Surgery Treatments Flashcards
Cancer of the tongue
Partial glossectomy +
supraomohyoid dissection (N0) MRND (N+)
With mandibular involvement: composite resection (Partial glossectomy + floor of the mouth and mandibulectomy)
Cancer of the base of the tongue
Early: Surgery + RT + BND
Advanced: Total resection with or without laryngectomy
Cancer of the alveolus of gingiva
Resection of the tumor plus
marginal mandibular resection or segmental mandibular resection plus
ipsilateral supraomohyoid dissection (N0)
MRND (N+)
Cancer of the larynx (Supraglottic / Glottic)
Early lesion: RT
Advanced: Surgery plus RT
Cancer of the larynx (Subglottic)
total laryngectomy plus neck dissection regardless of status
Benign epithelial and non epithelial salivary gland tumor like Pleomorphic adenoma
Surgical excision
Parotid: superficial parotidectomy with facial nerve presevation
Enucleation is not recommended
Mucoepidermoid Cancer of the parotid gland
Lateral lobe: Superficial parotidectomy with facial nerve preservation
Deep lobe: Total parotidectomy with facial nerve preservation
Nerve sacrifice: if encased by tumor and non functional preoperatively
Mucoepidermoid cancer of the submandibular gland
En bloc resection of the gland and submental and submandibular LN
MRND (N+)
Graves disease drugs given prior to surgery
Lugol’s solution: Decrease vascularity of thyroid thus decreased risk for thyroid storm
PTU, Methimazole
What is the Hartley-Dunhill or subtotal thyroidectomy procedure?
total lobectomy, isthmusectomy, and subtotal thyroidectomy on the other side.
Toxic adenoma
Unilateral lobectomy and isthmusectomy
Thyroid storm
beta blockers, oxygen supplementation, hemodynamic support, PTU, Lugol’s iodine, and ipodate
Corticosteroids
non-aspirin compounds
Acute suppurative thyroiditis (Preceeded by URTI in children)
Parenteral antibiotics
Drainage of abscess
Subacute thyroiditis (Painful type) - preceeded by URTI
Symptomatic
Short term thyroid hormone replacement
Thyroidectomy reserved for medical failure
Subacute thyroiditis (Painless type) - autoimmune in origin
Short term thyroid replacement
Chronic thyroiditis (Hashimoto’s / Lymphocytic thyroiditis)
Thyroid hormone replacement
Surgery only when CA is suspected
Reidel’s thyroiditis (Invasive fibrous thyroiditis)
Wedge excision of the thyroid isthmus
L-thyroxine
Steroids
Solitary Thyroid nodule investigation pathway
- TSH test (IF thyrotoxic -> Scan for either hot [Radioactive iodine or surgery] or cold)
- FNAB
Either:
a. Observe for cystic that regresses
b. Thyroid lobectomy for benign or high clinical suspicion
c. Total or partial thyroidectomy for malignant
Simple thyroid cysts when do you do unilateral lobectomy
> 3 attempts, >4 cm, complex cysts
Papillary carcinoma of the thyroid (Orphan Annie nuclei, Psammoma bodies)
TT / NTT
Follicular carcinoma (More common in iodine deficient areas)
Adenoma: lobectomy + Isthmusectomy
Older and > 4cm: TT/ NTT
Hurthle cell carcinoma (subtype of follicular carinoma)
Adenoma: Lobectomy + Isthmusectomy
Carcinoma: TT / NTT + Routine central neck node dissection
Medullary thyroid carcinoma (from the parafollicular cells located at the superolateral lobes of the thyroid gland)
Pheocromocytoma (Treat first)
TT + BCND
Thyroid Lymphoma
CHOP
Cyclophosphamide, doxorubicin, Vincristine, prednisone
Most common injury in thyroid surgery
Parathyroid injury
Most common location of ectopic parathyroids
Paraesophageal
Clinical manifestation of primary hyperparathyroidism
Kidney stones Painful bones abdominal groans Psychic moans Fatigue overtones
Parathyroid
adenoma: Resection
Hyperplasia: 3 1/2 Parathyroidectomy or total parathyroidectomy + Autotransplantation
Carcinoma: en bloc resection + Ipsilateral thyroid lobe
Preoperative localization test for parathyroid adenoma
Sestamibi
Secondary or tertiary hyperparathyroidism
3 1/2 parathyroidectomy or total parathyroidectomy + autotransplantation
Values of a defective LES
mean resting pressure <1 cm most common)
GERD
12 week antacid or PPI
Antireflux procedure: Nissel fundoplication
Diaphragmatic (Hiatal Hernia) Types
- sliding - upward disclocation of the cardia (Most common)
- rolling / paraesophageal - upward dislocation of the fundus
- mixed
- additional organ herniates
Borchardt’s triad
Chest pain, retching with inability to vomit, and inability to pass an NGT
Diaphragmatic hernia treatment (Type II)
Asymptomatic: Observation
Symptomatic: Elective reduction surgery with repair of diaphragmatic defect +/- fundoplication
Zenker’s diverticula (Found in the Killian triangle situated behind the esophagus at the level of the cricopharyngeus muscle)
2cm: diverticulectomy or diverticulopexy
Gold standard test for achalasia
Manometry
Treatment for achalasia
Heller’s myotomy + Partial fundoplication
Most common primary esophageal motility disorder
Nutcracker esophagus
Phases of caustic injury
Acute necrotic phase (1-3 days)
Ulceration and granulation phase (3-5 days)
Cicatrization and scarring phase (3rd week)
Esophageal carcinoma
Trans-thoracid esophagectomy, trans-hiatal esophagectomy
Ivor Lewis procedure
Mallory weiss tear
Non-operative
Gastric outlet obstruction which presents as nonbillous vomiting leading to profound hypokalemic, hypochloremic, metabolic alkalosis
NPO, NGT, IVF, Acid suppression
Gastric Ulcer types
- Antral lesser curvature
- Antral plus duodenal
- Pre-pyloric
- High in lesser curvature
- NSAID
Bleeding peptic Ulcer
- Oversew
2. V&D or A (D) or Distal Gastrectomy (G)
Perforated peptic ulcer
- Patch Graham’s procedure (Both) + BX or wedge resection (G)
- HSV or V&D or A (D) or Distal Gastrectomy (G)
Dumping syndrome - due to the destruction of the pyloric sphincter causing abrupt delivery of hyperosmolar load to the small intestines
Dietary: avoidance of liquids during meals & High fiber diet
Medical: Octreotide for early dumping, alpha glucosidase inhibitor for late
Surgical: Conversion to Roux-en-Y anastomosis
Passaro’s triangle
Head of the pancreas
Junction of the hepatic and cystic duct
junction of the 2nd and 3rd portion of the duodenum
Gastric adenocarcinoma
Endoscopic mucosal resection for tumors <2cm limited to the mucosa or submucosa
The rest: resection of all tumor (R0) with 5cm grossly negative margins with enbloc removal of adjacent LN and involved organs.
Standard operation: Radical subtotal gastrectomy
Gold standard for the diagnostic evaluation of gastric adenocarcinoma
upper endoscopy and biopsy
Low grade vs High grade Gastric MALT lymphoma
Low grade: H. pylori eradication
High grade: Chemo and or radical subtotal gastrectomy
GIST tumor marker
c-KIT and CD34
Gastrointestinal Stromal Tumor
Wedge resection with negative margins
for unresectable: Imatinib
Appendicitis Stages
- Congestion
- Suppurative
- Gangrene
- Rupture
GI carcinoid of the appendix that will warrant a right hemicolectomy
Between 1-2 cm located at the base (mesoappendiceal invasion)
> 2cm will also warrant a right hemicolectomy
Adenocarcinoma of the appendix
Right hemicolectomy
Sigmoid volvulus
Soft rectal tube for decompression
Resection with primary anastomosis (prepped bowel)
Resection of the sigmoid colon with construction of a colostomy Hartman’s pouch for emergent operation
Acute diverticulitis
Uncomplicated: clear liquid diet and broad spectrum antibiotics
Generalized peritonitis: Urgent celiotomy
Diverticulitis with abscess: Drainage
Diverticulitis with fistula: Antibiotics, TPN, bowel rest, excision of diseased colon
Rectal prolapse
Low anterior resection
retrorectal sacral fixation
retrorectal sacral rectopexy
Thiersch procedure
Hemorrhoid
1st and 2nd: Medical management
3rd and 4th: Surgery
External hemorrhoid: Excision
Acute variceal bleeding
Vasopressin
Octreotide
Early endoscopy and vericeal ligation
Refractory bleeding: Surgical shunt or TIPS
Budd-Chiari syndrome
Systemic anticoagulation
Pyogenic Liver abscess
Broad spectrum antibiotic
Percutaneous aspiration
Liver hemangioma
Small: enucleation
Large: Resection
Liver adenoma
Resection
Hepatocellular & Cholangiocarcinoma
Resection
Choledochal Cyst Triad (This is due to pancreatic secretions backing up the bile duct)
Right upper quadrant pain, jaundice, mass
Sclerosing cholangitis (Presents as weight loss, fatigue, intermittent jaundice, pruritus, abdominal pain)
Liver Transplantation
