Surgery

Question 1

What do you do if someone had MI and needs surgery? If they have CHF?

Answer 1

MI - wait 6 mo then do stress test

CHF - optimize w/ beta blockers, ACE and spironolactone

Question 2

Revised Cardiac Risk Index

Answer 2

• Hx ischemic heart disease
• Hx CHF
• Hx CVD (stroke or TIA)
• CKD (cr > 2)
• Hx DM on insulin
• Suprainguinal vascular, intraperitoneal or intrathoracic surgery

If 2 or more … perioperative beta blockers

Question 3

ASA Classification

Answer 3

1 - healthy

2 - Mild systemic disease

3- severe systemic disease

4 - severe systemic disease + constant threat to life

5 - not expected to survive without operation

6 - brain-dead for organ removal

** If greater than 3 - do pre-operative assessment if elective and medication optimization if emergent

Question 4

SIRS Criteria

Answer 4

Temp < 36 C or > 38 C

WBC < 4000 or > 12000

HR > 90

RR > 20 or PCO2 < 32

If 2+ criteria then SIRS

Question 5

Splenic Rupture Mgt by Grade

Answer 5

Grade I - subcapsular < 10% SA
Grade II - subcapsular 10-50% SA
Grade III - subcapsular > 50% SA or expanding
Grade IV - involves segmental or hilar vessels
Grade V - shattered spleen

If grade I - III … supportive care, monitor HgB

If grade IV or V … ex lap

Question 6

Tx of Ischemic Colitis v. Acute Mesenteric Ischemia v. Chronic Mesenteric Ischemia

Answer 6

Colitis - IV normal saline + abx if fever

AMI - emergency lap to remove necrotic bowel

CMI - angiography - stenting/bypass

Question 7

Median Arcuate Ligament Syndrome

Answer 7

External compress of the celiac trunk by the MAL

Present with postprandial pain, nausea and wt loss

Do duplex US - see dec flow thru celiac artery

Tx - surgical decompression of the celiac artery

Question 8

Most common location of Boerhaave v. Mallory Weiss Tear

Answer 8

B - posterolateral aspect of the distal esophagus (FULL THICKNESS TEAR)

MW - GE junction (mucosal only)

Question 9

Diagnostic Imaging in Diverticulitis

Answer 9

CT scan because NO SCOPES (risk perforation)

Question 10

Fever, ab pain and bilious ascites after a GB removal

Answer 10

BILE LEAK

Do HIDA scan to diagnose

If large loculated collections then drain percutaneously, otherwise ERCP with stenting

Question 11

Mgt of Sphincter of Oddi Dysfunction by Type

Answer 11

1 - biliary pain + abnormal LFTs + dilated CBD (endoscopic sphincterotomy right away)

2 - biliary pain + abnormal LFTS OR dilated CBD (manometry first, followed by sphincterotomy)

3 - biliary pain + dilated CBD but NORMAL LFTs (medical mgt without sphincterotomy)

Question 12

What is the most common organism in pyogenic liver abscess? What should you think of if Klebsiella?

Answer 12

Most common - gram neg enteric bacteria (because caused by seeding from inflammatory GI process)

Klebsiella associated w/ colon cancer - do colonoscopy

Question 13

Indications for Removing GB Polyps

Answer 13

Asymptomatic but > 10 mm

Symptomatic at any size

Question 14

Mgt of Anal Fissures

Answer 14

< 8 wks - conservative (sitz bath, fiber, stool softeners, topical vasodilators)

> 8 wks - lateral internal sphincterotomy, if older or multiparous (inc risk fecal incontinence) also do botulinum injection

Question 15

Tx of Trigger Finger

Answer 15

Steroid injection

Question 16

Indications for Knee Replacement in OA (3)

Answer 16

Difficulty Walking

Inability to perform ADLs

Bone on bone disease on Xray

Question 17

Hiradenitis Suppurativa

Answer 17

Occluded apocrine glands and hair follicles

Chronic, recurrent cutaneous nodules and draining sinus tracts

Axilla and inguinal areas most common

Tx - smoking cessation, wt loss, keep areas clean, topical antibiotics

May later try short course tetracycline or TNF-alpha inhibitors or surgery

Question 18

Which urethral abnormality is associated w/ bladder exstrophy and urinary incontinence?

Answer 18

Epispadias (on dorsal surface)

Requires surgical correction

Question 19

Mgt of Priapism

Answer 19

Aspirate blood from corpora cavernosum

If black, hypoxic, hypercarbic … ischemic priapism (due to decreased venous outflow) –> intracavernosal phenylephrine injection and drainage of blood

If red, normal oxygen and CO2 … non-ischemic priapism (fistula between cavernosal artery and corporal tissue) ==> monitor

Question 20

AAA Monitoring Guidelines

Answer 20

US q 2-3 yrs if 3-4 cm

US q 6-12 months if 4-5.4 cm

Surgery if > 5.5 cm

Question 21

Indications for Bariatric Surgery

Answer 21

BMI > 40 without comorbidity

BMI > 35 with at least one serious comorbidity (DM, fatty liver, HTN)

Must r/o untreated depression, psychosis or eating disorder

Question 22

3 Types of Thoracic Outlet Syndrome + Mgt of Each

Answer 22

Neurogenic - MOST COMMON, pain/weakness/thenar atrophy (can observe w/ PT, surgical decompression only if disabling sx)

Venous - swelling, pain, cyanosis of arm (surgical decompression)

Arterial - pain, cold, pallor of arm (surgical decompression)

Question 23

Which hernia is most common?

Indirect v. Direct Inguinal

Answer 23

Indirect = most common in men and women

Direct - medical to inf epigastric vessels so in H triangle

Indirect - lateral to inf epigastric vessels, thru internal inguinal ring

Question 24

Why do you get urine leak after kidney transplant?

Answer 24

Poor blood supply to distal ureter

Question 25

Post-Op Fever by Timing

Answer 25

Wind, Water, Walking, Wound, Weird

POD 1-2 - atelectasis or pneumonia, get CXR and sputum cx

POD 3-5 - UTI

POD 5-7 - PE/DVT

POD 7 - wound infection, cellulitis, look for pus at site, I&D with antibiotics

POD 8-15 drug fever or deeper wound, do CT of wound +/- drainage

Question 26

Which meds need to be discontinued prior to surgery? (9)

What about dialysis?

What about smoking?

Answer 26

Anti-coagulation

ASA (unless CABG or cardiac patient)

Diuretics (hold day of)

Statins (hold day of)

Oral hypoglycemics (stop 3 days before)

No short acting insulin on day of / half bolus dose

Estrogen (stop weeks before due to DVT risk)

NSAIDs (7 days before)

All immunomodulators stopped 2 weeks before unless transplant patient (they cont all except sirolimus because poor wound healing)

STOP smoking 6-8 wks before (check PFTs for vital capacities)

Dialysis 24 hrs before surgery

Question 27

Who needs stress dose steroids for surgery?

Answer 27

Anyone on steroids > 3 wks

Question 28

Early v. Late Dumping Syndrome

Answer 28

Early - hypotension because hyperosmolar food pulls fluid into lumen

Late - (several months after surgery) hypoglycemia, dizziness, fatigue, weakness, diaphoresis esp after high carb means, too much insulin because do not absorb all carbs

Tx - small frequent meals, no liquids for 30 min after meals, octreotide for late (slow motility)

Question 29

Ab X-ray Findings in …

Post-operative ileus

Bowel obstruction

GI Perforation

Acute Mesenteric Ischemia

Answer 29

Post- op ileus - air fluid levels (but no transition point on CT)

Bowel Obstruction - air fluid levels with dilated loops (transition point on CT)

GI perforation - free air under diaphragm

Acute mesenteric ischemia - air in the bowel wall

Question 30

Indications for Mitral Valve Repair (in MR)

Indications for Aortic Valve Replacement (in AS)

Answer 30

Mitral - EF 30-60% or if EF < 30% but highly likely to be successful

Aortic - Severe AS (jet acceleration 4 m/s OR pressure gradient > 40) + one of the following …

• symptoms (syncope, chest pain)
• EF < 50%
• undergoing another heart procedure (CABG)