Surgery Flashcards
most common metastasis sites of adrenal tumors?
Think L3 Liver Lung Lymph Bone
make sure to scan for all these if carcinoma
Classification of a adrenal adenoma?
Size is <4cm Regular shape and borders Contrast was out is > 50% after 10 min CT attenuation is < 10 HU MRI showes same shade as liver both in T1 and T2
Classification of a Adrenal Carcinoma?
Size > 4cm
Irregular shape and infiltrating borders
CT attenuation is > 20 HU
Contrast washout < 50% at 10 min
Increased vascularization
Calsification
MRI hypointense (black) compared to liver in T1
how can you confirmed it the adrenal carcinoma is a primary of metastatic tumor?
Take a FNAB
Process of deciding treatment of adrenal tumor
- is it functional or not (hormones)
- Overnight dexa test ( > 1.8ug/dl in morning is confirming)
- measure metanephrins in 24h urine (pheo)
- SURGERY
what is the surgical procedure in Adrenal tumor? when do you wait and when do you to in asap?
If non functional you monitor for 6-12 months, if it grows more then 1cm you remove
If it is a producing tumor then remove asap with No touch tech.
what to do before removing a pheo tumor?
2-3 weeks before - give A-blockers
2-3 days before - give B-blockers
right before - give glucocorticoids
location and bloodsupply of the adrenals?
12th IC space
- sup. suprarenal ( inferior phrenic)
- middle suprarenal (direct aorta)
- inferior suprarenal ( renal a.)
diseases caused by actively secreting adrenal tumor?
Conns (aldosteron)
Cushings (cortisol)
Pheochromocytoma (NE/epi)
contraindications for laparoscopic adrenalectomy?
tumor > 9cm
local invasive tumor
general contraindications for laparoscopic surgery
what is goiter?
irregular growth of the thyroid, either overall enlargement or nodules
symptomes of HYPERthyroidism
- weightloss
- tachycardia
- palpitations
- arrhythmias
- irritability, anxiety, nervousness
- heat sensitivity
symptomes of HYPOthyroidism
- weight gain
- bradychardia
- dry skin
- constipation
- fatigue, muscle loss
- puffy face
- hoarsness
- cold sensitivity
Ethiology of goiter?
- iodine deficiency
- Graves
- Hashimoto
- DeQuervian (subacute)
- tumor
- pregnancy
- Riedel thyroditis
types of Goiter?
Diffuse: symetric enlargment
Nodular: non symmetric enlargment
causes of nodular goiter
Thyroiditis
Graves
hypothyroidism
causes of diffuse goiter
cysts
autonomous nodules (adenomas)
degenerative nodules
tumors
Diagnosis of goiter
anamnesis physical examination, palpitation sonography lab tests CT MRI FNAB
sonography findings in goiter - Benign lesions?
Hyperechoic/anechoic Halow sign Peripheral calcification < 1cm peripheral vascularization
sonography findings in goiter - Malignant lesions?
Hypoechoic Star-sky calcification in nodule No halow sign > 2cm intranodal calcification
Define hypoechoic US?
darker then surrounding tissue but NOT black like vessles
define anechoic and hyperechoic?
Anechoic is black like vessles
Hyperechoic is white/lighter then surrounding tissue
the strong 3 indications of malignant thyroid nodules?
- > 2cm
- calcification
- Solid structure
Types of thyroidectomy
- Lobectomy (one lobe)
- Hemithyroidectomy (lobe and ishtmus)
- Total thyroidectomy
- subtotal (leave 4g on each side to save nerve)
- Near total (leave 2g on each side)
- Heartly Dunhill (leave 4g on ONE side)
riskfactors of thyroid cancer?
radiation
family history
> 65 years
physical examination indications of thyroid cancer
Nodules in patient < 25 yrs Dysphagia Hoarsness Firm on palpitation and not moving swollen, painless lymph nodes on one side
Diagnosis of thyroid nodules?
- Examination
- US
- Lab tests
- Scintigraphy (I-isotope uptake test with I133)
- FNAB
Thyroid scintigraphy procedure and results?
Give I-133 to patient, then use Gamma camera to look for nodules taking up the iodine, they will become darker if active and have no colore if not active
Active:
One nodule = toxic adenoma
multiple nodules = Multinodular Toxic goiter
Non-active:
High risk of malignancy - do FNAB of ALL nodules and US tripple positive sign
origin of thyroid tumor cells?
mostly from follicular cells except medullary which is from parafollicular C-cells
Types pf thyroid cancers?
Papillary 70% good prognosis
Follicular 20% good prognosis if removed
Anaplastic 5% poor prognosis
Medullary 2% Poore prognosis
what is spescial with the anaplastic thyroic cancer?
undifferentiated highly agressive cancer, no response ro RAI
morphology of papillary thyroid cancer?
often cystic with fibrosis and calcification
diagnosis based of orphan annie nucleus ( clear)
nuclear invaginations
can have papillary architecture
psammomma (calcified) bodies
metastasis nature of follicular thyroid carcinoma
hematogenous to liver, lung and bone, not lymph like papillary form
occurance of medullary thyroid cancer
mostly sporadic if not they are ass. with MEN 2a/2b and the person will have other cancers ass cell
nature of cells in medullary thyroid cancer?
they are spindle shaped neuroendocrine cells derived from the parafollicular C cells and secrete calcitonin BUT hypocalcemia is not present
anaplastic thyroid cancer comed from?
belived to be dedefferentiation of an already ongoing cancer ex. papillary. agressive with 100% death rate within 1 year
which thyroid cancer is most sees in young people?
papillary can happen at young ages as well
causes of Hyper parathyroidism?
adenoma (95%)
Primary hyperplasia
parathyroid carcinoma (1%)
pathogenesis of parathyroid tumor genes?
D1 cell cycle regulator relocation on the 11 chromosome to PTH gene expression site
MEN1 tumor supressor gene mutation
what can HPT due to bone?
increased metabolist by OC
in severe cases osteitis fibrosa cystica
HPT in GI?
constipation neausea peptic ulcers pancreatitis gallstones
HPT in kidney?
polyuria
kidney stones
lab diagnosis of PHPT?
Imaging?
high PTH
high Calsium
Calciuria > 400mg/day
Scintigraphy with Tc-99m sestamibi washout method SPECT
MRI
treamt ment rules in HPT?
- Ca < 3.0mg/L and no symptomes = no treatment
- Ca - 3.0-3.5mg/L and no symptomes = no treatment but hydration
- Ca - 3.0-3.5mg/L but symptomes = must treat
- Ca > 3.5 = must treat regardless of no symptomes
What is the definit treatment for PHPT?
in first line is contraindicated then pharmacologic treatment of HPT?
THE ONLY CURATIVE TREATMENT FOR PHPT IS SURGERY
IF CONTRAINDICATED: Bisphosphatases Denosumab Calcitonin Loop diuretics (increase kidney excretion) Glucocorticoids (GI untake decrease)
what must you do before parathyroid gland surgery?
you have to localize the 4 grands
- US
- Scintigraphy SPECT
- CT
- MRI
- selective arteriography
- selective venous sampling
- methionine PET CT
- SPECT-CT
the 10 rules of parathyroid by J. Norman
- NO drugs can cure
- all have symptomes
- symptomes not correlated with Ca2+ level
- all patient have Ca and PTH fluctuations
- all get osteoporosis
- drugs will not help bones in long run
- gets worse over time
- only treatment of PHPT i surgery
- mininal invasive surgery can cure all
- sucsess rate repends on surgeon skills
surgical approach in PTH surgery
- Bilateral exploration without localization - this is a open surgery and the most used type, where the surgeon does not know where the glands are before surgery
- Unilateral ecploration after preopeative localization
- minimal access surgery with pre and intraoperative diagnostic procedure.
this one can be converted to open surgery during procedure if the level of PTH is not decreased during operation
How do we measure intraoperativly the PTH leven during minimal access surgery?
we measure the level at the beginning of surgery. The half life of the PTH is 5 minutes so measuring the level of PTH in veins after 10 minutes should show a decrease
etiology of GERD
- hyperacidity ( Zollinger-Ellison, H. pylori, hypergastrinemia
- Smoking (relaxes LES)
- obesity
- Pregnancy
- Alcohol
- Hiatal hernia
diagnosing GERD?
- endoscopy
- esophageal pH monitoring
- barium swallow test
- esophageal monometry (strength and muscle coordination of your esophagus)
treatment of GERD
- PPI
- H2I
- lifestyle
- Fundoplication
- endoscopic mucosectomy
Fundoplication surgery?
part of stomach fundus is pulled up and secured around the lower esophagus. causing stronger LES.
Endoscopic mucous resection in GERD
we go in through the mouth down to esophagus, sucks mucous and submucousa into endoscope device. puts ring around creating pollyp and cuts it off.
GERD complications
- barret
- refluc esophagitis
- esophageal strictures and schatzki rings
- aspiration pneumonia
Saint triad
combination of cholelithiasis, diverticulosis, hiatal hernia (seen in 1.5%)
diagnosis of hiatal hernia
- barum swallowing test
- endoscopy (check Z line - squamocolumnar separation of esophaugus and stomach)
- CXR
- CT
- esophageal manometry
- pH monitoring
treatment of hiatal hernia
- open fundoplication and hiatoplasty
2. gastropexy/fundopexy if type II, III, IV
what is gastropexy
Gastropexy is a surgical operation in which the stomach is sutured to the abdominal wall or the diaphragm.
cause of zenkers diverticulum
impaired relaxation of cricopharyngeal muscles
location of zenkers diverticulum?
killians triangle
classification of esophageal divertcula - location
UED - killians
MED - trachea biforcation
LED - epiphrenic
classification of esophageal divertcula - histology
TRUE - all layers
FALSE - mucosa and submucosa
classification of esophageal diverticula - pathophysiology
Pulsion - increased intraluminal pressure, only mucosa and submucosa
Traction - scarring and retraction from inflammation, with all layers involved
treatment of esophageal diverticulums
SURGERY
- zenker: cricopharyngeal myotomy
- epiphrenic: esophageomyotomy
NON-SURGIAL IF CI
1. botox + PPI
what is achalasia?
motility disorder of the esophagus due to inadequate relaxation of LES and destruction of inhibitory neurons causing loss of peristalsis
ethiology of secondary achalasia
- esophageal cancer
- gastric cancer
- chagas disease
- amyloidosis
- neurofibromatosis type 1
- sarcoidosis
achalasia treatment
- pneumatic dilation with ballon in LES
- LES myotomy (HELLER)
- if CI surgery then botox and CCB
esophageal injuries
- fistula
- esophageal web
- diverticulum
- mallory-wess
- varices
- achalasia
- barret esophagus
- GERD
- perforation
boerhaave syndrom?
spontaneous rupture of the esophagus. can be seen in mallory-wess syndrom
treatment of esophageal rupture
- stabilization: IV fluids, electrolytes, AB
2. surgery: suture, muscle or pleural flap, fundoplication, resection, delayed reconstruction
location of peptic ulcers
stomach and duodenum
difference between erosion and ulcer?
ulcer involves more the the muscularis mucosa
surgical treatment for peptic ulcers
- vagotomy
2. partial gastrectomy (billroth)
types of partial gastrectomy - Billroth I
Billroth I
distal gastrectomy with end-end or side-end gastroduodenostomy by removing gastric atrum and pyloris and the duodedal loop is freed from the peritoneum and sutured together
types of partial gastrectomy - Billrot II
lower 2/3 of stomach is removed and the duodenum is left with a stump end. The remaining stomach is sutured to jejunum - gastrojejunostomy in a side-side manner (prevents bile to enter stomach)
total gastrectomy with Roux-en-Y anastomosis?
remove stomach except cardia and funcus. cut dudenum and leave stump end, other end is sutured to lower down jejunum in a end-side manner. The upper jejunum is sutured to stomach in a side-side manner
Virchow’s node
An enlargement of a supraventricular lymphnode can be the first sign of gastric cancer due to the association between left supraclavicular lymphadenopathy and gastric cancer.
paraneoplastic signs of gastric cancer
seborrheic keratosis
acanthosis nigricans
thromboplebitis migricans
drug in HER2 positive gastric cancer?
traztuzumab
drug treatment with TK inhibitor is GIST?
imitinib or dasatinib
surgucal treatment of GIST?
tumor < 2cm - drugs and observe
tumors > 2cm surgical excision + drugs
gastric tumors?
adenocarcinoma GIST MALT neuroendocrine tumor sarcoma
post gastrectomy complications
malnutrition
dumping syndrom (early/late)
reoccurance of cancer
what i early dumping syndrom?
premature gastric emptying with early symptomes (10 min) causes water do be pushed fro blood into bowel to dilute causing distention of bowel. Hypotention bloted cramps diarrhea
what is late dumping syndrom?
premature gastric emtying with late symptomes (1h). Increased sugar absorption trigger increased insulin release causing hyperglycemic induced hypoglycemia
Murphy sign
Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.
CI for cholecystectomy?
- hemodynamic unstable
- respiratory unstable
- history of extensive abdominal surgery
- cirrhosis
- portal HTN
- extreme obesity
- acute phase cholangitis
what is MRCP and ERCP (bile)
Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction. The use of MRCP, a non-invasive procedure, may prevent the use of unnecessary invasive procedures.
labfindings in cholelithiasis?
Normal
Lab findings in choledocolithiasis?
- high bilirubin
- high GGT
- high ALP
- high ASAT, ALAT
Lab findings in cholecystitis
fever
high CRP
high WBC
benign liver tumors
- cavernous hemangiomas
- focal nodular hyperplasia
- hepatic adenomas
which benign liver tumor should you not take a biopsy from?
hemangiomas due to bleeding risk
what does the pancreas do?
enocrine hormones
exocrine digestive enzymes
etiology of acute pancreatitis? I GET SMASHED
Idiopathic Gallstones Ethanol Trauma Scorpion sting Mumps Autoimmune Steroids Hyper TG an Ca ERCP Drugs
what are the three things happening in pancreas under Acute pancreatitis? and what is the result?
liquification
hemorrhage
Digestion
causes Liquifactive hemorrhagic necrosis
external signs of acute pancreatitis?
Grey turner sign (hip) Cullen sign (periumbilical)
complication in acute pancreatitis?
- Psaudocyst which can either rupture releasing enzymes causing massive inflammation or become infected by e.coli cuasing abcess
- bleedign due to destruction of vessle causing hypovolemic shock
- ARDS
surgical treatment of acute pancreatitis?
urgent ERCP, spinchterotomy in choledocolithiasis or cholangitis followed by cholecystectomy
cholecystokinin test or secretin test or both together
cerulin or secretin given to patien IV and a tube in duodenum measures secretion of bicarbonate and pancreatic enzymes, low levels proves pancreatin insufficiancy
surgical treatment of chronic pancreatitis and why do we want to operate?
surgery is the most effective long term treatment of pain
- psaudocyst drainage
- endoscopic stent therapy if obstruction
- ERCP
- whippel procedure
courvosier sign?
enlarged non-tender gallbladder indicates pancreatic malignancy
Trousseau sign
superficial palpable thrombophlebitis ass. with pancreatic tumors
Lab markers for pancreatic cancer?
CEA
CA 19-9
Imaging of choice in pancreatic cancer
abdominal contrast CT
treatment of pancreatic cancer?
surgery is only curative treatment but can only be done if no metastasis
types of surgery in pancreatic cancer?
if tumor is in head: Whippel (pancreas, duodenum and gallbladder removed
if in body or tail: Traverso-longmire (spleen, pancreas and some times duodenum is removed)
whats a hemorrhage? when do they become pathological?
normal physiological structures acting as cushions for feces when passing through the rectum. They become pathological when they get swollen
what divides the rectum from the anus?
Pectinate or dentate line
classification of internal hemorrhoids
- no protrusion outside
- protrude but retracts when pressure decrease
- prolapsed - protrude without retraction but can be pushed in manually
- . prolapsed - protrude without retraction but can NOT be pushed in manually
hemorrhoid complications?
anemia due to bleeding
spinchter spasms causing strangulation and necrosis
thrombotic hernia
classification of hemorrhoids based on location?
In respect to the dentate line
- internal
- external
- mixed
CT disorders causing hemorrhoids?
Ehlers-Danlos
Scleroderma
Location dependent pain in hemorroids?
external are somatically innervated so they are painfull but external may be painless even though they bleed
diagnosing hemorrhoids?
PDE
anoscopy
sigmoidoscopy
barium enema to exclude malignancy
treatment of hemorrhoids grade I-II
lifestyle diet analgestics topical agents stool softeners sitz bath antispasmodic agents
hemorrhoid treatment grade III
Rubber band ligation
Sclerotherapy
infrared coagulation
Hemorrhoid treatment grade IV
other treatmets have been trie but does not work then we do surgery
1. subcutaneous hemorrhoidectomy
(closed - Ferguson/open - Millian-Morgan)
2. Staple hemorrhoidopexy
parts of a staple hemorrhagiopexy?
anal dilator
optorator
sutures
stapler
complications of internal hemorrhoids?
prolaps and accumulatin of mucus and fecal debris in external anal tissue - local irritation and inflammation
ecternal hemorrhagic complication
thrombosis of the hemorr. causing necrosis of overlying skin and bleeding
anal abcess
mostly due to obstruction of the anal glands by debris causing puss filled cavity that most commonly is due to bacteria accumulation and infection in a anal crypt.
anal abcess classification
perianal
Ischiorectal
intersphincteric
supralevator
anal fistular classification
intersphincter
transsphincter
suprasphincter
extrasphincter
what is a anal fistula
connection between an abcess and the anal canal or the abcess to the perianal skin
treatment of anal fistulas
- fistulotomy (most common)
- seton placement (like a rubber silicon band)
- fistula plug
types of abdominal hernias
- groin
- ventral
- pelvic
- flank
types of groin hernias?
inguinal (direct(indirect)
femoral
location of a direct inguinal hernia?
hasselback triangle
ventral henias?
true umbilical peroumbilical epigastric spielian (linneasemilunaris) inscisional
classification of hernia nature?
- reducable - can be pushed in
- incarcerated - cannot be reduced back, risk of infection is higher
- strangulated - starts as incarserated, no bloodsupply
differential diagnosis of hernia
hydrocele varicocele lipoma lymphadenopathy tumor cyst
hernial surgery basic classification?
- open surgery or laporascopic
2. transperitoneal/preperitoneal
types of hernia surrgery?
herniorraphy
hernioplasty
placement of mesh in herniaplasty?
- onlay repair - subcutneous
- inlay repair - between edges of fascia as bridge gap
- sublay repair - before peritoneum
usually we use hernioplasty with mesh what is the CI and what do we use then?
CI if there is an ongoing infection or necrosis of hernia tissue. then we do a herniorraphy surgery
laparoscopic procedure in hernia name?
transabdominal preperitoneal (TAPP) total extraperitoneal (TEP)
umbilical repair of hernia name?
Mayo repair if < 4cm (double suture)
Mesh closure if < 4cm
mechanical wounds
inscision laceration abrasion puncture penetrating animal bite gunshot
N-block removal means?
removal of the tumor and the organs it is involved with
markers for bacterial peritonitis with bowel perforation
high ALP and CEA
marker for pancreatitis induced peritonitis?
high Amylase
what is the most frequent cause of primary peritonitis?
liver cirrhosis with acitis
types of appenticitis?
mucous
Phlegmous
necrotic
ethiology of appendicitis?
lymphoid proliferation
fecalith
neoplasm
paracite
appendicitis tests?
Hamburg - if no loss of appetite then no appendicitis
Blumsburg - rebound tenderness
rosving - contralateral side palpitation increase pain
psoas - flextion pain
adductor flexion pain
Alvarao score i apendicitis
MANTREL-N
Migrating of pain Anorexia Nausea vomiting Tenderness in RLQ Rebound tenderness Temprature > 38.5 Leukocytosis Neutropenia
why is pancreatic transplant so complicated
due to 10 anastomosis sites vs kidney that have 3
when do we remove sutures?
5 days normally
2 weeks for transplant
complications post cholecyctectomy?
bile leakage
jaundice
Anatomical landmark in cholecystectomy?
Calot triangle
transplant when malignancy?
5 years after remission and no metastasis
gold standar for liver staging?
MRI because cholangio cancinoma shows better in this imaging method so must be done
child pugh score?
liver staging billirubin albumin prothrombin time encephalopaty
liver resection rules
20-35% must be healthy (over 35 if fatty liver)
ALPPS PROCEDURE
we want to get hepatotrophy before resection, sp ve ligate portal vein and after 9 days there should be around 10% increase in mass. ligation on side of tumor so health side grows
