defect, pyloric exclusion, G-J with REY or Billroth 2
    - consider drainage procedure if HDS and unlikely. to comply with PPI or developed ulcer on PPI
679
Q

Tx of small bowel polyps

A

Tx: bx all SB lesions
- excision of adenomas or all sx’atic tumors
- < 3 cm: endoscopic resection
- > 3cm: surgical resection (trans-duodenal polypectomy, segmental resection). Whipple if peri-ampullary and worrisome features.
- routine surveillance for recurrence

680
Q

Causes of thyrotoxicosis on RAI and tx

A
  • diffuse uptake ➡ Grave’s: BB, PTU, RAI ➡ total/subtotal thyroidectomy if refractory (consider lugol’s solution before surgery)
  • focal uptake ➡ toxic adenoma: BB, PTU and lobectomy
  • multiple areas of increased uptake ➡ TMN ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy if refractory
681
Q

Management of penetrating cardiac injury

A
  1. FAST+, HDS ➡ OR for pericardial window ➡ extend to median sternotomy if blood found
  2. FAST+, HDUS ➡ immediate median sternotomy (preferred) or ED thoracotomy (left anterolateral)
    - Finger compression
    - If failure ➡ pledgeted repair (avoid balloon/staples if possible). Horizontal mattress, permanent (prolene)
682
Q

CXR of aortic trauma

A
  1. Widened mediastinum
  2. Apical cap
  3. Displacement of trachea
  4. Depression of L mainstem bronchus

*suggest injury at ligamentum arteriosum

683
Q

Polycystic kidney disease a/w

A
  • HTN
  • Hepatic cysts
  • Head (Intracranial) aneurysms
684
Q

Tx of thrombophlebitis and catheter releated DVT

A

Thrombophlebitis:
1. Superficial veins: dc the IV, warm compress, NSAIDS
- abxs if you suspect infection
- surgery if failure of abxs or septic

  1. Deep veins: abxs + AC x 2-3 weeks ➡ thrombectomy and vein excision only if refractory (high morbidity)

Catheter-related DVT:
- anticoagulation
- catheter can remain in place if functional, needed, and not infected

685
Q

Indications for iHD

A
  1. GFR < 6 and asx
  2. GFR < 15 with sxs
    - absolute: uremic pericarditis, pleuritis, encephalopathy
    - relative: AEIOU
686
Q

MOA of abxs: (cell wall, protein, or DNA inhibitor)
- cell wall
- protein 30S
- prostein 50S
- DNA synthesis

A

MOA of abxs:
- cell wall: PCN, cephalsporin, vanc
- protein 30s: AG (gent), tetracyclines (doxy)
- protein 50s: macrolide (azithro), clinda, linezolid
- dna synthesis: quinolones (gyrase), bactrim (folate), flagyl (free radicals)

687
Q

Abx ppx for suspected colonic injury

A
  • ancef, cefoxitin, or cefotetan + flagyl
  • unasyn
  • pen allergic: clinda or vanc + gent, cipro, levo, aztrenoam
688
Q

Guidelines to prevent SSI

A
  • make albumin > 3.5
  • stop smoking 4-6 weeks pre op
  • mechanical and PO prep before colectomy
  • glucose 110-200
  • use clipper over blade
  • give abxs w/in 1h (2h for vanc/FQ)
  • closing tray for colons
  • keep patient warm
689
Q

QI strategies
- six sigma
- teamSTEPPS
- SBAR
- re-AIM
- PDSA

A

QI strategies:

  • six sigma: improve quality by covering all variables to measurable parameters
  • teamSTEPPS: optimize teamwork through leadership, communication, mutual support, situation monitoring
  • SBAR: communication tool for team safety. situation, background, assessment, recommendation
  • re-AIM: strategy to reach targeted population of evidence-based practice. reach, effectiveness, adoption, implementation, maintain
  • PDSA: test a change. plan, do study, act.
690
Q

Requirements for SBP ppx

A

Cirrhotic w/:
1. GI bleed
2. Low protein ascites
3. Hx of SBP
4. Cr > 1.2
5. Billi > 3, C/P > 9
6. Na < 130

691
Q

Tx of appendix carcinoid

A
  1. > 2cm or at base: R hemi
  2. high risk (high MI, KI > 2%, mixed histology, LV invasion meso invasion): R hemi
  3. Otherwise: appe only

**require c’scope post-op b/c 15% have synch lesions

692
Q

MCCO acute liver failure

A
  1. US: tylenol
  2. Worldwide: viral hepatitis (Hep B)
693
Q

LA class for esophagitis

A

A- mucosal breaks <5 mm
B- mucosal breaks >5 mm
C- mucosal breaks spanning 2 folds, <75% circ
D- mucosal breaks >75% circumference

694
Q

Scleroderma manometry

A
  • absent peristalsis
  • normal/low LES pressure

**contrast to achalasia: aperistalsis and high LES pressure

695
Q

Immuno-nutrition

A
  1. arginine
  2. omega-3 FA
    - a/w less infections, shorter LOS
696
Q

Renal arterial anatomy

A
  • Renals come off just under the SMA at L2
  • SMA hugs the left renal vein
  • Renal arteries run behind the veins and the IVC
697
Q

Belsey IV fundoplication

A
  • Thoracic approach with anterior 270-degree wrap
  • Bailout after failed abdominal approaches
698
Q

How to access cervical esophagus for esophagectomy

A
  1. Anterior to SCM. Divide platysma
  2. Divide omohyoid, strap muscles
  3. Retract carotid structures laterally
  4. Ligate middle thyroid vein and inferior thyroid artery
699
Q

Most important prognosticator of survival in stage IV (liver mets) colon cancer

A
  • response to neoadjuvant chemo
  • not size. or node status (its already disseminated)
700
Q

MC location of small bowel lymphoma

A

Ileum (has most lymphoid tissue)

701
Q

SMA exposure options for bypass

A
  1. Anteior: base of transverse mesocolom
  2. Lateral: mobilize 4D and LOTz
702
Q

Consequences of ileal resection

A
  • megaloblastic anemia
  • fat malabsorption/ADEK def
  • cholesterol stones (EH circulation)
  • oxalate stones (ca binds fat instead of Ox)
703
Q

BPD for weight loss surgery

A
  1. BPD/DS: prevent marginal ulcers and dumping syndrome (keep pylorus)
    - sleeve
    - resect TI 100 cm from ICV
    - roux limb end-to-end to duo
  2. BPD: good for weight loss but high ulcer/dumping syndrome
    - resect stomach
    - ileum to stomach (250 cm from ICV)
    - more distal ileum to BP limb (100 cm from ICV)
704
Q

MC Vit def after REYGB and sxs

A
  1. Vit D- bone dz, hypoCa
  2. Vit A- night blind
  3. Folate- skin changes
  4. Iron- anemia
  5. Thiamine- encephalopathy
705
Q

Surviving Sepsis 1-hour bundle

A
  1. Measure lactate
  2. Blood cx b4 abxs
  3. Abxs after cx
  4. 30 ml/cc bolus if HoTN, LA
  5. Pressors for MAP >65
706
Q

Immuno-nutrition and benefits

A
  1. arginine
  2. omega-3 FA
    - a/w less infections, shorter LOS
707
Q

S/e of Amiodarone

A
  1. Pulmonary dysfunction: tx w/ steroids
  2. Thyroid dysfunction: tx w/ steroids or thionamides
708
Q

Virulence of G+ and G- bacteria

A

G+: exotoxins
G-: endotoxins (lipid A)

709
Q

Tx of atypical ductal hyperplasia (ADH)

A
  • Get diagnostic mammo
  • Then excisional bx (15-30% of cancer)
  • Like LCIS you do not need a negative margin
  • Finally chemo-ppx with tamoxifen

**ALH and LCIS if low risk and concordant

710
Q

Axilla boundaries

A

medial- pec minor
lateral- lat dorsi
superior- ax vein
posterior- subscap

711
Q

Histology of pap thyroid ca

A
  • Pale cytoplasm
  • Prominent nucleoli (orphan annie)
  • Psammoma bodies
  • Large/crowded nuclei
712
Q

Adrenal blood supply

A

Artery: R and L the same
- Superior a: from inf phrenic
- Middle a: from aorta
- Inferior a: from renal a

Vein
- L adrenal vein: into L renal v
- R adrenal vein: into IVC

713
Q

Advantages of robotic surgery

A

-7 degrees of freedom

714
Q

Damage control trauma to visceral vessels

A

Celiac- ligate

SMA- shunt or repair

IMA- ligate

715
Q

Lap band imaging

A
  • Band should be at 45-degree angle
  • Too much contrast past the band means its underfilled
  • Fundus above means slipped band
  • Band melding with lumen of the stomach: erosion
716
Q

Melanoma indications for SLNBx

A

> 1mm
< 1mm w/ ulceration or > 1 mm2 mitoses

717
Q

Causes for AV fistula failure to mature

A
  1. venous branches (doesn’t fill enough)
  2. fistula is too deep (can’t pop out)
718
Q

CEA operative pearls

A
  • take out plaque between media and adventitia
  • pull out plaque transversely
  • acute deficit post op: get an U/S
    1. thrombus/initimal flap: re-explore
    2. normal U/S ➡ cerebral angio
719
Q

Tx of aortoenteric fistula

A

Fistula takedown, prior graft revmoval (if s/p evar) and extra-anatomic bypass

720
Q

U/S findings for thyroid nodule suspicious of cancer

A
  1. Unclear boundary of solid component
  2. Irregular shape
  3. Calcs
  4. Hypoechoic
721
Q

Indications for ICP monitor

A
  1. GCS <=8 with abnormal head CT
  2. GCS <=8 with normal head CT and 2 of the following:
    - age > 40
    - abnormal posturing
    - hx of HoTN
722
Q

Submental triangle - boundaries and contents

A

Boundaries:
- Anterior bellies of digastric
- Hyoid bone
- Symphysis menti
- Mylohyoid is floor

Contents:
- Contents: mylohyoid nerve, anterior jugular veins

723
Q

Morphine equivalents of narcs

A

5 IV morphine =
- .7 IV HM
- .05 IV fentanyl

15 PO morphine =
- 3 PO HM
- 10 POD Oxy

724
Q

FRC

A

FRC = RV + ERV
- TV not included
- Increases with age
- Decrease with obesity, pneumoperitoneum