QE Flashcards
Pheo w/up:
- Spot plasma or urine metanephrine (sensitive)
- 24-urine metanephrine (specific)
- CT (> MRI)
- MIBG (if suspect multi-focal)
Mucinous cystic neoplasm - dx and tx
- dx: EUS-FNA w/ high CEA (>190), low Amylase
- tx: resect
Tx pelvic fx
- Binder
- Angio OR packing w/ fixation (especially if IR n/a)
- Early external fixation
- refractory bleed after angio → packing + fixation
**MC source is presacral venous plexus
Dx and Localize a gastrinoma
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
Tx pseudocyst/WON
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)
Tx of pancreatitis masses
1. WON sterile
2. WON infected
3. Pseudocyst
4. Infected pseudocyst
- WON sterile: conservatively
- WON infected: step-up approach
- Pseudocyst: tx if sxs (infxn, obstruction, pain)
- 4-6w → internal drain → cyst-enterostomy - Infected pseudocyst: drainage (internal, external, endoscopic). Endoscopic preferred.
Indications to tx ICA stenosis and sxs
- Asx: > 60%
- Sxs: > 50% (>125 cm/s)
- Sxs: contralateral motor/sensory sxs, ipsi vision sxs
Bethesda criteria for thyroid
**1 cm is cutoff to get an FNA
- Non-diagnostic → repeat FNA
- Benign → follow-up
- Undetermined significance → repeat FNA or lobectomy
- Follicular neoplasm → lobectomy
- Suspicious for malignancy → lobectomy vs. thyroidectomy
- Malignant → thyroidectomy
Achalasia - Px, Dx, Path and Tx
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.
Tx Medullary thyroid cancer
- TOTAL thyroidectomy
- > 1 cm or bilobar: bilateral central/level 6 dissection
- Lateral neck dissection on that side if central+
- Start T4 postop. Monitor w/ calcitonin AND CEA
- RAI is c/i! (C cell origin)
Radial scar- Dx and Tx
- 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) - Tx: core bx ➡ excisional bx (to r/o ca)
Tx for ectopic pregnancy
- Stable ➡ methotrexate or salpingotomy
- MTX: absolute c/i if the patient is breast-feeding - Unstable, free fluid, ongoing pain/bleeding ➡ salpingectomy
Hyperkalemia EKG
Hypokalemia EKG
- hyperK: peaked T wave, eventual SINE
- hypoK: flat T waves, U waves
HS reactions
- IgE allergic rxn; anaphylaxis; tx w/ epi
- Ab rxn; AIHA
- immune cx; serum sickness, hep’s
- delayed; t-cell; dermatitis, PPD
- auto-immune
Tx of thyroid ca in pregnancy
- 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)
Mastodynia tx
- Cyclic: OCP/NSAIDS
- sxs improve after menses - non-cyclic and >30 OR cyclic + mass ➡ mammo
Tx mucinous neoplasm of the appendix
- Confined to appendix: appe only (no LADN’y)
- must have negative margin
- scope in 6w to r/o sync lesions - Involving base, ruptured, or +margin: R hemi +/- LADN
- 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
GCS eye opening
4- spon
3- to voice
2- to pain
1- none
Torsades
- “polymorphic ventricular tachycardia”
- 2/2 hypoK, hypoCa, hypoMg, macrolides
Normal values: CVP, WP, SVR, CI
- CVP 2-6
- WP 4-12
- SVR 700-1500
- CI 2.5-4
When to excise burns
- < 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)
TTP - Path, Px, Tx
Path- def in ADAMtS13
Px- fever, anemia, TCP purpura, renal dz, neuro sx (FATRN)
Tx- plasmapheresis ➡ steroids ➡ splenectomy
LE angio
AT comes off first and goes lateral
TP trunk- PT behind tibia, peroneal behind fibula
Liver lesions on arterial phase:
HCC
Mets
Adenoma
Hemangioma
FNH
- 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
Methanol and Ethylene glycol toxicity - Px and Tx
Px: profound AG metabolic acidosis
- oxalate stones → renal failure
Tx: NaB + fomipazole (ADH inhibitor)
- consider iHD
Ureter anatomy
Runs under the vas/uterine arteries
Runs over the iliacs
Elective surgery after stent
- ASA lifelong
- Plavix
- BMS: 1 month
- DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)
UE Injuries:
1. supracondylar humerus
2. DRF
3. Mid shaft
4. ant shoulder disloc
5. post shoulder disloc
- supracondylar humerus- brachial artery
- DRF- median nerve
- Mid shaft- radial nerve
- ant shoulder disloc- ax. nerve
- post shoulder disloc- ax. artery
Teg interpretation:
R time
K time
a angle
MA
LY 30
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%
DeMeester score
Score: pH <4 , changes in position, duration, # of episodes
> 14.7 is positive
Standard Deviations
1, 2, and 3 SD = 67%, 95%, and 99.7% of the data
s/e of ileal conduit
Hyperchloremic metabolic acidosis (urine high in Cl is exchanged for bicarb which is excreted)
Angiodysplasia of the colon - Dx and Tx
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
Stewart-Treves syndrome - px, dx, tx
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)
Tx for gallstone ileus
Stable and healthy- stone removal and take down fistula
Unstable, old/frail- stone removal only!
Sorafenib
Tyrosine kinase inhibitor
Tx of HCC
Stricturoplasties
- Heineke s’plasty
- Finney s’plasty
- Side2Side isoperistaltic s’plasty
- Heineke: <10cm; open long and close transversely
- Finney: > 10cm; segment folded on itself and common wall created
- Side2Side isoperistaltic (Michellassi): > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together
**Bleeding is MC complication
Dx and tx of gastroparesis
Dx: Scintigraphy gastric emptying
Tx:
- Metoclopramide (Reglan): dopa antagonist
- gastric pacemaker or pyloroplasty
- feeding tube
- TPN
Burn degrees
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
Tx and Survival Benefit of ARDS
- TV at 4-6 ml/kg
- Permissive hypercapnia
- Proven benefit: prone, lung protection, paralyze
-P/F < 100 = severe
Interleukins 1, 2, 4, 5, 10
C5-9
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
Glucagonoma - loc, px, dx, tx
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
Aminocaproic acid vs. streptokinase
ACA: Plasmin inhibitor
- Use: DIC, excess tpa
Streptokinase/Urokinase/TPA: plasmin activator
- bust clot
s/e of carb, protein, and lipid
- carb: immunosuppression, resp failure
- lipid: pro inflammatory
- protein: false neurotransmitters, rise in ammonia/urea
- can worsen hepatic encephalopathy (use branched chain AA instead of aromatic AA)
Dx, Bx, and Tx actinic keratosis
- Dx: red, crusty, weeping lesion
- Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
- Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)
Hirschsprung surgeries
- Duhamel
- Soave
- Swenson
- 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.
z11 trial implications
- 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
Hard signs of vascular injury
shock
expanding hematoma
pulsatile bleed
thrill/bruit
absent pulse
ischemia
If negative ➡ ABI…if positive ➡ CTA (to localize)
Polyps that require surgery instead of endoscopic resection
- Submucosal invasion > 1mm
- Poorly differentiated
- <1 mm margin
- LV invasion
- Tumor budding
- Taken piecemeal
Iron deficiency sxs
anemia, glossitis, brittle nails, cardiomegaly
T staging indications for neoadjuvant
- eso
- stomach
- colon
- rectal
- lung
- eso: T2 (MP)
- stomach: t2 (MP)
- colon: t4b (adjacent organs)
- rectal: t3 (through MP)
- lung: n2 nodes
Atlanta classification pancreatits
- Interstitial:
<4w- acute peripanc collection
>4w pseudocyst - Necrotic:
<4w- acute necrotic collection
>4w- walled of necrosis
Fuel for:
- SB
- LB
- SB: glutamine
- LB: short-chain fatty acids (acetate, butyrate). Directly absorbed by intestinal epithelium w/out lipolysis
Motilin
Motilin – released by intestinal cells of gut; acts. on smooth muscle to↑ intestinal motility (erythromycin acts on this smooth muscle receptor)
Screening in IBD patients
- 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
NEC - px and tx
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.
W/up of thyroid nodule found on exam or incidental imaging
- 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
Tx male breast ca
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
Nutcracker eso - manometery and tx
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
General principles - repair of Bile Duct Injury
- Intro-op:
- convert to open, intra-op cholangio, repair OR
- widely drain and send to specialty center - Post-op:
- Perc cholangiography to define the anatomy
- Control spillage: external drain +/- stent +/- PTC
- Repair in 6-8 weeks
Eso dysplasia tx
- LGD: ablation OR scope q6-12m
- OK for fundoplication - HGD: ablation + Q3m scope
- fundoplication c/i - T1a: ablation
- t1b (or low risk T2): upfront esophagectomy
*Fundoplication does not decrease cancer risk
Superior epigastrics
Inferior epigastrics
SE: runs between rectus and posterior rectus sheath; branch of int mammary
IE: runs between rectus and transversalis fascia; branch of EI
When to intubate burn patients
- hypoxia, hypercarbia, severe upper airway edema
- If stable/GCS > 8 and level of injury unknown ➡ ABG ➡ nasoendoscopy/bronchoscopy to visualize cords ➡ intubate for swelling
Tx hemobilia after trauma
- EGD → CTA (if stable)
- angio embolization (no surgery)
- catheterize the celiac artery first ➡ R/L hepatic ➡ SMA
Paget Von Schroetter syndrome - path, px, tx
Path: narrowing of SC/Ax vein 2/2 mech compression
Px: acute swelling
Tx: catheter-directed thrombolysis before anything else (NOT open thrombectomy)
Tx of AT3 def
Tx- recombinant at3 or FFP followed by heparin then warfarin
Vitamin C mechanism and deficiency
Mech:
- hydroxylation of lysine and proline
- type 3 collagen cross-linking
Def: Scurvy
- gingivitis, wound healing, rough skin
Indications for chemotherapy for rectal cancer
- Neoadjuvant:
Stage 2 and above
Stage 2: at least t3 (crossing muscularis prop) or any n (stage 3) - Adjuvant chemo as well for Stage 3+ (nodes)
**XRT either pre or post-op (not both)
**Typical course: chemo-XRT ➡ surgery ➡ chemo
Periop anticoagulation - risks and tx
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.
What is not suppressed by high dose dexa
Adrenal mass
Ectopic mass (small cell cancer)
**dexa is strongest steroid (hydrocort is weakest)
Metabolic alkalosis - chloride responsiveness
- Cl responsive (Ur Cl < 20)
- temporary loss, replaceable
- vomiting - Cl resistant (Ur Cl > 20)
- hormonal, continuous loss
- conn’s, steroids, hyperaldosterone
Heller myotomy margins and fibers
6 cm proximal, 2 cm distal
- Esophagus: vertical fibers first (outside), then circular (inside)
Margin for invasives cancer vs. dcis
- Invasive cancer- no tumor on ink
- DCIS- 2 mm
**if both in specimen, margin is no tumor on ink
ITP- path, dx and tx
- path: IgG against gp 2b/3a
- dx: of exclusion- increased megakaryocytes, petechia, TCPenia
- smear: normal with low PLTs - tx:only if PLT < 30K!
steroids → IVIG 2nd line → splenectomy
- spleen is source of Ab’s
Staph species causing graft infection
G+/aerobe/clusters
coag+ → staph aureus
- MC early graft infections
coag- → staph epidermidis
- MC late graft infection 2/2 biofim
Cryptorchidism tx
- wait until 6 month old
- if no resolution: elective orchiopexy to decrease r/o torsion, infertility, seminoma
- risk of ca higher in both testes.
Sarcoma grade
- differentiation
- mitotic coun
- necrosis
** more important than size, nodal/distal mets for prognosis
Neuroblastoma dx and tx
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
Gastrin - MOA and stimulation
- 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
Esophagus blood supply
- Cervical- inf thyroid
- Thoracic- aortic branches (bronchial arteries)
- Abd- left gastric/inferior phrenic
- CBD and PD on ERCP
- Blood supply of CBD
- 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’
Tx urethral injury
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
TEF - MC types. dx and tx
- Type C - MC, 85%
- Proximal esophageal atresia (blind pouch) and distal TE fistula
- dx: AXR ➡ distended, gas-filled stomach, coiling tube
- no UGI needed! - 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
Tx of Ogilvie’s
- CT or scope to confirm dx. R/o obstruction.
2 supportive, dc narcotics, ng tube, neostigmine
- if > 10cm ➡ scope decompression and neostigmine
- failure ➡ OR
Px and Tx of prolactinoma
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
Pros/Cons:
- Sevoflurane
- Isoflurane
- Halothane
- NO
- 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.
Atropine MOA
- competitive inhibitor of ACh at muscarinic receptor
- liver metabolism
FMD- Dx, Path and Tx
Dx: string of beads on angiogram
Path: fibroplasia, thickened media, collagen formation
Tx: angio + balloon (no stent)
MEN1/MEN2 genes
MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene
Birads score
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)
MOA, use, s/e of antifungals:
Fluconazole
Voriconazole
Micafungin
Amphotericin
- Fluconazole: ergosterol synth inhibitor
- Non-systemic candida (yeast infection, c. albicans)
- s/e: liver toxic, GI upset - Voriconazole: ergosterol synth inhibitor
- aspergillosis
- s/e: visual changes, psychosis - Micafungin: echinocandin; inhibit glucan
- invasive/disseminated candidiasis
- s/e: TCPenia - Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access)
- invasive mucor, cryptococcal meningitis
- s/e: nephrotoxic, electrolytes (hypoK)
Recurrent laryngeal nerve + aberrant anatomy
- 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
PFTs for lung resection
- Preop FEV1 and DLCO predicted > 80% ➡ no further testing
- >.8L wedge, >1.5L lobe, >2L pneumo
- < 80% ➡ lung scan for PPO FEV1, DLCO - PPO FEV1, DLCO > 60% ➡ no further testing
- < 60% ➡ exercise test - VO2 > 10 ml/min/kg ➡ OK for surgery
- < 10 ➡ high risk for surgery
Origins of medullary thyroid cancer
- 4th pharyngeal arch releases NCC which form parafollicular C cells
Gastrinoma - loc, px, dx, tx
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
qSOFA score
- AMS (<15)
- RR > 22
- SBP < 100
MC Benign and Malignant H/N tumors - tx
- Benign: Pleomorphic adenoma
- Tx: superficial parotidectomy even if asx - Malignant: mucoepidermoid carcinoma tx
- Tx: total parotidectomy (facial nerve preservation) + MRND + XRT
Tx frostbite
- Frostnip: rapid moist/pool re-warming
- 2d: clear/milky blister- drain
- 3d: HMHG blister- leave intact
- 4d: bone- prostacyclin/TPA, amputate
Tx of Pilonidal cyst
- ASx: NTD
- Acute abscess: drain only
- Chronic cyst: offer surgery if effecting QOL
- marsupialization and leave open: lower recurrence
- primary closure: faster healing. Off midline- less complication (preferred)
Tx TCPenia
<10k if asx
<20k if septic, chemo/rads, RF’s
<50K if elective surgery
Dx and Tx annular pancreas
Dx: UGI with double bubble at 2D
Tx:
- neonates: duo-duo (mobile duo)
- adults: duo-jej
Production and function:
- TNFa
- IF-gamma
TNF-a: produced by PMNs, mphages
-cachexia, inflammation
IF-gamma: produced by T lymphos
- activate PMNs, mphages
W/up of pancreatic cystic neoplasms:
Pseudocyst
Serous cystadenoma
MCN
IPMN
- MRI
- 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
Propofol - MOA, pros and cons
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
Enterohepatic circulation
Primary bile salts
- cholic acid, cheno-cholic acid (C’s) → hepatocytes → conjugated BS:
- 80% conjugated ➡ active ileum absorbed
- 20% deconjugated by bacteria ➡ passive colon absorbed
- 5% out in stool
Dx and Tx CO poisoning
- 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%
- Intubate if comatose, severe acidosis
Indication for APR
- Rigid proctoscopy: w/ in 2cm of anal verge (levators)
- PE: baseline sphincter dysfxn
- Recurrent SqCC (s/p Nigro)
Cancer associations:
- CEA
- AFP
- CA 19-9
- CA 125
- Beta-HCG
- PSA
- NSE
- BRCA I and II
- Chromogranin A
- Ret oncogene
- KRAS
- 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)
Types of esophagectomy compared
- 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 - 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 - McKeown: abdominal + L neck
- anastomosis: cervical
***Gastric conduit supply- R gastroepiploic (off GDA/CHA)
Somatostatinoma - loc, px, dx, tx
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
Etomidate - Pros and Cons
Induction agent
Pros- Fewer hemodynamic changes, fast acting, fewest cards s/e
Cons- adrenocortical suppression
W/up and Tx testicular mass:
- Seminoma
- Non-seminomatous
- PE
- Ultrasound
- AFP, HCG, LDH
- Seminoma: no AFP! (most common)
- Non-seminoma: high AFP, HCG, LDH - Inguinal orchiectomy: any patient with solid testicular mass
- 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
Liver collection dx and tx:
1. Pyo
2. Amoebic
3. Echino
4. Fungal
- Pyogenic: after cholangitis (MC) or div’s (via portal vein);
- drain and abx (+mica if fungal) - Amoebic: after mexico trip (or aMazon).
- dx w/ serology/hemagglutination 1st
- metronidazole (no drain) - Echinococcal: wall Ca+ and sub-cysts
- albendazole and resect/PAIR - Fungal: 2/2 chemo/neutropenia
- perc drain + micafungin
EVAR specs:
- Proximal landing
- Common iliac (distal landing)
- Neck angulation
- External Iliac
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
Tx of anal fissure
- Sitz bath, fiber
- topical nifedipine/nitroglycerin
- nitro causes headache - Surgery (or botox)
- Good sphincter tone: LATERAL, INTERNAL sphincterotomy
- Poor tone: botox
**If 2/2 crohn’s dz: optimize medical management
Lynch genes and gene funtions
Genes:
- MLH1
- MSH2, MSH6
- PMS2
- EPCAM
Fxn:
DNA MM repair gene causing microsatellite instability
Condyloma types
- acuminatum- HPV (6, 11- warts; 16, 18- Cancer)
- lata- syphilis
Tx of liver lesions:
1. Hemangioma
2. FNH
3. Adenoma
- Hemangioma: only if sxatic or KM syndrome
- enucleate (or resect); angioembo if active bleed - FNH: NTD
- Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing
Dx and Tx congential DPGM hernia
-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
Stages of empyema formation
- Exudative ➡ drainage or VATS (1-7 days)
- Fibrinopurulent ➡ VATS (7-21 days)
- Organizing ➡ thoracotomy (21+)
**VATS between days 3-7
- Preferred over 2nd CT placement or fibrinolytic therapy
Vertebral artery occlusion px
posterior circulation
sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia
5T’s of cyanosis
- TOF
- Transposition of GVs
- Truncus art
- Tricuspid atresia
- TAPVC
DES - Manno and Tx
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
Supraceliac aortic control
- HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram
- Stable: left medial visceral rotation is preferred
Mondor disease - px and tx
px- tender, “cord-like” structure
tx- NSAIDs
Dx and Tx Phyllodes
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)
Replaced Rand L hepatic
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
Effective for enteroccous
Ampicillin/Amoxacillin
Vancomycin
Zosyn
(Resistant to all cephalosporins)
Loss in excess weight for each surgery
REYGB- 75%
SG- 60%
Lap band- 50%
Acid/Base of Ng suctioning
HypoCl, HypoK metabolic alk
- Mech: Loose HCl and fluid ➡ turn on RAA system
Retain Na/Excrete acid (paradoxic acidurea)
Indications for total thyroidectomy (pap and follicular)
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
Soft tissue sarcoma - dx and tx
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
Step up approach
Infected pancreatic necrosis (WBC + gas on CT)
- CT with gas
- Carbapenem
- FNA + Perc drain OR endo drain (if stomach is close to pancreas)
- Upsize drain
- MIS retrop necrosectomy (VARD)
- Open necrosectomy
CN11 - nerve, location, muscle/injury
- nerve: spinal accessory nerve
- location: exit jugular foramen (post triangle)
- injury: SCM and trapezius. no shoulder shrug, winged scap!
- Central cord syndrome
- Anterior cord syndrome
- Central cord: loss of pain, temp, motor
- motor UE> LE loss (vs. anterior syndrome)
- hyperextension in the setting of SS - Anterior cord: loss of pain, temp, motor
- below the level of the lesion
- ASA injury or anterior cord compression
Types and Tx SVT
types: af, aflutter, paroxysmal SVT, WPW
- vagal → adenosine
- may unmask afib/flutter - HDS: BB, CCB ➡ sync cardioversion
- HDUS ➡ sync cardioversion
Von Hippel Lindau - mechanism and surveillance
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
Melanoma w/up and tx
- Punch bx or excisional bx (if < 2cm, non-sensitive area)
- MIS- 5mm margin
- <1mm- 1cm
- 1-2mm- 1-2cm
- >2mm- 2cm - Clinical positive nodes (stage 3) require FNA for confirmation
- negative: SLNBx
- positive: completion LN dissection - SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
- 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.
Steps of rapid sequence intubation
c-spine stabilize → preO2 → fentanyl → etomidate → succinylcholine
PSC vs. PBC - assocaited and tx
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
CPP
MAP - ICP
normal CPP > 60
Normal ICP < 20
- would prefer low MAP with CPP of 60 then higher MAP for brain bleed
Draining peri-rectal abscess
- Perianal, intersphincteric, horseshow, and ischiorectal: through the skin (all are below the levator muscles)
- Supralevator abscesses need to be drained trans-rectally
Px, Dx and Tx malrotation
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
Epidural hematoma - shape, vessels, px
Shape: Biconvex. DOES NOT suture lines
Vessel: MMA
Px: lucid interval. Ipsilateral blown pupil is early sign
- (vs. subarachnoid thunderclap, worst HA)
MEN syndromes
1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD
2a- Parathyroid (PTC),MTC, Pheo (catecholamines); ret; AD
2b- Pheo, MTC, marfanoid/neuroma; ret; AD
Nitrogen balance
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
Periop Warfarin
stop 5 days before
Indications to bridge- mech valve, h/o TE event, afib only if CHAD/VASC 5-6+
Management of PE
- no RH strain → acoag
- RH strain → IR catheter
- RH strain + HDUS → systemic tPA
Methemoglobinemia - px, dx and tx
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)
Layers of colon/rectum
- mucosa
- sub-mucosa (strength layer)
- muscularis propria
- serosa
LE vascular trauma
- small: patch plasty
- large: contralateral GSV (must maintain venous system b/c deep vein may be injured)
- limited time/unstable: shunt
Tx for DVT
- unprovoked: malignancy, inherited ➡ indefinite
- 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
Loop diuretics vs. Ca sparing diuretics
- loop: furosemide
- Ca sparing: thiazides (can cause gynecomastia)
MALT lymphoma dx and tx
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)
lower extremity bypass graft failure depends on temporal relation to the surgery.
- <30d: technical error
- 1m-2y: intimal hyperplasia, (at the distal anastomosis)
- > 2y: progressive atherosclerotic disease
Dx and Tx Parathyroid ca
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)
- Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT)
- no chemo
- usually don’t perform any node dissection unless palpable nodes
Tx infected pseudocyst
aspirate/gram stain to dx → drainage (internal, external, endoscopic)
Tx melanoma of anal canal
Tx:
- WLE (1 cm). No SLNBx
- APR if sphincter involved, LADN, or > 4mm
- No chemo-XRT
**5y-S is 20% w/ R0
**WLE = APR
Kaposi’s sarcoma - cause and px
- Case: HSV8
- Px: Violet/brown papules
Mechanism and Tx of thyroid dz:
1. Graves
2. TMN
3. Hashimoto’s
4. DeQuervains/Subacute
5. Reidels
- Graves: IgG stimulates TSHr ➡ hyperT
- BB, PTU, RAI ➡ thyroidectomy - TMN: chronic TSH stimulation ➡ hyperT
- BB, PTU, RAI ➡ total/subtotal thyroidectomy - Hashimoto’s: antiTPO/TG Ab ➡ hypoT
- thyroxine ➡ partial thyroidectomy - DeQuervains/Subacute: viral URI
- path: giant cells, leukocytes
- NSAIDS/ASA ➡ steroids - Reidels: autoimmune inflammation
- steroid, thyroxine ➡ surgery for compression
Sonograph FNA recs
- cystic: no bx
-isoech/hyperech: FNA if > 2cm
-hypoech (high sus): FNA if > 1cm
Tx anal incontinence
- 1st line: fiber/bulking, exercises
- Refractory: endoanal U/S
- defect: overlapping sphincteroplasty
- no defect or refractory: sacral modulator
s/e of burn topical treatments:
- silver nitrate
- silver sulfadiazene
- mafenide
- bacitracin
- 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
Triple therapy
PP1 + 2 antibiotics abxs: amoxicillin, metronidazole, tetracycline, clarithromycin for 2 weeks
APC gene
- chromosome 5
- 1st mutn in adenoma to carcinoma
- mc mutation in colon ca
- a/w FAP
Contents of post triangle
- CN 11
- subclavian artery
- EJV
- brachial plexus trunks
Gail model
- age
- age 1st period (earlier is worse)
- age 1st birth (earlier is better)
- 1d relative
- previous bx
- race
Associated orthopedic injuries:
1. post hip disloc’n
2. post knee disloc’n
3. DRF
4. Supracondylar humerus fx
5. Anterior shoulder disloc’n
- post hip disloc’n: sciatic nerve (peroneal branch)
- post knee disloc’n: popliteal atery
- DRF: median nerve
- Supracondylar humerus fx: brachial artery
- Anterior shoulder disloc’n: axillary nerve
Dobutamine
B1 at low dose
- inotropy
B2 at high dose
- vasodilation
types of endoleak and tx
- proximal/distal seal: immediate balloon expansion of distal/proximal attachments + stent
- 1a: proximal leak
- 1b: distal leak - back bleeding: observe. coil embolization if enlarging
- graft defect (tear or junctional leak): immediate additional graft coverage
- porosity- reverse anticoagulation
Carcinoid vs. GIST vs. Desmoid- cells and tx
- Carcinoid- Kulchinsky cells (enterochromaffin-like)
tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable - GIST- cajal cells
tx- resection (MC stomach), imantinib - Desmoid- spindle cells
tx- resect if extra-abdominal. NSAID/estrogen if intra
Meckel’s Diverticulum Pathophys
- Anti-mesenteric border of SB
- 2/2 peristant viteline duct
- pancreatic and gastric tissue
- 2 feet from IC valve
VRE coverage
Linezolid, Dapto
- Amp if not amp resistant
MOA:
- Milrinone
- Midodrine
Milrinine- PD inhibitor, contractility with vasodilation
- c/i in renal failure
Midodrine- a1 agonist
Hyperaldosterone w/up
Px: resistant HTN and hypokalemia
- AM plasma aldo/renin
- A/R < 20: 2nd hyperaldo
- A/R > 20: primary hyperaldo ➡ - Confirmatory test: salt load suppression test
- give salt load ➡ 24h urine aldo remains elevated - 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
Dx and Tx of SBP
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)
HLA test
- Tissue typing
- Donor organ: carries Ag (on WBC)
- Recipient body: carried Ab
- Recipient serum with donor wbc
Tx acute variceal HMHG
- Resuscitate, ensure airway
- Octreotide + antibiotics
- Endoscopic intervention (ligation/sclerotherapy)
- Blakemore
- TIPS (temporized with Blakemore)
Tx SVC syndrome tx
- Elevate HOB
- Chest CT with IV contrast (can skip CXR)
- Consider bronch
- 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
Crystalloid and colloid for trauma kids
Crystalloid: 20cc/kg
PRBC: 10cc/kg
Melanoma characteristics:
- superficial spreading
- lentigo
- nodular
- acral
- superficial spreading: MC
- lentigo: sun exposed, best prog
- nodular: worst prog
- acral: AA
**thickness is most indicative of prognosis
Tx appendicitis
- Uncomplicated: lap appe
- Septic/Unstable: immediate lap appe
- Stable w/ abscess
- < 3cm: lap appe
- > 3cm: IR drain ➡ interval appe, offer scope - Crohn’s ileitis
- intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty
Tx MEN2A/B
- urine metanephrine to r/o pheo 1st
- tx pheo 1st w/ adrenalectomy
- Address thyroid
- 2A: total thyroid + bilateral central neck by 5y
- 2B: total thyroid + bilateral central neck by 1y
Tx MEN1
- HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
- Asses other lesions
Prog and Tx anaplastic thyroid ca
Prognosis:
- aggressive, undiff
- mort ~ 100%; no tx
Tx: XRT improves short-term survival +/- surg
- BRAF inhibitor for chemo
GI Hormone Release and action:
- Glucagon
- Insulin
Glucagon: alpha cells of pancreas
- glycogenolysis, gluconeogenesis
Insulin – beta cells of the pancreas
- cellular glucose uptake; promotes protein synthesis
Criteria for transanal excision of adenocarcinoma
- T0 or T1 (submucosa)
- < 3 cm
- < 30% circumference
- Palpable on DRE (<8cm from anal verge)
- No high-risk features (poorly diff, LV invasion)
**local recurrence rate is higher
Merkel cell ca - dx, histo, and tx
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)
Breast abscess tx
- 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
5 steps to LADDS procedure
- Resect Ladd’s bands
- Widen the mesentery
- Counterclockwise rotation
- Cecum in LLQ (cecopexy), place duodenum in RUQ
- Appendectomy
HNPCC screening and treatment
- CRC: scope q1-2y starting at 20-25
- Surgery if:CRC or endoscopically unresectable lesions
- TAC with IRA w/ q1y rectum surveillance - Endometrial ca
- childbearing: endometrial sampling q1y
- after children: TAH-BSO - Ovarian ca: annual pelvic exam and TVUS
Dx and Tx choledochal cyst
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
Vit D vs. PTH
Vit D: increase Ca and Ph
PTH: increase Ca and decrease Ph
Arterial content
(1.34 x Hb x Sa02) + (.003 x PaO2)
Px, Dx, and Tx:
Duo atresia
TEF
Pyloric stenosis
Intussusception
Malro
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
Cori cycle
- recycling of lactate and pyruvate to liver for gluconeogenesis and glucose production
- requires alanine
- provides 40% of glu when starving
Tx of GB cancer
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)
Layers of mucosa
Epithelium
Lamino Propria
Muscularis mucosa
Stage 3 breast cancer and tx
3a: 4 to 9 nodes ➡ +/- neoadj
3b: chest wall (not pec wall) or breast skin ➡ +/- neoadj
3c: supra clavicular nodes ➡ neoadj required
Tx of CBD stone intra-operatively
- Flush ➡ glucagon x 2
- Lap exploration
A. Transcystic: stone < 1 cm, <8 stones, no CHD stones
B. Lap CBD: stone > 1cm, > 8 stones, CHD or junction stones - 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
W/up Hurthle Cell Cancer
- FNA- hurthle cells (can be seen in other conditions)
- Lobectomy 1st for diagnosis
- If malig: total thyroidectomy +/- L6 nodes
- If palpable nodes: MRND
No RAI
Conduit after esophagectomy
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)
Cancer Markers:
Ca 125
bHCG
AFP
Inhibin
Ca 125- epithelial
bHCG- choriocarcinoma
AFP- germ cell/endodermal/yolk sac
Inhibin- granulosa/sex-cord
Tx of High grade AIN/bowen’s disease of anal margin
- Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin
- otherwse: cryo, curettage, 5-FU, laser - Lifetime surveillance even if tx!
- Bowen disease = SqCC in situ = high grade AIN
- Actinic keratosis is precursor
*vs. pagets disease- excision
Types of rejection - px, path, and tx
- hyper-acute: w/in 1 hour
- path: ABO Ab (t2 HS)
- px: mottled organ
- tx: remove organ - 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 - 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)
Dx and Tx DPGM injury
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)
Hypocalcemia vs. Hypercalcemia - sxs and ekg
- HypoCa: tingling, chvostek/trousseau sign
- EKG: qt prolongation - HyperCa: stones, bones, groans, overtones, DI
- EKG: shortened QT
Calcitonin
Parafollicular C cells
Inhibits osteoclast resorption
Increases Ph excretion
Crohn’s drugs MOA:
- Azathioprine/6-MP
- Sulfasalazine/5-ASA
- Infliximab
- Azathioprine/6-MP: inhibit DNA synthesis
- Sulfasalazine/5-ASA: COX/LOX inhibitor
- Infliximab: monoclonal Ab to TNF; moderate Crohns, recurrent perianal fistula!
GI Hormone Release and action:
Gastrin
Somatostatin
CCK
Secretin
VIP
- Gastrin - G cells in antrum
- ↑ HCl, IF, and pepsinogen - Somatostatin – D cells in pancreas
- inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output - CCK – I cells of duodenum
- gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells) - 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 - VIP – pancreas and gut
- ↑ intestinal secretion (water and electrolytes) and motility
Anal canal
Dentate line
Anal verge
Anal margin
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
Px, Dx, Tx Galactocele
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)!
Stages of graft healing
- imbibition (direct diffusion)
- inosculation (cap beds meet)
- revascularization
Hernia repairs:
Bassini
McVay
Lichtenstein
Shouldice
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
EBUS accesible nodes:
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
Order of cells in healing
- Hemostasis: PMNs
- 24-48h
- PMNs: remove necrotic tissue - Inflammatory: monocytes/macrophages
- 48-96h
- mphage: growth factors, angiogenesis, cell proliferation
- chronic wounds - Proliferative: fibroblasts
- 3 days+
- fblasts: collagen production - Maturation: fibroblasts
-10 days+
- myofibroblasts for wound contraction
PMN (24-48h) ➡ MPhages (48-96h) ➡ Fblast (3d) ➡ MFblast
Hemophilia A
f8 deficiency, SLR
MC inherited disorder
tx- DDAVP (mild), f8 concentrate (severe)
Adenoid cystic carcinoma - px and tx
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
Tx for cholangiocarcinoma
Tx:
1. Resectable if:
- contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor
- no distant mets or organ invasion
- Consider location
- Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
- Middle ⅓: hepaticojejunostomy
- Lower ⅓: Whipple - Chemo + transplant if unresectable
acid and alkali burns - px
- Alkalis (Liquid Plumr, Drano) produce deeper burns than acid due to liquefaction necrosis
- Acid burns (battery acid) produce coagulation necrosis
- copious water irrigation as soon as possible
- cagluc if HF acid
IPMN - dx and tx
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
Tx PDA
to close- indomethacin
to open- PGE1
Airway management anatomy
Anatomy:
1. Elective trach: between 2nd and 3rd trach rings
2. Crich: CT membrane between thyroid cart and cric
- Thyroid ➡ cricoid ➡ rings
Dopamine dosing and s/e
low: d1/2-ago (renal dose)
medium: B-ago (heart)
high: A-ago (vaso)
**s/e: high UOP. difficult to titrate. tachyarrythmias
Parkland formula
- 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
Who needs stress dose steroids and how to dose
> 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
Path, Dx and Tx of Zenkers
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
Tx SIADH
Acute – vaptan, demeclocycline
Chronic – fluid restriction, diuresis
Spinal vs. Epidural
Spinal- below l1/l2; SA space; fast; n/m block
Epidural- any level; epidural space; slow; no block
VIPoma - loc, px, dx, tx
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
Gastric CA tx - chemo, margins, nodes
- 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
DDAVP/Vasopressin - production and effect
- Made in SON of HT. Stored PP
- Cause endothelium to release f8 and vWF
Milan criteria
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
Posterior and anterior vagal trunk branches
Vagotomies
Right ➡ Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet
Left ➡ Anterior trunk- Liver (hepatic branch) and ant Laterjet (L’s)
- 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 - Highly selective: transect @ crow’s ft, preserve laterjet
- removes innervation to lesser curvature
- preserves pylorus → no drainage procedure
- lowest morbidity
Insulinoma - loc, px, dx, tx
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
Dx and Tx fat necrosis
- dx: breast oil cyst w/ Ca+ rim
- smooth, circumscribed lesion outlined in white (course, egg-shell calcs)
- suspect post-op - tx:
no trauma- bx
trauma- watch
Px, Dx and Tx Pancreatic divisum
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)
Indications for neoadjuvant therapy eso cancer
- high grade t1b or T2 and above OR any nodal involvement
- Also get XRT
Marfans vs. Ehlers-Danlos
- Marfans- Fibrillin-1 defect (elastin);
- AD; mitral regurg, aortic root dilation, lens defect, arachnodactyly - Ehlers Danlos- t3 collagen defect
- hyper elastic skin, hypermobile joints, aortic root dilation
**Both need CTA of aorta to r/o aortic root``
Bladder ca - dx and tx
px- hematuria in a smoker
dx- CT urogram 1st (bladder, kidney, or ureter ca)
- T1a- no muscle/including LP
tx- transuretehral resexn (TURBT) + mitoM + BCG - T2a- muscle/beyond LP
tx- cystectomy + LND + chemo - T3- fat/nodes
tx- neoadjuvant
Tx tracheal inj
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
Specific to Crohn’s and UC
- Crohn’s:
- Creeping fat
- Skip lesions
- Transmural
- Cobblestoning
- Granulomas
- Fistulas - UC:
- Crypt abscess
- Pseudopolyps
Uremic PLT dysfunction - px, dx, tx
Px- 2/2 renal disease.
dx- normal coags. elevated BT only.
tx- ddavp
Escharotomy indications
- 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
Gastric ulcers: elective classification and management
Dx- EGD and Bx (Bx needed to r/o ca!)
Tx-only tx if refractory to max medical management after 12 weeks.
- lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2
- gastric + duo; high acid ➡ antrectomy + vagotomy
- pre pyloric: high acid ➡ antrectomy + vagotomy
- GE junction: normal acid ➡ sub-total gastrectomy + REY
Emergent vs. Elective UC Tx
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
Kasabach-Merritt Syndrome
- hemangioma + thrombocytopenia
- usually infants
- resect!
Peutz-Jeghers - px and screening
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
Omphalocele
- 2/2 failure of umbo ring closure
- 11th week gut returns to abdominal cavity
- normal bowel (protected)
- Other congenital defect are more common
Cryo contents and uses
- Contents: VWF, f8, fibrinogen
- Uses:
1. VWD
2. Fibrinogen def
3. Hemophilia A
Zone injuries and management
- penetrating:
- zone 1-3 –> explore - blunt:
- zone1 –> explore
- zone 2-3 –> do not explore
TOS tx
- neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
- venous- catheter-directed thrombolysis → surgical decompression
- arterial- C7/1r resection, subc artery resection/reconstruction
FAP - Dx and Tx
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
BRCA risks and tx
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!
When to operate on adrenal mass
- all functioning tumors
- all > 6 cm ➡ open resection
- if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection
**DO NOT biopsy first
Adjuvent chemo for breast ca
- Adjuvent chemo: tumor > 1cm, nodal dz, triple neg
- echo before for cardiotox - Tamoxifen/Anastrazole: 5y for HR+ tumors
- Tamox for men - Trastuzumab- 1y for Her2/neu+ tumors
- echo before for cardiotox - Olaparib- 1 year for triple negative/BRCA+ tumors
- PARP inhibitor
**Oncotype recurrence score > 26 requires adjuvant chemotherapy
FNH - path, dx and tx
path- CENTRAL STELLATE SCAR!
dx- bright on arterial phase homogenous
tx- resect if sxatic. no malignant potential.
Secretin vs. CCK
Both released by duo
S cells ➡ Secretin- duct cells ➡ bicarb
I cells ➡ CCK- acinar cells ➡ enzymes
Pancreas drainage procedures
- duct > 7mm- Peustow, pancreaticojej (for large duct)
- duct > 7mm and large head- Frey, pancreasticojej + core out head
- duct < 7mm and large head- Berger, pancreatic head resection
Tx papillary/follicar thyroid cancer
- Indications for total thyroidectomy:
- Tumor > 4cm
- Distant mets or extra-thyroid disease
- Poorly differentiated
- Prior radiation - 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 - 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
Heparin - MOA and measurement
MOA: Accelerates AT3 activity and INDIRECTLY inhibits thrombin
Measurement:
- PTT
- ACT: better intra-op if high doses of hep given
Screening guidelines for breast ca
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
Tx SDH
- Nonop: HDS, <10 mm, <5 mm shift
- Evacuate: > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP
Central venous O2 vs. mixed venous O2
Mixed venous: from PA
Central venous: from SVC only (estimation of mixed)
Reversals:
- BB
- CCB
- Tylenol
- Benzos
- CN/Nitroprusside
- Vecuronium/Rocuronium
- Ethylene glycol
- Methemoglobinemia
- 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
Orientation of portal triad
Bile duct lateral
Hepatic artery medial
Portal vein posterior
Px an tx:
Cryoptococcus
Coccidiomycosis
Histoplasmosis
Mucormycosis
- Crypto- CNS sxs in AIDs pt
tx- amphotericin - Coccidio- pulm sxs in the southwest
tx-amphotericin - Histo- pulm sxs in ohio river valley
tx- itraconazole → ampho B (only if sxs) - Mucormycosis- burns/trauma w/ bloody cough
tx- emergent debride, ampho
LN harvest/margin
eso
stomach
colon
rectum
eso- 15/7cm
stomach- 15/5cm
colon-12/5 cm
rectum- 12/5 cm
Succinylcholine - MOA, s/e, c/i
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
Breast nerve - muscle and actions:
- Thoracodorsal
- Intercosto-brachial
- Lateral petoral
- Medial pectoral
- Long thoracic (medial)
- 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
Cohort study vs. Case control
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
Tx acute limb ischemia
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
Papillary cystadenoma (Warthin tumor) - px, tx
Px: benign tumor of salivary gland
- often BILATERAL and 2/2 smoking
- Slow growing
Tx: complete resection with uninvolved margins even if ASx
Hemangioma - path, px, and tx
path- PERIPHERAL ENHANCEMENT with continued late filling
px- young women
tx- if rupture, size change, or KM syndrome
Pancreatic ducts
Wirsung- major, lies inferior
Santorini- minor, lies superior
Gluconeogenesis precursors
lactate , pyruvate, AA (alanine, glutamine)
Sirolimus - MOA, s/e
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
Tx of rectal prolpase
- 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
Li Fraumeni - gene, mechanism, and px
- 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
Chylothorax dx and tx
- dx: fluid TG > 110
- 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
Tumor lysis syndrome - px, path and tx
Px: Common 2/2 B cell lymphoma
- hyperU, K, Ph w/ hypoCa
Path: CaPh crystal ➡ renal failure + hypoCa
tx: IV hydration ➡ iHD
CRC T and N stages
t1- SM
t2- MP
t3- xMP/subserosa
t4- invade
n1- 1-3, n2- >=4
Rectovaginal fistula tx
wait 3-6m
low- endorectal advancement flap
high- abdominal approach
Schiatzki’s Ring - Path and Tx
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
NNT
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
Tx childhood GI disease:
- Pyloric stenosis
- Intussusception
- Duo atresia
- TEF
- Malro
- Pyloric stenosis: pyloromyotomy
- Intussusception: air contrast enema (air > water)
- Duo atresia: DD or DJ
- TEF: right extrapleural thoracotomy
- Malro: LADDS proc
Pancreatic fistula - dx and tx
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)
Max dose of lido and bupiv and tx of OD
lido = 5mg/kg (7 w/ epi)
bupiv = 2.5 mg/kg (3 w/ epi)
tx- lipid emulsion
Epi, Dx and Tx Aspergillosis
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)
Dx and Tx of GIST
- 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 - 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
Vitamin K - MOA and def
MOA: gamma CARBOXYLATION (not decarb) ofGLUTAMATE on 2, 7, 9, 10, c, s
Px of def: coagulopathy, suspect if obstructive jaundice
Rectum:
1. Arterial supply
2. Venous drainage
- Arterial supply:
- IMA to superior rectal a.
- II to middle rectal a
- II to internal pudendal a. to inferior rectal a. - Venous drainage-
- SRV ➡ IMV ➡ PV (portal)
- MRV/IRV ➡ internal pudendal ➡ internal iliac (systemic)
Kcal per macronutrient
Total kcal req
- protein = 4 kcal/g
- dextrose = 3.4 kcal/g
- lipid = 9kcal/g
- carb = 4 kcal/g
total req = 25-30 kcal/kg
- use ideal body weight if BMI > 25
- 50% carb, 30% fat, 20% protein
Hinchey
1- pericolic abscess
2- pelvic abscess
3- purulent
4- feculent
Contents of ant triangle of neck
- Carotid sheath, anca cervicalis, CN 12 (hypoglossal)
- Contents of carotid sheath: CN10 (vagus), CCA, ICA, internal jugular
- Facial vein is the gateway
Px and Tx for Leriche syndrome
px: diminished femoral pulse, butt claudication, ED
- younger than infra-inguinal vascular dz patient
tx: aortobifemoral bypass
Benign lesions that require excisional bx
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
Future Liver Remnant requirements and indications for PVE
- minimum 20% if normal liver
- pre-op chemo/some dysfxn = 30%
- cirrhosis = 40%
-Otherwise should undergo PVE
-Overt PH is a c/i to PVE
type 1 vs. type 2 error
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”
hepatic adenoma - imaging, tx, and risks
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
Types of mastectomy
- Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin (no nodes)
- MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes
- BCT: partial mastectomy + XRT
Pyoderma gangrenosum and erythema nodosum - px and tx
- Pyoderma: pre-tibial ulcer
- Erythema Nodosum: pre-tibial erythematous plauque
- both associated w/ IBD
- both RESOLVE after resection
- tx: steroids
anion gap - equation and causes
Cases of NAGMA
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
MOA reglan and erythromcyin
- reglan: dopamine antagonist
- erythromycin: motlin receptor agonist causing SM contraction
Modality and staging for eso cancer (T and N)
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+
Barrett’s eso surveillance (progress to cancer)
Bx: Goblet cells and columnar cells
- No dysplasia: 4 quad every 2 cm q 3-5y
- 1 cm if mucosal irregularities
- Ca .1%/y - LGD: 4 quad every 1 cm q6m. Consider ablation.
- Ca .5%/year - HGD: ablation/endoscopic resection. 4 quad every 1 cm q3m
- Ca 5%/year
*Fundoplication is only c/i in HGD
*No screening if asx
HNPCC vs. Lynch S
Dx and Screening
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
Serum osmolarity
Osm = 2xNa + Glu/18 + urea/2.8
Superior laryngeal nerve (external branch) - fxn, injury, and tx
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
GCS motor
6- obeys commands
5- localized
4- w/draws
3- flexion (decort) - ‘flex your core’
2- extension (decErebrate)
1- none
LeFort fxs
I- palate
II- nose and palate
III- entire face
Human bite tx and organism
tx: amox/clavulanate (augmentin)
- requires I&D if joint appears septic (pain w/ passive motion)
**MC for human bites- eikenella
MCCO healthcare infection:
- HAP/VAP
- central line infection
- SSI
- UTI
- GI infection
- SBP
- Cholangitis
- NSTI
- ICU infection
- Fungal infection
- Graft infection
- Lymphangitis
- 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
Tx of trx of great vessels
1st give PGE1 → ballon atrial septostomy
RF, Dx and Tx SqCC of anal canal
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
TOF - defects and tx
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
Cutoff for low risk lung nodules not requiring follow-up
- 6mm ➡ NTD
- 6-8 mm ➡ q6-12m CT
- > 8mm
- low risk pt- q3m CT
- high risk pt- bx or resection
Light’s criteria
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;
Treatment of colo-cutaenous fistula
- Start with conservative tx
- Quantify output:
- High output: > 500 cc/day ➡ likely OR. Start with NPO/TPN.
- Low output: < 200 cc/day ➡ likely conservative. OK for PO intake. - If input increased with PO intake ➡ NPO and TPN
- OR if failed after about 6 weeks
Most abundant bacteria in the colon
Bacteroides fragiles (anaerobe)
T staging for esophageal cancer
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
Exposing the pancreas: head, body, tail and order of operations in trauma
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
Thoracic duct course
- originates at L1-L2 @ c. chyli
- cross from R to L at T4-5
- empties into L SC/IJ jxn
**Carries chylomicrons and LCFA
Stomach vs. Duo ulcer px
- Stomach ulcer: pain right after meal
- 75% H. pylori, 25% NSAIDS/ASA - Duo ulcer: pain 2-3h after meal
- 90% H. pylori, 10% NSAIDS/ASA
**NSAID/ASA: decrease mucosal mucus secretion and bicarb secretion
Effective for Pseudomonas
- Zosyn
- 3/4G cephalosporin (ceftriaxone, cefepime)
- Aminoglycodies (genta, tobra)
- Flouroquinolones (cipro)
- Meropenem/Imipenem
**Not linezolid (good for G+/MRSA)
most common organism in burn wound infection
most common viral burn wound infection
- Pseudomonas (< 10^5 organisms – not a burn wound infection)
- HSV
Cuff size for kids
age/4 + 4
Grading and tx of BCVI
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
Ectopic parathyroids
- 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 - 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 - 4 normal appearing galnds
- supranumary PT in the thymus
**Overall, thymus is MC location or ectopic gland
Trauma to the pancreas
- Head
- main duct: drain + post-op ERCP + staged resection
- no duct: drain - Tail
- main duct (grade 3+): resect w/ splenectomy (unless CHILD and HDS)
- no duct (grade 1-2): drain
MOA and s/e of trx meds
- Tacro
- Cyclosporine
- Sirolimus
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
Interossei and lumbrical innervation
palmar- ulnar n, adduct
dorsal- ulnar n, abduct
lumbricals- median (1-2)/ulnar (3-4)
MOA and S/e of tamoxifen
MOA: competitive E inhibitor in breast; weak agonist in uterus/liver
S/e:
- dvt/pe
- endometrial cancer
- cant take with SSRI (CYP inhibitors)
DCIS mammo and tx
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)
DCIS SLNBx
- does not metastasize
- not w/ l’omy unless >4cm, multicentric, palpable, high grade
- required w/ mastectomy b/c 20% have invasive ca
Dx and Tx of Cystadenoma
low CEA, low Amylase
tx- resect if sxs
Post polypectomy screening
-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)
Encapsulate organisms and empiric tx
-Organism: “Shin”
1. Strep pneumo (MC)
2. Neisseria
3. Haemophilus
- Empiric tx: vanc + 3GC
Casues of increased ET CO2
Increased muscle activity (shivering)
Increased metabolism (sepsis, fever, malignany hyperT)
Increased CO
Decreased minute ventilation
Dx and Tx of Meckels
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.
Products of posterior pituitary
“PAO in the POST”
ADH, Oxytocin
2/2 direct stem from neurosecretory cell
Hereditary pancreatitis - dx and tx
dx
- PRSS1 trypsinogen mut’n
- AD
tx: none
- smoking cessation is important
**different from AI pancreatitis (IgG+)
Cilostazol - MOA and use
MOA- PDi, inhibits PLT aggregation
tx for periph claudication
- c/i in any degree of HF (PDi)
Esophagus and Trachea access
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
Ureter injuries
- proximal ⅓ (U/P jxn and above) → primary uretero-urostomy.
Other options: ileal transposition, nephrostomy - middle ⅓ → primary u-u (preferred)
- Other options: tran uretero-urosotomy, Boari flap - lower ⅓ (distal to iliacs) → re-implanation +/- hitch
- early: w/in 5 days- stent, explore, or repair
- HDUS intra-op: ligate, perc neph, delayed repair (3m) - late: > 10 days- perc nephro and delayed repair (3m)
Vitamin D processing
7-DHC + sunlight ➡ d3 liver ➡ 25-d3 kindey ➡ 1,25-d3
Tx papillary/follicar thyroid ca
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
Tx Odontoid fx
1: upper D, stable, non-op
2: base of D, unstable, worst, +/- surg
- may require intubation
3: c2 vert, usually no OR
GCS verbal
5- normal
4- confused
3- inappropriate words
2- incomprehensible
1- none
MELD vs. CTP
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
Intraductal papilloma dx and tx
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
Tx Umbo and Inguinal hernia in child
most close by 2
<3cm- primary repair
>3cm- mesh
repair by 5
Inguinal- repair by 2 weeks if reducible
- otherwise, OR then
Gastroschisis - px and tx
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
Mineral def:
-Zn
-Sel
-Chromium
-Copper
-B1
-B3
-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)
UES vs LES muscles
UES- cricopharyngeus; higher resting pressure (70)
LES- lower resting pressure (15)
Stiewert-Stein Class and Tx
Relation to GEJ:
1. 1-5 cm above: eso ca
- esophagectomy and prox gastrectomy (Ivor lewis)
- 1 cm above-2 cm below: eso ca
- esophagectomy and prox gastrectomy (Ivor lewis) - 2-5 cm below GEJ: gastric ca
- total gastrectomy
*Require 5 cm eso margin, 4 cm gastric margin, 15 nodes for eso CA
Esophageal CA tx
- HGD, TIS, T1a: endoscopic ablation/resection
- T1b: upfront esophagectomy or endo ablation (if low risk)
- T2 or N: neoadjuvant then esophagectomy
- Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso - T4b or M: definitive chemo-XRT
< 5cm from cricoP: definitive chemo-XRT
> 5 cm from cricoP: esophagectomy
Indications and C/I to anti-reflux surgery
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
Classic and Alarm sxs for GERD
Classic sxs: heart burn + regurg
Alarm:
1. dysphagia (not regurgitation)
2. odynophagia (pain)
3. bleeding
4. weight loss
5. anemia
*Require EGD
Tx of Leiomyoma
- sxs or > 4cm- enucleate
- < 4cm- observe
- > 8cm or circumferential- esophagectomy
Approach:
Cervical- L
Mid eso- R
Distal eso- L
Required for staging esophageal CA
- CT of chest, abdomen- M
- Whole-body PET scan- M
- EUS- T and N stage
Caustic injury w/up
- Avoid NGT. No neutralizing agents
- CT scan if stable
- Early endoscopy (AFTER CT)
- OR if unstable. Otherwise, restart orals in 48h.
*alkali- liquefaction necrosis. worse outcome
*acid- coagulation necrosis
Steps of Heller myotomy
- Divide G-H ligament
- ID R crus and posterior vagus
- ID L crus and anterior vagus
- Divid short gastric vessels
- Expose GEJ (excise eso fat pad)
- Myotomy (6 eso, 2 stomach)
- outer long 1st
- inner circular 2nd - Partial wrap
How to mobilize the stomach for intra-thoracic anastamosis
- Divide G-H ligament
- Transect the L gastric. Keep the R gastric.
—- Lesser Curve Mobilized—- - Transect gastro-colic until prox duo. Avoid R gastro-epiploic!
- 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
Epiphrenic divertciulum
Loc: distal eso. R > L. Pulsion
Tx: only if sxs.
- L diverticulectomy w/ contra myotomy
Dx and Tx of Eso perf
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
FeNa equation and interpretation
(U Na/S Na) / (U Cr / S Cr) * 100
<1% = Pre-renal
>1% = Intrinsic
>4% = Post-renal
Refeeding Syndrome - mech and px
- 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
pH relation to pCO2
10 mmHg increase in pCO2 = .08 decrease in pH
Tx of DI
- Central- DDAVP
- Peripheral- tx underlying causes (stop Li), amiloride, HCTZ
W/up and Tx of endometrial CA
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
Pregnant lap appe
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
Px, Dx and Tx of ovarian torsion
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
Monitor and reverse TPA
Fibrinogen level (<100 = r/o bleeding)
Reverse: a-CA
Cause and Tx of Warfarin skin necrosis
Cause: protein C def (not S!)
Tx:
Stop Coumadin
Give vitamin K
Start hep gtt or argatroban
Intrinsic vs. Extrinsic Pathways
Intrinsic: 8, 9, 11, 12
Extrinsic: 7 (shortest t 1/2), Tissue factor
Common: 1, 2, 5, 10
Reversal of NOACs:
Apixaban
Rivoroxaban
Dabigatran
Apixaban: andexanet
Rivoroxaban: andexanet
Dabigatran: idarucizumab (+iHD)
VWD dx and tx
dx: normal PLTs. Abnormal BT, PTT
- ristocetin test or measure vWF level
tx:
1. type 1: not enough; ddavp ➡ cryo
- MC congenital bleeding disorder
- type 2: qualitative; VWF/f8 concentrate, cryo
- DDAVP for some subtypes - type 3: VWF/f8 concentrate, cryo
**only type 1 (and some type 2 subtypes) can use DDAVP
Tx of hepatic encephalopathy
- Correct precipitating cause
- Lactulose (goal 2-3 stools/day)
- Rifaximin
- Neomycin
PEP:
1. HIV
2. HBV
3. HCV
- HIV: 4wks of anti-retroviral combo
- HBV: HBIG + Vaccine
- HCV: No recommendations.
Segmental liver anatomy
7 - 8 - 4a - 2
6 - 5 - 4b - 3
Dx and Tx of Budd-Chiari Syndrome
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
Tx of Isolated Gastric Varices
2/2 chronic pancreatitis induced splenic vein thrombosis
tx- Splenectomy
Effects of pneumoperitoneum
Increase preload initially, then decrease
Increase afterload. Decrease CO
Increased PCO2. Decrease FRC
Decrease renal function
Pancreas blood supply and anatomy
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
Indication for ERCP w/ GB dz
- Bili > 4
- CBD stone on U/S
- CBD > 6 mm and Billi > 2
- Ascending cholangitis
Autoimmune pancreatitis - px, dx, tx
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
W/up of pancreatic cancer
- Pancreatic protocol CT
- EUS: if questionable LN or vessel involvement
- ERCP: if jaundice or dx uncertainty
- 90% sensitive for dx - PET/CT: selectively if suspicion for malignancy.
- Staging scope: if suspect disseminated dz
- > 3cm, high Ca 19-9, tail tumor, high weight loss/malnutrition - Bx: Not if resectable. Only if neo-adj chemo
Tx of acute mesenteric ischemia
Thrombotic: at origin of SMA; prox. jejunum to transverse colon
- smokers
Embolic: distal SMA; jejunal sparring
- embolism (usually from left atrial appendage)
- IVF, abxs, AC
- Emergent revascularization
- peritonitis: ex lap to evaluate bowel, open embolectomy
- consider endovascular if specialized center, no peritonitis, and low suspicioun for necrotic bowel
Dx and Tx of chronic mesenteric ischemia
- 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
Tx of renovascular stenosis
- BB
- ACEi: unless 1 kidney or bilateral dz
- efferent dil’n can worsen kidney dz - PTA: perc trans-luminal angio +/- stent (or open revascularization)
- only if refractory to meds! - Nephrectomy
**CORAL trial: PTA is not better than maximum medical therapy
Open SMA embolectomy
- Lift transverse mesocolon
- Trace MCA. Palpate the SMA at root of mesentery along inferior margin of pancreas
- Incise peritoneum and dissect down to the artery (left of the SMV)
- Therapeutic heparinize
- Proximal and distal control
- Transverse arteriotomy PROXIMAL to middle colic origin
- 2 or 3 Fogarty balloon passed proximal and distal
- Close arteriotomy with interrupted proline
Tx of air embolism
- LEFT lateral decubitus and Trendelenburg (trap air in the RV)
- Aspirate central line
Timing of endarterectomy after a stroke
- Non-disabling stroke or TIA: 2d-2w
- Big stroke: no consensus
When to consider ppx fasciotomy + steps
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
Femoral embolectomy
- 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
Exposure of LE arteries:
1. Femoral
2. AK Pop
3. BK Pop
4. TP Trunk
- Femoral: vertical incision over the artery from inguinal ligament
- AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus lateralis. I
- 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
Preference for peripheral fistula
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
SC Steal syndrome - path and tx
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
Tx of type B dissection
- Uncomplicated: b-blocker for impulse control, elective repair
- Surveillance q3, 6, 12m. TEVAR if progression - 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
Tx of splenic aneurysm
- > 2cm, sxatic, or fertile age female
- embolize distal AND proximal (back bleeding from short gastric)
- trauma/rupture situation may require splenectomy - Otherwise, monitor
Tx of aneurysms
- splenic
- renal
- iliac
- femoral
- pop
- splenic: > 2cm or sxs ➡ embolize
- iliac: > 3 cm ➡ covered stent
- femoral: > 2.5 cm ➡ covered stent
- pop: > 2 cm ➡ exclusion and bypass
Tx of psuedoaneurysm
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,
Nerve injuries during CEA:
- Recurrent laryngeal
- Marginal mandibular
- Hypoglossal nerve
- G/Ph nerve
- Superior laryngeal
- Accessory
- 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
Tx of Type A dissection
- Treat with immediate surgery
- Put patient on bypass
- Median sternotomy
May-Thurner Syndrome
Iliofermoal dvt 2/2 R iliac artery compressions L iliac vein against lumbar spine
tx- venogram, thrombolysis and stenting
W/up of non-variceal UGI bleed (M/W tear)
- NGT+ ➡ EGD w/in 24h- clips, coags, banding, sclerose
- NGT-:
- HDUS: IR angio (must be brisk)
- HDS- C’scope/consider RBC scan, surgery
Surgical indications for acid reduction surgery
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)
Acute surgical options for duodenal ulcer disease
Indications: bleeding, perforation, obstruction
- Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed
- can tie off the GDA if continues to bleed
- no vagotomy - 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 - 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
Tx of gastric ulcer disease
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
Tx of Complications after Billroth 2:
- Afferent limb obstruction
- Dumping syndrome
- Alk reflux
- Post-vag DRH
- 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 - Dumping syndrome: small meals, no sugar ➡ octreotide
- Alkaline reflux gastritis: prevent w/ roux limb > 40 cm.
- pro-kinetics, bile-acid binding ➡ convert to REY with long roux - Post vagotomy DRH: cholestyramine (dx of exclusion) ➡ reversed jejunal segment
How to confirm H. pylori eradication
4-weeks after triple therapy:
- Urea breath test: preferred 1st line
- EGD + Bx: preferred if known gastric ulcer (r/o CA)
- Fecal Ag test
**Gram-, spiral-shaped
Primary fuel source in fasting state
- 1st 4 hours: exogenous glucose
- 4h-1d: Liver glycogen
- 1d-1w: gluconeogenesis phase (alanine from muscle)
- 1w+: protein-sparing phase
- FA/Ketones are used everywhere
- RBCs use glucose only
Dx and Tx of rectus sheath hematoma
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
Removal of perc chole tube
- Remain in place for 3-6 weeks for tract to form
- Cholangiogram to assess CD patency
- Clamp tube or elective chole if surgical candidate
Essential fatty acids and deficiency px
- Linoleic acid- omega-6 (Cis, Unsturated)
- inflammatory - α-linolenic acid- omega-3 (Cis, Unsturated)
- anti-inflammatory
Deficiency: waxy skin, dermatitis, hair loss, TCP
RQ interpretation (metabolic cart)
CO2/O2
< .7 = underfeeding/starving
.7 = pure fat
.8 = pure protein
.8-.9 = desired
1 = pure carb
>1 = overfeeding
BSC vs. SqCC - dx and tx
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
Dx and Tx of Nec Fac
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
Dx and Tx of pancoast tumor
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
Types of hyperPTH
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
Dx and Tx of Ewing Sarcoma
Dx: “onion skin” in diaphysis
- pelvis is MC location
Tx: chemotherapy (1st line) + surgery or XRT
Pulmonary sequestration
No bronchial commmunication
1. Intra-lobar: MC; blood from aorta; pulmonary veins
2. Extra-lobar: systemic arteries and veins
Tx- lobectomy or segmentectomy
Lung anatomy: R vs. L
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
RF and Tx of T/I fistua
RF- trach below 4th ring OR, high pressure cuff, high innominate cross
- Over-inflate the cuff
- Intubate from above
- Compress against the sternum
- Median sternotomy
- Ligation AND division of innominate artery
- Buttress tracheal hole w/ muscle
**aorto-enteric fistula should also be treated aggressively with operative takedown and extra-anatomic bypass
Indications for pleurodesis
- Air Leak > 5 days
- Recurrent (even if contra-side)
- High risk occupation (scuba, pilot)
Px, dx and tx Lymphocele
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
Px, Dx, Tx of RAS and thrombosis after kidney transplant
- Thrombosis: sudden cessation of UOP immediately post op
-Dx: U/S
-Tx: nephrectomy unless small branch - Stenosis: refractory HTN and elevated Cr
- Dx: US (vel > 180, 70%)
- Tx: perc angio/stent
**No pain with arterial issue (pain = venous issue)
W/up and Causes of low UOP after kidney trx
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
Inflow and outflow for pancreas transplant
- 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 - 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
w/up of kidney graft dysfunction
- Elevated Cr. Low UOP.
- 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
Post transplant hepatic artery vs. PV thrombosis
- HA thrombosis: MC
- Early: FHF ➡ thrombectomy OR re-trx
- Late (months): abscess, strictures ➡ temporize, re-trx
- Stenosis: angio and stent - PV thrombosis: rare
- Early: FHF ➡ thrombectomy or re-trx
- Late (months): encephalopathy, varices ➡ AC
- Stenosis: angio and stent
GVHD - px, path, dx, tx
-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
Tx of testicular torsion
- Surgical de-torsion of involved testes
- If doubtful viability: <10 keep, >10yo orchiectomy - Exploration and fixation of uninvolved testis as well!
**don’t delay OR for U/S if suspicion is high
Dx and Tx of RCC
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
Types of hydrocele and Tx
- Communicating: children. 2/2 patent processus
- <2yo: conservative, observe
- >2yo: surgical excision of processus - 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
Dx and Tx of LCIS
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
Dx and Tx of inflammatory breast ca
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
Fibroadenoma - px, dx, tx
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”
Tx of breast ca in preg
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!
Indications for post-mastectomy radiation
- > 5cm (T3+)
- 4+ nodes (N2)
- margin
- skin involvement
- inflammatory BC
**if prefer recon must be delayed or used a tissue expander for immediate recon
Bolus fluid and blood in children
Fluid: 20cc/kg
Blood: 10cc/kg
Repair aortic trauma
Access usually with Mattox maneuver
If < 50% closure primary with polypropylene suture
If > 50% perform a PTFE patch
Small bowel trauma
- Serosal tear: interrupted, non-absorbable
- <50%: 1 or 2 layer closure
- > 50%: resection and anastaoisis
- Multiple short segments: resection and anastamoisis
Access to neck zones
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
Causes of R-shift/decrease affinity on Oxy-Hb curve
2,3 DPG
Elevated temp
Higher paCO2
Acidosis
Shock class
- No VS changes
- Tachycardia
- Hypotension and combative
- No UOP and obtunded
Ketamine MOA, s/e and c/i
MOA: NMDA glutamate ANTAgonist,
s/e: tachycardia, hallucinations
c/i:
- MI (b/c SNS activity/cardiac demand)
- Space occupying brain lesion
SCIP Quality Measures
- abx 1h prior to incision (for approrpaite pts)
- include G negative coverage for GI procedures - abx dc w/in 24h
- appropriate hair removal
- controlled 6am glucose in cards pts
- dc foley on POD1-2
- normothermia
Insulin peri-op
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
Frey Syndrome
- Gustatory sweating
- 2/2 auriculotemporal nerve
- Suspect after parotidectomy for H/N tumor
- tx with anti-persiperant
Dx and Tx:
1. TG duct cyst
2. Brachial cleft cyst
3. Cystic hygroma
- TG duct: midline through hytoid bone; sistrunk procedure
- if infected tx w/ abxs first - Brachial cleft: anterior SCM; resection
- 2nd cleft cyst MC (mid/lower neck) - Cystic hygroma: posterior triangle; resection (avoid infection)
STITCH trial
5 mm bites every 5 mm
Tx of parastomal hernia
- ASx- can observe
- Sxs- sugarbaker is preferred
- keyhole is alternative
- do not relocate
- Only repair for obstruction or strangulation
- LB herniates more than SB
Tx of hiatal hernia
Type 1- asx: NTD; sxatic: PPI; Surgery if refractory
Type 2-4: surgery even if asx
Dx and Tx Ischemic Orchitis
dx- venous congestions from damage to pamp plexus after open hernia repair. POD 2-5
tx- NSAID and pain meds. Orchiectomy is last resort.
MCCO Cushing syndrome
- Exogenous steroids
- ACTH pituitary adenoma (Cushing disease)
- Cortisol secreting adrenal adenoma
- ACC
Dx and Tx of Addison’s
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
Px and W/up of Hypercortisolism (Cushing’s syndrome)
px: moon facies, striae
- Initial tests: choose 1-2
- 24h urine free cortisol (most se)
- late night salivary cortisol (when cortisol is lowest)
- overnight 1 mg dexa suppression - 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)
Dx, Path and Px, and Tx of carcinoid tumors
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
Tx of mesenteric vein thrombosis
- AC
- Surgery if peritonitis or failure to improve
- can also consider endovascular thrombolytics - 2nd look operation 24-48 hours
Tx of Grave’s disease
- Beta blocker
- Methimazole. PTU if preggo
- RAI once euthyroid: worsens opthalmopathy and c/i in pregnancy/breast-feeding
- 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
W/up of Hashimoto’s disease
- FNA- r/o ca
- Bloodwork- antiTPO/TG Ab
- Tx- thyroxine ➡ partial thyroid
**MCCO hypoT and goiter in the US
Tetanus ppx
- Full immunized (>= 3 toxoid doses)
- clean/minor: toxoid vaccine if dose >= 10 years
- dirty or > 1cm: toxoid vaccine if dose >= 5 years - Unknown or not fully immunized
- clean/minor: toxoid vaccine
- dirty or > 1 cm: toxoid vaccine + Ig
Px, Dx and Tx of CMV colitis
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
Standard w/up for lung ca
- PET/CT
- PFTs
- Bronchoscopy (can be intra-op)
- Mediastinal eval- EBUS or mediastinoscopy
Bronchiolitis obliterans
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)
Pressor for neurogenic shock
- Above T6: nor-epi (b/c HoTN and brady)
- Below T6: Phenylephrine (may worsen brady above T6)
**don’t normally get neuorgenic shock below T6
Vitamin A
- wound healing especially in steroid patients
- def: night blindness, dry eyes
PPV and NPV
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
Pearson’s R Value
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
Phases of clinical trail
- Safety in a small group of humans
- Effectiveness and side effects
- RCT compared to standard of care
- Long term safety and monitoring
Subclavien exposures
- Median sternotomy: right
- Left Anterolateral thoracotomy: left subclavian
- trap door supraclav incision for distal access
Indications for hepatectomy instead of liver trx in HCC patient who meets Milan criteria
Compensated cirrhosis, no portal HTN, low MELD, and solitary mass < 3 cm
- hepatectomy is preferred to transplant if they are Childs A
SMA embolus vs. thormbosis px
Embolus- lodges after the middle colic. Jejunal sparring
Thrombus- at ostium; pan-bowel
Desmoid Tumor - associations, path and tx
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
Serologic work-up for adrenocortical mass
- Dexa suppression (cortisol)
- Urine androgens (sex hormones)
- Plasma metanephrines (pheo)
- aldo/rennin ratio > 30 (salts)
Px, Dx and Tx endometriosis
Px- cyclic pain, pain with sex
Dx- dx laparoscopy
Tx-
1. Medical therapy
2. Surgery if unresponsive. Ablation if young.
MCCO primary hyper-aldosteronism and tx
- Idiopathic bilateral adrenal hyperplasia (60%)- medical
- Adrenal adenoma (Conn’s syndrome)- lap adrenal
- Adrenal adenoca- open adrenal + mitotane
* Can use adrenal vein sampling to distinguish
Respectability of pancreatic tumor and next step
Triple phase CT:
- Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV
- EUS/FNA for tissue dx for neoadjuvant - Borderline- <180 SMA/celiac, reconstructable PV/SMV
- EUS/FNA for tissue dx for neoadjuvant - Resectable
- dx lap (to confirm resectability) + whipple
Tx of horseshoe abscess
Hanley procedure:
- Midline drainage incision of deep posterior space (through ano-coccygeal ligament)
- Bilateral lateral counter-incisions for ischiorectal space
**all external drainage
Tx of anorectal fistula
<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.
Tx of Internal HMHDs
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)
Tx of External HMHDS
1st line: sitz, stool softener, bowel reg, fiber, fluids
2nd line: surgical HMHD’ectomy
Thrombosed: incise or excision if w/in 48h
Paget’s disease of the anus (px and tx)
Px: intractable pruritis, eczematoid rash
Tx: scope (r/o malignancy)
- dc topical agents
- perianal punch bx + WLE
Unresectable cholangiocarcinoma
Criteria
- bilateral HA or PV
- unilateral HA with extensive contra duct
Tx
- no extrahepatic dz ➡ neoadj chemo-XRT + liver trx
- extrahepatic dz ➡ chemo-XRT
Bismuth classification and tx
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
Lap CBD exploration
- Dissect CD to the level of the duo
- Cholodochotomy distal to the CD/CBD junction
- Fush, basket, or fogarty balloon the stone out
- Close primarily, over a T-tube, or over a stent
Px and Tx of Chalangitis
Dx: fever, RUQ, and jaundice
- stones > malignancy > stricture
Tx:
- signs of sepsis: resuscitate/abx then urgent ERCP
- no sick: US/MRCP
Px and Tx of Sphincter of Oddi dysfunction
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
Ideal setting for stone formation
Low bile salts
Low lecithin
High cholestersol
Mirizzi syndrome tx
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
Types of GB polyp
- Cholesterolosis: MC; CE mphages in LP; benign
- Adenomyomatosis: benign
- Adenoma: malignant; >1cm is RF for CA (resect)
Tx strategy for CBD transections
- Intra-op
- <50%, not cautery: primary repair
- >50%, or cautery: REY-HJ - 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
Management of GB polyps
- Sx: cc’ectomy
- 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
PSC screening guidelines
- Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9
- GB CA: US q6-12m
- CRC: colonscopy q1-2 years (regardless of UC)
Dx and Tx of Colovesicular Fistula
- CT w/ oral/rectal (no IV b/c will obscure bladder)
(not cystoscopy, colonoscopy, or Ba enema) - Colonoscopy to r/o malignancy
- 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
Colon cancer and arterial resection
- R hemi- IC, RC, RBMC
- cecum/asc colon - Extended R- IC, RC, MC
- hepatic flex/prox t colon - L hemi- LBMC, LC
- Distal TV, splenic flex, prox descending - Extended L- LBMC, origin of IMA
- splenic flex - Sigmoid- IMA (hi- b4 LC, low- after LC)
- dist desc/sig
Colon CA surveillance after curative resection
- Exam and CEA q3-6m x 3 years
- Colonoscopy @ q1, 3, and 5 years
- No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel) - CT CAP q1y x 3 years
- At 2 years: recurrence local or hepatic
- after 2 years: hepatic more often
Staging w/up of rectal cancer
- TRUS (avoid if > t2) or MRI- T/N stage
- suspicious nodes on MRI count as clinical stage N (neo-adj) - CT CAP- M stage
- C’Scope- for initial dx and sync lesion. not for T stage
- Rigid Sig’Scope- for distance from anal verge (required! even. if c’scope done)
Tx of refractory Crohn’s pan-colitis
- Segmental colitis- partial colectomy
- Rectal sparing pan-colitis- TAC w/ IRA
- 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
Tx of cecal volvulus
Stable- R hemi and primary mosis (no pexy)
Unstable- R hemi with end ileostomy
Dx of Juvenile polyposis
Dx: 5+ polyps or any polyps w/ family hx
- SMAD4+
Non-adenomatous polyps ~ hamartomas
Tx of Lynch Syndrome
- CRC: MC
- q1y C-scope @ 20-25
- TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma
- q1y scope post op - Endometrial: 2nd MC
- q1y endometrial sampling @ 30-35
- ppx TAH-BSO after children - Ovarian:
- q1y TVUS and Ca-125 @ 30-35
- ppx TAH-BSO after children - Stomach:
- EGD/Bx q2-3y @ 30-35 - Renal: transitional cell ca
- q1y UA and US @ 30-35
APR vs. LAR
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
Polyposis syndromes:
-Muir-Torre
-Gardner
-Turcot
-P/J
-Cowden
-JuP
-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
Indications for colonic stent
- Bridge to surgery in acute obstruction (usually with metastatic cancer)
- Palliative measure
* Usually for L-sided lesions
Gram, Tx and Virulence of C. diff
Gram: G+ bacillus, anaerobic
Tx:
1. Primary: oral fidox
- oral vanc is 2nd line now
- Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus
- no fidox - Recurrence: PO fidox or vanco
- Multiple recurrence: tapered fidox or vanco
- consider fecal transplant - Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm)
Virulence:
- Toxin A: intestinal necrosis
- Toxin B: cytotoxin
Dx and Tx of ischemic colitis
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
Dx and Sx of PNETs
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma
**All require bichemical testing before imaging!
- Glucagonoma: glucagon > 1k; NME, DM, DVT (no stones vs. SS’oma)
- Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad
- Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1
- VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH)
- SSoma: High fasting SS; DM, STONES, steatorrhea
*Do not perform imaging or go to the OR until biochemical diagnosis!
Dx and Tx of Pancreatic cysts:
1. Serous cystadenoma
2. MCN
3. IPMN
4. Psuedocyst
-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
Tx of PNETs:
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma
6. Non functional
- Glucagonoma: distal panc w/ splenectomy + cc’y
- Inuslinoma: enucleate
- Gastrinoma: enucleate if < 2 cm; >2 cm, whipple
- VIPoma: distal panc w/ splenectomy + cc’y
- SSoma: resect w/ cc’y
- Non functional: < 2cm observe or enucleate. > 2cm resect
Perform splenectomy for distal panc PNET?
No only if low malig risk- insulinoma, non function < 2cm, gastrinoma < 2cm
Arterial anatomy of the celiac trunk
- CHA: gives off GDA then R gastric
- GDA gives of SPDA and R gastroepi - Splenic: gives off short gastrics and L gastroepi
ECG findings of PE
Sinus tach is MC
S1Q3T3 pattern w/ TWI
Dx and Tx of Pulmonary Blastoma
MC primary lung tumor in children
Dx- air/fluid filled cystic lesions. Looks like pneumo.
Tx- Surgical resection +/- chemo-XRT
lead vs length time bias
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.
Brown-Sequard
Ipsi loss of motor
Contra loss of pain/temp
Dx of biliary dyskinesia
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)
Emergent ariway in a child
- Try ETT placement with a miller blade
- Needle cric is preferred over open if < 12 yo
- use cuffed tubes for everyone except newborns
Tx of peptic stricture 2/2 GERD
- Serial dilations
- PPI
- Consider stenting
- Surgery is last resort (in contrast to achalasia)
Exposure to bronchial tree in trauma
Carina or either mainsteim: RIGHT thoracotomy (aorta in the way on the left)
CREST Trial
- Carotid stenting has higher incidence of stroke
- CEA has high incidence of MI
- Composite end-point of stroke, death, MI was the same
Px, Dx and Tx of Bacterial Overgrowth
- px: 2/2 bill2 or REYGB
- watery stools, bloating, b12 deficiency
- dx: d-Xylose (carb test breath test)
- tx: abxs (Rifaximin) ➡ surg 2nd line
Inguinal hernia nerves + MC injuries
- Ilioinguinal: under to EO, anterior to cord
- sensation to medial thigh - Ilio-hypogastric: supero/medial to the ilio-inguinal. Between EO and IO
- sensation to lower abdomen - 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
HRS- Path, Px and Tx
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
Treatment of lung ca
- No N2 disease (stage 1-2) ➡ up-front surgery
- lobectomy + MLNDx. Can consider segmentectomy.
- can wedge if 2:1 margin ratio - 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
Lung ca w/up
- < 8mm ➡ surveillance
- > 8 mm ➡ PET-CT
- FDG- ➡ surveillance - FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy)
- nodal disease –> EBUS - No N2 dz –> Segmentectomy or lobectomy
- n2 disease –> chemo
Steps of hiatal hernia repair
- 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 - At least 3 cm of esophagus into the abdomen!
– Colis gastroplasty if insufficient - Close the hiatus with sutures or mesh (posterior and inferior)
– mesh has better short term outcomes only
– RELAXING incision if can’t reapproximate
Pre-op and intra-op regiments for aldosteronoma and pheo
- Aldosteronoma: Spironolactone + ACEi/ARB +/- CCB +/- K sparing diuretic
- Pheo: phenoxybenzamine then BB
Intra-op:
- HTN crisis: Nitro gtt
- Tachy arrythmia: Esmolol gtt
Tx of HCC
- 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 - 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
When to re-implant the IMA in EVAR
- Back-pressure < 40
- Previous colon surgery
- SMA stenosis
- Inadequate left colon flow
Lynch vs FAP Screening
- FAP- chromosomal; APC
- > 100 polyps, including small bowel (duodenum)
- Surveillance: start at 10 - HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM
- <10 polyps in the colon
- Surveillance: start at 20
Surgical Tx of thyroid/PT cancers
1. Papillary/Follicular
2. MTC
3. Hurthle
4. Anaplastic
5. PT
- Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk
- MTC: total + bilateral L6 (usually) + T3 post op
- RAI is c/i - Hurthle: lobectomy then total + bilateral L6
- Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes
- PT: hemi-thyroid +/- L6 (usually not)
**MRND if L6 is positive
Confirmation of brain death
- Neuro exam:
- absent brain stem reflexes
- no response to stimuli - 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 - Confirmatory test: CTA, MRA or nuclear scan
Bleeding during mesh fixation, inguinal hernia
- Open: sewing mesh onto EO –> femoral vein
- TEP: tacking mesh medially –> corona mortis (obturator branch)
Tx of H/N tumors
- Mucoepidermoid
- Adenoid cystic
- Pleomorphic adenoma
- Warthin/Papillary cystadenoma
- Mucoepidermoid: MC malignant
- total parotid + ppx MRND + XRT - Adenoid cystic: malignant
- total parotid + ppx MRND + XRT - Pleomorphic adenoma: MC benign
- superficial parotidectomy - Warthin/Papillary cystadenoma
- superficial parotidectomy
**Use modified Blair incision for these tumors
W/up of UGI bleed/perf:
1. Boerhave
2. Traumatic esophogeal perf
2. UGI bleed
- Boerhave: XR suggestive ➡ UGI (CT controversial)
- Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI
- UGI bleed: +/- NGT ➡ EGD
Tx of Cellular vs. Ab Rejection
- Cellular:
- mild: steroids (inhibit COX2)
- severe: TG - Ab:
- Plasmaphoresis (clear Ab)
- IVIG (so body thinks there are still ab)
- Rituximab (CD20 Ab)
IS for transplant - induction and maintenance
Induction: choose 1
1. Thymoglobulin - polyclonal Ab (potent)
2. Basiliximab - IL2 inhibitor (mild)
Maintenance
1. Tacrolimus
2. MMF
3. Prednisone
4. Sirolimus
Transplant ABX ppx
- Bactrim- PCP, toxo gondi, listeria, nocardia
- Diflucan- antifungal
- Valganciclovir- CMV
Transplant cross-matching
- ABO Incompatibility
- A, B, O Ab - 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
MAC
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
CDH1
High r/o gastric ca
ppx gastrectomy by age 40
px, dx, and tx of meconium ileus
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)
Congenital thoracic disorders - px and tx
1. Pulm sequestration
2. Cystic adenoid malformation
3. Congenital lobar emphysema
4. CDH
- Pulm sequestration: infection w/ abnormal CXR
- tx: resection - Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree
- tx: lobectomy - Congenital lobar emphysema: XR looks like tension PTX
- tx: lobectomy - CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior
- a/w pulm HTN, NTD, malrotation
- tx: intubate +/- ECMO. Delayed repair.
- Ig crosses the placenta
- Ig in brast milk
- Ig first responder
- IgG (small, y-shape)
- IgA (two y’s with joined tails)
- IgM (pentad)
Nutrition requirements per day
1. Protein
2. Fat
3. Carb
Nutritional requirements for average healthy adult male (70 kg)
- 20% protein calories: 1 g protein/kg/day
- burn: 1g/kg/day + 3 g/day x % BURN…(usually 2-2.5g/kg/day) - 30% fat calories
- 50% carbohydrate calories
Wilcoxon test
Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed
- ex: patient satisfaction before and after an intervention (1-5)
COX proportion hazard modeling
Like a regression model but for survival analysis
Allow you to control for different factors
Changes to VS and labs with preggo
- Increased HR, increased SV
- Decreased SVR, Decreased BP
- Dilutional anemia. More PRBC but also more water. Requires more blood loss for HoTN
Afferent limb syndrome - cause, px, dx, tx
- Cause: affarent limb is too long from LOTz
- Px: acute or chronic
- Acute: complete obstruction requiring emergent OR
- Chronic: partial obstruction w/ bacterial overgrowth
- steatorrhea, B12 deficiency. MC w/ antecolic Bili2 - Dx:
- Acute: abdominal pain with dilated afferent limb in early post op
- Chronic: d-xylose breath test - Tx
- stat OR for REY revision
- Chronic: abxs –> REY/shorten the limb
Medical tx for melanoma
- Pd1 inhibitors: pembrozilumab, nivolumab
- CTLA inhibitors: ipilmumab
- If Braf+: braf inhibitor remains 2nd line
MC benign/malignant thoracic tumors in adults/children
Adults
- benign: hamartoma (popcorn calcification)
- malignant: sqcc
Children
- benign: hemangioma
- malignant: carcinoid
Tx of Rhabdomyosarcoma
MC soft tissue tumor in children
tx: surgery + SLNBx
- consider neo-adjuvent if unresectable
- post-op chemo-XRT (very radiosensitive)
C/i to covering the left subclavian artery
- Aberrant or Dominant left vertebral a.
- Previous CABG using LIMA (cardiac ischemia)
- LUE AVF
Mesothelioma - px, dx, tx
px- asbestos exposure (shipyard)
dx- CT then tissue dx
tx- surgery, XRT, systemic chemotherapy, HIPEC
Marginal ulcer - dx and tx
S/p REY GB
On the jejunal side
Dx- EGD
Tx- PPI + sucralfate + stop smoking + avoid NSAID +/- tx H. pylori (if present)
Hipec is most effective for which cancers? (5ys)
c/i
- Appendix (75%)
- Mesothelioma (45%)
**c/i: extra-peritoneal dz
Tx of HPV precursors in the anus
- Condyloma in low risk patient: simple anoscopy (internal extent defined) and ablate
- 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
Tx of rectal carcinoid
<1 cm - endoscopic removal
1-2 cm- full thickness excision
> 2cm- LAR or APR
**Invasion into muscularis/LN involvement- require TME
Polypectomy criteria that require formal resection
- Poor differentiation
- Vascular/Lymphatic invasion
- Invasion below the SM
- < 2mm of surgical margin
- Base involvement (Haggit 4)
Cancer screening in FAP
- CRC- q1-2y c’scope starting at 10
- Duo/Stomach ca- EGD at 20 or when polyps occur
- Pap thyroid ca- thyroid U/S q2-5y at 18
- Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs
Staging Melanoma and MC mets
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
Perforated diverticulitis tx
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
Zenker location
- Killian’s triangle
- Inferior to pharyngeal constrictor (thyropharygneous)
- Superior to cricopharyngeous
Tx for reflux after heller
Lifetime PPI
DO NOT convert to a Nissen b/c baseline achalasia
Narrowest portions of the eso
- Criciopharyngeous
- AA/Left mainstem bronchus
- Hiatus
Sxs of vagus injury after hiatal repair
- Gastroparesis
- Delayed gastric emptying
- Reflux
- DRH
- normal UGI!
Required w/up before anti-reflux surgery
- EGD- r/o ca
- 24h pH- prove reflux
- Esophagram- r/o motility disorder (DES, eso web)
- Manometry- r/o other motility disorders
Deficiency of fat soluble vitamins
A- xeropthalmia
D- hypoca, hypoPh
E- hemolytic anemia
K- elevated INR
**suspect with any fat malabsorption
Na deficit
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
Lung cancer paraneoplastic syndromes
Squamous cell- PTHrP
Adenoca- hypertrophic osteodystrophy
Small cell- SIADH
Lithium toxicity
HyperCa, hypocalcuria
HyperMg
Elevated PTH, normal Ph
**gastric bypass can elevate Li levels
Ferritin
Main storage protein of Iron
Low in iron def anemia
High in anemia of chronic dz (acute phase rxn)
Sheehan syndrome
Hypopituitarism (anterior pit) 2/2 gland necrosis from HoTN
Usually px w/ hypoNa
Tx for STI:
1. Chlamydia
2. Gonorrhea
3. Trich/BV
- Chlamydia: doxy
- Gonorrhea: CTX
- Trich/BV: flagyl
HIT - path, dx, and tx
path: IgG to PF4
dx: 50% PLT fall ➡ Ser release assay
tx: stop SQH. start fondaparinox, argatroban
- use bivalirudin is liver/cirhotic patients
Hormone and production:
- CCK
- Gastrin
- Glucagon
- Histamine
- Insulin
- Motilin
- Secretin
- SS
- 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
Steps of hepatectomy
- Mobilize ligaments
- CC’y and cannulate CD
- Isolate vessels
- Ligate HA ➡ PV ➡ HV
- Divide parenchyma
Tx of HCC
- Trx: tumor < 5cm or 3+ tumors < 3cm
- Resection: early stage, preserved liver function
- RFA: early-stage BUT poor OR candidate
- TACE: intermediate stage disease
- Sorafenib: advanced/Unresectable
Indication and s/e for TIPS
2-3 paracentesis/month despite Na restriction and diuretics
s/e:
- increase r/o encephalopathy
- no change in overall survival
kwashiorkor vs. marasmus
kwashiorkor
- moderate calorie intake; inadequate protein
- large belly. normal weight.
marasmus
- insufficient calorie and protein
- simian face. low weight.
Absorption of glucose, galactose, fructose
glucose: Na-dependent secondary active transport
galactose: Na-dependent secondary active transport
fructose: Na-independent facilitated diffusion
Tx of MCN
- 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)
S/e of protamine
- Hypotension, Bradycardia
- Administer slowly: 1 mg per 100 units of insulin
- Has partial reversal on lovenox
- No renal/liver adjustment required
Dermatofibrosarcoma protuberans - px, histo, tx
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`
In transit melanoma tx
Lesions > 2cm from primary but not beyond regional tumor basin
- immunotherapy or BRAF inhibitor
- only excise if feasible (few lesions)
Pressure wound staging
1- non-blanching erythema
2- dermis
3- full-thickness subcutaenous
4- muscle, bone fascia
Post-splenectomy blood smear + best way to ID
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
Gastro-gastric fistula - px, dx, and tx
Px- weight gain, reflux years after a bypass
Dx- UGI or CT with oral contrast
Tx- observation, resection of the involved segment
ERCP with REY anatomy
- Laparoscopic-assisted ERCP or ERCP through a gastrostomy
- Double balloon endoscopy
Posterior Mediastinal Mass - dx and tx
dx: neurogenic- schwannoma, neurofibroma
- CT then MRI. Bx not needed
tx: all require resection (even if asx)
**lymphoma if middle
**thymoma if anterior
Lung ca resectability
- carina/contra trachea involvement is still resectable ➡ sleeve pneumonectomy
- SVC involvement can still be resectable
- c/i: N3 disease ➡ contralateral mediastinal LN involvement
Internal thoracic (mammary) anatomy
- 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
Management of lung abscess
- Abxs 1st. No drain if < 4 cm
- Cath drainage: > 4 cm or failure of abxs
- perc (peripheral) or bronch (central) - Surgical resections
Indications for surgery:
- failed medical tx
- BP fistula
- hemoptysis
- suspect cancer
- empyema
Prostate ca - px, dx
Px- asx or abnormal PSA
Dx:
- Transrectal U/S guided bx - 12 samples
- Gleason score 1-5
CAH - px’s
“salt and sex”
21: most common; sex
- dx: high 17 levels
17: salt
11: salt and sex
Amide vs. ester
amide- two “i’s”; plasma cholinesterase metab;
ester- one “i”; liver metab; PABA analogue –> allergic reactions
Px, Mech, Tx of Malignant Hyperthermia
px: AD; ryanodine receptor type 1
mech: huge increase in INTRAcell Ca
tx: stop drug, dantrolene, Bicarb, cooling, tylenol
- dantrolene: ryanodine rec antagonist
Dx adrenal insufficiency in the ICU
- Early morning salivary or serum cortisol (screen when cortisol is highest)
- vs. cushing’s which requires PM cortisol (when cortisol is lowest) - 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)
Breast cancer endocrine chemo: MOA, tx duration/indications, s/e:
1. Tamoxifen
2. Anastrazole
3. Trastuzumab
- Tamoxifen: ER partial agonist
- for ER/PR positive and < 70
- 5 years
- s/e: dvt, endometrial ca - Anastrazole: reversible aromatase inhibitor
- for ER/PR positive and > 70
- 5 years
- s/e: MSK fractures - Trastuzumab: monoclonal Ab to Her2/Neu rec
- for HER2 positive
- 2 years
- s/e: cardiotoxic
Paget’s disease of the breast
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
Indications for transcutaneous pacing
- Symptomatic sinus bradycarias
- Mobitz II (2nd degree) AV block
- 3rd degree AV block
- New L or R BBB
**If transcutaneous is unsuccessful ➡ transvenous
Types of AV block
- 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
Digoxin - MOA and S/e
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
Indications for emergent C-section in preggo trauma
- 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)
Management of penetrating coronary artery injury
- LAD is MC
- Primary repair is preferred
- If too much loss of length then CABG
- Do not ligate
Tx of blunt cardiac injury
- EKG +/- trop
- negative: can dc
- positive: admit to tele (Sinus tach is abnormal) - Persistant arrhythmia or HoTN ➡ echo
Dx and Tx of rectal injuries
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
Tx of gastric trauma
- 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
SC artery control
Right: median sternotomy
Left:
- anterior thoracotomy: proximal control
- supraclavicular incision: distal control
- can connect with sternotomy for “trap door”
Central vs. Peripheral DI - cause and tx
- Central: disrupted ADH synthesis ➡ responds to DDAVP
- Peripheral: genetic or Li induced defective ADH receptor ➡ low salt diet, amiloride
Px and Tx of Steal syndrome vs. IMN
- 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 - IMN: pain, normal pulse, warm hand
- Tx: immediate ligation
- 2/2 nerve ischemia
Tx of superficial venous thrombosis
Thrombus is in GSV, SSV
- AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months
- No near the jxns ➡ prophylactic AC for 45 days
- 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
Tx of varicose veins
- 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
Sensory nerves of the foot
- Dosal: superfial peroneal n.
- 1st webspace: deep peroneal n. (is deeper)
- Medial: saphenous n.
- Lateral: sural n.
Tx of perforated colon ca
- 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.
Contents of cord structures
- Cremasterics (vessels, muscle, lymphatics)
- GB of GF
- Testicular artery and veins
- Vas deferens
- Processus vaginalis
**round ligament in women
Levels of evidence
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
Tx and prognosticators of hepatoblastoma
- neoadjuvant 1st unless pure fetal histology and low mitotix index
- resection
- transplant if 4+ section involved/unresectable after chemo
Good prog: < 5 yo, AFP > 100
VACTERL defects
Vertebral
Anal
Cardiac
TE fistula
Renal, Radial bone
Limb defects
Biliary atresia - px, dx, and tx
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
Catelcholamine synthesis
Tyrosine ➡ L-dopa ➡ dopamine ➡ NE ➡ adrenal PNMT ➡ Epi
BK Virus- rf, px, and tx
rf’s- high IS, pulse steroids
px- hematuria, nephritis after kidney trx
tx- decrease IS, cysto/possible stent
Strategies to decrease SSI
- 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
Aminoglycosides - MOA, coverage, s/e
MOA- inhibit 30s; bacteriocidal
Coverage- GNRS, pseudomonas
s/e- nephrotoxic, ototoxic
Tx of thyroid storm
- PTU or methimazole
- Steroids
**No alpha/beta blockade
Polypsos syndromes: px and gene mutations
- MutY
- FAP
- Peutz-Jeghers
- Juvenile polyposis
- Lynch/HNPCC
- Cowden
- 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
Tx of dysplasia with IBD (UC and Crohn’s)
- 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
Indications for surgery of brain bleeds:
1. Epidural
2. SDH
3. Intraparenchymal
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
Indications for trx of cholangioca
- cant be intrahepatic (prognosis is too poor)
- must be unresectable, perihilar, < 3cm
- no distant mets
Short gut syndrome - risk/length + feeds
- Adults risk starts at < 180 cm
- Infants risk starts at < 75 cm
- Feeds with elemental nutrition
Tx of toxic megacolon
- 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
Repair of bile duct injuries based on Strasburg class
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
Indications for MRM
- Prior radiation
- Radiation therapy contraindicated by pregnancy
- Inflammatory breast cancer
- Diffuse suspicious or malignant-appearing microcalcifications
- Widespread disease that is multicentric
- A positive pathologic margin after repeat re-excision
MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes
p450 inducers and inhibitors
CRAP GPs spend all day on SICKFACES.com.
Inducers:
Rifampicin
Alcohol
Phenytoin
Sulphonylureas
Inhibitors:
Sodium valproate
Isoniazid
Fluconazole
Grapefruit juice
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Pseudomyxoma peritonei - dx and tx
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
Condyloma acuminata - tx
- Imiquimod, Podophyllotoxin, Sinecatechins
- Cryo, acetic acid, surgery, laser
- Podophylin, 5-FU
Px and w/up of cholangioca
- Px: painless jaundice.
- W/up:
- Ca 19-9
- CT/MRI
- Tissue: - ERCP w/ stent: brushings + in 50% (preferred if obstuctive)
- EUS/FNA: negative bx does NOT rule out
RF’s for cholangioca
- PSC
- UC
- Choledochal cyst
- Biliary tract infection
Hypothermia classes
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
Emergent management of lower GI bleed of unknown origin
- If patient is hypotensive - TAC w/ end ileostomy
- If stabilized- prep 1st with 4-6L of PEG. Scope w/in 24h.
Haggit stage and management
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
Path, Dx and Tx of rectocele
Path- bulging of rectum into vagina
Dx- bimanual exam reveal large bulge in posterior vagina
Tx- transvaginal plication of vaginal muscularis +/- mesh
ERAS protocol of CRC
- CLD 2h preop
- Preop gabapentin and tylenol
- Thoracic epidural or TAP block
- Pre-op entereg + 7 days post-op
- Scope patch
- Non-opiate
- Normothermia, good O2, glycemic control, skin preop
- Net zero fluids
- Avoid draina nd prolonged foley
- Dc w/in 3 days
Dx and Tx of slow transit constipation
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
Impediments to fistula closure
- Foreign body
- Radiation
- Inflammation/Infection
- Epithelialization
- Neoplasia
- Distal obstruction
NCCM CRC screening
- average risk: start at 45. Screen q 10 years.
-1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.
Tx of sigmoid volvulus
- Colonoscopic detorsion
- Sigmoid resection DURING the admission
Colon/Rectum Transitions
- Colon: has taenia/above reflection
- Rectum: no taenia/below reflection
Dx and Tx of contained esophageal perforation
dx: gg swallow then thin barium
tx:
- NPO, IV abxs
- consider stenting
- generally don’t need IR drain
- includes cervical and thoracic
Tx of Barrett’s
- PPI or H2 block daily x 8 weeks
- BID if severe sxs, HGD, or esophagitis - Work-up for anti-reflux surgery
- dysplasia should be eradicated prior to surgery - Continue surveillance
- no dysplasia: q5y
- LGD: q6m. ablation.
- HGD: q3m. ablation or endoscopic resection.
Tx of TOA
- Abxs first
- unless rupture or HDUS - Drainage/Surgery if failure
Types of collagen and life cycle
- 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
Tx of eso varices
- > 5mm or < 5mm w/ red spots
- Tx: beta blocker or banding ➡ TIPS - < 5 mm: repeat scope in 1-2 years
**bleed rate 10%/year w/ 20% mortality
Branched chain AA - importance and use
- leucine, isoleucine, valine
- metabolized by the muscle instead of liver
- use to feed liver impaired patients
Peroneal nerve injury
- Superficial: inability to evert. numbness at dorsum (except 1st web space)
- Deep: foot drop. numbness of first web space
Px and Tx of Pancreatic Lymphoma
Px- pancreatic head mass with LADN. Normal Ca 19-9. Constitutional sxs
Tx- chemo only
Indications for MOHS
- 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
Indications for deep inguinal LN dissection for melanoma and operative considerations
- > 4 nodes on superficial dissection
- Positive cloquet’s node
- Enlarged ileo-obturator nodes on CT
- Clinically palpable femoral nodes
Pernicious anemia - pathophysiology
- IF secreted by parietal cells
- improves absorption of b12 in the TI
- post gastrectomy can get megaloblastic anemia
Tx of Bronchial Carcinoid
Surgical resection with complete LADN
- usually lobectomy
Immunotherapy agents and use by target:
- PD-1
- EGFR
- CTLA4
- RET
- Aromatase
- HER2
- 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
Histoplasmosis - px, dx, tx
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
MOA and s/e of trx meds
- MMF
- Basiliximab
- Azathioprine
MMF: purine (T cell) inhibitor
- GI sxs, myelosuppression, anemia
Basilixamab: il2 inhibitor
- GI sxs
Azathioprine: purine (T cell) inhibitor
- myelosuppression, marrow suppression, pulm fibrosis
Meperadine (demerol) - MOA and s/e
MOA: mu agonist
s/e: seizures
- 2/2 to metabolite normeperadine
- worse with renal impariment
s/e of local anesthetic and opioid epidural
Bupivocaine: HoTN
Morphine: respiratory depression
Absolute c/i to BCT
- Pregnancy
- Diffuse micro-calcs
- Positive pathologic margin
- Multi-quadrant disease
Tx of Lymphedema s/p breast surgery
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
Most common recon after mastectomy with blood supply
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
Pressor receptors:
- NE
- Epi
- Phenyl
- Vaso
- NE: alpha1 > beta1
- Epi: beta1 > alpha 1, some beta 2
- Phenyl: all alpha1
- V1 stimualtor
Effects of hypovolemia on RAA
- 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
Nerves in triangle of pain
medial-to-lateral:
1. GB of GF
2. FB of GF
3. Femoral
4. Anterior femoral cutaneous
5. Lateral femoral cutaneous (MC injured)
Phase of cell cycle
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
WAGR Syndrome - chrom anomaly and px
Chrom: deletion of short arm of chrome 11
Px:
Wilm’s tumor
Aniridia- absent iris
GU anomalies- cryptorchidism, hypospadia, streak ovary
Retardation
Dx and Tx of pediatric Intussusception
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
Tx of duodenal ulcer
- 1-2 cm: simple closure
- 2+ cm: graham patch repair
- > 4 cm: resection and reconstruction
- thal patch, pyloric exclusion, G-J - > 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
Tx of small bowel polyps
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
Causes of thyrotoxicosis on RAI and tx
- 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
Management of penetrating cardiac injury
- FAST+, HDS ➡ OR for pericardial window ➡ extend to median sternotomy if blood found
- 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)
CXR of aortic trauma
- Widened mediastinum
- Apical cap
- Displacement of trachea
- Depression of L mainstem bronchus
*suggest injury at ligamentum arteriosum
Polycystic kidney disease a/w
- HTN
- Hepatic cysts
- Head (Intracranial) aneurysms
Tx of thrombophlebitis and catheter releated DVT
Thrombophlebitis:
1. Superficial veins: dc the IV, warm compress, NSAIDS
- abxs if you suspect infection
- surgery if failure of abxs or septic
- 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
Indications for iHD
- GFR < 6 and asx
- GFR < 15 with sxs
- absolute: uremic pericarditis, pleuritis, encephalopathy
- relative: AEIOU
MOA of abxs: (cell wall, protein, or DNA inhibitor)
- cell wall
- protein 30S
- prostein 50S
- DNA synthesis
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)
Abx ppx for suspected colonic injury
- ancef, cefoxitin, or cefotetan + flagyl
- unasyn
- pen allergic: clinda or vanc + gent, cipro, levo, aztrenoam
Guidelines to prevent SSI
- 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
QI strategies
- six sigma
- teamSTEPPS
- SBAR
- re-AIM
- PDSA
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.
Requirements for SBP ppx
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
Tx of appendix carcinoid
- > 2cm or at base: R hemi
- high risk (high MI, KI > 2%, mixed histology, LV invasion meso invasion): R hemi
- Otherwise: appe only
**require c’scope post-op b/c 15% have synch lesions
MCCO acute liver failure
- US: tylenol
- Worldwide: viral hepatitis (Hep B)
LA class for esophagitis
A- mucosal breaks <5 mm
B- mucosal breaks >5 mm
C- mucosal breaks spanning 2 folds, <75% circ
D- mucosal breaks >75% circumference
Scleroderma manometry
- absent peristalsis
- normal/low LES pressure
**contrast to achalasia: aperistalsis and high LES pressure
Immuno-nutrition
- arginine
- omega-3 FA
- a/w less infections, shorter LOS
Renal arterial anatomy
- Renals come off just under the SMA at L2
- SMA hugs the left renal vein
- Renal arteries run behind the veins and the IVC
Belsey IV fundoplication
- Thoracic approach with anterior 270-degree wrap
- Bailout after failed abdominal approaches
How to access cervical esophagus for esophagectomy
- Anterior to SCM. Divide platysma
- Divide omohyoid, strap muscles
- Retract carotid structures laterally
- Ligate middle thyroid vein and inferior thyroid artery
Most important prognosticator of survival in stage IV (liver mets) colon cancer
- response to neoadjuvant chemo
- not size. or node status (its already disseminated)
MC location of small bowel lymphoma
Ileum (has most lymphoid tissue)
SMA exposure options for bypass
- Anteior: base of transverse mesocolom
- Lateral: mobilize 4D and LOTz
Consequences of ileal resection
- megaloblastic anemia
- fat malabsorption/ADEK def
- cholesterol stones (EH circulation)
- oxalate stones (ca binds fat instead of Ox)
BPD for weight loss surgery
- BPD/DS: prevent marginal ulcers and dumping syndrome (keep pylorus)
- sleeve
- resect TI 100 cm from ICV
- roux limb end-to-end to duo - 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)
MC Vit def after REYGB and sxs
- Vit D- bone dz, hypoCa
- Vit A- night blind
- Folate- skin changes
- Iron- anemia
- Thiamine- encephalopathy
Surviving Sepsis 1-hour bundle
- Measure lactate
- Blood cx b4 abxs
- Abxs after cx
- 30 ml/cc bolus if HoTN, LA
- Pressors for MAP >65
Immuno-nutrition and benefits
- arginine
- omega-3 FA
- a/w less infections, shorter LOS
S/e of Amiodarone
- Pulmonary dysfunction: tx w/ steroids
- Thyroid dysfunction: tx w/ steroids or thionamides
Virulence of G+ and G- bacteria
G+: exotoxins
G-: endotoxins (lipid A)
Tx of atypical ductal hyperplasia (ADH)
- 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
Axilla boundaries
medial- pec minor
lateral- lat dorsi
superior- ax vein
posterior- subscap
Histology of pap thyroid ca
- Pale cytoplasm
- Prominent nucleoli (orphan annie)
- Psammoma bodies
- Large/crowded nuclei
Adrenal blood supply
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
Advantages of robotic surgery
-7 degrees of freedom
Damage control trauma to visceral vessels
Celiac- ligate
SMA- shunt or repair
IMA- ligate
Lap band imaging
- 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
Melanoma indications for SLNBx
> 1mm
< 1mm w/ ulceration or > 1 mm2 mitoses
Causes for AV fistula failure to mature
- venous branches (doesn’t fill enough)
- fistula is too deep (can’t pop out)
CEA operative pearls
- 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
Tx of aortoenteric fistula
Fistula takedown, prior graft revmoval (if s/p evar) and extra-anatomic bypass
U/S findings for thyroid nodule suspicious of cancer
- Unclear boundary of solid component
- Irregular shape
- Calcs
- Hypoechoic
Indications for ICP monitor
- GCS <=8 with abnormal head CT
- GCS <=8 with normal head CT and 2 of the following:
- age > 40
- abnormal posturing
- hx of HoTN
Submental triangle - boundaries and contents
Boundaries:
- Anterior bellies of digastric
- Hyoid bone
- Symphysis menti
- Mylohyoid is floor
Contents:
- Contents: mylohyoid nerve, anterior jugular veins
Morphine equivalents of narcs
5 IV morphine =
- .7 IV HM
- .05 IV fentanyl
15 PO morphine =
- 3 PO HM
- 10 POD Oxy
FRC
FRC = RV + ERV
- TV not included
- Increases with age
- Decrease with obesity, pneumoperitoneum
