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1. CE prep > Quick Facts > Flashcards

Quick Facts Flashcards

1
Q

Pheo w/up:

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

Mucinous cystic neoplasm - dx and tx

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

Tx pelvic fx

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

**MC source is presacral venous plexus

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4
Q

Dx and Localize a gastrinoma

A

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

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

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5
Q

Tx pseudocyst/WON

A

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

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

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6
Q

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

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

Indications to tx ICA stenosis and sxs

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

Bethesda criteria for thyroid

A

**1 cm is cutoff to get an FNA

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

Achalasia - Px, Dx, Path and Tx

A

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

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

Path: injured ganglion cells

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

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10
Q

Tx Medullary thyroid cancer

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

Radial scar- Dx and Tx

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

Tx mucinous neoplasm of the appendix

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

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

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13
Q

When to excise burns

A
  • < 72 hours but not until after appropriate fluid resuscitation
  • Used for deep 2nd-, 3rd-, and some 4th-degree burns
  • Viability is based on punctate bleeding (#1), color, and texture after removal (use dermatome)
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14
Q

Liver lesions on arterial phase:
HCC
Mets
Adenoma
Hemangioma
FNH

A
  • HCC: rapid enhancement. rapid w/out. “hot” on nuclear imaging
  • Mets: Hypoattenuation
  • Adenoma: rapid enhancement. rapid w/out. “cold” on nuclear imaging. gado/eovist not retained
  • Hemangioma: peripheral nodular enhancement. delay: centripetal fill-in (no early washout!)
  • FNH: Centrifugal enhancing. w/out except for scar enhancement. take up sulfer colloid and gado/eovist
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15
Q

Elective surgery after stent

A
  1. ASA lifelong
  2. Plavix
    - BMS: 1 month
    - DES: 6 months (ideally). Can be 1 month if needed for urgent surgery (cancer)
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16
Q

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

A

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

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

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17
Q

Tx and Survival Benefit of ARDS

A
  • TV at 4-6 ml/kg
  • Permissive hypercapnia
  • Proven benefit: prone, lung protection, paralyze
    -P/F < 100 = severe
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18
Q

Glucagonoma - loc, px, dx, tx

A

Loc: distal (a cells)

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

Dx: gluc > 1000

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

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19
Q

z11 trial implications

A
  • If less than 3 nodes positive on SLN and T1 or T2 disease, BCT is OK
  • if >70, t1, ER+ and SNLBx neg ➡ can consider no XRT after lumpectomy
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20
Q

Hard signs of vascular injury

A

shock
expanding hematoma
pulsatile bleed
thrill/bruit
absent pulse
ischemia

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

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21
Q

Polyps that require surgery instead of endoscopic resection

A
  1. Submucosal invasion > 1mm
  2. Poorly differentiated
  3. <1 mm margin
  4. LV invasion
  5. Tumor budding
  6. Taken piecemeal
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22
Q

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

A
  • eso: T2 (MP)
  • stomach: t2 (MP)
  • colon: t4b (adjacent organs)
  • rectal: t3 (through MP)
  • lung: n2 nodes
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23
Q

Screening in IBD patients

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

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

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

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24
Q

NEC - px and tx

A

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

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

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25
Q

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

A
  • U/S and TSH:

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

b. Nodule + Normal/High TSH ➡ FNA

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26
Q

Tx male breast ca

A

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

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27
Q

General principles - repair of Bile Duct Injury

A
  1. Intro-op:
    - convert to open, intra-op cholangio, repair OR
    - widely drain and send to specialty center
  2. Post-op:
    - Perc cholangiography to define the anatomy
    - Control spillage: external drain +/- stent +/- PTC
    - Repair in 6-8 weeks
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28
Q

Eso dysplasia tx

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

*Fundoplication does not decrease cancer risk

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29
Q

Tx hemobilia after trauma

A
  1. EGD → CTA (if stable)
  2. angio embolization (no surgery)
    - catheterize the celiac artery first ➡ R/L hepatic ➡ SMA
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30
Q

Indications for chemotherapy for rectal cancer

A
  1. Neoadjuvant:
    Stage 2 and above
  2. Adjuvant chemo as well for Stage 3+ (nodes)

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

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31
Q

Periop anticoagulation - risks and tx

A

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

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

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32
Q

Margin for invasives cancer vs. dcis

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

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

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33
Q

Neuroblastoma dx and tx

A

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

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

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34
Q

TEF - MC types
dx and tx

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

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

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

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35
Q

Birads score

A

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

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

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36
Q

PFTs for lung resection

A
  1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing
    - >.8L wedge, >1.5L lobe, >2L pneumo
    - < 80% ➡ lung scan for PPO FEV1, DLCO
  2. PPO FEV1, DLCO > 60% ➡ no further testing
    - < 60% ➡ exercise test
  3. VO2 > 10 ml/min/kg ➡ OK for surgery
    - < 10 ➡ high risk for surgery
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37
Q

Gastrinoma - loc, px, dx, tx

A

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

Px: refractory PUD
- Mostly malignant

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

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

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38
Q

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

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

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

***High CEA > 190

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39
Q

Indication for APR

A
  1. Rigid proctoscopy: w/ in 2cm of anal verge (levators)
  2. PE: baseline sphincter dysfxn
  3. Recurrent SqCC (s/p Nigro)
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40
Q

Somatostatinoma - loc, px, dx, tx

A

Loc: head

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

Dx: sx’s + high fast SS

Tx: resect + LADN’y + CC’y

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41
Q

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

A

Proximal landing: > 1.5 cm
- diameter < 3cm

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

Neck angulation < 60 degrees

External Iliac diameter> 7mm

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

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42
Q

Tx of anal fissure

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

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

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43
Q

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

A
  1. Hemangioma: only if sxatic or KM syndrome
    - enucleate (or resect); angioembo if active bleed
  2. FNH: NTD
  3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing
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44
Q

Dx and Tx congential DPGM hernia

A

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

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

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45
Q

Supraceliac aortic control

A
  1. HDUS: Enter lesser sac through gastrohepatic ligament, divide posterior crus of diaphram
  2. Stable: left medial visceral rotation is preferred
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46
Q

Dx and Tx Phyllodes

A

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

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

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47
Q

Indications for total thyroidectomy (pap and follicular)

A

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

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

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48
Q

Soft tissue sarcoma - dx and tx

A

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

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

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49
Q

Step up approach

A

Infected pancreatic necrosis (WBC + gas on CT)

  1. CT with gas
  2. Carbapenem
  3. FNA + Perc drain OR endo drain (if stomach is close to pancreas)
  4. Upsize drain
  5. MIS retrop necrosectomy (VARD)
  6. Open necrosectomy
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50
Q

Types and Tx SVT

A

types: af, aflutter, paroxysmal SVT, WPW

  1. vagal → adenosine
    - may unmask afib/flutter
  2. HDS: BB, CCB ➡ sync cardioversion
  3. HDUS ➡ sync cardioversion
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51
Q

Melanoma w/up and tx

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

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

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52
Q

Steps of rapid sequence intubation

A

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

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53
Q

Px, Dx and Tx malrotation

A

Px: bilious emesis

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

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

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54
Q

MEN syndromes

A

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

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

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

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55
Q

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

A
  • <30d: technical error
  • 1m-2y: intimal hyperplasia, (at the distal anastomosis)
  • > 2y: progressive atherosclerotic disease
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56
Q

Dx and Tx Parathyroid ca

A

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

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

  1. Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT)
    - no chemo
    - usually don’t perform any node dissection unless palpable nodes
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57
Q

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

A
  1. Graves: IgG stimulates TSHr ➡ hyperT
    - BB, PTU, RAI ➡ thyroidectomy
  2. TMN: chronic TSH stimulation ➡ hyperT
    - BB, PTU, RAI ➡ total/subtotal thyroidectomy
  3. Hashimoto’s: antiTPO/TG Ab ➡ hypoT
    - thyroxine ➡ partial thyroidectomy
  4. DeQuervains/Subacute: viral URI
    - path: giant cells, leukocytes
    - NSAIDS/ASA ➡ steroids
  5. Reidels: autoimmune inflammation
    - steroid, thyroxine ➡ surgery for compression
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58
Q

Sonograph FNA recs

A
  • cystic: no bx

-isoech/hyperech: FNA if > 2cm

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

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59
Q

Triple therapy

A

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

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60
Q

Gail model

A
  1. age
  2. age 1st period (earlier is worse)
  3. age 1st birth (earlier is better)
  4. 1d relative
  5. previous bx
  6. race
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61
Q

types of endoleak and tx

A
  1. proximal/distal seal: immediate balloon expansion of distal/proximal attachments + stent
    - 1a: proximal leak
    - 1b: distal leak
  2. back bleeding: observe. coil embolization if enlarging
  3. graft defect (tear or junctional leak): immediate additional graft coverage
  4. porosity- reverse anticoagulation
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62
Q

Carcinoid vs. GIST vs. Desmoid- cells and tx

A
  1. Carcinoid- Kulchinsky cells (enterochromaffin-like)
    tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable
  2. GIST- cajal cells
    tx- resection (MC stomach), imantinib
  3. Desmoid- spindle cells
    tx- resect if extra-abdominal. NSAID/estrogen if intra
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63
Q

Hyperaldosterone w/up

A

Px: resistant HTN and hypokalemia

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

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

**tx HTN with spironolactone

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64
Q

Dx and Tx of SBP

A

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

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

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65
Q

Tx acute variceal HMHG

A
  1. Resuscitate, ensure airway
  2. Octreotide + antibiotics
  3. Endoscopic intervention (ligation/sclerotherapy)
  4. Blakemore
  5. TIPS (temporized with Blakemore)
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66
Q

Tx SVC syndrome tx

A
  1. Elevate HOB
  2. Chest CT with IV contrast (can skip CXR)
  3. Consider bronch
  4. Assess sxs
    A. Life-threatening sxs: secure airway ➡ consider AC (if thrombus) ➡ venogram ➡ endovascular stenting
    B. Mild sxs ➡ tissue bx ➡ decide on XRT/chemo
    - no chemo/XRT unless its 2/2 cancer
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67
Q

Tx appendicitis

A
  1. Uncomplicated: lap appe
  2. Septic/Unstable: immediate lap appe
  3. Stable w/ abscess
    - < 3cm: lap appe
    - > 3cm: IR drain ➡ interval appe, offer scope
  4. Crohn’s ileitis
    - intra-op with normal appendix AND cecum ➡ appe to r/o dx uncertainty
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68
Q

Tx MEN2A/B

A
  1. urine metanephrine to r/o pheo 1st
  2. tx pheo 1st w/ adrenalectomy
  3. Address thyroid
    - 2A: total thyroid + bilateral central neck by 5y
    - 2B: total thyroid + bilateral central neck by 1y
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69
Q

Tx MEN1

A
  1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
  2. Asses other lesions
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70
Q

Prog and Tx anaplastic thyroid ca

A

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

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

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71
Q

Criteria for transanal excision of adenocarcinoma

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

**local recurrence rate is higher

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72
Q

HNPCC screening and treatment

A

CRC: scope q1-2y starting at 20-25
- Surgery if:CRC or endoscopically unresectable lesions
- TAC with IRA w/ q1y rectum surveillance
- endometrial/ovarian cancer screening

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73
Q

Dx and Tx choledochal cyst

A

Dx: U/S or HIDA

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

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74
Q

Px, Dx, and Tx:

Duo atresia
TEF
Pyloric stenosis
Intussusception
Malro

A

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

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

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

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

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

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75
Q

Tx of GB cancer

A

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

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

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76
Q

Tx of CBD stone intra-operatively

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

**thin CD can be dilated

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77
Q

W/up Hurthle Cell Cancer

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

No RAI

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78
Q

Hernia repairs:
Bassini
McVay
Lichtenstein
Shouldice

A

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

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

Lichtenstein: mesh to inguinal ligament and conjoint tenown

Shouldice: divide the floor ➡ 4-layer tissue closure

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79
Q

Tx for cholangiocarcinoma

A

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

  1. Consider location
    - Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
    - Middle ⅓: hepaticojejunostomy
    - Lower ⅓: Whipple
  2. Chemo + transplant if unresectable
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80
Q

IPMN - dx and tx

A

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

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81
Q

Path, Dx and Tx of Zenkers

A

Path: outpouching SUPERIOR to cricopharyngeous

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

Tx: open or scope approach:

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

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82
Q

VIPoma - loc, px, dx, tx

A

Loc: distal

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

Dx: high VIP

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

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83
Q

Gastric CA tx - chemo, margins, nodes

A
  • neo-adj chemo for T2+ or N
  • proximal- total gastrectomy
  • distal- partial
  • 5 cm margin; 15 nodes
  • Can consider endoscopic mucosal resection: if < 2cm, well-differentiated, mucoa only, no LV invasion
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84
Q

Milan criteria

A

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

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

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

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

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85
Q

Insulinoma - loc, px, dx, tx

A

Loc: throughout (B cells)

Px: whipple’s triad. Most benign.

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

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

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86
Q

Specific to Crohn’s and UC

A
  1. Crohn’s:
    - Creeping fat
    - Skip lesions
    - Transmural
    - Cobblestoning
    - Granulomas
    - Fistulas
  2. UC:
    - Crypt abscess
    - Pseudopolyps
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87
Q

Gastric ulcers: elective classification and management

A

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

  1. lesser curve/antrum; normal acid ➡ distal gastrectomy w/ bil 2
  2. gastric + duo; high acid ➡ antrectomy + vagotomy
  3. pre pyloric: high acid ➡ antrectomy + vagotomy
  4. GE junction: normal acid ➡ sub-total gastrectomy + REY
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88
Q

Emergent vs. Elective UC Tx

A

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

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

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

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89
Q

Zone injuries and management

A
  1. penetrating:
    - zone 1-3 ➡ explore
  2. blunt:
    - zone1 ➡ explore
    - zone 2-3 ➡ do not explore
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90
Q

FAP - Dx and Tx

A

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

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

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91
Q

BRCA risks and tx

A

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

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

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92
Q

When to operate on adrenal mass

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

**DO NOT biopsy first

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93
Q

Adjuvent chemo for breast ca

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

**Oncotype recurrence score > 26 requires adjuvant chemotherapy

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94
Q

FNH - path, dx and tx

A

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

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95
Q

Pancreas drainage procedures

A
  1. duct > 7mm- Peustow, pancreaticojej (for large duct)
  2. duct > 7mm and large head- Frey, pancreasticojej + core out head
  3. duct < 7mm and large head- Berger, pancreatic head resection
96
Q

Tx papillary/follicar thyroid cancer

A
  1. Indications for total thyroidectomy:
    - Tumor > 4cm
    - Distant mets or extra-thyroid disease
    - Poorly differentiated
    - Prior radiation
  2. Nodes dissection:
    A. Lateral neck dissection: of involved compartments if palpable or bx+ nodes
    B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes.
    - Usually not performed for follicular
  3. Radio iodine indications (6w post op, want TSH high)
    - Only after total thyroidectomy to be effective
    - For high risk tumors: tumor > 1 cm, extra-thyroidal disease
97
Q

Screening guidelines for breast ca

A

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

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

98
Q

LN harvest/margin
eso
stomach
colon
rectum

A

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

99
Q

Tx acute limb ischemia

A

Tx: Rutherford

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

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

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

3: paralysis ➡ amputation

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

100
Q

Hemangioma - path, px, and tx

A

path- PERIPHERAL ENHANCEMENT with continued late filling

px- young women

tx- if rupture, size change, or KM syndrome

101
Q

Chylothorax dx and tx

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

**for cancer patients: pleurodesis > ligation

102
Q

Tumor lysis syndrome - px, path and tx

A

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

Path: CaPh crystal ➡ renal failure + hypoCa

tx: IV hydration ➡ iHD

103
Q

Dx and Tx of GIST

A
  1. Dx: MC GI Sarcoma
    - EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC.
    - Bx: cajal cells. c-KIT+
    - don’t require bx if high suspicion
  2. Tx: wedge resection (gross margin)
    - can be R0 or R1 resection
    - Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf
    - mitosis/hpf is most predictive of prognosis (>mets)
    - neoadjuvant if need to down-stage for resection
    - adjuvant for 3 years
104
Q

Benign lesions that require excisional bx

A

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

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

105
Q

Future Liver Remnant requirements and indications for PVE

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

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

106
Q

hepatic adenoma - imaging, tx, and risks

A

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

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

risks:
1. rupture MC
2. malig transformation

107
Q

Types of mastectomy

A
  1. Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin (no nodes)
  2. MRM: removal of breast parenchyma, NAC, skin, AND level 1-2 nodes
  3. BCT: partial mastectomy + XRT
108
Q

Barrett’s eso surveillance (progress to cancer)

A

Bx: Goblet cells and columnar cells

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

*Fundoplication is only c/i in HGD

109
Q

RF, Dx and Tx SqCC of anal canal

A

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

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

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

110
Q

Treatment of colo-cutaenous fistula

A
  1. Start with conservative tx
  2. Quantify output:
    - High output: > 500 cc/day ➡ likely OR. Start with NPO/TPN.
    - Low output: < 200 cc/day ➡ likely conservative. OK for PO intake.
  3. If input increased with PO intake ➡ NPO and TPN
  4. OR if failed after about 6 weeks
111
Q

T staging for esophageal cancer

A

t1a: muscularis mucosa: endo resection

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

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

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

112
Q

Grading and tx of BCVI

A

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

*most are not surgically accessible

113
Q

Ectopic parathyroids

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

**Overall, thymus is MC location or ectopic gland

114
Q

Trauma to the pancreas

A
  1. Head
    - main duct: drain + post-op ERCP + staged resection
    - no duct: drain
  2. Tail
    - main duct (grade 3+): resect w/ splenectomy (unless CHILD and HDS)
    - no duct (grade 1-2): drain
115
Q

DCIS mammo and tx

A

Mammo: clustered calcs

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

116
Q

DCIS SLNBx

A
  • does not metastasize
  • not w/ l’omy unless >4cm, multicentric, palpable, high grade
  • required w/ mastectomy b/c 20% have invasive ca
117
Q

Post polypectomy screening

A

-2-6m: piecemeal removal

-1 year: > 10 adenomas

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

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

-10 years: hyperplastic polyps (<20)

118
Q

Dx and Tx of Meckels

A

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

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

119
Q

Ureter injuries

A
  1. proximal ⅓ (U/P jxn and above) → primary uretero-urostomy.
    Other options: ileal transposition, nephrostomy
  2. middle ⅓ → primary u-u (preferred)
    - Other options: tran uretero-urosotomy, Boari flap
  3. lower ⅓ (distal to iliacs) → re-implanation +/- hitch
  4. early: w/in 5 days- stent, explore, or repair
    - HDUS intra-op: ligate, perc neph, delayed repair (3m)
  5. late: > 10 days- perc nephro and delayed repair (3m)
120
Q

Tx papillary/follicar thyroid ca

A

Start with lobectomy

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

Consider ppx level 6 for high risk

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

Indications for MRND
- extra thyroid extension

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

121
Q

Intraductal papilloma dx and tx

A

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

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

122
Q

Tx Umbo and Inguinal hernia in child

A

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

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

123
Q

Esophageal CA tx

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

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

124
Q

Indications and C/I to anti-reflux surgery

A

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

C/I:
1. Cancer
2. Barrett’s w/ HGD

125
Q

Classic and Alarm sxs for GERD

A

Classic sxs: heart burn + regurg

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

126
Q

Caustic injury w/up

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

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

127
Q

Dx and Tx of Eso perf

A

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

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

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

Stenting: contained perf or minimal extrav after EGD

128
Q

Refeeding Syndrome - mech and px

A
  • Mech: fat to carb metabolism ➡ resumption of ATP production and Insulin surg ➡ Ph influx into cells ➡ hypoPh
  • Px: HypoMg, Ph, K; paresthesia, confusions, RD
  • COD is cardiac failure
129
Q

Pregnant lap appe

A

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

130
Q

Segmental liver anatomy

A

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

131
Q

W/up of pancreatic cancer

A
  1. Pancreatic protocol CT
  2. EUS: if questionable LN or vessel involvement
  3. ERCP: if jaundice or dx uncertainty
    - 90% sensitive for dx
  4. PET/CT: selectively if suspicion for malignancy.
  5. Staging scope: if suspect disseminated dz
    - > 3cm, high Ca 19-9, tail tumor, high weight loss/malnutrition
  6. Bx: Not if resectable. Only if neo-adj chemo
132
Q

Dx and Tx of chronic mesenteric ischemia

A
  • Dx:
    1. duplex (Celiac > 200, SMA > 275) is 1st line for screening
    2. CTA (>70%) for definitive dx (best test)
  • Tx: Sxs + stenosis of > 70%
    1. Endovascular plasty/stent is 1st line. 1V SMA stenting is enough even if both celiac/SMA are inovlved
    2. Open surgery: if can’t tolerate endovascular
  • aorto-mesenteric/celiac bypass graft vs. endarterectomy vs. mesenteric re-implantation
133
Q

Tx of air embolism

A
  1. LEFT lateral decubitus and Trendelenburg (trap air in the RV)
  2. Aspirate central line
134
Q

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

A
  1. Femoral: vertical incision over the artery from inguinal ligament
  2. AK Pop: frog-leg position. 10 cm MEDIAL incision along groove between Sartorius and vastus medialis. I
  3. BK Pop: frog-leg position. MEDIAL incision below the tibia (along the GSV). Dissect to the deep compartment.
    4, TP trunk: MEDIAL incision below the tibia. Divide soleus origin of the tibia
135
Q

Preference for peripheral fistula

A

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

**Upper extremity preferred to LE

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

**artery at least 2 mm

136
Q

SC Steal syndrome - path and tx

A

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

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

137
Q

Tx of type B dissection

A
  1. Uncomplicated: b-blocker for impulse control, elective repair
    - Surveillance q3, 6, 12m. TEVAR if progression
  2. Complicated: impending rupture, propagation, expansion, malperfusion of aortic branch, refractory pain, refractory HTN ➡ TEVAR
    - Need at least 2 cm landing zone distal to L SC
138
Q

Surgical indications for acid reduction surgery

A

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

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

139
Q

Acute surgical options for duodenal ulcer disease

A

Indications: bleeding, perforation, obstruction

  1. Bleeding: EGD ➡ EGD ➡ duodenotomy/gastrotomy w/ over-sewing of ulcer bed
    - can tie off the GDA if continues to bleed
    - no vagotomy
  2. Perforation: get h pylori status! ➡ omental patch w/ post op h. pylori treatment (90% H.pylori related)
    - If close to pylorus: pyloroplasty (+/- truncal vagotomy)
    - If giant ulcer (> 2 cm): controlled duodenostomy, jejunal or omental graft/patch, partial gastrectomy
  • 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

140
Q

Tx of gastric ulcer disease

A

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

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

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

141
Q

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

A
  1. Afferent limb obstruction: prevent with afferent limb < 20 cm
    - acute: convert Bil 1 or REY (STAT!)
    - chronic: Bacterial overgrowth: try abxs 1st (Rifaximin)
    . convert to REY
  2. Dumping syndrome: small meals, no sugar ➡ octreotide
  3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm.
    - pro-kinetics, bile-acid binding ➡ convert to REY with long roux
  4. Post vagotomy DRH: cholestyramine (dx of exclusion) ➡ reversed jejunal segment
142
Q

How to confirm H. pylori eradication

A

4-weeks after triple therapy:

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

**Gram-, spiral-shaped

143
Q

Removal of perc chole tube

A
  1. Remain in place for 3-6 weeks for tract to form
  2. Cholangiogram to assess CD patency
  3. Clamp tube or elective chole if surgical candidate
144
Q

BSC vs. SqCC - dx and tx

A

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

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

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

145
Q

Dx and Tx of Nec Fac

A

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

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

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

146
Q

Types of hyperPTH

A

1- High Ca/Low Ph: over-secretion

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

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

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

147
Q

RF and Tx of T/I fistua

A

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

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

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

148
Q

Px, dx and tx Lymphocele

A

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

Dx: US

Tx: perc drain (if sxs) ➡ peritoneal window

149
Q

w/up of kidney graft dysfunction

A
  1. Elevated Cr. Low UOP.
  2. US: high RI is a non-specific finding
    - Vascular abnormality ➡ angio, stent, or surg
    - Lymphocele/Urinoma ➡ perc drain ➡ perit window
    - Negative: graft dysfunction ➡ Core needle bx
150
Q

Dx and Tx of LCIS

A

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

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

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

151
Q

Dx and Tx of inflammatory breast ca

A

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

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

152
Q

Fibroadenoma - px, dx, tx

A

Px: painful/larger w/ periods or pregnancy

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

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

153
Q

Tx of breast ca in preg

A

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

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

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

**No blue dye!

154
Q

Indications for post-mastectomy radiation

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

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

155
Q

Access to neck zones

A

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

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

Zone 3: angle of mand to skull base ➡ IR

156
Q

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

A

px: moon facies, striae

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

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

157
Q

Dx, Path and Px, and Tx of carcinoid tumors

A

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

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

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

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

158
Q

W/up of Hashimoto’s disease

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

**MCCO hypoT and goiter in the US

159
Q

Standard w/up for lung ca

A
  1. PET/CT
  2. PFTs
  3. Bronchoscopy (can be intra-op)
  4. Mediastinal eval- EBUS or mediastinoscopy
160
Q

Pressor for neurogenic shock

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

**don’t normally get neuorgenic shock below T6

161
Q

Subclavien exposures

A
  1. Median sternotomy: right
  2. Left Anterolateral thoracotomy: left subclavian
    - trap door supraclav incision for distal access
162
Q

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

A

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

163
Q

Desmoid Tumor - associations, path and tx

A

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

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

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

164
Q

Serologic work-up for adrenocortical mass

A
  1. Dexa suppression (cortisol)
  2. Urine androgens (sex hormones)
  3. Plasma metanephrines (pheo)
  4. aldo/rennin ratio > 30 (salts)
165
Q

Respectability of pancreatic tumor and next step

A

Triple phase CT:

  1. Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV
    - EUS/FNA for tissue dx for neoadjuvant
  2. Borderline- <180 SMA/celiac, reconstructable PV/SMV
    - EUS/FNA for tissue dx for neoadjuvant
  3. Resectable
    - dx lap (to confirm resectability) + whipple
166
Q

Tx of horseshoe abscess

A

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

167
Q

Tx of anorectal fistula

A

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

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

168
Q

Tx of Internal HMHDs

A

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

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

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

169
Q

Tx of External HMHDS

A

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

170
Q

Unresectable cholangiocarcinoma

A

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

171
Q

Lap CBD exploration

A
  1. Dissect CD to the level of the duo
  2. Cholodochotomy distal to the CD/CBD junction
  3. Fush, basket, or fogarty balloon the stone out
  4. Close primarily, over a T-tube, or over a stent
172
Q

Px and Tx of Chalangitis

A

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

173
Q

Tx strategy for CBD transections

A
  1. Intra-op
    - <50%, not cautery: primary repair
    - >50%, or cautery: REY-HJ
  2. Late phase
    - Place drain
    - Define anatomy w/ ERCP, PTC, or MRCP
    - Place PTC tube
    - CTA to assess for R/L HA injury
    - Delayed reconstruction 6-8 weeks once optimized
174
Q

Management of GB polyps

A
  1. Sx: cc’ectomy
  2. For asx:
    - > 18 mm: tx as GB cancer
    - > 10 mm: CC’y
    - 6-10 mm: q6m U/S for 1 year. cc’ectomy if PSC
175
Q

Dx and Tx of Colovesicular Fistula

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

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

176
Q

Colon cancer and arterial resection

A
  1. R hemi- IC, RC, RBMC
    - cecum/asc colon
  2. Extended R- IC, RC, MC
    - hepatic flex/prox t colon
  3. L hemi- LBMC, LC
    - Distal TV, splenic flex, prox descending
  4. Extended L- LBMC, origin of IMA
    - splenic flex
  5. Sigmoid- IMA (hi- b4 LC, low- after LC)
    - dist desc/sig
177
Q

Colon CA surveillance after curative resection

A
  1. Exam and CEA q3-6m x 3 years
  2. Colonoscopy @ q1, 3, and 5 years
    - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel)
  3. CT CAP q1y x 3 years
  • At 2 years: recurrence local or hepatic
  • after 2 years: hepatic more often
178
Q

Staging w/up of rectal cancer

A
  1. TRUS (avoid if > t2) or MRI- T/N stage
    - suspicious nodes on MRI count as clinical stage N (neo-adj)
  2. CT CAP- M stage
  3. C’Scope- for initial dx and sync lesion. not for T stage
  4. Rigid Sig’Scope- for distance from anal verge (required! even. if c’scope done)
179
Q

Tx of Lynch Syndrome

A
  1. CRC: MC
    - q1y C-scope @ 20-25
    - TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma
    - q1y scope post op
  2. Endometrial: 2nd MC
    - q1y endometrial sampling @ 30-35
    - ppx TAH-BSO after children
  3. Ovarian:
    - q1y TVUS and Ca-125 @ 30-35
    - ppx TAH-BSO after children
  4. Stomach:
    - EGD/Bx q2-3y @ 30-35
  5. Renal: transitional cell ca
    - q1y UA and US @ 30-35
180
Q

APR vs. LAR

A

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

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

181
Q

Indications for colonic stent

A
  1. Bridge to surgery in acute obstruction (usually with metastatic cancer)
  2. Palliative measure
    * Usually for L-sided lesions
182
Q

Tx of C. diff

A

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

  1. Fulminant: oral vanco w/ IV flagyl; +vanc enema if ileus
    - no fidox
  2. Recurrence: PO fidox or vanco
  3. Multiple recurrence: tapered fidox or vanco
    - consider fecal transplant
  4. Sepsis/Megacolon: total colectomy (colon > 6 cm, cecum > 10 cm)
183
Q

Dx and Tx of ischemic colitis

A

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

184
Q

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

A

**All require bichemical testing before imaging!

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

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

185
Q

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

A

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

186
Q

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

A
  1. Glucagonoma: distal panc w/ splenectomy + cc’y
  2. Inuslinoma: enucleate
  3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple
  4. VIPoma: distal panc w/ splenectomy + cc’y
  5. SSoma: resect w/ cc’y
  6. Non functional: < 2cm observe or enucleate. > 2cm resect
187
Q

Px, Dx and Tx of Bacterial Overgrowth

A
  • px: 2/2 bill2 or REYGB
  • watery stools, bloating, b12 deficiency
  • dx: d-Xylose (carb test breath test)
  • tx: abxs (Rifaximin) ➡ surg 2nd line
188
Q

Treatment of lung ca

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

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

189
Q

Lung ca w/up

A
  1. < 8mm ➡ surveillance
  2. > 8 mm ➡ PET-CT
    - FDG- ➡ surveillance
  3. FDG+ ➡ tissue dx (either intra-op frozen or CT-guided, bronchoscopy)
    - nodal disease –> EBUS
  4. No N2 dz –> Segmentectomy or lobectomy
    - n2 disease –> chemo
190
Q

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

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

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

191
Q

Tx of HCC

A
  1. Solitary nodule, confided to the liver, < 5 cm (not strict), child A, no portal HTN, and adequate liver remnant
    - Consider portal vein embolization if remnant is insufficient
    - Consider pre-op TACE to as an adjunct
  2. Un-resectable disease: child B+, > 5cm (not strict), portal HTN, inadequate liver remnant
    - Transplant if candidate: UNOS criteria
    - Otherwise: loco-regional therapy or systemic therapy
192
Q

When to re-implant the IMA in EVAR

A
  1. Back-pressure < 40
  2. Previous colon surgery
  3. SMA stenosis
  4. Inadequate left colon flow
193
Q

Lynch vs FAP Screening

A
  1. FAP- chromosomal; APC
    - > 100 polyps, including small bowel (duodenum)
    - Surveillance: start at 10
  2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM
    - <10 polyps in the colon
    - Surveillance: start at 20
194
Q

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

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

**MRND if L6 is positive

195
Q

Confirmation of brain death

A
  1. Neuro exam:
    - absent brain stem reflexes
    - no response to stimuli
  2. Apnea test: CO2 > 60 after 10 minutes
    - if test aborted OR CO < 60 ➡
    - can’t perform test if confounding factors: unstable, hypercarbia, intoxication, paralytics (unable to wean), c-spine injury
  3. Confirmatory test: CTA, MRA or nuclear scan
196
Q

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

A
  1. Boerhave: XR suggestive ➡ UGI (CT controversial)
  2. Traumatic esophogeal perf: Trauma CT ➡ EGD or UGI
  3. UGI bleed: +/- NGT ➡ EGD
197
Q

px, dx, and tx of meconium ileus

A

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

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

198
Q

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

A

Nutritional requirements for average healthy adult male (70 kg)

  1. 20% protein calories: 1 g protein/kg/day
    - burn: 1g/kg/day + 3 g/day x % BURN…(usually 2-2.5g/kg/day)
  2. 30% fat calories
  3. 50% carbohydrate calories
199
Q

Afferent limb syndrome - cause, px, dx, tx

A
  1. Cause: affarent limb is too long from LOTz
  2. Px: acute or chronic
    - Acute: complete obstruction requiring emergent OR
    - Chronic: partial obstruction w/ bacterial overgrowth
    - steatorrhea, B12 deficiency. MC w/ antecolic Bili2
  3. Dx:
    - Acute: abdominal pain with dilated afferent limb in early post op
    - Chronic: d-xylose breath test
  4. Tx
    - stat OR for REY revision
    - Chronic: abxs –> REY/shorten the limb
200
Q

Medical tx for melanoma

A
  • Pd1 inhibitors: pembrozilumab, nivolumab
  • CTLA inhibitors: ipilmumab
  • If Braf+: braf inhibitor remains 2nd line
201
Q

Polypectomy criteria that require formal resection

A
  1. Poor differentiation
  2. Vascular/Lymphatic invasion
  3. Invasion below the SM
  4. < 2mm of surgical margin
  5. Base involvement (Haggit 4)
202
Q

Perforated diverticulitis tx

A

Primary anastomosis with DLI (DIVERTI trial) or without DLI (LADIES trial) is safe except if:
- HDUS
- Acidosis
- Acute/Chronic organ failure
- I/S
- Very old
- Poor pre-op sphincter function

203
Q

Indication and s/e for TIPS

A

2-3 paracentesis/month despite Na restriction and diuretics

s/e:
- increase r/o encephalopathy
- no change in overall survival

204
Q

Tx of MCN

A
  • Dx: EUS/FNA ➡ high CEA, low amylase
  • Location: body/tail
  • Spleen Preserving Distal Pancreatectomy (usually can be spleen preserving)
  • No follow-up is needed (no increase r/o recurrence)
205
Q

In transit melanoma tx

A

Lesions > 2cm from primary but not beyond regional tumor basin
- immunotherapy or BRAF inhibitor
- only excise if feasible (few lesions)

206
Q

Px, Mech, Tx of Malignant Hyperthermia

A

px: AD; ryanodine receptor type 1

mech: huge increase in INTRAcell Ca

tx: stop drug, dantrolene, Bicarb, cooling, tylenol
- dantrolene: ryanodine rec antagonist

207
Q

Breast cancer endocrine chemo: MOA, tx duration/indications, s/e:
1. Tamoxifen
2. Anastrazole
3. Trastuzumab

A
  1. Tamoxifen: ER partial agonist
    - for ER/PR positive and < 70
    - 5 years
    - s/e: dvt, endometrial ca
  2. Anastrazole: reversible aromatase inhibitor
    - for ER/PR positive and > 70
    - 5 years
    - s/e: MSK fractures
  3. Trastuzumab: monoclonal Ab to Her2/Neu rec
    - for HER2 positive
    - 2 years
    - s/e: cardiotoxic
208
Q

Paget’s disease of the breast

A

px: scaly, ulcerated crust of the areola

dx: nipple punch bx with epidermal cells w/ clear cytoplasm and oval nuclei

tx: total mastectomy (including NAC) and SLNBx
- don’t need ax dissection
- no breast conservation
- total mastectomy even if small underlying lesion

209
Q

Indications for emergent C-section in preggo trauma

A
  • Within 4 minutes of CPR for cardiac arrest
  • Fetus must be at least 24 weeks
  • Give O, Rh negative blood if needed
  • usually 2/2 abruption (vaginal bleeding)
210
Q

Tx of blunt cardiac injury

A
  1. EKG +/- trop
    - negative: can dc
    - positive: admit to tele (Sinus tach is abnormal)
  2. Persistant arrhythmia or HoTN ➡ echo
211
Q

Dx and Tx of rectal injuries

A

Dx: CT w/ rectal contrast is best

Tx:
1. Intraperitoneal ➡ colonic injury
2. Extraperitoneal ➡ primary repair w/ loop sig colostomy
- if inaccessible just leave open and divert
- avoid presacral drainage or distal washout

212
Q

Px and Tx of Steal syndrome vs. IMN

A
  1. Steal: pain, diminished pulse, cold hand
    - Tx: DRIL (distal revasc interval ligation)
    - Ligate immediately artery side AVF. Bypass distal to the ligation site w/ PTFE
    - 2/2 to impaired compensatory mechanisms
  2. IMN: pain, normal pulse, warm hand
    - Tx: immediate ligation
    - 2/2 nerve ischemia
213
Q

Tx of superficial venous thrombosis

A

Thrombus is in GSV, SSV

  1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months
  2. No near the jxns ➡ prophylactic AC for 45 days
  3. Otherwise: surveillance

**Superficial femoral vein is a DEEP vein
**EHIT: heat induced thrombus after RFA
- tx with AC until resolution if it involves femoral jxn and > 50% occlusion
- < 50%: compress, NSAID, surveillance

214
Q

Tx of varicose veins

A
  • RFA or EVLA are 1st line
  • Indications for surgery instead: high ligation and vein stripping:
    1. proximal/dilated and tortuous GSV
    2. previous thrombophlebitis
    3. vein too large (RFA > 15mm, EVLA > 8 mm)
  • lower extremity telangiectasias, reticular veins, and small varicose veins ➡ sclerotherapy recommended
215
Q

Tx of perforated colon ca

A
  • HDS: perform a cancer resection
  • HDUS: resect and divert
  • Scope in 3-6 months to r/o synch lesion

**Divert if unstable, contaminated, poor nutrition, etc.

216
Q

Tx and prognosticators of hepatoblastoma

A
  1. neoadjuvant 1st unless pure fetal histology and low mitotix index
  2. resection
  3. transplant if 4+ section involved/unresectable after chemo

Good prog: < 5 yo, AFP > 100

217
Q

VACTERL defects

A

Vertebral
Anal
Cardiac
TE fistula
Renal, Radial bone
Limb defects

218
Q

Biliary atresia - px, dx, and tx

A

px: infant with bilirubinemia

dx:
0. Rule out TORCH infections/neonatal hepatitis
1. HIDA with no contrast in the duo
2. Cholangiogram: look at what segments are strictured
3. perc bx (tissue dx)

tx: REY-HJ vs. REY-portoenterostomy (Kasai) ➡ transplant if unsuccessful

219
Q

Tx of dysplasia with IBD (UC and Crohn’s)

A
  • Screening scopes 8 years after onset. Scope q1-3 years thereafter.
  • Invisible HGD: confirm w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA
  • Visible HGD:
    1. Resectable: endoscopic resection + serial scopes
    2. Not-resectable: TC w/ IPAA
  • for Crohn’s can do segmental resection
220
Q

Short gut syndrome - risk/length + feeds

A
  • Adults risk starts at < 180 cm
  • Infants risk starts at < 75 cm
  • Feeds with elemental nutrition
221
Q

Tx of toxic megacolon

A
  • suspect when colon > 6cm
  • TAC w/ end ileostomy
  • Keep the ileocolic intact for future J pouch
  • Keep the SRA intact for good staple line flow
  • Divide rectum above the posterior peritoneal reflection at level of sacral promontory
222
Q

Repair of bile duct injuries based on Strasburg class

A

A- CD stump leak:
- Intraop: clip/ligate and leave drain
- Postop: perc drain + ERCP plasty/stent

B- Aberrant right hepatic ligation:
- Only if sxs ➡ REYHJ

C- Transect aberrant right hepatic:
- Only if sxs ➡ REYHJ

D- Lateral injury to CHD/CBD:
- No devascularization and small: 1’ T-tube closure
- Devascularized: REY-HJ

E- full transection of CHD/CBD
- < 1cm or distal w/out tension: 1’ T-tube closure
- > 1cm OR proximal injury: REY-HJ

e1- > 2cm, below confluence
e2- <2cm, below confluence
e3- at confluence (confluence intact)
e4- at confluence (confluence separated)
e5- aberrant RH duct injury w/ CBD stricture

223
Q

Indications for MRM

A
  1. Prior radiation
  2. Radiation therapy contraindicated by pregnancy
  3. Inflammatory breast cancer
  4. Diffuse suspicious or malignant-appearing microcalcifications
  5. Widespread disease that is multicentric
  6. A positive pathologic margin after repeat re-excision

MRM = removal of breast parenchyma, NAC, skin, AND level 1-2 nodes

224
Q

Px and w/up of cholangioca

A
  1. Px: painless jaundice.
  2. W/up:
    - Ca 19-9
    - CT/MRI
    - Tissue:
  3. ERCP w/ stent: brushings + in 50% (preferred if obstuctive)
  4. EUS/FNA: negative bx does NOT rule out
225
Q

Emergent management of lower GI bleed of unknown origin

A
  • If patient is hypotensive - TAC w/ end ileostomy
  • If stabilized- prep 1st with 4-6L of PEG. Scope w/in 24h.
226
Q

Haggit stage and management

A

Stage: extent of submucosal invasion!
0- superficial to MM (no SM)
1- invasion into head
2- invasion into neck
3- invasion into stalk
4- in SM. superficial to MP.

**all superficial. toMP

Mx:
- all sessile are 4 by definition
- 4 is an indication for resection
- < 4 cancer without high risk features ➡ polypectomy alone w/ follow-up scope in 3 months

227
Q

NCCM CRC screening

A
  • average risk: start at 45. Screen q 10 years.
    -1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.
228
Q

Dx and Tx of contained esophageal perforation

A

dx: gg swallow then thin barium
tx:
- NPO, IV abxs
- consider stenting
- generally don’t need IR drain
- includes cervical and thoracic

229
Q

Tx of Barrett’s

A
  1. PPI or H2 block daily x 8 weeks
    - BID if severe sxs, HGD, or esophagitis
  2. Work-up for anti-reflux surgery
    - dysplasia should be eradicated prior to surgery
  3. Continue surveillance
    - no dysplasia: q5y
    - LGD: q6m. ablation.
    - HGD: q3m. ablation or endoscopic resection.
230
Q

Indications for deep inguinal LN dissection for melanoma and operative considerations

A
  1. > 4 nodes on superficial dissection
  2. Positive cloquet’s node
  3. Enlarged ileo-obturator nodes on CT
  4. Clinically palpable femoral nodes
231
Q

Absolute c/i to BCT

A
  1. Pregnancy
  2. Diffuse micro-calcs
  3. Positive pathologic margin
  4. Multi-quadrant disease
232
Q

Dx and Tx of pediatric Intussusception

A

Dx: U/S, current jelly stools, abdominal mass

Tx:
1. Air contrast enema (75% effective)
- surgery if unstable, perforation, mass, or completely unsuccessful on repeat U/S
2. Repeat enema
3. Observe for 4 hours if success
- only 5% recur

233
Q

Causes of thyrotoxicosis on RAI and tx

A

Low tsh —> thyroid scint

  • 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
234
Q

Management of penetrating cardiac injury

A
  1. FAST+, HDS ➡ OR for pericardial window ➡ extend to median sternotomy if blood found
  2. FAST+, HDUS ➡ immediate median sternotomy (preferred) or ED thoracotomy (left anterolateral)
    - Finger compression
    - If failure ➡ pledgeted repair (avoid balloon/staples if possible). Horizontal mattress, permanent (prolene)
235
Q

Surviving Sepsis 1-hour bundle

A
  1. Measure lactate
  2. Blood cx b4 abxs
  3. Abxs after cx
  4. 30 ml/cc bolus if HoTN, LA
  5. Pressors for MAP >65
236
Q

Tx of atypical ductal hyperplasia (ADH)

A
  • Get diagnostic mammo
  • Then excisional bx (15-30% of cancer)
  • Like LCIS you do not need a negative margin
  • Finally chemo-ppx with tamoxifen

**ALH and LCIS if low risk and concordant

1. CE prep (3 decks)

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