True Learn Flashcards
Indications for Surgery
UC Elective
1) Failure of Medical Management
2) Complications/side effects of meds
3) dysplasia
4) Invasive Cancer
5) Extraintestinal manifestations
6) Growth retardation
Indications for Surgery
UC Emergent
1) Toxic Megacolon
2) Sepsis/fulminant colitis
3) Perforation
4) Hemorrhage
Indication for Drainage
Pancreatic Pseudocyst
1) Persistence >6 weeks
2) Enlarging size
3) infection
4) Symptomatic
Indication for Surgery
Distal Pancreatectomy
1) MCN
a) Symptomatic
b) Asymptomatic > 3 cm
c) Solid component
d) Enlarged Duct
2) Pancreatic Neuroendocrine tumors
3) Poorly differentiated solid mass
4) Adenocarcinoma of Pancreatic tail without mets
5) Symptomatic SCN
6) Chronic Pancreatitis or Pseudocyst of only tail
7) Grade III and some grade IV trauma
** Preservation of Spleen only in benign disease or trauma**
Indications for Surgery
Type B Aortic Dissection
1) impending/actual rupture
2) Sx related to dissection ( CHF, Angina, Aortic Regurgitation, Stroke, Pain)
3) Malperfusion
4) Aneurysm >6.5 cm OR expansion >1cm/year
RELATIVE Indications for Carotid Stenting
1) Severe cardiac risk
2) Previous LATERAL neck surgery/Radiation
3) Extremely proximal/distal plaques
4) Tortuous Vessel Anatomy
5) Contralateral nerve palsy
Diagnosis B/l absence of iris Intellectual disability Hypospadia, cryptochordism OR Streak ovaries Del short arm chromosome 11
WAGR Syndrome Wilms Tumor Anidiridia Genitourinary Malformations Retardation
Non-Hodgkin’s Lymphoma Staging
I- confined to GI tract (single or multiple) II (tumors below diaphragm) IIE- through serosa II1- local LN involvement II2- distant LN involvment III- Supradiaphragmatic disease
Type I Endoleak
Failure of seal proximally (Ia) ir distally (Ib)
TREAT ALL
Balloon, stent proximally and distally
Type II Endoleak
Filling of sac by lumbar branches or IMA
TX if size increasing
(Embolization, sac puncture (thoracolumbar approach), lap/open ligation of feeding vessels
Type III Endoleak
failure of graft to seal with itself (component to component leaks)
TREAT ALL: replace components
Type IV Endoleak
Leak through porous graft (self-limited with reversal of AC)
Type V Endoleak
sac leaks fuck knows why
Evidence of fistula with 2 openings and single tract
Poss. Horseshoe fistula
Tx: Hanley’s Procedure (Post aspect incised, anterior aspect incised with secondary incision and penrose drain)
Diagnostic Criteria
Hepatorenal Syndrome
1) Cirrhosis and Ascites
2) Cr >1.5
3) No improvement in serum Cr despite 2 days diuretic abstinence and albumin 1g/kg
4) Absence of shock
5) No nephrotoxic drugs
6) Absence of parenchymal disease
Pathophysiologic Mechanism
Hepatorenal Syndrome
splanchnic vasodilation causes activation of RAAS and SNS and secretion of ADH resulting in renal hypoperfusion.
Treatment
Hepatorenal Syndrome
Liver Transplant
Complications
Laparoscopic Sleeve Gastrectomy
Bleeding
Stenosis
Staple Line Leakage
Complications
Laparoscopic Sleeve Gastrectomy
Gastric Stenosis
TREATMENT
Endoscopic Balloon Dilation
MCC
Anal fissure
Posterior Midline
Constipaton
Other Causes
Anal Fissure
Anterior Midline
Constipation in FEMALES
Other Causes
Anal Fissure
Location OTHER than Posterior Midline
Crohn's Disese TB Syphillis HIV/AIDS Anal Cancer
Cytologic Criteria (In ascitic fluid) Spontaneous Bacterial Peritonitis
2 of the 3 in setting of Pt with appropriate hx and sx
Total protein > 1 g/dl
Glucose <50 mg/dl
LDH > upper limit or normal for serum
Diagnosis
Ascites + “Obstruction of lymphatic vessels at the base of the mesentery”
Chylous Ascites
Pathophysiology
Chylous Ascites
Obstruction of lymphatic vessels at the base of the mesentery or cisterna chylii
Ddx
Chylous Ascites
End Stage Pancreatic Cancer (compresses cysterna chylii)
Congenital lymphangiectasia
Thoracic duct obstrution
Lymph peritoneal fistula
Steroid MOST effective in active Crohn’s Disease
Budesonide
Prednisone used typically
Amount of Endogenous fluid produced by GI tract per day
7 liters
Amount of saliva produced per day
1500cc
Stomach fluid produced per day
1000-2000cc
Amount of bile produced per day
500cc
Pancreatic secretion produced per day
1500cc
Amount of fluid produced by small bowel per day
1500cc
MCC Death in 1st year post cardiac allograft
Allograft vasculopathy
signs of atherosclerosis without calcification
Rutherford Classification + Treatment Sensory Loss: None Motor Loss: None Arterial Doppler: Audible Venous Doppler: Audible
Class I: Limb viable, not immediately threatened
Heparin Drip
CDT possible
Rutherford Classification + Treatment Sensory Loss: None or Minimal (toes) Motor Loss: None Arterial Doppler: Often Inaudible Venous Doppler: Audible
Class IIa: Marginally threatened, salvageable if treated promptly
Heparin Drip
CDT Possible
Rutherford Classification + Treatment Sensory Loss: More than toes, associated with rest pain Motor Loss: Mild or moderate Arterial Doppler: Usually Inaudible Venous Doppler: Audible
Class IIb: Immediately threatened, salvageable with immediate revascularization.
Heparin Drip
Open Thrombectomy
Rutherford Classification + Treatment Sensory Loss: Profound, anesthetic Motor Loss: Profound, paralysis, rigor Arterial Doppler: Inaudible Venous Doppler: Inaudible
Class III: Limb irreversibly damaged, major tissue loss or permanent nerve damage inevitable
Heparin Drip
Open thrombectomy in early presentation
Amputation if late presentation
Access preference (KDOQI) for ESRD on HD
1) Autologous radiocephalic (forearm) AVF
2) Autologous brachiocephalic AVF
3) Transposed Brachiobasilic AVF
4) Upper arm Brachial-cephalic prosthetic graft
Characteristics of working fistulas
Rule of 6’s
1) Bloodflow adequate to support HD (>600ml/min)
2) Diameter greater than 6mm in a location accessible for cannulation and discernible margins for repeated cannulation
3) Depth approximately 6 mm
Relative indications for prosthetic graft vs fistula
1) small basillic vein b/l
2) hx of several central venous catheter infections
3) obesity
Electrolyte abnormalities
Tumor lysis syndrome
HYPOcalcemia (good question answer)
HYPER K, Phos, Uric Acid, Creatinine
AAST Pancreatic Trauma Grade
hematoma with minor contusion/laceration but without duct injury
Grade 1
advance one grade for multiple injuries up to grade III.
AAST Pancreatic Trauma Grade
major contusion/laceration but without duct injury
Grade 2
advance one grade for multiple injuries up to grade III.
AAST Pancreatic Trauma Grade
distal laceration or parenchymal injury with duct injury
Grade 3
advance one grade for multiple injuries up to grade III.
AAST Pancreatic Trauma Grade
proximal (i.e. to the right of superior mesenteric vein) laceration or parenchymal injury with injury to bile duct / ampulla
Grade 4
AAST Pancreatic Trauma Grade
massive disruption to pancreatic head
Grade 5
Indications for Angiography in Blunt Pelvic Trauma
PELVIC FX AND…
1) Hemodynamic instability in a patient with little or no hemoperitoneum by FAST/DPL
2) Requires >4 U RBC in 24 hours
3) Requires >6 U RBC in 48 Hours
4) Large or expanding hematoma identified at celiotomy
5) CT evidence of large retroperitoneal hematoma with extravasation of contrast
6) need for detection and treatment of other injuries during angiography.
Most appropriate 1st step in workup
Postmenopausal vaginal bleeding
Endometrial biopsy (Transvaginal u/s does NOT rule out disease if negative)
3 principles of safe PEG placement
Endoscopic gastric dilation
Endoscopic visual focal finger invagination
Transillumination
RELATIVE Contraindications
PEG Placement
Failure of transillumination
Previous history of GERD
Previous abdominal surgery
Esophageal or oropharyngeal cancer (d/t seeding of PEG tract)
ABSOLUTE Contraindications
PEG Placement
Coagulopathy
Completely obstructing esophageal cancer
Any contraindication to endoscopy
Most common indication for hysterectomy (USA)
symptomatic uterine fibroid
Indications
Hysterectomy
Symptomatic uterine fibroid (MCC) Ovarian Ca Cervical Ca Endometrial Ca Vaginal Bleeding
Intraop Management of volume status
Pheochromocytoma
High Intravascular volume during and immediately after procedure (Pts have low volume at baseline d/t catecholamine excess).
Pts with CHF or elderly may need arterial line +/- PA catheter
Intraop Management of HTN
Pheochromocytoma
Sodium nitroprusside drip
Magnesium IV
Intraop Management of arrythmias
Pheochromocytoma
Short acting beta blockers (esmolol)
Lidocaine
Landmark
Recurrent laryngeal nerve in neck surgery
tubercle of zuckerkandl lies immediately lateral to and covers the RLN.
(can also be medial)
MCC
Liver abscess
ascending infection from portal vein
Most common site of recurrence
Melanoma
Skin
Subcutaneous tissues
distant lymph nodes
Visceral sites
Most common site of recurrence
Melanoma, Visceral
lung liver brain bone GI tract
Indication for collis gastroplasty in nissen fundoplication
if <2-3cm of esophagus is present intra abdominally
Lap stapler is fired parallel to lesser curvature at the level of the cardia to create neo-esophagus
Key elements of Nissen fundoplication
Lap is standard of care
esophageal mobilization
division of short gastrics to create tension free wrap
mandatory crural repair
Most important predictor of survival
Adrenal cancer
adequacy of resection
5 year survival with adequate resection is 50%
with inadequate resection median survival is less than one year
CT findings suggestive of adrenal ca
Size >6cm tumor heterogeneity irregular margins presence of hemorrhage adjacent lymphadenopathy liver mets
Location of placement for end colostomy
through rectus, at summit of infraumbilical fan fold
Location of mesh
Chevel’s Repair
Ventral hernia
Between anterior rectus sheath and subcutaneous layer
Soap bubble sign
Meconium ileus, seen in RLQ.
Ascites with “scalloping” of solid organs and calcifications of peritoneum
pseudomyxoma peritonei
Management
Penetrating trauma MEDIAL to lateral canthus of eye
some loss of sensation
Irrigation, debridement, primary closure in multiple layers.
Nerve exploration/repair NOT indicated
Management
Penetrating trauma LATERAL to lateral canthus of eye
some loss of sensation
Irrigation, debridement, primary closure in multiple layers.
NERVE EXPLORATION/REPAIR IS INDICATED
Operative technique
Exposure of SMA for embolectomy
anterior approach, base of transverse mesocolon
Operative technique
exposure of SMA for bypass
lateral approach with formal mobilization of duodenum or ligament of treitz
Preferred site of SMA bypass
R common iliac
(second choices L common iliac, infrarenal aorta)
supraceliac aorta can be used if retrograde disease
Methods of documenting parathyroid allograft function
normocalcemia
measuring AC vein PTH concentration
“transient parathyroidectomy” tourniquet on one arm, measure other arm.
Most common presentation of gallbladder cancer if symptomatic
abdominal pain (biliary colic/cholecystitis presentation)
Early complications
Gastric banding
acute stomal obstruction band infection gastric perforation hemorrhage bronchopneumonia delayed gastric emptying PE
Late complications
Gastric banding
Band erosion band slippage/prolapse port or tubing malfunction leakage at port site tubing or band pouch or esophageal dilation esophagitis
Malignant hyperthermia mutation
RYR1 (ryanodine receptor gene)
AD
incidence of marginal ulcers
s/p gastric bypass
3-15%
incidence of bowel obstruction
s/p gastric bypass
7%
incidence of DVT/PE
s/p gastric bypass
0.33%
Incidence of devastating anastomotic leak
s/p gastric bypass
0.3%
Incidence of anastomotic stenosis
s/p gastric bypass
1-19%
What the magnet does to pacemaker/ICD
turns off defibrillator
resets pacemaker to factory settings (demand mode at a fixed rate)
most common site of recurrence
Colon cancer s/p surgical removal
liver
80% in first 2 years
90% in first 4 years
Puestow procedure
Longitudinal pancreaticojejunostomy
Frey procedure
Coming out of the pancreatic head and roux en y pancreaticojej
Type I gastric ulcer
Angularis incisura of lesser curvature
Normal/low acid
Type II gastric ulcer
Stomach and duodenal ulcers
Associated with acid (may be normal)
Type III Gastric ulcer
Prepyloric
Normal or HIGH acid
Type iv gastric ulcer
GE junction
Acid normal or low
Ligaments divided in extended left hemi
Renocolic
Splenocolic
Pancreaticocolic
Gastrocolic
Firm flesh colored plaques
Fingerlike projections of spindle cells
Fermatofibrosarcoma protuberans
Trace mineral deficiencies
Pancytopenia
Neuropathy with ataxia
Copper
Trace mineral deficiencies
Hyperglycemia confusion peripheral neuropathy
Chromium
Trace mineral deficiencies
Pellagra with diarrhea dementia, dermatitis
Niacin B3
Trace mineral deficiencies
Cardiomyopathy
Hypothyroidism
Neurological changes
Selenium
Trace mineral deficiency
Poor wound healing
Wasting
Skin rash
Zinc
Correct procedure
Carotid Trauma lateral tear
Lateral arteriorrhaphy with 6-0 polypropylene interupted
Correct procedure
Carotid Trauma loss of wall or large defect
Patch angioplasty with saphenous vein thin walled ptfe or bovine pericardium
Correct procedure
Carotid Trauma through and through
Segmental resection and end to end anastomosis or interposition graft with saphenous vein or ptfe
Large abdominal bulge hernia sx WITHOUT fascial defect
Diastasis recti
Contraindications
Saphenous vein stripping
Outflow obstruction of deep system where saphenous is the only outflow
I.e. occlusion of superficial femoral vein
Largest risk factor
Post op cardiac complications
Uncompensated CHF
Not CAD
Indications
ICP monitoring
Postrecussitative GCS 40
Any hx of hypotension
Abnormal motor posturing
Indications for Surgery
Transanal resection of malignant Tumor
<3 cm in size <30% of the circumference of bowel Within 8 cm of the anal verge T1 only Mobile nonfixed Tumor Well to moderately differentiated No lymphovascular or perineural invasion No LAD on imaging Margin clear > 3 mm
Distal Gastrectomy
D1.5
extended lymphadenectomy (D1: 1, 3, 4sb, 4d, 5, 6, 7 PLUS 8a, 9)
Omentectomy
Preservation of spleen and pancreas
Free water deficit
(Serum Na -140)/140 * tbw
Tbw = 0.6bw male 0.5bw female
Indications for Surgery
BKA
Non salvageable lower extremity infection
Chronic non healing le wounds
Acute lower extremity infection
Trauma with vascular or neurological injury
Open tibia fx with post tibial n distruption
Warm ischemia > 6 hours
