SESAP GI AND VASC

Question 1

Best test for C diff

Answer 1

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.

Question 2

infected, necrotizing pancreatitis treatement

Answer 2

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.

Question 3

non occluisive mesenteric ischemia

Answer 3

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.

Question 4

non operative treatment of mesenteric arterial or venous embolism or thrombosis

Answer 4

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.

Question 5

Treatment of a symptomatic Meckel diverticulum involves

Answer 5

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.

Question 6

manage an asymptomatic Meckel diverticulum found incidentally on abdominal exploration.

Answer 6

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%).

Question 7

most common cause of gastrointestinal perforation,

Answer 7

Peptic ulcer disease (PUD) remains the occurring in up to 10% of patients with ulcers.

Question 8

Operative treatment of perforated PUD

Answer 8

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

Question 9

Achalasia

Answer 9

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

Question 10

Nutcracker esophagus

Answer 10

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.

Question 11

Systemic sclerosis (scleroderma)

Answer 11

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.

Question 12

Transplant who with HCC

Answer 12

single tumors less than 5 cm
or
3 or fewer lesions less than 3 cm.

Question 13

Managemnt of hepatic adenoma in pregnancy

Answer 13

resect

Question 14

management of hepatic adenoma

Answer 14

All lesions greater than 4 cm should be resected, if it can be done safely.

Question 15

HCC less than 2 cm

Answer 15

RFA is the preferred treatment

unless the patient’s liver disease is advanced enough to qualify for liver transplant.

Question 16

HCC large tumor managemtn

Answer 16

Resection - if it wont kill them

NOT transplant since can’t be over 5 cm

Question 17

Chemoembolization is best for HCC tumors of what size

Answer 17

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.

Question 18

most common type of functional neuroendocrine tumor of the pancreas.

Answer 18

Insulinomas

Question 19

Insulinomas

Answer 19

Whipple and designated the Whipple triad:

1. hypoglycemia after fasting or exercise
2. blood glucose of less than 45 mg/dL
3. symptoms relieved by intravenous or oral glucose

The vast majority of insulinomas are benign.

Question 20

Gastrinomas

Answer 20

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.

Question 21

Glucagonomas

Answer 21

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.

Question 22

Somatostatinomas

Answer 22

are neuroendocrine tumors

usually are very large at presentation.

commonly have gallstones caused by cholestasis.

Question 23

VIPomas

Answer 23

watery diarrhea syndrome associated with

hypokalemia and achlorhydria

WHA

Question 24

Fully covered stents

Answer 24

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.

Question 25

Uncovered metal stents

Answer 25

used for obstructing:
esophageal cancers
duodenal cancers
colonic cancers

Uncovered metal stents have fewer problems with migration

much more difficult to remove.

Question 26

Celestin tubes

Answer 26

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.

Question 27

T-tube use to manage esophogeal perf

Answer 27

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

Question 28

Stroke rates of stent v CEA

Answer 28

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

Question 29

intervention for smaller AAA

Answer 29

NO long‑term survival benefit

Question 30

current recommendations for infrarenal AAA by size:

Answer 30

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

Question 31

Effort thrombosis of the subclavian vein (Paget-Schroetter syndrome) management

Answer 31

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.

Question 32

Significant predictive factors of in-hospital mortality with either elective open or EVAR repair of AAA include

Answer 32

age older than 80 years, female sex, congestive heart failure, and renal failure.

Question 33

order of preference for fistulas

Answer 33

radial–cephalic fistula

brachial–cephalic fistula.

transposed brachial–basilic vein fistula over prosthetic AV grafts.

Question 34

polytetrafluoroethylene (PTFE) prevalent and patency

Answer 34

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!

Question 35

stent v CAE complications rates

Answer 35

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.

Question 36

Tx and success for fibromuscular dysplasia (FMD)

Answer 36

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.

Question 37

popliteal aneurysms patency rate after operation

Answer 37

Aneurysm patency rate after ligation and bypass is 33%.

Question 38

contraindications of thrombolytic therapy for PE

Answer 38

(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.

Question 39

preferred approach for emergency treatment of catastrophes of the thoracic aorta, particularly acute rupture.

Answer 39

TEVAR

Thoracic endovascular aortic reconstruction

Question 40

The tracheostomy should be placed

Answer 40

either the second or third tracheal ring

Question 41

Tracheoinnominate fistula treatement

Answer 41

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.

Question 42

upper-extremity DVT diagnosis and complication rate compared to lower extremity DVT

Answer 42

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.

Question 43

In patients with catheter-associated upper-extremity DVT managemnt

Answer 43

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.

Question 44

The patient has a venous ulcer, typically found where

Answer 44

above the medial malleolus on the lower extremity

Question 45

Above-knee amputations are advisable in patients with l

Answer 45

limited preoperative ambulatory ability, 
age older than 70 years, 
dementia, 
end-stage renal disease, 
advanced coronary artery disease

Question 46

Absolute ankle pressures predict below-knee amputation healing

Answer 46

greater than 60 mm Hg

50–90% of these patients will heal BKA

Question 47

HIT confirmatory testing performed

Answer 47

(platelet factor 4 enzyme-linked immunosorbent assay or serotonin release assay).

Question 48

platelet contraindications for starting warfarin

Answer 48

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.

Question 49

renal cleared anticoagulation

Answer 49

Fondaparinux and lepirudin

renally cleared and therefore would not be used in patient with end-stage renal disease.

Question 50

Anticoagulation options that do not cause HIT

Answer 50

Fondaparinux and lepirudin

however renal cleared

Question 51

Fondaparinux

Answer 51

(trade name Arixtra) is

chemically related to low molecular weight heparins.

Factor Xa inhibitor

Question 52

Enoxaparin

Answer 52

trade names Lovenox

low molecular weight heparin

Question 53

Argatroban

Answer 53

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.

Question 54

lepirudin

Answer 54

direct thrombin inhibitor

renal cleared

Question 55

Raynaud phenomenon presentation

Answer 55

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.

Question 56

Primary Raynaud phenomenon

Answer 56

occurs in otherwise healthy individuals.

Question 57

Secondary Raynaud phenomenon

Answer 57

related to an associated disease or an identifiable environmental exposure.

Question 58

Association of Raynauds and scleroderma

Answer 58

Raynaud phenomenon occurs in 90% of patients with scleroderma.

Question 59

Association of Raynauds and Lupis

Answer 59

It is seen in 10–45% of patients with systemic lupus erythematosus

Question 60

Association of Raynauds and RA

Answer 60

10–20% of patients with rheumatoid arthritis.

Question 61

The development of Raynaud phenomenon is associated with

Answer 61

beta-blockers,
caffeine,
cocaine.
use of vibrating tools

occupational hazard among lumberjacks

Question 62

Primary treatment for Raynaud phenomenon

Answer 62

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.

Question 63

traumatic aortic injury treatment

Answer 63

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.

Question 64

upper extremity, contraindications for endovascular treatment of subclavian/axillary injuries

Answer 64

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)

Question 65

Treatment of renal artery stenosis

Answer 65

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.

Question 66

treatment of blunt cerebrovascular injuries

Answer 66

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.

Question 67

Dacron or PTFE for superficial femoral artery stenoses

Answer 67

equivalent 5-year primary patency rates of approximately 50%.

Question 68

Angioplasty or stent for superficial femoral artery stenoses

Answer 68

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%.

Question 69

cadaver saphenous vein grafts

Answer 69

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.

Question 70

Reasons to prefer a prosthetic graft include

Answer 70

a small basilic vein, a patient with numerous long-term central venous catheter infections, or an obese patient.

Question 71

basilic vein, it has to be transposed when of A-V fistula

Answer 71

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).

Question 72

1-year primary patency transposed brachial-basilic A-V fistulas

Answer 72

65–70% of transposed brachial-basilic A-V fistulas are functioning at 1 and 2 years without any further interventions.

Question 73

1-year primary patency transposed A-V grafts

Answer 73

50–70% 1-year primary patency.

Question 74

Both fistula and graft patency can be improved by how much by doing what

Answer 74

10–15% with aggressive surveillance and secondary procedures.

Question 75

Hard signs of arterial injury include

Answer 75

obvious arterial bleeding, 
absent distal pulses, 
limb ischemia, 
expanding or pulsatile hematoma, 
bruit or thrill over the area of injury, 
shock without other injury

Question 76

soft signs of vascular injury and work up

Answer 76

bruising,
swelling,
localized hematoma,

repeated physical examination,
ankle-brachial index measurement,
observation

Question 77

An ankle-brachial index of less than 0.9 in a patient with injury in proximity to a major extremity artery work up

Answer 77

should be studied with either CTA or angiography.

Question 78

Glutaraldehyde-cross-linked albumin

Answer 78

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.

Question 79

Oxidized cellulose

Answer 79

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.

Question 80

Microfibrillar collagens

Answer 80

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.

Question 81

Fibrin sealants

Answer 81

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.

Question 82

Thrombin with gelatin

Answer 82

FloSeal
combines bovine collagen and human thrombin

requires blood as a source of fibrinogen.