True Learn Absite - 2020 COPY Flashcards
Indications for ppx abx for SBP
GI HMHG, low protein ascites (< 15 g/L), hx of SBP
Tx desmoid tumor
WLE
Tx mesenteric cyst
enucleation
Tx appendicitis
Perforated w/ abscess → drain and tx medically
Perforated w/out abscess → medical management or OR; no consensus
Non-perforated → lap appe
Indications for local excision of rectal cancer
< 3 cm, <30% circ, mobile, no nodes, SM only, no high risk histo
Tx with least incontinence for anal fissue
LATERAL, INTERNAL sphincterotomy
Treatment of anal melanoma
WLE (DO NOT respond to chemo-XRT)
Tx melanoma
resect w/ proper margin, avoid Mohs, resect palpable/SLN+
goal to resect nodes (not stage)
Tx of rectal abscess
supralevator- transrectally
all others- drain to the skin
Tx of HMHD
1-2: sclerotherapy, infrared coag
2-3: rubber band ligation
3-4: HDHD’ectomy (less recurrence), stapled HMHD’pexy (less painful)
HMHD grading
1- bleeding, 2- prolapse w/ spon reduction, 3- prolapse w/ manual reduction, 4- irreducible
condyloma types
acuminatum- HPV ( 6, 11- benign; 16, 18- Ca)
lata- syphilis
Anal verge
Anal margin
Anal canal
Anal verge: separates anal canal/anal margin. hair bearing to non hair-bearing; ext anal sph ends
Anal margin: below anal verge
Anal canal: above anal verge
Tx of High grade AIN/bowen’s disease of anal margin
lifetime surveillance even if tx!; excise if > 3cm, sxatic, atypical
Tx of SqCC of anal margin
tx like SqCC of the skin
Tx SqCC of anal canal
Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC; Recurrence- APR
SqCC equivalents- large cell ker. (SqCC), transitional zone, LCl non-ker, basaloid, mucoepidermoid
Tx Melanome of anal canal
unresponsive to chemo-RT; 5y-S is 20% w/ R0; WLE = APR
Tx of Thrombosed external HMHD
w/in 48h- excision
after 48h- medically manage
Tx of rectal prolapse
rectopexy (presacral facia) + sigmoidectomy if const’n/slow transit
old/sick- perineal
Tx of anal fissure
itz/fiber; chronic- add nitro/dilt; failed medical- lateral internal sphincterotomy
Tx anal incontinence
1st line- fiber/bulking, exercises
refractory- overlapping sphincteroplasty
Tx of Pilonidal cyst
leave open!; midline- longer healing/lower recurrence; off midline- less comps (preferred)
Tx of CBD stone intraop
transcystic/transductal (larger stones) lap bile duct exploration; ERCP if unable
PSC
M; intra/extra hepatic; onion fibrosis; chain of lakes; a/w UC, cholangioca; tx- trx, cholesty., UDCA
PBC
F; intra hepatic; granulomas; +AMA; a/w Sjogren, RA; tx- trx, cholesty., UDCA
Tx for cholangiocarcinoma
Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe; consider neoadj + trx if unresectable
Middle ⅓: hepaticojejunostomy
Lower ⅓: pancreaticoduodenectomy (Whipple)
Strasburg classification of bile duct injuries
A- leak B- ligation of aberrant R hepatic C- transection of aberrant R hepatic D- lateral injury to major duct E- complex injury with complete bile duct transection
Replaced hepatics
R hepatic: posterior to cystic duct; off of SMA
L hepatic: within hepatogastric ligament; off of L gastric; medial to portal triad
CBD exploration techniques
transcystic- small stones or large CD
transductal- large stones or small CD
Leave T-tube- avoid spasm and back pressure that could blow out your stump
Lap chole w/ intraop choledocho
- Saline flush, 2. Glucagon, 3. Lap CBD exploration (TC or TD)
Tx CO poison
1st 100% 02 NRB, then hyperbaric O2 (most effective); intubate if comatose, severe acidosis
Tx thoracic eschar
early intubation then escharotomy along ant. ax lines (b4 CT)
Burn degrees
1D: red without blisters
2D superficial: papi dermis; blisters; most painful; blanches +hair; no surg
2D deep: red/white; ret dermis; mild pain; no blanch; surg if not healed >3w
3D burn: white/waxy; leathery skin; insensate; early surg/graft
4D: fat/muscle/bone; surg
Tx of Hypothermia
Mild- <94: shivering, AMS; tx- passive ext (remove wets, blankets)
Moderate- <89: combative, mydriasis, afib; tx- active ext (warm blankets/air/bath)
Severe-<84/29: long QRS, osborne waves, VFib; coma; tx- active int (warm O2/IVF, bypass/lavage)
Profound-<70: loss of vital signs, cardiac activity, EEG; tx- ACLS, active internal
Tx of freezing
Frostnip: ice crystal on skin; pain, numbness; tx- rewarming
1D frostbite: frozen below skin; numbness/edema; firm plaque; tx- 1-2 wks to heal
2D frostbite: milky white blister; tx- 2-4 wks to heal
3D frostbite: hemorrhagic blister; tx- 3m to heal
4D frostbite: bone; black mummified tissue;
Parkland Formula
4 x TBSA x wt; ½ in 1st 8 hours; modified Brook’s formula: use 2 instead of 4
Rule of 9s
ant/post C/A-18 each; ant/post leg-9 each; ant/pos arm- 4.5 each; H/N- 9; genital-1
Indication for APR
w/in 2cm of anal verge (levators), baseline sphincter dysfxn, recurrent SqCC (s/p Nigro)
Tx GIST
resect ALL (any size) w/ -MICRO margin
Imatinib post op if C-Kit+
neoadj if inoperable
FAP Tx
TAC w/ IRA→ q1y scope post op → polyposis/high grade dysplasia @ stump → proctectomy +/- pouch
Elective UC Tx
TAC w/ IJP; indications- ANY dysplasia, refractory
incontinence is a c/i
Surgery reduces: erythema nodosum, arthritis; no effect on PSC!
Hinchey
1- pericolic abscess, 2- pelvic abscess, 3- purulent, 4- feculent; scope 6-8w post dc
Neoadjuvant therapy related to T stage
esophagus- t1b+, stomach- t2+, colon- t4b, rectum t3+
LN harvest/margin eso stomach colon rectum
eso- 15/7cm
stomach- 15/5cm
colon-12/5 cm
rectum- 12/5 cm
APC gene
chrom5; mc mutation in colon ca; 1st mutn in adenoma to carcinoma; a/w FAP
Lynch Syndrome
DNA mm repair- MLH1, MSH2/6, PMS2
scope @ 25 or 10yrs before relative
any ca → TAC IRA
Infliximab
monoclonal Ab to TNF
use- moderate crohns, recurrent perianal fistula!
Sulfasalazine/5-ASA
COX/LOX inhibitor
suppress inflammation
quiescent crohn’s
Azathioprine/6-MP
inhibit DNA synthesis
immunosuppression by blocking Cyto T and NKC
MEN 2A
RET gene
thyroidectomy b4 5 (age 2 for 2B)
Mucinous cystic neoplasm
malig potential; viscous, “string like”
high CEA, low Amylase
tx- resect
Cystadenoma
serous aspirate
low CEA, low Amylase
tx- resect if sxs
IPMN
high CEA, high amylase
in communication w/ panc duct
main vs. branched
Pseudocyst
low CEA, high amylase
tx- wait 6 weeks then drain or resect
Von Hippel Lindau
VHL gene
upreg. of VEGF
CNS/retinal hemangioblastoma, clear cell RCC, pheo
Li Fraumeni S
breast cancer, soft tissue sarc
Esophagus blood supply
Cervical- inf thyroid
Thoracic- aortic branches
Abd- L gastric/inf phrenic
Heller myotomy margins
5cm proximal, 2cm distal
DeMeester score
pH <4 , changes in position, duration, # of episodes; > 14.7 is positive
Eso dysplasia tx
LGD- scope q6-12m lifetime (even if fundoplication) HGD- ablation + Q3m scope T1a- ablation t1b- esophagectomy *Fundop does not decrease cancer risk
Fundoplications
dor- ant 200
toupet- post 180
belsey/mark IV- transthoracic ant 270
GERD alarm sxs
wt loss, early satiety, blood, dysphagia, odynophagia → EGD
Zenker’s tx
left C incision; cricopharyngeal myotomy + staple channel (large) or diverticulectomy (small)
Tx acute variceal HMHG
octreotide + antibiotics → endoscopic intervention (ligation/sclerotherapy) → TIPS
Transhiatal esophagectomy
C+A incision
gastric conduit supply- R gastroepiploic (off GDA/CHA)
DES tx
CCB (+TCA if chest pain) → botox; surgical management is last resort
Corrected Ca
[0.8 x (4 - patient’s albumin)] + serum Ca level
Metabolic alk
Cl responsive- temporary loss, replaceable
- vomiting
Cl resistant- hormonal, continuous loss
- conn’s, steroids, hyperaldosterone
Serum osmolarity
Osm = 2xNa + Glu/18 + urea/2.8
MC etiology of ESRD leading to kidney trx
- DM, 2. HTN, 3. PCKD
AG
Na - (Cl+Bic)
NaCl = non-AG, metabolic acidosis
Ferritin
storage, intra/extra cellular
low in IDA/high in ACD (2/2 inflammation)
Tumor lysis syndrome
hyperU, K, Ph w/ hypoCa; CaPh crystal—> renal failure + hypoCa
Vit D vs. PTH
Vit D: increase Ca and Ph
PTH: increase Ca and decrease Ph
4-2-1 rule
4 cc/kg/hr for 1st 10 kg, then 2 for 10-20 kg, then 1 for everything above 20
Free water def
.5/.6 x kg x (Na - IdealNa)/(IdealNa)
Sodium def
.5/.6 x kg (Na ideal - Na)
Rectovaginal fistula tx
wait 3-6m; low- endorectal advancement flap; high- abdominal approach
Tx of cervical ca
conization/LEEP for 1a; primary chemoRT, brachytx B4 surg
pelvic/aortic LN’s
Tx of endometrial ca
TAH+BSO, peritoneal w/o (for cytology), LN sampling
TRALI
DONOR Ab attacks recipient WBC
ADP antagonists
clopidogrel, prasugrel, ticagrelor (reversible)
TXA2 antagonist:
ASA (via Cox-1); irreversible
Reversible DTA:
dabigatran
tx VWD
tx- DDAVP (ineffective for t3), cryo
Tx ESRD PLT dysfxn
2/2 uremia; tx w/ desmo; cryo 2nd line; don’t use PLTs → become dysfxn
Consider bridging if
troke/TIA w/in 1 month, mechanical valve, high CHADS-VASC
Acute hemolytic trx reaction
rapid RBC destruction by host IgM/IgG
+direct coomb’s
Amphotericin
antifungal
lipid soluble- penetrates CNS
↑ s/e- hypoK/Mg, hepatotoxic, anemia, arrhythmia
HS reactions
1- IgE mediated; allergic rxn 2- aB mediated rxn 3- immune cx; ex- serum sickness 4- delated; t-cell mediated 5- auto-immune
IF-gamma
NKC, macrophage activation
TGF-B
inhibits T-cell activation
Tx liver lesions
- Hemangioma
- FNH
- Adenoma
- Hemangioma: resect if sxs
- FNH (+kuppfer): resect if sxs
- Adenoma (-kuppfer): <5cm- stop OCP, observe; > 5cm- resect
Functional Liver Remnant
minimum 20% if normal liver; pre-op chemo/some dysfxn = 30%; cirrhosis = 40%
Tx and dx of SBP
3GC abx AND albumin (survival benefits)
dx- ↑ascitic PMN and + culture;
Sorafenib
TK inhibitor; tx of HCC
Tx of liver abscess:
- fungal:
- hydatid cyst:
- amoebic:
- pyogenic
- fungal: perc drain + micafungin (ampho is 2nd line)
- hydatid cyst: albendazole qwks then drain
- amoebic: metronidazole
- pyogenic:
Indications for trx
ALF- INR > 1.5
CLF- MELD >=15, INR > 1.5
Enterohepatic circulation
Liver → P BSalts → hepatocytes → conjugated BS → 80% active ileum absorbed
20% deconjugated by bacteria → passive colon absorbed; 5% out in stool
Maneuvers
Kocher- lateral peritoneal attachment of D2
Maddox- white line from sig to splenic flex
Cattell- continuation of kocher; from D2 to sigmoid
Tx of GB polyps
surg if- any size w/ lithiasis, > 1cm
< 1 cm w/out stones can observe
Tx of pancreatic necrosis
ICU, fluid, pain meds → MRCP (no cholangitis) or ERCP (cholangitis) → delay OR
If evidence of fluid infection (w/out cholangitis): proceed with CT guided drain placement
S/e of trx meds
- Tacro
- Azathioprine
- Mycophenolate
- Sirolimus
- Tacro: neuro sxs (tremor), neph’tox, HTN, alopecia, hyperK, hypoMg, GI sxs
- Azathioprine: marrow suppression, leukopenia, hep’tox, pancreatitis, pulm fibrosis
- Mycophenolate: GI sxs, leukopenia
- Sirolimus: hypterTG, impaired wound healing,
Wt loss/surgery
lap band 50-55
sleeve 55
REY 60
Duo switch 70
Mineral def: Zn Sel Chromium Copper
Zn- wound heal/skin
Sel- cardiomyopathy
Chromium- hyperglycemia
Copper- micro anemia
B1 def:
cardiomyopathy, wernicke’s encephalopathy, p. Neuropathy
T1/2 albumin vs. pre-albumin
Albumin- 20 days, prealbumin- 2 day
N balance
(protein intake/6.25) - (protein in urine + 2); 6.25 = g of N/g of P
2 = insensible loss
Cori cycle
recycling of lactate and pyruvate for gluconeogenesis
provides 40% of glu when starving
Gluconeo precursors
lactate , pyruvate, AA
UE Injuries
supracondylar humerus- brachial a
DRF- median n
ant shoulder disloc’n- ax. n
post shoulder disloc’- ax. a
LE injuries
post hip disloc’n- sciatic n. (peroneal branch)
post knee disloc’n- popliteal a.
Interossei innervation
palmar- ulnar n, adduct
dorsal- ulnar n, abduct
lumbricals- median (1-2)/ulnar (3-4)
Pancreatic mucinous lesions
Pseudocyst- high Am, low CEA, KRAS neg
Serous cystadenoma- low Am, low CEA, KRAS neg
MCN- low Am, high CEA (>200), KRAS pos
IPMN- high Am, high CEA (>200), KRAS pos
Tx pseudocyst/WON
wait 4wks; < 6cm- NTD (unless sxs); >6cm and asx- NTD; > 6cm and sxs- drain
attempt endoscopic 1st; near stomach/duo- cystenterostomy; otherwise REY cystojej
Tx infected pseudocyst
aspirate/gram stain to dx → drainage (internal, external, endoscopic)
Tx Infected panc necrosis
stable- wait 4 weeks, IR retroP drain; unstable- debride
Debride: VARD (video-assist retroP)- utilize retoP drain, DEN (endoscope), open necrosectomy
Infected pancreatic abscess
external drainage
Step up approach
Infected panc necrosis
IR/endo drain → 2nd drain → VARD → lap necrosectomy
Tx Panc fistula:
tx- NPO, TPN x 4-6 wks → ERCP w/ stent → surgery
Blood supply panc:
tail pancreatic branches of splenic a, head- super PD (GDA/celiac), inferior PD (SMA)
Atlanta classifications:
< 4w- acute pancreatic or necrotic collection; > 4w- pseudocyst or WON
Tx Panc divisum
sph’otomy by cutting the minor papilla to enlarge the opening and allow pancreatic enzymes to flow
Acute pancreatitis tx:
NPO + IVF; enteral feeds ASAP ( > TPN); NG or NJ; octreotide not useful
PMN tx
Branched: resect- malig cells, mural nodularity, > 3cm; 1-3cm re-image q6m; <1cm- q1y
Main duct: resect- > 10 mm; 5-9 mm EUS/FNA; < 5mm- surveil
Tx Serous cystic neo/cystadenoma
resect if > 4cm or sxs
Tx mucinous cystic neo
resect all
Puestow
kocherize duo, aspirate duct, split open duct 1-2 cm from duo to > 7 cm, REY panc-jej in 2 layers
Whipple
resect panc head, duo, distal stomach; gastro-jej + panc-jej + hepatico-jej
Tx of pancreatitis masses WON sterile WON infected Pseudocyst: Infected pseudocyst
WON sterile: conservatively
WON infected: step up
Pseudocyst: tx if sxs (infxn, obstruction, pain); 4-6w → internal drain → cystenterostomy
Infected pseudocyst: drainage (internal, external, endoscopic)
Tx Annular pancreas
duodenojejunostomy
Melanoma characteristics:
- mc
- best prog
- AA
- worst prog
- mc: superficial spreading
- best prog: lentigo
- AA: acral
- worst prog: nodular
Tx Actinic keratosis
topic 5FU. Photodynamics, imiquimod, cautery; no margin
Staph species
G+/aerobe/clusters; coag+ → aureus
coag- → epidermidis
Strep species
G+/aerobe/chains;
a hemo- pneumo, viridans
b hemo- GAS(pyo)/GBS(aga)
non hemo- enterococci
Melanoma tx
MIS- 5mm; <1mm- 1cm; 1-2mm- 1-2cm; >2mm- 2cm; SLNBx
SLNBx: if > 1mm or if .75-1 mm w/ ulceration or high risk features w/ clinically negative nodes
BSC tx
SLNBx- only if clinically palpable nodes; tx- WLE w/ .5cm margin
Sarcoma prognosis
GRADE used for staging; more important size/depth, nodal/distal mets, mitosis count
ITP vs. TTP tx
ITP- steroids (only if PLTs < 30k), splenectomy if unresponsive
TTP- plasmaphoresis
Tx TCPenia
<10k if asx; <20k if septic, chemo/rads, RF’s; <50K if elective surgery
Tx splenic echinococcal cyst
sterilize w/ etoh injection → splenectomy; opening could cause anaphylaxis
Splenic vein thrombosis
px- gastric varices w/ normal portal p
tx- ppx splenectomy
Vagotomies
truncal- transect ant/post @ distal eso
HSV- transect @ crow’s ft, preserve laterjet, no drainage
Posterio and anterior vagal trunk branches
Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet
Anterior trunk- hepatic branch, ant laterjet
Tx hiatal hernia
t1- PPI x 8-12w → surg
t2-4- repair all sxatic pts
Duo vs. stomach ulcer
Duo ulcer: pain 2-3h after meal; 90% H. pylori, 10% NSAIDS
Stomach ulcer: pain right after meal; 75% H. pylori, 25% NSAIDS
T3 ulcer: tx
pre-pyloric
antrectomy + Bile1/2 + vagotomy
Gastric CA tx
neo-adj chemo for T2+ or N; proximal- total gastrectomy; distal- partial; 5cm margin; 15 nodes
Barrett’s eso surveillance
no dysplasia- 4 quad every 2 cm q 3-5y
dysplasia 4 quad every 1 cm q 3-6m
Minimum FEV1 for resections
pre-op → FEV1 > 2L- pneumo, >1.5L; post op: >.8 or 40% predicted
SVC syndrome tx
stent, radx, steroids (no chemo/surg)
Chylothorax tx
CT and NPO → 7d: thoracic duct lig
Transudate
protein (pl/se) < .5, LDH (pl/se) < .6 or ⅔ ULN → CHF, pericarditis, cirhosis, nephrotic s
Exudates
protein (pl/se) > .5, LDH (pl/se) > .6 or ⅔ ULN → AI, eso rupture, infxn, malig, pancreatitis, PNM
EBUS accesible nodes:
2, 3, 4, 7, 10, 11, 12; innominate seperates level 3, 4; 7- sub-carinal; 10- R/L hilar
Trx drugs MOA MMF Cyclosporine Azathioprine Tacro Sirolimus
MMF: purine synthesis inhibitor Cyclosporine: calc inhibitor Azathioprine: purine synthesis inhibitor Tacro- calc inhibitor Sirolimus- mTor inhibitor
Post trx lymphoproliferative disorder
B sxs; 2/2 EBV+ B cells; may cause l’oma
tx- reduice IS, rituximab
Bladder ca tx
Ta/T1- no muscle, tx- trans-U resexn + transU BCG/mitoM
T2a- invasive, tx- cystectomy +/- chemo
Cause of stones: CaOx Uric Acid Cysteine CaPh MgAmPh
CaOx- diet Uric Acid- protein Cysteine- AA metab. error CaPh- high pH MgAmPh- urease infxn
Stages of healing:
stasis (1-3d), inflammation (3-20), proliferation (1-6w), remodeling (6w-2y)
Order of cells in healing:
PMNs (24-48h) → macro (48-96h) → lympho (3d) → fibro (10d)
Fibroblasts
dominant cell during proliferation AND remodeling
Inflammatory phase
macrophages are most important (phago + cytokines); PMNs come first
Proliferative phase
neovascularization, collagen syntehsis; mphasges intially but fblasts dominant; HIF-1
Stages of graft healing
imbibition (direct diffusion) → inosculation (cap beds meet) → revascularization
Increased ETCO2
MC hypoventilation, atelectasis; malig hyperthermia, meta acid, hypermetab, pneumo
c/i to epidural
high ICP, therapeutic acoag, AVM, HDUS
SQH- wait 4h; lovenox- wait 24h; ASA is not c/i
Ketamine
not c/i with high ICP!
s/e- HTN, tachy
amnestic + analgesic; no resp depression
Tx Post dural puncture headache
after epidural; tx with blood patch
Tx fat necrosis
no trauma- bx
trauma- watch
Tx Galactocele
dx/tx- aspiration; no tx if asxatic, continue bfeeding
Tx Inflammatory breast ca
neoadj + surg + XRT
SLNBx c/i!
Types of mastectomy
Simple/Total mastectomy: removal of all breast tissue, NAC, most of skin
BCT = partial mastectomy + XRT
MRM: removal of breast parenchyma, NAC, skin, and level 1-2 nodes
LCIS Tx
surv + tamox OR bilateral l’omy; DUCTAL ca; no (-) marg
Tx male breast ca
usually simple mastectomy w/ SLNBx; BCT usually can’t be done b/c not enough tissue
DCIS tx
lumpectomy (2mm) + XRT +/- boost (no SLNBx)
if XRT c/i → mastectomy AND SLNBx
Tx Phyllodes
WLE w/ 1mm margin
Tx Malig BC in preg
1t- MRM
2/3t- lumpectomy, SLN (no blue dye), chemo (6w later),
RT post-delivery
Breast nerves:
TD- LD, ADduct ICB- hypesthesia LPN- p major MPN- p major/minor LTN- SA, wing scap
Breast lesions that require bx
radial scar, any atypia, any invasive ca, vascular proliferations, discordant bx
DCIS SLNBx:
not w/ l’omy unless >4cm, multicentric, palpable, high grade
required w/ mastectomy
Thrombophlebitis (Mondor’s disease) tx
NSAIDS
Intraductal papilloma dx and tx
MCCO bloody nipple dc
dx- contrast ductogram
tx- resection
Mastodynia tx
cyclic 2/2 fibrocyst dz- OCP/NSAIDS
non-cyc + >30 OR cyclic + mass → mammo
Breast abscess tx
US aspiration BEFORE I&D
I&D if refractory
Dobutamine
B1 at low dose- inotropy
B2 at high dose- vasodilation
Milrinone:
intotropy + vasodilate; PDEi→ decreased cAMP → SR Ca uptake
relaxes smooth muscle
Arterial O2 content
(1.34 x Hb x SaO2) + (.003 x PaO2); Hb is most important factor
tx for post pneumo empyema
Eloesser flap
Tx SVT
vagal → adenosine
may unmask” afib/flutter; synch
Car’verison last resort
qSOFA
tachypnea + AMS + SBP
Tx Hypertrophic cardiomyopathy
avoid inotropes; use neo if needed
Management of PE
no RH strain → acoag
RH strain → IR catheter
RH strain + HDUS → systemic tPA
MC nosocomial infection
MC nosocomial ICU infection
MC nosocomial infection- UTI
MC nosocomial ICU infection- VAP
Tx FMD
angio + balloon
Tx acute limb ischemia
Tx: 1- hep gtt
2a- thrombolysis (sensation)
2b- surg (weakness)
3- amputation (paralysis)
Tx RA stenosis
perc translumen angio; ACEi unless 1 kidney/bilateral dz
ACEi for renal HTN: dilate efferent arterial but reduce GFR
DVT tx:
ileofemoral- cather directed thrombolysis; other- anticoagulation
LE arteries:
CF → DF (70%) and SFA (30%); DF → cx, genicular, perforating; SFA → AT (DP), P, PT
TXX Pop aneurysm
: >2cm- ligation and bypass; <2cm- observation; avoid stents
TX for leriche s
bypass
tx venous TOS:
2/2 repetitive exercise; tx- anticoag, thrombolysis → 1st rib/ant scalene resection wks later
Tx Failure of maturation of AVF
fistulogram or arterio/veno gram → endovascular intervention → open
Tx peripheral PsA
tx- compress 20m → thrombin; immediate surg- infxn, HDUS, pulsatile, skin changes, ischemia, AMS
Tx Hemobilia after trauma:
EGD → CTA (if stable)
unstable- angio embolization (no surgery)
Cilostazol:
tx for periph claudication; MOA- PDi, inhibits PLT aggregation; c/i in any degree of HF (PDi)
Vertebral artery occlusion
posterior circulation sxs- dizziness, diplopia, dysphagia, dysarthria, ataxia
Elective surg after DEStent
postpone for 6m, hold plavix 7d b4, c/w ASA; need plavix fat least 6m after DES
TOS tx
neurogenic PT → rib resection, scalenectomy, BPlex dissection
Venous- catheter directed thrombolysis → surgical decompression
Arterial- C7/1r resection, subc artery resection/reconstruction
Tx facial nerve inj
relative to lateral canthus of eye; medial- non op OK (arborization); lateral- OR!
Tx Pelvic fx HDUS
binder, angio (OR packing if n/a), fixation; refractory bleed after angio → needs fixation
Tx Neck trauma
OR if platysma violation + crepitus, odynophagia, pulsatile bleed, expanding h’oma, bruit, thrill
Non-op w/up: 4V angio, doppler or CTA, UGI (esophagography) or esophagoscopy, bronchoscopy
Tx tracheal inj
ABSORBABLE in 1 LAYER w/ strap; large → tracheostomy, avoid below 3rd ring (TI fistula)
can perform primary repair up to 5-6 rings; must mobilize; large ant defect- tracheostomy
LE vascular trauma
small- patch plasty
large- contralateral GSV
limited time/unstable- shunt
Grading BCVI
anti-PLT + angio/OR if sxs; g4/5 require OR (no angio)
1- <25% narrowing, 2- > 25% narrowing, 3- PsA, 4- complete occlusion, 5- transection
Ureter injury
prox- primary anastomosis
middle- transUU
distal- reimplant +/- psoas hitch
Access supraceliac aorta
mattox maneuver → divide left crus → supraceliac clamp
Indics for ED thorac
trauma with witnessed loss of vital but SOL
SOL = ECG activity, reflexes, GCS > 3
Tx Odontoid fx
1- upper D, stable, non-op
2- base of D, unstable, worst, +/- surg
3- c2 vert, usually no OR
tx Flank wound
HDS- CT w/ triple contrast (oral, IV, rectal)
HDUS- OR
Tx Urethral injury
Grade: 1/2- contusion/stretch, cath
3- part disruption, OR
4/5-complete disruption, cystostomy + OR
Tx Supra-renal aorta inj:
can’t resect (exposure); repair w/ (non-abs) polyprop; adj perfs connected/closed
Close defect transversely to avoid stenosis; if stenotic → patch angioplasty
Tx DPGM injury
ABD approach, close w/ NAb
Thoracotomy access
Right thoracotomy- mid esophagus and DISTAL trachea
Left thoracotomy- distal esophagus, left mainstem
Tx congential DPGM hernia
prenatal dx on US; intubate (in delivery rm), NGT +/- ECMO → OR when stable
Hernia repairs
Lichtenstein: mesh recreates the floor; inferior → shelving edge; medial → PT; super → TA/conjoint tendon
Bassilini: conjoint tendon to shelving edge recreates the floor
Cooper’s/McVay: conjoint tendon to cooper’s lig; needs relaxing incision; use for fem hernia!
Shouldice: 4-layer w/ 2 running sutures; no mesh; lowest recurrence
Superior epigastrics
Inferior epigastrics
SE: runs posterior to rectus but anterior to posterior rectus sheath; branch of int mammary
IE: runs in pre perit space between transversalis fascia and parietal perit; branch of EI
Umbo ligs
round- umbo v.
median- urachus
medial- umbo a
Omph/M- vitelline duct (Meckel’s)
Tx Umbo hernia in child
most close by 2
<3cm- primary repair
>3cm- mesh; repair by 5
Tx SB fistula
⅓ close
feed enterally unless high output (>500cc/day)
Consider OR at 12w
Crohn’s stricture tx:
no surg hx- resct
prior surg + <10 cm- Heineke
10-20 cm- Finney
>20- S2S IsoP
Stricturoplasties
- Heineke s’plasty:
- Finney s’plasty:
- Side2Side isoperistaltic s’plasty:
Heineke s’plasty: ideal for <10cm; open long and close transversely
Finney s’plasty: ideal for > 10cm; structured segment folded on itself and common wall created
Side2Side isoperistaltic s’plasty: > 20 cm; overlap stricture/dilated area; 2x enterotomy/sew bowel together
Tx maltoma
triple therapy
Tx T cell SB lymphoma:
poor prog
tx w/ chemotherapy; surgery is palliative
FAP Tx
scope q1y at 10; scope= 100+ polyps
100% r/o CRC, especially peri-ampula
offer ppx colectomy
Lynch S Tx
HNPCC
scope q1y at 25
CRC by age 40
Tx Meckel’s
base < 2 cm → diverticulectomy
> 2 cm → seg resection
do appe too
Tx Mucinous neoplasm of appendix
confined to appendix/unruptured→ appe only; otherwise → R hemi
Tx Primary thyroid lymphoma
chemo/XRT
Tx follicular thyroid ca
- if < 4cm, <45 yo, no distal dz, no fam hx → lobectomy
- otherwise completion thyroidectomy
- neck dissection: clinically positive nodes (rare), extrathyroid spread
- RAI: >2cm, extrathyroid/vascular invasion, node +, anti-TG Ab, elevated TG
Thryoid nodes
Delphian nodes: w/in anterior suspensory ligament; connect L and R glands
Rotter’s nodes: between pec major and pec minor
Level VI: central compartment LNs
Tx Pap thyroid ca in perggo
postpone until 2T; if stable, post until after delivery; RAI is c/i
Tx Anaplastic thyroid ca
aggressive,undiff; mort ~ 100%; no tx; tx- XRT improves short-term survival +/- surg
Tx med thyroid ca
TOTAL thyroidectomy AND bilateral L VI dissect → complete lateral if +
Tx of Thyroiditis:
Hashimoto’s thyroiditis
De Quervain’s/Subacute thyroiditis
Reidel’s thyroiditis
Hashimoto’s thyroiditis: AI/lymphocytic; tx- LT4, surg if compression sxs
De Quervain’s/Subacute thyroiditis: tx- NSAID +/- steroids
Reidel’s thyroiditis: tx- steroids, surg if compression
Sonograph FNA recs
cystic- no bx
isoech/hyperech- FNA if > 2cm
hypoech (high sus)- FNA if > 1cm
Tx MEN2A
tx pheo 1st w/ adrenalectomy! → then resect T/PT
Tx Parathyroid ca
en block resection + XRT (not chemo)
Pheo w/up:
plasma or urine metanephrine (se) → 24-urine metanephrine (sp) → CT +/- MIBG (multi-focal)
Tx MEN1
tx hyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) → asses other lesions
MEN1/MEN2 genes
MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene
Hyperaldo w/up:
CT → unilateral → lap adrenal; CT → negative or bilateral → bilat venous sample
Indic for retroperitoneal adrenalectomy:
multiple previous ab surgeries, bilateral lesions
Cryptorchidism tx
wait until 6m old
if no resolution- elective orchiopexy to decrease r/o torsion, infertility, ca
Tx choeldochoal cyst
1- fusiform, excise/REY 2- divertic, excise 3- ampulla, transduo 4- extra/intra, REY 5- intra, trx
Tx Biliary atresia
REY portoenterostomy (Kasai) → liver trx
Neuroblastoma
S1-2 (low risk) → surg alone
S3+ → surg + chemo/XRT
Hirschsprung surgeries
- Duhamel
- Soave
- Swenson
Duhamel: agang stump in place/gang colon pulled behind; neo-rectum; less dissection/stricture
Soave: pull-through; “reverse alte”; remove M/SM; pull bowel within an aganglionic cuff; least dissection
Swenson: original; aganglionic segment resected to sigmoid colon; oblique anastomosis- colon x rectum.
Tx Thyroglossal duct cyst
excise cyst, duct + mid hyoid
Tx ASD
surg if sxs or asx < 5 yo; surg before school
Tx PDA
to close- indomethacin; to open- PGE1
Tx Trx of great vessels:
1st give PGE1 → ballon atrial septostomy
Tx SqCC Lip
WLE w/ 3cm margin
radical neck dissection if palp nodes
Tx SDH
nonop- HDS, <10 mm, <5 mm shift
evac- > 10mm, >5mm shift, delta GCS > 2, cx signs of ICP
Tx afib
stable- BB/CCB, amio if HF
unstable- SYNCHRONIZED cardioversion
consider acoag after 48h
Tx Aspergillosis
MC fungal infxn in IC
aspergilloma- resect
inv aspergillosis- voriconazole
Px and Tx Histoplasmosis
px- ohio river valley
tx- itraconazole → ampho B
MOA of antifungals:
Micafungin
Azoles
Amphotericin
Micafungin: echinocandin; inhibit glucan x linking
Azoles: ergosterol synth inhibitor
Amphotericin: binds ergosterol and inhibits
Tx Soft tissue sarcoma
resect w/ 1-2 cm marg
neoadj- rhabdomyosarcoma, Ewing sarc, high grade > 10 cm
adj XRT- > 5cm, high grade, recurrence, close marg
adj chemo- never
Tx of seminoma
surveillance or chemo/XRT
NNT
1/ARR
ARR = control rate - event rate
RRR
(control rate - event rate)/(control rate)
Cohort:
prosepective; exposed vs. non-exposed
RR- [a/a+b]/[c/c+d]
Case control
retrospective; diseased vs. non-diseased
OR- (a/b)/(c/d)
Type 1 error
Type 2 error
Type 1: false positive (a)
Type 2: false negative (b)
Periop Warfarin
stop 5 days before
indics to bridge: mech valve, h/o TE event, afib only if CHAD/VASC 5-6
Periop NOAC
stop 2 days before elective surgery
Tx keloid
Z plasty + steroids + silicone sheets
