SESAP GI AND VASC Flashcards
Best test for C diff
PCR detects more cases of C. difficile because of the significantly improved sensitivity
BETTER than more common enzyme immunoassay that is currently most commonly used.
Another advantage of PCR is the need for only a single sample and the rapidity with which the results are available.
PCR does not distinguish between asymptomatic carriers and those with symptomatic disease.
infected, necrotizing pancreatitis treatement
OPEN exploratory laparotomy with open necrosectomy remains the standard therapy
Necrosectomy is necessary only in the setting of infection.
In cases of sterile necrosis, nonoperative supportive care is sufficient, including resuscitation, nutritional support, and adjuncts to support organ function.
non occluisive mesenteric ischemia
Direct thrombin inhibitors are used to treat heparin-induced thrombocytopenia. Intravenous papaverine can be used for vasospasm treatment in cases of NOMI, but it should not delay operative exploration in the presence of abdominal sepsis.
non operative treatment of mesenteric arterial or venous embolism or thrombosis
Intravenous heparin or direct thrombin inhibitor infusion can be used effectively to treat cases of arterial or venous embolism or thrombosis but should not be initiated until the etiology of the ischemia is determined.
Treatment of a symptomatic Meckel diverticulum involves
diverticulectomy or segmental resection of the involved segment of bowel.
Segmental resection is required in cases of bleeding because the source of bleeding is typically the normal bowel opposite the mouth of the diverticulum.
manage an asymptomatic Meckel diverticulum found incidentally on abdominal exploration.
left in situ, especially in older patients.
A systematic review from 2008 found a higher postoperative complication rate in patients undergoing resection of an incidental Meckel diverticulum compared with those in whom it was left in situ (5.3% vs. 1.3%).
most common cause of gastrointestinal perforation,
Peptic ulcer disease (PUD) remains the occurring in up to 10% of patients with ulcers.
Operative treatment of perforated PUD
JUST perforation closure with treatment of H. pylori infection and PPI initiation.
Graham patch closure of the perforation site, in which an omental tongue is placed over the perforation and sutured into place, remains the procedure of choice for most surgeons.
Biopsy or ulcer excision (if feasible), of gastric ulcers should be undertaken to rule out malignancy.
It can be undertaken by means of an open or minimally invasive approach.
Pyloroplasty alone is not a therapeutic option. Prepyloric ulcers are treated in the same manner as duodenal ulcers.
NO LONGER recommend definitive antiulcer interventions such as:
truncal or selective vagotomies with or without pyloroplasty
Achalasia
loss of peristalsis in the distal esophagus
failure of the lower esophageal sphincter (LES) to relax
Dysphagia for both solids and liquids
dysphagia with liquids being the most characteristic symptom
Nutcracker esophagus
characterized by peristaltic waves in the distal esophagus of high amplitude (>180 mm Hg) prolonged duration (>6 seconds).
The LES can have normal or elevated resting LES pressures, similar to achalasia.
Systemic sclerosis (scleroderma)
aperistalsis or low amplitude distal esophageal contractions
absent or low LES pressure.
Up to 90% of patients with systemic sclerosis have esophageal involvement.
disease involves the smooth muscle layer, resulting in atrophy and sclerosis leading to the poor contractile/aperistalsis of the esophagus.
These changes lead to symptoms of heartburn and progressive dysphagia. These patients are at particular risk for reflux and subsequent stricture formation.
Transplant who with HCC
single tumors less than 5 cm
or
3 or fewer lesions less than 3 cm.
Managemnt of hepatic adenoma in pregnancy
resect
management of hepatic adenoma
All lesions greater than 4 cm should be resected, if it can be done safely.
HCC less than 2 cm
RFA is the preferred treatment
unless the patient’s liver disease is advanced enough to qualify for liver transplant.
HCC large tumor managemtn
Resection - if it wont kill them
NOT transplant since can’t be over 5 cm
Chemoembolization is best for HCC tumors of what size
Chemoembolization is best for tumors 5–7 cm (sometimes larger)
or
patients with smaller tumors not amenable to RFA or surgery.
For chemoembolization, patients cannot have advanced liver disease.
A bilirubin greater than 3 or significant ascites is a relative contraindication.
most common type of functional neuroendocrine tumor of the pancreas.
Insulinomas
Insulinomas
Whipple and designated the Whipple triad:
- hypoglycemia after fasting or exercise
- blood glucose of less than 45 mg/dL
- symptoms relieved by intravenous or oral glucose
The vast majority of insulinomas are benign.
Gastrinomas
second most common type of functional neuroendocrine tumor of the pancreas.
majority of gastrinomas are malignant at presentation,
usually multicentric
gastrinoma triangle
Oversecretion of gastrin leads to formation of ulcers.
Glucagonomas
rare neuroendocrine tumors of the pancreas.
Four Ds: diabetes, dermatitis, deep vein thrombosis, depression.
rash is pathognomonic:
necrolytic migratory erythema
The rash occurs in 70% of patients at diagnosis and commonly predates other systemic symptoms.
Somatostatinomas
are neuroendocrine tumors
usually are very large at presentation.
commonly have gallstones caused by cholestasis.
VIPomas
watery diarrhea syndrome associated with
hypokalemia and achlorhydria
WHA
Fully covered stents
exclude the area of perforation
easier to remove
migration rates are more problematic.
Undrained fluid or abscess that is excluded by the stent might require additional drainage procedures.
Uncovered metal stents
used for obstructing:
esophageal cancers
duodenal cancers
colonic cancers
Uncovered metal stents have fewer problems with migration
much more difficult to remove.
Celestin tubes
largely been replaced by current generation covered stents -useful if endoscopy or modern stents are not available.
fully covered, can be placed antegrade over a guidewire, or can be placed retrograde via a gastrotomy to relieve obstruction or cover a perforation of the distal esophagus.
T-tube use to manage esophogeal perf
NOT be appropriate for a proximal thoracic esophageal perforation, especially if a fully covered stent is available.
T-tube to create a controlled fistula given the high rate of repair breakdown for delayed repairs for esophageal perforation
Stroke rates of stent v CEA
stroke rates are lower after CEA
stroke and death rate at 4 years was significantly less in the group randomized to endarterectomy
when using the 3 endpoints of stroke, death, or myocardial infarction, the outcomes were found to be similar
intervention for smaller AAA
NO long‑term survival benefit
current recommendations for infrarenal AAA by size:
4–5 cm: annual serial ultrasound
greater than 5 cm: 6‑month serial ultrasound screening for aneurysms .
5.5 cm: intervention and repair of aneurysms
Effort thrombosis of the subclavian vein (Paget-Schroetter syndrome) management
require prompt diagnosis with upper-extremity venogram followed by
catheter-directed thrombolysis with
periprocedural anticoagulation
Thoracic outlet decompression with first rib resection and release of fibrous bands is the current standard of care.
Venous reconstruction with vein interposition graft is occasionally required.
A high rate of rethrombosis of the subclavian vein is likely if decompression of the thoracic outlet is not undertaken.
Significant predictive factors of in-hospital mortality with either elective open or EVAR repair of AAA include
age older than 80 years, female sex, congestive heart failure, and renal failure.
order of preference for fistulas
radial–cephalic fistula
brachial–cephalic fistula.
transposed brachial–basilic vein fistula over prosthetic AV grafts.
polytetrafluoroethylene (PTFE) prevalent and patency
PTFE accesses remain the most prevalent form of access in the United States,
10-fold increase in the thrombosis rate of PTFE compared with autogenous fistulas!
stent v CAE complications rates
CEA
lower stroke
lower short-term mortality rate
(but does not affect long-term mortality)
CEA
increase cranial nerve injury
increase postprocedure myocardial infarction is lower in patients receiving CAS than CEA.
Tx and success for fibromuscular dysplasia (FMD)
PTA is not any better than for surgical revascularization less than 50% cure
less antihypertensive medications needed rate is approximately 75%
In patients younger than 30 years, more than 60% are cured, but in patients older than 50 years, fewer than 30% are cured.
popliteal aneurysms patency rate after operation
Aneurysm patency rate after ligation and bypass is 33%.
contraindications of thrombolytic therapy for PE
(1) hemorrhagic stroke or stroke of unknown origin at any time;
(2) ischemic stroke within the previous 6 months;
(3) central nervous system damage or neoplasms;
(4) major trauma, surgery, or head injury within the previous 3 weeks; or
(5) concomitant active bleeding.
preferred approach for emergency treatment of catastrophes of the thoracic aorta, particularly acute rupture.
TEVAR
Thoracic endovascular aortic reconstruction
The tracheostomy should be placed
either the second or third tracheal ring
Tracheoinnominate fistula treatement
reatment for this rare complication has traditionally been an open surgical procedure; however, advances in endovascular technology have led to recent reports of therapy with endovascular stenting or coil occlusion. Long-term outcomes from these approaches are not available. Stent grafting is inappropriate in children because of stent–body size mismatch will occur as the child grows.
Most patients tolerate innominate artery ligation with minimal or no disability!
Intraoperative electroencephalography can also be used to assess for signs of ischemia and necessary revascularization.
Controversy exists regarding immediate vascular repair with saphenous vein or other conduit.
Measurements of innominate artery stump pressures and selective revascularization for those with very low backpressure is helpful to guide surgical intervention.
upper-extremity DVT diagnosis and complication rate compared to lower extremity DVT
Diagnosis is by means of compression ultrasonography, as with lower-extremity DVT. Complications of DVT are less common in the upper-extremity DVT than lower-extremity DVT.
In patients with catheter-associated upper-extremity DVT managemnt
Routine catheter removal is not recommended.
if the line is needed and fully functional, it should be left in place while anticoagulation is instituted.
If the line is not essential, it can be removed; however, completion of 3–5 days of anticoagulation therapy is recommended before removal.
Initial anticoagulation should be with low molecular weight heparin or unfractionated heparin in patients with renal failure.
After initial heparin therapy, warfarin is used for at least 3–6 months.
The patient has a venous ulcer, typically found where
above the medial malleolus on the lower extremity
Above-knee amputations are advisable in patients with l
limited preoperative ambulatory ability, age older than 70 years, dementia, end-stage renal disease, advanced coronary artery disease
Absolute ankle pressures predict below-knee amputation healing
greater than 60 mm Hg
50–90% of these patients will heal BKA
HIT confirmatory testing performed
(platelet factor 4 enzyme-linked immunosorbent assay or serotonin release assay).
platelet contraindications for starting warfarin
Warfarin should be initiated only when platelet counts are greater than 150 × 103/μL
to the risk of paradoxical thrombosis or warfarin-induced skin necrosis.
renal cleared anticoagulation
Fondaparinux and lepirudin
renally cleared and therefore would not be used in patient with end-stage renal disease.
Anticoagulation options that do not cause HIT
Fondaparinux and lepirudin
however renal cleared
Fondaparinux
(trade name Arixtra) is
chemically related to low molecular weight heparins.
Factor Xa inhibitor
Enoxaparin
trade names Lovenox
low molecular weight heparin
Argatroban
direct thrombin inhibitor
cleared by the liver
(NO Argatroban or Aeromatic protein for liver failure)
indicated in the prevention and treatment of DVT when HIT is suspected.
lepirudin
direct thrombin inhibitor
renal cleared
Raynaud phenomenon presentation
The classic triad of color change includes initial vasospasm pallor cyanosis rubor
Attacks typically start in a single digit and spread to involve the fingers of both hands.
Primary Raynaud phenomenon
occurs in otherwise healthy individuals.
Secondary Raynaud phenomenon
related to an associated disease or an identifiable environmental exposure.
Association of Raynauds and scleroderma
Raynaud phenomenon occurs in 90% of patients with scleroderma.
Association of Raynauds and Lupis
It is seen in 10–45% of patients with systemic lupus erythematosus
Association of Raynauds and RA
10–20% of patients with rheumatoid arthritis.
The development of Raynaud phenomenon is associated with
beta-blockers,
caffeine,
cocaine.
use of vibrating tools
occupational hazard among lumberjacks
Primary treatment for Raynaud phenomenon
avoid cold environments; cigarette smoking; vibrating tools; and vasoconstrictor substances such as caffeine, cocaine, decongestants, and beta-blockers.
Vasodilators such as calcium channel blockers, topical nitrates, and angiotensin receptor blockers are used to treat Raynaud phenomenon.
Surgical treatment of Raynaud phenomenon involves sympathectomy - localized digital sympathectomy using microsurgical techniques. This procedure involves stripping the adventitia of the digital arteries, which includes the sympathetic fibers.
NO Cervicothoracic sympathectomy, once commonly performed, is associated with significant morbidity and frequent recurrence of symptoms, and it is no longer the preferred surgical option.
traumatic aortic injury treatment
body of evidence strongly suggests improved outcome with an endovascular approach to the majority of patients with this injury.
If the injury is too close to the subclavian artery, the left subclavian must be covered by the stent graft.
This is acceptable, because a minority of patients will become symptomatic in the postoperative period. If symptoms of left upper-extremity ischemia occur, a carotid–subclavian bypass can be performed.
upper extremity, contraindications for endovascular treatment of subclavian/axillary injuries
contraindications:
long segmental injuries,
lack of fixation points either proximal or distal,
arterial transection.
relative contraindications:
Concomitant venous injury and compartment syndrome are
(operative intervention would be required to address either of these conditions, and the advantages of the endovascular approach would be lost)
Treatment of renal artery stenosis
angioplasty and stent not only improves the anatomic lesion but also improves or stabilizes renal function in approximately two-thirds of patients treated in this way.
Given the increased risk of open approaches to renal revascularization, stenting is the first-line treatment for these patients.
treatment of blunt cerebrovascular injuries
dissections caused by intimal disruption, are initially best treated with anticoagulation or antiplatelet therapy.
Follow-up imaging often demonstrates complete resolution.
Grade III injuries are the only ones that usually require intervention, because they are pseudoaneurysms that are unlikely to heal spontaneously or with medical therapy.
Dacron or PTFE for superficial femoral artery stenoses
equivalent 5-year primary patency rates of approximately 50%.
Angioplasty or stent for superficial femoral artery stenoses
For patients with shorter areas of stenosis (<5 cm), there is no difference in the rate of restenosis when comparing primary angioplasty with adjunctive stenting
3-year primary patency rates of nearly 80%.
cadaver saphenous vein grafts
significantly higher cost and low primary patency rates of 24% at 2 years, which appears to be unaffected by additional treatment with anticoagulation.
Currently, cadaver saphenous vein grafts are recommended for patients without suitable conduit in settings of bacterial contamination because of the relative resistance of the material to infection.
Patency rates remain low, but short-term patency may be enough to achieve wound healing in patients with distal ulceration.
Reasons to prefer a prosthetic graft include
a small basilic vein, a patient with numerous long-term central venous catheter infections, or an obese patient.
basilic vein, it has to be transposed when of A-V fistula
MOST even in a thin patient, because of its proximity to the median antebrachial cutaneous nerve.
Because the basilic vein is thin walled, it is more prone to injury and devascularization during mobilization.
Therefore, some surgeons recommend a 2-stage procedure:
formation of the A‑V fistula;
mobilization is the second stage (i.e., mobilizing after it has been arterialized).
1-year primary patency transposed brachial-basilic A-V fistulas
65–70% of transposed brachial-basilic A-V fistulas are functioning at 1 and 2 years without any further interventions.
1-year primary patency transposed A-V grafts
50–70% 1-year primary patency.
Both fistula and graft patency can be improved by how much by doing what
10–15% with aggressive surveillance and secondary procedures.
Hard signs of arterial injury include
obvious arterial bleeding, absent distal pulses, limb ischemia, expanding or pulsatile hematoma, bruit or thrill over the area of injury, shock without other injury
soft signs of vascular injury and work up
bruising,
swelling,
localized hematoma,
repeated physical examination,
ankle-brachial index measurement,
observation
An ankle-brachial index of less than 0.9 in a patient with injury in proximity to a major extremity artery work up
should be studied with either CTA or angiography.
Glutaraldehyde-cross-linked albumin
trade name Gluetiss®
glutaraldehyde and bovine serum albumin that when mixed form a tough scaffold, which achieves 65% of its strength within 20 seconds, even when wet. It should not be used circumferentially around developing structures, because it can restrict growth.
Oxidized cellulose
surgicel
is applied dry and is held against bleeding tissue. Both agents decrease the local wound pH, causing red cell lysis, generating an artificial clot, and having a theoretical antimicrobial effect.
Must not be used with other biologic hemostatic agents (e.g., thrombin) because of low pH.
Microfibrillar collagens
Avitene
powdery foam
provide for a large surface area for platelet adherence that leads to platelet activation and thrombus formation.
requires platelet activation and is affected by thrombocytopenia.
Is less effective in patients with thrombocytopenia.
Fibrin sealants
Tisseel
Fibrin sealants are composed of thrombin and fibrinogen that interact to form a stable clot.
two-component system in which a solution of concentrated fibrinogen and factor XIII are combined with a solution of thrombin and calcium in order to form a coagulum, simulating the final stage of the clotting cascade. Once the thrombin/calcium is combined with the fibrinogen/factor XIII, a fibrin clot forms in seconds, or somewhat slower if a more dilute form of thrombin is used.
Thrombin with gelatin
FloSeal
combines bovine collagen and human thrombin
requires blood as a source of fibrinogen.
