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QUICK REVIEWS

BREAST

  • Intraductal papilloma: the most common cause of bloody nipple discharge; treatment is with excision of the involved lactiferous duct only; remember, all kinds of stuff causes nipple discharge (Tricyclics, cimetidine, HRT, phenothiazines, thiazide diuretics, metoclopramide, reserpine); pathologic nipple discharge, particularly bloody, is almost uniformly benign (10% of all patients with any type of nipple discharge have cancer); more worrisome if unilateral;
  • Thoracodorsal: nn. latissimus dorsi, if cut weak arm adduction at shoulder; Long thoracic nn. serratus anterior, if cut winging of the scapula; medial pectoral nn. both major and minor; lateral pect. nn. to pec. minor only; Batson’s plexus of vertebral veins are valveless and therefore breast cancer cells gain access directly to the spine spine mets.
  • GAIL model: of risk assessment over a 5-yr period for invasive breast cancer; age, race, age at menarche, age at 1st birth, h/o DCIS or LCIS, bx. with atypia, + family history; magic # is 1.66%
    • Lumpectomy + axillary node dissection + XRT to the breast is equivalent to MRM in terms of survival
  • Axillary nodal dissection: level I=lateral to pectoralis minor, level II=posterior to pectoralis minor, level III=medial to pectoralis minor
  • Contraindications to BCT: Multicentric disease, bad cosmetic result (large lesion in a small breast), large primary, usually 4cm, lack of access to XRT, EIC
    • Medullary cancer: has a favorable prognosis and tumor biology despite its often very large appearance at initial presentation
  • Paget’s disease: Most often associated with an underlying infiltrating ductal or intraductal cancer; The first presentation is often eczema and itching of the nipple areolar complex with some superficial erosions or ulcerations; Patients will have tried steroid creams without improvement; Frequently no palpable abnormality; Diagnose by punch biopsy; Early diagnosis early treatment (if there is an associated palpable lesion or (+) MMG mastectomy only; if there is no palpable lesion and (-) MMG, then BCT may be considered with complete resection of the nipple areolar complex + XRT) excellent prognosis; ALND only if there is an invasive component to the cancer
  • Mondor’s disease: Will almost always be presented with a pt. with a palpable cord (superficial) leading to the axilla and they will ask you what to do; This is superficial thrombophlebitis of the veins; completely benign and treated with NSAIDS
  • Mastodynia: Treat with Danazol, OCP’s, primrose oil?; tamoxifen and Vitamin E has been shown to not be useful
  • Cystosarcoma Phyllodes: Treat with WLE only with adequate (4 cm if possible) margins; no need to do nodal dissection; spread is like sarcoma via hematogenously
  • Giant fibroadenoma: seen primarily in adolescents, <16 y/o, as a solitary, firm, NT large mass, 5cm usually, asymmetric and prominent veins; This is completely benign and treated with enucleation only (do not do a MRM)
    • In a patient who has undergone neoadjuvant chemo., even though the tumor may disappear, you should realize that there is a 90% chance of residual tumo r there which must be treated with surgery
  • Stewart-Treves: lymphangiosarcoma in a pt. who previously underwent a MRM about 10-15 years ago. Pt. develops a purple mass on the arm
    • Angiosarcoma of the breast: pts. usually 10-15 years younger than typical IDC; lymph node spread is rare, spreads hematogenously, tx. with simple mastectomy without LND; ? benefit of XRT, chemo. no benefit
  • DCIS: age 54-58, 2% incidence, can have pain, a mass or nipple discharge, microcalcifications are present in vast majority, 1/3 premenopausal, 18% incidence of synchronous invasive carcinoma, 40-80% mutlicentric, 10-20% bilateral, 2% axillary mets., 25-70% incidence of a subsequent cancer (ipsilateral) with an interval of 5-10 years; if it comes back, it will most likely be an infiltrating ductal carcinoma; the greatest risk for recurrence is size 2.5cm and comedo necrosis; Treat with salvage mastectomy.
  • DCIS: 4 subtypes: papillary (best prognosis), cribriform, solid, and comedo (worst prognosis); Comedo assoc. with poor prognostic indicators: overexpression of HER-2/neu, ER/PR (-) receptor, high thimidine index, p21 ras oncogene expression, aneuploidy and high S-phase fraction
  • DCIS: local recurrence following a lumpectomy alone is 17%; if you give XRT to the breast after lumpectomy, this decreases the local recurrence rate to 7%. There is absolutely no difference in overall survival. XRT only helps decrease local recurrence rate.
  • Comedo DCIS: represents a high grade, aggressive, poor prognosis type of DCIS; It is only for this form of DCIS would you probably perform a SLNB with lumpectomy and XRT
    • The most common genetic abnormality in breast cancer is a mutation in the tumor suppressor gene p53 (seen in 30-40% of all breast cancers)
    • Locally advanced cancer seen in patients with primary tumors 5cm (T3 lesion), fixed or matted axillary nodes (N2 disease), primary tumor fixed to the chest wall (T4 lesion) and inflammatory breast cancer. For any of the above, give neoadjuvant chemo. prior to any surgery. Remember, even if the patient has a great response to neoadjuvant chemo., you must assume there will be residual microscopic disease at the primary site (in over 90% of cases), therefore, you need to operate after neoadjuvant chemo, most likely with MRM.
    • In a pt. with a low risk of tumor recurrence (T1N0MX) and ER+, the addition of chemo. (CMF) adds no improvement in survival compared to tamoxifen alone
    • Trials with adjuvant chemo. do not demonstrate any comparable reduction in cancer in the opposite breast (as tamoxifen does)
  • LCIS: It is not a premalignant condition; it is a marker for the development of a subsequent cancer; there are no clinical signs, seen on pathology specimen for some other breast surgery, there are no microcalcifications, 1% incidence of axillary mets., 70-80% bilaterality, incidence of a subsequent infiltrating ductal cancer developing is 20-35%, in either breast at a 15-20 year interval from the time of diagnosis; There are only 2 treatment options for all patients: bilateral simple mastectomies, close follow-up with yearly MMG’s. There is no confusion on this.
  • Inflammatory breast cancer: Patient presents with an inflamed, tender breast, often near and/or involving the nipple areolar complex with enlargement of the entire breast; they will have been previously treated with ABX. for a suspected breast abscess or mastitis which doesn’t get better. Do a punch biopsy for diagnosis; cancer cells penetrate and involve the dermal lymphatics; treat with neoadjuvant chemo. mastectomy XRT consolidation chemo. Associated with a 50% 5-yr survival
  • Tamoxifen: It is a SERM (selective estrogen receptor modifier); It binds to the estrogen receptor on cancer cells and prevents any estrogen from binding to it. Remember, it is an anti-estrogen for breast tissue, but acts as an estrogen for other tissues like endometrium, bone and liver. Thus, this is why tamoxifen causes a slight increase in the risk of developing endometrial cancer (and DVT’s and PE’s). It is effective in ER/PR + pre- and post-menopausal women as an adjuvant endocrine therapy at 20 mg/day; 5 years duration (no improvement if given for 10 years). NSABP P1/24: high risk women (GAIL 1.66%, 60y/o, LCIS) have a 49% reduction in risk for the development of invasive breast cancer in the ipsilateral and contralateral breast; increased survival in stage I,II pts. NSABP-24: DCIS lumpectomy and XRT randomized to placebo vs. tamoxifen; tamoxifen associated with a decrease in all breast cancer events (invasive ipsi. cancer 3.4% in placebo vs. 2% in tamofien group, with similar decrease in noninvasive cancer)
  • CI’s to SLNB are: multifocal disease, palpable axillary adenopathy, primary tumor 5 cm, locally advanced cancer, pt. who received neoadjuvant chemo.
    • In patients with negative LN’s, tumor size is the most important prognostic factor for relapse; <1cm 90% 10-yr. Survival; 1cm 25-44% of stage I,II patients will develop recurrent disease, therefore, adjuvant chemo. is indicated in these patients with either AC (adria/cycloph) or CMF (cyclo/methotr/FU)
  • BRCA 1, BRCA 2: About a 60-80% lifetime risk of developing breast cancer if mutation is present (general population is 12%); BRCA1 (chrom.#17) is also associated with ovarian cancer and prostate cancer; higher occurrence of medullary cancer; BRCA2 (chrom# 13) is associated with male breast cancer; higher occurrence of tubular- lobular invasive cancer
  • Li-Fraumeni Syndrome: AD/ SBLA (Sarcoma, Breast, Leukemia, Adrenocortical Cancer); Breast cancer is the most common cancer associated with LFS, but overall accounts for <1% of all breast cancers; caused by germline mutation in the TP53 tumor suppressor gene protein product is p53.
    • For patients s/p lump/breast irrad./ALND would give axillary radiation to patients with high risk features: 5 (+) nodes, bulky nodes 2cm, extranodal extension of tumor.
  • Radiation mastitis: Occurs most commonly after XRT and doxorubicin; Tx. of choice is pentoxifylline.
  • Lobular carcinoma of the breast: uniform cells seen in a single file (Indian filing).
  • BIRADS classification: 0=incomplete, 1=negative, normal, 2=benign finding, 3=prob. benign finding, risk of malig. ~1-2%, 4=suspicious abnormality, bx. is recommended (really required), 5=highly suggestive of malignancy, high prob. of cancer, bx. Required
  • Triple test for palpa ble abnormalities: based on physical exam, MMG and FNA NPV=100%, PPV=75%
    • In general, adjuvant chemo. (usually CMF) is used in all breast cancer patients who are premenopausal with a primary tumor 1cm, +/- tamoxifen if ER/
    • Any pt. with a very strong family history of breast cancer should have their 1st screening MMG 10 years before the earliest age of cancer onset in family member; Otherwise, without any history, current recommendations are 1st MMG at age 40

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ORTHOPEDICS

  • Salter-Harris Fractures: In general, a grade III, IV or V fracture are intraarticular and general need open reduction and fixation
    • A Volkmann’s contracture often will occur with a supracondylar humerus fracture which results in a compromised anterior interosseous artery; This results in a deep forearm flexor compartment syndrome with a need for fasciotomies; The first sign will often be pain in the forearm with
    • extension median nerve injury; paralysis and paresthesias are late findings; tx:
    • 4 compartment fasciotomies (lateral and medial)
    • The earliest and most reliable sign of anterior tibial compartment syndrome is referred pain to the anterior compartment on passive plantar flexion of the toes and ankle
  • Monteggia fracture: Proximal ulnar fracture with a radial head dislocation
  • Galeazzi fracture: fracture of the distal radial shaft with dislocation of the distal ulna
  • Colle’s fracture: Always pt. who falls on the outstretched hand; fracture of the distal radial metaphysis with fx. of carpal scaphoid bone; pain over snuffbox
  • Nursemaid’s elbow: Always presented with a young child who’s mother yanks and pulls on the outstretched arm, causing a dislocation at elbow; tx. with pronation of arm
  • Chance fracture: Always presented with a restrained pt. in a high speed car wreck with rapid deceleration; This is a 3rd lumbar vertebral fx. which causes a small bowel injury (perforation) and/or mesenteric injury (tearing of vessels); If presented with this EXLAP.
  • Shoulder dislocation: 90% are anterior with greatest risk to the axillary nerve; exception seen with seizures and electrocution causing a posterior injury
  • Ewing’s sarcoma: Usually <20 yoa/ associated F/C/N/V/malaise/anemia and increased ESR/ onion skin appearance on XRAY (elevation of periosteum) Osteogenic sarcoma: Usually <20 yoa/ enlarged painful mass/ sunburst appearance on XRAY/ no symptoms like Ewings; tx: preop. Chemo. 1st surgery XRT
  • Slipped capital femoral epiphysis: Always presented with a 10-15 y/o fat child (male or female) c/o knee pain after after a fall; this is referred pain from the hip; tx. with immobilization until stable
  • Torn Achilles: always presented with an athlete (tennis player serving) who after feels a sudden severe pain in the calf after jumping
    • Femoral shaft fracture is treated within 24 hours with IM rod fixation; In children, these are always treated conservatively with traction
  • Open femoral fractures: operative debridement within 8 hours repeat within 24-48 hours empiric ABX never close these primarily, wait 5-7 days for secondary closure

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RENAL, ADRENAL, PITUITARY

    • JG cells, decreased Na, hyperkalemia and decreased BP in afferent arterioles increased renin production by the macula densa conversion of angiotensinogen to angiotensin I angiotensin converting enzyme in the lung converts angiotensin I to AG II AG II causes a potent vasoconstriction and an increase in aldosterone (RE: both can be in response to hemorrhage and hypotension)
  • Adrenal incidentaloma: All non-functioning tumors greater than 6 cm. should be resected as the risk of adrenocortical carcinoma increases. Do not forget to R/O a pheochromocytoma prior to any surgery, do so by sending 24 hour urine catechols and metanephrines.
  • Acute Adrenal Crisis: This is adrenocortical insufficiency; Classic signs are hypotension/hypoglycemia/hyperkalemia(+/- N/V/ anorexia/ lethargy/ confusion) / bronzing of the skin; tx. with hydrocortisone, saline and glucose
    • The best screening test for an extra-adrenal pheo is a 24 hour urine catechols and metanephrines; Can localize the mass with an I(131) MIBG scan (better than MRI or CT)
  • PNMT: is made only in the adrenal medulla; it converts NE EPI; therefore, you can differentiate b/t an adrenal pheo. vs. an extra-adrenal pheo. by the ratio of NE:EPI; Adrenal pheo high EPI, low NE; extra-adrenal pheo low EPI and high NE
  • Cushing’s syndrome: prolonged exposure to excessive cortisol; most common cause is exogenous synthetic steroids; Cushing’s disease specifically refers to chronic hypersecretion of ACTH adrenal cortex with 90% caused by a pituitary adenoma; can treat with cyproheptadine which blocks the release of CRH from the hypothalamus, causing regression in 30-50% of patients with Cushing’s disease
  • Cushing’s syndrome: dx. by 24 hour free cortisol markedly elevated; to determine where the problem is, check plasma ACTH levels; if from adrenals, plasma ACTH is undetectable; if from pituitary or ectopic source, plasma ACTH is normal to elevated
  • High dose dexamethasone test: results in suppression of ACTH levels in patients with a pituitary source, no suppression with ectopic producing ACTH tumor or adrenal source
  • Bromocriptine: is a dopamine agonist and inhibitor of prolactin secretion and is used to treat patients with prolactinomas (with over 70% response rate)
  • Primary hyperaldosteronism: Increased serum aldosterone/low plasma renin activity/HTN/hypokalemia/weakness/polyuria/plasma aldosterone:renin ratio 20 is diagnostic; usually due to a single adrenal adenoma
  • Secondary hyperaldosteronism: high PRA, treat medically, no surgery
  • Chronic renal insufficiency/failure (CRF): The kidneys don’t work phosphate retention hyperphosphatemia; decreased hydroxylation of Vit.D and decreased active Vit.D3 decreased Ca absorption by the gut increases PTH production vicious cycle of secondary HPTH osteomalacia, osteitis fibrosa cystica, ectopic calcifications (Calcium binds to excess PO4); tx: dialysis with low phosphate bath, bisphosphonates (etidronate and pamidronate) to bind PO4 and stabilize the bone matrix

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SPLEEN

  • ITP: circulating IgG antibodies to platelets causing their destruction; The spleen is the source of these antibodies; F:M 3:1; Acute ITP occurs in kids <16 yoa and over 80% recover without specific therapy (don’t wack out their spleen); However, if they don’t improve and in the adult, try 2 months of steroids 1st; if no response splenectomy; if the patient responds to steroids but recurs later splenectomy; Don’t forget to give pneumovax. For kids, prophylactic PCN until adolescence (age 12 to 16 y/o).
  • Hypersplenism: Is a syndrome of splenomegaly and pancytopenia with a normal BM; peripheral blood smear normalizes after splenectomy
  • Splenic vein thrombosis: Most commonly seen secondary to pancreatitis and presents often as an UGI bleed +/- splenomegaly, abd. pain and chronic anemia; EGD reveals gastric varices; TX: splenectomy
  • Splenectomy is of benefit for patients with portal HTN when pt. has gastric varices (only instance)
  • TTP: hemolytic anemia/decreased platelets/neuro symptoms/ fever/renal dysfunction (all seen in only 40%); F:M 2:1; poor prognosis, especially during the 1st attack; Initial tx: exchange plasmapheresis + plasma infusions; no benefit for splenectomy
  • Sickle cell disease: sequelae include atrophy, infarction, splenomegaly (early) with later atrophy; no rupture
  • A patient with splenosis will not have Howell-Jolly bodies on a peripheral blood smear (splenic remnants removes them from the circulation)
  • Hereditary spherocytosis: deficiency of spectrin; splenomegaly; AD; dx. by osmotic fragility test; tx; curable with splenectomy THORACIC/ MEDIASTINUM / CV
  • 3 T’s of the anterior mediastinum: teratoma/thymoma/thyroid(substernal)
  • Most thymomas (50-60%) are associated with myasthenia gravis (MG), with only 10-30% of MG patients having a thymoma
  • Chondrosarcoma: most common primary chest wall tumor/slow growing/ painful/ M F/ usually involves 1st 4 ribs arising from the anterior cartilage/ en bloc resection with good 4-5 cm margin if possible
  • MG assoc. with proximal mm weakness/generalized weakness/ptosis; it is a deficiency of the Ach receptors due to Ab’s bound to them;treat with acetylcholinesterase inhibitors (tensilon); Any patient with MG and symptoms should have a thymectomy because almost all improve after surgery
  • Thymoma: most common anterior mediastinal tumor (neurogenic tumors arise in the posterior mediastinum); All thymomas should be resected; of all patients with thymomas, 50% will have MG; only 10-15% of pts. with MG have thymoma; Treat prior to surgery with plasmapheresis and stop tensilon to decrease pulm. secretions and prevent inadvert. cholinerg. weakness; Almost all are retrievable through a standard collar incision; rarely a partial superior median sternotomy is necessary; If malignant (as determined by clinical behavior and not type), treat with post-op. XRT (it decreases local recurrence and increases survival)
  • Pulmonary sequestration: Extralobar sequestrations: Left sided/have their own pleura/ 50% assoc. with other congenital anomalies, especially CDH; blood supply usually directly from the aorta with venous drainage via azygous and hemi-azygous; Intralobar: no separate pleura, has a bronchial connection, L sided more common, artery from aorta in 70% of cases and runs within the inferior pulmonary ligament; venous drainage is into the pulmonary veins; tx: resection
  • FRC=ERV+RV; VC=IRV+TV+ERV; TLC=IC+FRC or VC+RV
  • Thoracic outlet syndrome rarely involves the artery or veins and over 90% present with neurological deficits, many involving the ulnar nerve first paresthesias
  • SVC syndrome: 90% are due to a lung cancer, usually bronchogenic carcinoma; primary collateral around the SVC is the azygous vein to the IVC below the diaphragm; S/S: headache, SOB, confusion, dizziness, venous distention, facial edema, plethora, hoarseness, dyspnea; Treatment in most cases of symptomatic SVC syndrome is with XRT first. However, standard treatment (non-emergent) is with diuretics, fluid restriction, +/- steroids, (+XRT +chemo for advanced cases)
  • Pre-thoracotomy PFT’s: If you are going to do a lobectomy, you need a minimal FEV1 of 800ml; fo r a pneumonectomy 2L; for a wedge resection 600ml; an FEV1 of <500ml/sec is prohibitive as well as a pt. with COPD with CO2 retention (resting PCO2 of 45); post-op. FEV1 should be at least 0.8L-1.0L
  • IIIB lesions are unresectable (T4 lesions are into the mediastinum, great vessels, esophagus, trachea, vertebrae, and effusions; N3 nodes are also unresectable into the contralateral chest, inot the scalene mm and/or subclavian region
  • Small cell lung cancer is treated with chemo., not surgery; extra-pulmonary manifestations are Cushing’s syndrome (ACTH secretion from tumor) and polymyositis and MG-like syndrome, increased ADH (hyponatremia); squamous cell PTH-like substance hypercalcemia; non-small cell (ie: adenocarcinoma) hypertrophic osteoarthropathy (clubbing)
  • Some IIIA tumors (non-small cell,+ipsi. nodes) are tx. with neoadjuvant chemo and XRT followed by surgical resection
  • Tetrology of Fallot is the most common cyanotic lesion in children <2yoa; transposition of the great vessels is the most common cause of cyanosis and heart failure in the newborn
  • Pancoast tumor: Almost always will involve the sympathetic chain early on causing the classic Horner’s syndrome; ulnar nerve can also be involved
  • Hamartoma of the lung: most common benign tumor of the lung/ presents as a solitary pulmonary nodule/ mostly composed of cartilage/ slow growing/ contains popcorn calcifications/ CT-guided FNAB often diagnostic
  • Only 5% of coin lesions are malignant (solitary pulmonary nodule): most are granulomas; However, in a pt. 80 y/o a coin lesion is associated with a cancer in nearly 100% of the cases, for pt.<50 y/o 50% chance; Always ask to look at old CXR’s to see if nodule has changed or stayed the same
  • Non-small cell cancer with a (+) supraclavicular node is a stage IIIB and is not respectable, treat with XRT and chemo. (N1: peribronchial or ipsi. hilar / N2: ipsi. mediastinal and subcarinal / N3: any contralateral nodes); All T4 lesions (malig. pleural effusion or invasion of adjacent structures) are at least a IIIB stage; stage I and II tumors are treated primarily with resection and lobectomy (don’t wedge)
  • Stanford Classification of Aortic Dissection: A= ascending (Debakey I,II) dissection and all should be surgically repaired; B=descending (Debakey III) and medical treatment for most, rare to operate
  • Left to right shunt: pulmonary HTN secondary to excessive pulmonary blood flow arteriolar thickening; seen with VSD, ASD, AV canal, TAPVR, Truncus arteriosus, do not get with pulmonic stenosis; main complication of a L R shunt is CHF and pulm. HTN
  • Right to left shunt: get cyanosis, clubbing and exercise intolerance; seen with TOF (most common in children) and Transposition of great arteries (most common in newborn)
  • IABP: decreases afterload/increases coronary perfusion pressure/decreases PVR/exacerbates AI
  • Congenital Lobar Emphysema: progressive hyperexpansion of 1 or more lobes of the lung; air is trapped during breathing over- inflation of lung mediastinal shift away from side; most common in upper lobes, 14% of children with other congenital anomalies; usually seen in 1st 1-2 months of life; TX: resection of affected lobe
  • ASD: left to right shunt, many asympt., fatigue, palpitations, exertional dyspnea, gracile habitus (thin, long narrow bones, poor mm. devclopment), split S2, systolic murmur, dx. With 2D ECHO; tx: surgery, unless pt. has high PVR
  • PDA: It is kept open with PGE1; close it with indomethacin (80% success); F M 3:1/rubella in the 1st trimester causes syndrome of mental retardation, cataracts and PDA/ produces a L R shunt/ never produces cyanosis/slow tissue development b/c of decreased peripheral blood flow/hallmark is a continuous machinery murmur with a palpable thrill/susceptible to bacterial endocarditis with s.viridans (most common after the first decade)
  • TOF: VSD, RV hypertrophy, pulmonic stenosis (obstruction of the RV outflow tract), overriding aorta; symptoms: polycythemia, clubbing (hypertrophic osteoarthropathy), CVA’s, brain abscess, endocarditis, hypercoagulable; hypercyanotic spells (TET spells); boot-shaped heart, squatting is common b/c this increases SVR increases pulm. Blood flow; tx: Blalock-Taussig SC artery PA shunt followed by definitive corrective surgery later; primary CI to corrective surgery is a severely hypoplastic PA
  • Type I pneumocytes: gas exchange; type II pneumocytes secrete surfactant to decrease the surface tension
  • LIMA: the best conduit to use for CABG with the highest 10- yr. Patency rate ( 90%); Using the LIMA is assoc. with a lower overall operative mortality and a lower incidence of future cardiac events such as MI and repeat CABG
    • Small cell lung cancer is th most common tumor to produce ectopic ACTH
    • Chylothorax chest tube and TPN 1st, try for at least 2 weeks (50-70% success), if unsuccessful thoracic duct ligation (80% success); if both fail, try pleuroperitoneal shunt
  • Actinomycoses: is not a fungus, it is a microaerophilic bacteria, forms abscesses, treat with ABX; Histoplasmosis is a fungus; it is the most common systemic fungal infection in the U.S. and endemic to the Miss. River basin; can get calcified lymph nodes in lung and mediastinum from past infections
  • Blastomycosis: see cutaneous and pulmonary infections together; Aspergillosis: fungus ball; treatment almost always entails a lobectomy b/c of ineffective antifungal therapy; Coccidiomycosis : Always presented with a migrant worker from the San Joaquin Valley; this is a fungus

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HEAD AND NECK

    • Early stage I, II treated with either XRT or surgery (not both, same outcome) and advanced stage III, IV are treated with combination XRT+surgery (superior outcome compared to either one alone)
    • XRT alone is the best treatment for SCC or BCC of the nose, eye, lip, eyelid, inner and outer canthi with cure rates of 96% (BCC), 92% for SCC.
    • SCC of the H + N: stage I and II (up to 4 cm, no nodes) single modality tx. with either surgery or XRT; stage III, IV combined modality
  • Frey’s syndrome: gustatory sweating, most often seen after parotid surgery; pt. gets sweating/flushing/warm sensation over-pre-auricular area with eating; tx: botulinum toxin A with response rate close to 100%
  • Glottic cancer: if the cords are fixed, tx. with surgery and XRT; if not XRT alone
  • Cholesteatoma: Associated with pars flacida (marginal perforation of the TM) secondary to OM or eustachian tube obstruction; after TM perf. desquamation of squamous cells accumulate destroy bone, including ossicles purulent labrynthitis facial paralysis, intracranial infection; you will see white pieces of crud in the middle ear on exam +/- destruction of the adjacent temporal bone; tx: radical/modified mastoidectomy
  • Juvenile angifibroma: purplish polypoid mass in the nose; non- metastasizing but locally aggressive; pt. is pre-pubescent with frequent nose bleeds; tx: excision only after pre-op embolization
  • Salivary gland tumors: benign: pleomorphic adenomas: most common benign tumor of the parotid; do not enucleate, do a superficial parotidectomy with preservation of the facial nerve/ Warthin’s tumor (papillary cystadenoma lymphomatosum; adenolymphoma); 70% are bilateral; path contains oncocytes; malignant: All malignant tumors of the parotid gland warrant a total parotidectomy with facial nerve preservation and only sacrificed if directly involved; mucoepidermoid is the most common malignant parotid tumor; most common in children; for a low grade(slow growth, low recurrence rate), treat with total parotidectomy; for a high grade (very aggressive, 60% local recurrence rate, regional mets 50%, distant mets 30%) treat with total parotidectomy, facial nerve preserva tion if possible, neck dissection (selective for N0, modified or radical for N+); adenoid cystic: most common tumor of the submandibular glands; treat same as mucoepidermoid; acinic cell: 13% of malignant parotid tumors; spectrum from indolent to aggressive; adenocarcinoma: 12% of parotid tumors and a high % of minor salivary gland tumors; most are high grade, treat as with mucoepidermoid; If you see a SCC of the parotid, submandibular or salivart glands, it is probably a met. from somewhere else, rather than a primary lesion, therefore should look for a primary
  • Postop. XRT: is indicated for all high grade tumors of the parotid and salivary glands (all histologies except low grade mucoepidermoid and acinic cell tumors <3cm), close surgical margins, recurrent disease, skin, bone nerve or extraparotid involvement, positive nodes, gross residual or unresectable disease
  • Erythroplakia is worse (pre -malignant) than leukoplakia: Retinoids can reverse leukoplakia and reduce the chance of a secondary H + N malignancy

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SKIN/ MELANOMA / SARCOMA

  • Actinic keratoses: is a pre- malignant lesion and should be resected with adequate margins; seborrheic keratoses, cavernous hemangioma and junctional nevi are not
  • Merkel cell tumor: rare, aggressive tumor of the dermis, neuroendocrine in origin, high frequency of locoregional recurrence even after adequate 2 cm margin; highly radiosensitive and should use XRT to the excision site and regional nodes; 85% express somatostatin receptors and are (+) on octreotide scan
  • Extremity melanoma: 3.7mm lesion has a 50% chance of nodal involvement (clinically negative); 1.6 to 3.7mm 35% chance; 1.5mm or < has a 15% chance of nodal involvement
  • Subungal melanoma: remove the nail and biopsy if positive amputation at one joint proximal
    • The only survival benefit for a prophylactic LND is for males, <60 yoa with a 1- 2 mm lesion without ulceration; All melanoma patients with palpable adenopathy get a therapeutic LND
  • Dysplastic nevus syndrome: familial tendency to develop atypical moles and melanoma; 10% of cases have such a genetic component
    • Among congential nevi, only the giant congenital nevus ( 20cm in diameter) is a precursor to melanoma
    • Stage of melanoma has a direct correlation with long term survival; the thicker the melanoma, the poorer the 5-yr survival
    • Any patients with a known h/o melanoma and palpable lymph nodes, confirmed by FNAB to be melanoma, should undergo a complete, therapeutic LND
  • Surgical margins: Any lesion <1 mm 1 cm margin is adequate; 1-4mm 2cm margin; 4mm at least 2cm, 3cm is probably better; For head and neck and distal extremity, <1mm lesion 1 cm margin and 1mm at least 1 cm margin (no data, this is accepted surgical practice)
  • Sentinel LNB: Current recommendation are to perform a SLNB on any lesion 1mm tumor thickness; Overall, if the SLNB is (-), the rest of the LN basin is also (-) (90-96% of the cases); Remember, the background must be <1/10 the reading of the sentinel node by gamma probe.
    • The only known adjuvant therapy for patients that has been shown in some trials to be beneficial in improving overall and disease free survival in resected stage II and stage III patients with melanoma is Interferon-alpha (2A) (not gamma), called INTRON-A. Currently, this is standard of care
    • Interleukin-2 is FDA approved for treating patients with metastatic melanoma (stage IV) and metastatic renal cell cancer. It is given IV at 600,000 IU/kg q8 until DLT; the side effects are a systemic leak syndrome causing hypotension; The SBP can be supported with inotropes in the ICU
  • Soft tissue sarcoma (STS): All arise from mesoderm/Most common sarcoma overall is malignant fibrous histiocytoma (MFH), second is liposarcoma/Biologic aggressiveness is best predicted by grade (not stage)/ survival is best predicted by grade, not stage/high grade sarcomas (# mitoses per high power field) have a high metastatic potential and most often spread hematogenously to the lung
    • STS biopsy techniques do not include FNA/ can sometimes get diagnosis by a core needle biopsy/ If less than 5 cm, can attempt an excisional biopsy, if 5cm, try a percutaneous core biopsy or incisional biopsy/The incision on the extremity is a longitudinal incisional directly over the mass (so if you do a WLE later, you encompass this scar in it)
    • STS: Surgery + XRT is better than surgery alone for local control, but no difference in overall survival; chemo (primarily doxorubicin-based) doesn’t work, so don’t give it
    • Epithelioid sarcomas are high grade sarcomas with a known propensity for multi- focal disease @ presentation; it occurs in very young males/mostly imbs/rarely H&N/has a tendency to spread locally
  • Hyperthermic isloated limb perfusion: Is used for STS in an attempt to preserve the limb (which would otherwise need to be amputated due to advanced disease); utilizes melp halan (without TNF) with an overall major tumor response rate of 87% (CR=36%, PR=51%), with limb salvage in 84% of all patients
  • Retroperitoneal sarcomas: Most common is liposarcoma (42%) and leiomyosarcoma (26%); CT and MRI are essential before operating; Do not need to biopsy pre-op except only if you have a suspicion it is a lymphoma, or unresectable or a metastasis and not a sarcoma primary; Surgical resection with negative margins remains the standard primary treatment for all patients with localized retroperitoneal sarcoma

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TRANSPLANT

  • Hyperacute rejection: This is an antibody (B-cell) mediated event; can test with the lymphocytotoxic crossmatch (B-cell crossmatch); kidney is the most susceptible organ; will often see immediately after vascular clamps are released during surgery
  • Renal transplant rejection: tenderness over the graft with enlargment, fever, malaise, HTN, increased WBC, oliguria and increased creatinine; dx. is confirmed by renal biopsy; tx: high dose IV prednisone, azathioprine and irradiation
  • OKT3: A monoclonal antibody (made in mice) that binds to the CD3 TCR complex; Rapamycin: macrolide antibiotic that inhibits T cell activation and maturation; FK506=Tacrolimus: macrolide antibiotic that acts by inhibiting/blocking calcineurin-calmodulin complex NF-AT activity decreased, prevents cytokine transcription of IL-2 gene and therefore arrests Tcell activation; CyA: same action as FK506, but is a fungus; CyA blocks TCR signal transduction but does not inhibit co-stimulation, T-cell becomes active again without CyA; Can overcome CyA effects with exogenous IL-2 and thus CyA is a maintenance agent and not a rescue agent for rejection; ALG: polyclonal Ab prep. against many different antigens on T-cells. It is made in a horse (ATGAM), basically removes T-cells from the system; side effects include severe thrombocytopenia, chills, fever, skin rash
  • Azathioprine: purine analogue, interferes with DNA synthesis; MTX: inhibits DHF reductase and prevents conversion of folic acid to THF acid
    • The most frequent complication after a liver transplant is always the biliary anastomosis (leak/obstruction/stricture); blood supply for this usually is from the hepatic artery
    • Graft thrombosis is the most common complication following pancreatic transplantation and usually occurs within the 1st 24 hours; tx: remove the transplant

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PANCREAS

    • Mucinous and serous cystadenomas are benign lesions, but cannot reliably be differentiated from malignant lesions, therefore you resect all cystic lesions of the pancreas because of the chance that it may come bacl on path as a mucinous or serous cystadenocarcinoma; In general, serous has central calcification,high glycogen levels, low CEA and low CA19-9 with mucinous just the opposite with peripheral calicification
  • Primary pancreatic lymphoma: diagnosis based on CT- guided biopsy, if unsuccessful, can do an open biopsy. There is no role for extensive surgery for pancreatic lymphoma; treat with chemo (Doxorubicin-based)
  • Glucagonoma: is a malignant pancreatic islet cell tumor assoc. with decreased A.A’s in serum/increased glucagons in serum/weight loss/NIDDM/ severe mm.wasting/cachexia and a characteristic rash called necrolytic migratory erythema (this will never appear as an answer); You must identify the rash as a raised, red, pruritic rash that can progress to bullous lesions that slough; increased risk of DVT’s and PE’s;
    • Metastatic glucagonoma: Debulk if possible; if not resectable, treat with octreotide
    • Nesidioblastosis: childhood hypoglycemia (~40 mg/dl) with no known etiology; treatment is with 95% pancreatectomy with sparing of the duodenum; do not do a splenectomy
  • Insulinoma: usually found in the tail of the pancreas (not in gastrinoma triangle), usually solitary and readily curable with enucleation; when malignant (rare), tumor debulking, streptozotocin and diazoxide is helpful to control the hypoglycemia; most common islet cell tumor
  • Factitious insulinoma: check a C-peptide level, if absent factitious (almost always presented with a health care worker with glucose of 40)
    • Prolactinoma: #1 cause of pituitary adenoma with galactorrhea and irregular menses; tx. with bromocriptine with 75% response rate, if not transphenoidal resection
  • Pancreatic cancer: Almost always presented with a pt. with painless jaundice, weight loss and back pain; assoc. with k-ras mutations;tx: Whipple vs. biliary and gastric bypass
    • Somatostatinoma: steatorrhea and diarrhea +/- stones; VIPoma: diarrhea and achlorohydria
  • MEN IIA/IIB: mutation in the ret proto-oncogene; chromosome #10
  • MEN I: pit/panc/para, most common presentation in over 90% is hyperparathyroidism, chromosome #11; MEN II: MCT defines MEN II; MEN IIA: MCT/pheo/para, do not forget about the pheo. because this is what you will operate on first, before treating the yperparathyroidism; MEN IIB: MCT/pheo/mucocutaneous lesions/marfanoid (think of Abe Lincoln), very aggressive, poor survival
  • Adrenal incidentaloma: resect all 5cm; prior to resection, check to R/O pheo. With urine metanephrines and catechols. b/c if present, need to prepare patients for OR (alpha blockade etc..)
  • Pheochromocytoma: control the BP with an alpha blocking agent like phenoxybenzamine, follow this with Beta blockade if they get tachycardic (always give the alpha blockade before the Beta blockade)
  • Ranson’s Criteria: LDH 350, age 55, WBC 16, glucose 200, SGOT 25; after 48 hours: HCT drop 10%, BUN up 5, Ca<8, PO2<60, BD 4, fluid sequest. 6L
  • Annular pancreas: Abnormal fusion and rotation of the ventral pancreatic primordium; forms a thin band of normal pancreatic tissue completely around the 2nd portion of the duodenum; do not cut this band, you will get a fistula; tx: duodenoduodenostomy or duodenojejunostomy (do not do a gastrojejunostomy)
  • Pancreatic divisum: dorsal and ventral pancreatic ducts don’t fuse together resulting in the main pancreatic duct draining via the minor papilla; results in development of pancreatitis due to a relative outflow obstruction of the main pancreatic duct; tx: duodenojejunostomy or gastrojejunostomy

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HAND

    • The most common carpal bone fx. by far is the scaphoid bone (80%); this causes tenderness in the anatomic snuffbox
  • Swan-neck deformity: usually occurs as a complication of a Mallet finger: blunt trauma to tip of finger (ball hits end of finger head on) causes avulsion of the extensor tendon mechanism +/- bony fracture
    • Kanavel’s Tenosynovitis (suppurative flexor tenosynovitis): fusiform swelling of digit/digit held in flexion/ pain evoked on passive extension/tenderness along the synovial sheath; s.aureus most common, look for Eikenella (not sus cept. To PCN); treatment of all human bites requires surgical exploration in the OR (I+D)
  • DeQuervain’s disease: compression of the extensor pollicic brevis and abductor pollicus longus in the 1st dorsal compartment; F:M 10:1; cause most commonly related to overuse; pain and tenderness of radial styloid in anatomic snuff box; + Finkelstein test tx: initially with rest/splint/steroid injections with improvement within 6 weeks; if not, surgery
  • Boutonniere’s deformity: disruption of the central tendon slip leads to volar displacement of lateral bands with a flexion deformity of the PIP (joint stuck in flexion) and extension deformity of the DIP (hyperextension)
  • Dupuytren’s contracture: Almost always presented with a white, middle-aged, diabetic, alcoholic; causes contracture of the palmar aponeurosis most commonly the 3rd and 4th digits/ afflicts primarily northern Europeans/M F by 2:1/AD/nodule formation within the palmar fascia with fixation to tendons; no known non-operative tx. therefore operate on all; surgical tx. with open fasciectomy with partial or complete fasciectomy; can be confused with a lowgrade fibrosarcoma on path
    • Human bites (including fist to teeth in a fight): 1st step in management is surgical exploration, I+D in the O.R., leaving the wound open with drainage of joints; wound heals by secondary intention; most common organisms are s.aureus, s.viridans, and eikenella corrodens which is an anaerobic GNR sensitive to PCN)
  • Animal bites: dog bites rarely become infected, however, 50% of cat bites do; for cat bites look for pasteurella multocida; most require only local wound care, empiric ABX. and immobilization
  • Carpal tunnel syndrome: F M (they will almost always give you a postmenopausal typist or secretary); + phalen test; + Tinel’s test, compression of the median nerve with neuropraxia within the carpal tunnel; medical tx. 1st with steroid injections, splinting of the wrist in a neutral position, NSAIDS, diuretics to decrease the edema (??); if no improvement, surgery
    • Thumb apposition and abduction median nerve; finger abduction, cross fingers ulnar nn.; extensor mm.of wrist (no intrinsic mm. of the hand) radial nn.
  • Ulnar nerve injury: claw deformity; radial nerve injury: waiter tip deformity (cannot extend wrist or thumb)

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BURNS

  • Silver Sulfadiazine: Broad spectrum/does cover candida/poor eschar penetration/not painful to apply/does not cover PSA/hemolytic anemia in G6PD def./reversible leucopenia
  • Mafenide: Broad spectrum/does not cover candida/good eschar penetration/ painful to apply/carbonic anhydrase inhibitor/wastes HCO3 and retains chloride/hyperchl.met.acidosis/ hemolytic anemia in G6PD def.
  • Silver Nitrate: Broad spectrum/stains everything black/causes hyponatremia and hypochloremia
  • High voltage injury: bone has a high resistance (nerves the least) and this is where most damage occurs; get a hemoglobinuria and myoglobinuria; tx. with alkalinization of urine with HCO3 and mannitol, brisk urine output of 50cc/hr All burn patients get an ileus if 25% TBSA and following resuscitation, return of GI motility by the 3rd to 5th day
    • Conversion of a partial to a full thickness burn with necrosis is the most sensitive sign of burn wound infection/sepsis
  • Scar carcinoma: Marjolin’s ulcer: this is a squamous cell carcinoma which often occurs in previous burn sites that have beenn grafted; Also found in chronic wounds; 20% incidence of LN mets., poor prognosis
    • Corticosteroid injections directly into the lesion, with or without scar excision is the treatment of choice for both keloids and hypertrophic scars
  • TENS: type I is seen in kids; uncommon, due to exfoliative toxin, PCN-resistant S.aureus; type II: high mortality (25-50%), caused by anything with sulfa in it and other things like viral infections, cancers; fever, sore throat, malaise, sloughing of the dermal-epidermal junction (Nikolsky’s sign); can occur anywhere from mouth to anus, all mucosa at risk; treatment is supportive, IVIG is experimental

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VASCULAR

  • Inflammatory aneurysms: 5% of all AAA’s/ tend to be 7cm/tender on exam, lots of pain/ marked thickening of the media and adventitia (not intima)/ dense adherence to the duodenum, ureters and IVC, much harder to dissect free of adjacent structures/increased ESR and C-reactive protein in 75% of patients
  • Restenosis following CEA: F M/ more common in smokers/ is reduced by using a patch at first surgery/ due to intimal hyperplasia
  • Wilke’s Disease: Vascular compression of the duodenum by the SMA; factors assoc. with this are acute weight loss, placement of a body cast, prolonged recumbency, and placement of spinal rods (scoliosis repair); test of choice is an UGI with SBFT; tx: duodenojejunostomy
  • Buerger’s disease (thromboangitis obliterans): Almost always presented with a young, male smoker with claudication; occurs in arteries and veins/ M F 4:1/ Only 5% come to amputation if treatment is followed with quitting smoking and exercise +/- pentoxyfilline (trental)
  • Dysphagia lusoria: anomalous R SC artery coursing b/t the trachea and esophagus causing compression of the esophagus with severe dysphagia; tx: carotid-subclavian artery bypass
    • 70% of all patients with LE claudication will improve or remain the same with non-operaitve therapy; only 20-30% experience worsening of this and only <10% will ever come to amputation secondary to ischemia: non-operative therapy with quitting smoking, exercise and pentoxyfylline is the standard therapy for most patients with claudication
  • Popliteal artery aneurysms: present with ischemia (secondary to thrombosis, only rarely rupture); most common peripheral aneurysm (70%), bilat. in 50-75%, assoc. with other aneurysms, especially AAA (50%), occurs predom. in males b/t 50-70 years old; repair all 2 cm.; some say repair ALL regardless of size in all patients without serious operative co- morbidities; repair with exision and interposition bypass grafting with reverse SVG if possible; compartment syndrome can easily develop after surgery, think about doing 4-compartment fasciotomies (this is a reperfusion injury)
  • Popliteal entrapment syndrome: presented as calf claudicatio n in a young, healthy male; vessels travel around the medial head of the gastrocnemius mm. with plantar flexion resulting in loss of pulses/M F 15:1/ bilat. in 25% of cases/majority present with thrombosis and absent pedal pulses, tx: acutely with thrombolytics then mm. lysis (treat with resection of the medial head mm. insertion); chronic with bypass
  • Fibromuscular dysplasia: 2nd most common in the ICA/see a string of beads appearance on angio./ no therapy if asymptomatic/ not assoc. with atherosclerosis/F M/most common in the renal arteries/symptomatic tx. with serial transluminal dilatation
  • Renal artery aneurysms: presents as dissection and thrombosis, occasionally with rupture/F M secondary to fibromuscular dysplasia/risk of rupture greatest for pregnanc y and HTN, aneurysms 2 cm./tx: direct open repair and bypass grafting ( 90% success)
  • Femoral artery aneurysms: All symptomatic and asymptomatic aneurysms 2.5cm should be fixed
    • Non-occlusive mesenteric ischemia: If there is narrowing of the lumen, but no clot, do not operate, try papaverine through the SMA
  • NASCET: 26% (medical) vs. 9% (surgery) at 2 years; beneficial for symptomatic patients with stenosis 70%
  • ACAS: 11% (medical) vs. 5% (surgery) at 5 years; beneficial for asymptomatic patients with stenosis 60%
  • Subclavian steal syndrome: due to a proximal occlusion/stenosis of the subclavian artery vertigo, diplopia and arm claudication; the most common site of atherosclerotic disease of the upper extremity is the origin of the subclavian artery proximal to the vertebral artery; may hear a supraclavicular bruit; symptoms due to decreased flow in the posterior cerebral arterial flow; tx: subclavian to carotid interposition graft
  • Effort thrombosis: caused by a first rib (compression of SCV b/t 1st rib and clavicle) causing stenosis +/- occlusion of the subclavian vein (Paget-Schroetter syndrome); sudden onset of arm pain, swelling and cyanosis in an otherwise healthy patient who performs some form of repetitive arm activity (carpenter, baseball player, weightlifter); acute events thrombolytics +/- coumadin; chronic tx. with anti-coagulation for minimum 3 months; definitive tx: transaxillary rib resection
  • Splanchnic artery aneurysms: splenic artery is the most common (60%); can tie off splenic artery (and preserve the spleen), but not the vein; prone to rupture in pregnancy; splenectomy for all pregnant pts. with aneurysm and women of child bearing age who may conceive
  • Aortocaval fistula: spontaneous ruptue of a AAA into the IVC; you see high output CHF in 33% of patients, tachycardia and venous HTN, marked leg swelling; tx: repair by closing fistula from within the aneurysm sac

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ESOPHAGUS

  • Boerhaave’s Syndrome: Usually presented with a drunk who presents after heavy retching and emesis; Diagnosis 1st with plain neck and chest look for mediastinal air; 2nd H2O-soluble esophagram, followed if necessary by barium; ith M/M is lowest with primary repair in <24 hours via a thoracotomy (no resection or defxn.)
  • Plummer-Vinson Syndrome: dysphagia/spoon fingers/Fe-defic. Anemia/ fibrous webs at cricopharyngeus mm.; All patients will develop malignant lesions of the oropharynx, hypopharynx and esophagus
  • Diffuse esophageal spasm: hallmark is a pt. who c/o chest pain and dysphagia (often the pt. will have already seen a cardiologist for this); the gold standard for dx. is standard manometry; medical treatment is only minimally effective with nifedipine; surgical tx. is a long myotomy carried through the LES onto the stomach with a partial wrap
    • Adenocarcinoma now accounts for the majority ( 50%) of esophageal cancers, with squamous cell second
    • The single best test for both establishing and quantifying the amount of reflux is the 24-hour pH monitoring
  • Traction diverticulum: mid-esophagus, small, usually secondary to histoplasmosis or TB in the adjacent nodes, usually asymptomatic and do not require surgery; it is a true diverticulum
  • Premalignant lesions: achalasia/reflux esophagitis/Barrett’s/radiation sophagitis/caustic burns/Plummer-Vinson/leukoplakia/diverticula/ectopic gastric mucosa/familial keratosis palmaris
  • Barrett’s esophagus: normal stratified squamous replaced with columnar lined epithelium; dx. with EGD and bx.; A previous Nissen does nothing to cause regression of Barrett’s; High grade dysplasia mandates an esophagectomy
    • The single most important CI to a transhiatal esophagectomy is the surgeon’s assessment on palpation of the esophagus through the hiatus to see if the tumor is fixed to contiguous structures and therefore unsafe
    • Esophageal reflux strictures are best treated with dilatation, Colle’s gastroplasty (to augment length of the foreshrortened esophagus) and fundoplication
    • The effects of a truncal vagotomy are that it abolishes vagally mediated receptor relaxation, causing an increase in emptying of both solids and liquids; also get an increase in gastrin, decrease in pancreatic exocrine function, decrease in HCO3, decrease in bile secretion, increase in fecal fat, decrease in CCK; increase risk of gallstone secndary to decreased GB emptying; most common side effect after a truncal vagotomy is diarrhea, controlled with dietary changes +/- somatostatin
  • Zenker’s diverticulum: Occurs most commonly on the left; best test for dx. Is a barium swallow; pt. c/o regurg. of undigested food and halitosis; can treat with a crycopharyngeal myotomy only if small, otherwise, need a myotomy and diverticulectomy (some will suspend it); Approach always from the left neck, anterior to the SCM; it is a false diverticulum of the pulsion type; Epiphrenic diverticulum is a false pulsion type, located in the distal esophagus and always approached through a left thoracotomy
  • Esophageal cancer: Adjuvant XRT alone no benefit; adjuvant chemo.(single or multiple) no benefit; periop. Chemo. or XRT no benefit; Data supports neoadjuvant XRT + chemo. followed by surgery; 3 yr survival is 32% vs. 6% (surgery alone)
    • When doing a transhiatal esophagectomy, you must preserve the right gastroepiploic artery; try to preserve the right gastric, but you can sacrifice if you need extra length;
    • The most common cause of esophageal perforation is iatrogenic (45-75%); ?? perf. plain neck and CXR (90% of the time, dx. is made) free perf.+<72 hours reinforced primary repair; if walled off perf., minimal symptoms and no sepsis conservative management if fails reinforced primary repair; free perf. of 72 hours consider resection, cervical esophagostomy, G-tube, J-tube; if you can’t make the dx. with plain films, do a gstrograffin swallow 1st, followed by barium
  • Almost all esophageal perf. of <24 hours are repaired primarily; approach based on location: cervical left neck, thoracic right posterolat. thoracotomy, lower 1/3 left thoracotomy; Even those 24 hours, primary repair is still the 1st choice of treatment; debride secure clo sure drainage reinforce with autologous tissue (Thal flap or fundoplication, omentum, pleura, diaphragm, intercostal mm., pericardium)
  • Achalasia: incomplete LES relaxation (<75% relaxation), aperistalsis in the body, neurogenic degener., beak- like narrowing on esophagram, increased incidence of cancer/ tx. most effectively with Heller myotomy and fundoplication (never do a 360 wrap b/c it will be too tight, instead, use a partial wrap like a Toupe)
    • Symptoms of achalasia: barium swallow motility testing EGD mild symptoms observe or dilatation (repeat x3) or nitrates and Ca-channel blockers; if symptoms not controlled or become worse Botox (repeat x3) no relief myotomy and partial wrap
  • Severe caustic injury: Lye (liquefaction) is worse than acid (coagulation); early EGD is the gold standard; tx: EXLAP total gastrectomy (for black tissue), transhiatal esophagectomy, cervical esophagostomy and a J-tube; post-corrosive esophageal cancer is increased a 1000 fold, therefore, must take out the esophagus; reconstruction with the colon is preferred (vs. the stomach)
    • Only give neoadjuvant chemo and XRT for patients with T2,T3 or (+) nodes esophageal cancer; Do not give for T0 or T1 b/c 90% survival with surgery alone
    • EUS is the gold standard for staging all patients with esophageal cancer;
    • Squamous cell cancer is the predominant form of esophageal cancer in black men
  • Transhiatal: Anast. Leak 16%, Chylothorax 3%, leak in chest, mortality uncommon, recurrent nn. Injury 11%, gastric necrosis yes Ivor-Lewis: Anast. Leak 10%, Chylothorax 3%, leak in chest, mortality 50%, recurrent nn. Injury 4%, gastric necrosis no

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STOMACH

  • Late post-gastrectomy dumping syndrome: pt. c/o sweating, dizziness, occasional fainting about 2-4 hours after meals (not 30 minutes early); dx. with a prolonged glucose tolerance test; tx. same as early dumping
    • Can treat early dumping with decreased carbs./decreased sugar/increased protein in diet; can add pectin +/- octreotide
    • Mallory-Weiss tears do not extend into the esophagus; they extend into the stomach along the lesser curvature just distal to the GE junction (only 8-10% extend into the esophagus); the tear is almost always limited to the mucosa only and most stop bleeding without surgical intervention; arterial bleeding from left gastric; never use an S-B tube (can make the tear worse)
  • Carney’s triad: GIST of the stomach/pulmonary chondromas/extra-adrenal paragangliomas
  • There are four main post-gastrectomy syndromes: dumping (early and late)/reflux bile gastritis/afferent loop syndrome/post-vagotomy diarrhea; blind loop syndrome is not a syndrome of gastrectomy
    • A type II ulcer (antral and duodenal) is generally benign and assoc. with gastric hypersecretion; treatment of choice is vagotomy and antrectomy to include the ulcer
    • Never do a parietal cell vagotomy for a type III ulcer because of a very high failure rate
    • Alkalinity, A.A.’s and Ach, proteins and gastric distention all act on the antral Gcell and cause gastrin release; gastrin, histamine and Ach all act on the parietal cell causing HCL release (inhibited by secretin); secretin stimulates the release of H2O and HCO3 from pancreatic ductal cells, neutralizing gastric acid, increasing bile flow, decreasing GI motility and decreasing gastrin release
    • In the presence of a perforated gastric ulcer, definitive ulcer surgery should only be performed if there is a known history of PUD (therefore, pt. with an unknown H.pylori status and NSAID has an unknown history); pt. also needs to be stable to perform a PCV (+ h/o PUD); Recalcitrant PUD best treated with a V+A, not PCV; for a perforated ulcer, unstable pt., do a V+P
    • Treat a type I gastric ulcer (lesser curve, nml. acid) with a partial gastrectomy or simple ulcer excision; you don’t need to do a vagotomy b/c increased acid is not the problem; type II and III: V+A with a B-I or B-II; type IV: near total gastrectomy with R-en-Y esophagojejunostomy
    • Early dumping can almost always be managed with dietary changes like decreasing frequent small meals, high protein, low carbs and sugar, low salt and fluid, lie supine after meals, add pectin
  • Gastric ulcer: type I: along the lesser curve, nml. to low acid, perforation, blood group A; type II: body and duodenum, hypersecretion, hemorrhage and obstruction and perforation; type III: prepyloric, hypersecretion, hemorrhage, perforation, blood group O; type IV: high on lesser curve near GE jxn., low acid, hemorrhage and perforation; type V: NSAID use and ASA
    • Vagotomy and antrectomy has the lowest recurrence rate; V+P has the highest morbidity; HSV has the highest recurrence rate (15%), but the lowest M+M
  • Type III paraesophageal hernia: GE jxn. is displaced into the thorax with a hernia sac containing fundus and body; has both organoaxial and mesoaxial rotation of the stomach (can get strangulation and perforation of the stomach)
  • All type II rolling hernias (paraesophageal) should be repaired: Has a normal G/E junction below the diaphragm (intact angle of His); fundus and body rolls alongside the esophagus with organoaxial rotation of the stomach; has a peritoneal sac; repair + fundoplication is the mainstay of tx. with anchoring of the stomach to the anterior abd. wall and arcuate ligament
  • Type I sliding hiatal hernia: GE jxn. displaced into the thorax, slides back and forth, no hernia sac;
    • Early MALT lymphomas can be effectively treated by eradicating H.pylori, without surgery; for late, advanced disease, total gastrectomy (probable standard R2 nodal dissection)
    • Only 15-20% of all patients with PUD have H. pylori, but almost all (90%) duodenal ulcers are associated with H.pylori; It is associated with an increased risk of cancer and is classified as a level I carcinogen
  • GIST: complete surgical resection remains the primary treatment of choice; unresponsive to chemo.
  • GI tract lymphomas: early stage I,II: treat with surgery followed by XRT and chemo.; for stage III,IV: XRT and chemo., no surgery, resect only for complicationsm
  • Gastric lymphoma: curative resection followed by adjuvant chemo and XRT is the best treatment option
    • Megaloblastic anemia can be seen secondary to chronic afferent loop obstruction blind loop bacterial overgrowth vit. B12 def.

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SMALL BOWEL /LARGE BOWEL/ RECTUM

    • Duodenal ulcers: assoc. with smoking, HpTH, high calcium, COPD, uremia, P.vera, and liver disease; treat wit h a V+P without resection of the ulcer (you oversew the ulcer and place an omental patch); remember, antrectomy without vagotomy is the accepted standard of tx. for gastric ulcers, but if an antrectomy is done for a duodenal ulcer, it requires the addition of a vagotomy
  • HNPCC (Lynch I, II): AD/familial form of colon and rectal cancer/not assoc. with FPC/6% of all CRC’s; predisposed to right-sided colon cancers by 40-45 yoa; Lynch I: site specific and no extracolonic malignancies and Lynch II (those with extracolonic malignancies) such as endometrium, ovary, stomach, small bowel, urinary tract and biliary tree; begin surveillance at 25 yoa; more common on the right side;tx: subtotal colectomy; mutation in the DNA repair genes (Mismatch repair genes, MSH2, MLH1,PMS1,PMS2)
    • The most common complication of a Meckel’s in the adult is obstruction (not bleeding as in the child)
    • Surveillance colonoscopy is advocated at 8 years of disease (not at a specific age) in patients with UC
    • The treatment for radiation proctitis is instillation of 4% formalin
  • Crohn’s disease: transmural inflammation/granulomas/skip lesions/ cobblestoning/primary sclerosing cholangitis / ankylosing spondylitis/ erythema nodosum/ pyoderma granulosum/ episcleritis/iridocyclitis
  • Celiac sprue: are at an increased risk of future malignant GI disease, especially T-cell lymphomas
  • Toxic Megacolon: Seen in pt. with UC/ treat with bowel rest/NGT decompression/high dose steroids/ABX; if no improvement in 48 hours, consider abdominal colectomy, ileostomy with Hartmann’s or mucous fistula
  • UC: assoc. with increased risk of cancer that increases with the duration of time having UC(10% at 10 years);
    • In the non-asian population, 95% of diverticular disease occurs in the left colon; in Asians, 15-20% occurs in the right colon
  • FAP: AD/ 100 adenomatous polyps in colon/All pts. will develop cancer if not treated/genetic defect in the APC gene on chromosome #5/polyps begin around puberty/ must perform EGD’s because 70% will develop gastric and duodenal polyps which are also at risk for cancer/10% get desmoid tumors which should be resected (if not respectable, tx. with tamoxifen or clinoril (PG inhibitor)); definitive tx. for FAP is colectomy with ileoanal pouch; if you do an ileorectal anastomosis, you must monitor the anastomosis with bi-annual scopes to look for recurrence (rectum still at risk); must screen all family members from 10-40 yoa + EGD q1-2 years after age 30 (look for gastric and duodenal adenomas); tx: total proctocolectomy with ileostomy or total colectomy with ileorectal anast. (if <50 polyps in rectum and no cancer) or total proctocolectomy with ileoanal anast.
  • Gardner’s syndrome: FAP + Osteomas + Epidermal inclusion cysts
  • Turcot’s syndrome: FAP + brain tumors
  • Peutz-Jegher: AD/mucocutaneous melanotic pigmentation/multiple hamartomatous polyps of the GI tract; no malignant potential
  • Juvenile polyposis: occurs at any age/AD/adenomatous (neoplastic) and juvenile (non- neoplastic components)/ anemia/clubbing/ tx. with aggressive polypectomy with C-scope or total abd. colectomy
  • Ischemic Colitis: Left sided cramping/seen after surgery, often AAA repair/abdominal pain/bloody diarrhea/temp./LLQ tenderness/thumbprinting on contrast enema/submucosal hemorrhage and edema
  • Carcinoid: check urine for 5-HIAA levels, the main metabolite of serotonin; most common site is the appendix, and 90% of small bowel primaries in the ileum; tx. carcinoid with liver mets with octreotide +/- alpha-INF, hepatic artery embolization, chemo., resection; Bronchial carcinoids Cushing’s syndrome, assoc. with N-myc and c-jun activation; p53 has not been implicated
  • Malignant carcinoid syndrome: hepatomegaly, diarrhea, flushing, right heart valvular failure, asthma, malabsorption and pellagra; tx: hepatic resection (debulking is helpful for symptom control); if unresectable, tx. with octreotide and niacin (to prevent pellagra)
  • Hallmark of carcinoid heart disease is: endocardial fibrosis involving the right heart, in particular the tricuspid valve and chordae
  • Anal fissures: posterior midline in 95% of cases; best tx. with lateral internal sphincterotomy; botox. also effective therapy; topical NTG not so good, causes bad headaches; if lateral fissure, think Crohn’s disease
    • Colorectal mets. to the liver: poor prognosis associated with <1cm margins, 3 mets. in any given lobe, bilobar disease, short DFI, Dukes C primary lesion
    • Celiac disease, Crohn’s, HIV, transplant patients, AIDS, Wegener’s granulomatosis, RA, Wiscott-Aldrich: All associated with small bowel lymphomas with almost all being NHL (B-cell)

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GU/ OB / GYN-ONC / NEUROSURG

    • An isolated extraperitoneal bladder rupture can be treated without an operation with a Foley for 2 weeks; f/u with a cystogram prior to removal; intraperitoneal injuries must be repaired in OR
  • Bladder cancer: superficial or in-situ: transurethral excision or fulgaration or laser ablation; can repeat for a superficial recurrence, but the treatment of choice becomes intravesical BCG or BCG + mitomycin or thiotepa or doxorubicin
  • Bladder cancer with any muscle invasion: segmental cystectomy if a 2 cm. margin is possible; if not, treat with radical cystectomy and pelvic LND for diffuse disease; urethrectomy should be included if cancer involves the trigone or prostatic urethra or those with carcinoma in-situ of the urethra; che mo. given to those with metastatic disease (+ pelvic LN’s included) or those with a recurrence;
    • Most kidney stones are calcium oxalate stones (75%) worldwide; they are radioopaque and easily seen on KUB and CT; CaPhos. stones seen with HPTH, RTA, medullary sponge kidney; CaMgNH4PO4 stones are called struvite stones and seen primarily with UTI’s (15%)
    • Seminomas are extremely radiosensitive and is the treatment of choice following orchiectomy; will never have an elevated alpha-FP or HCG; many will have elevated neuron specific enolase (NSE); uncommon presentation may be a young male with a large anterior mediastinal mass seminoma vs. NSGCT; if + nodes, cisplatin as well
  • NSGCT (non-seminomatous germ cell tumor): will often have elevated alpha-FP and HCG; are not radiosensitive and therefore treat with surgery followed by chemo.; stage I: orchiectomy, retroperitoneal LND; stage II: same, stage III or large stage II: chemo 1st (cisplatin-based), re-staged, if residual tumor, more chemo; if not, then surgical resection
    • Left spermatic vein L renal vein; Right spermatic vein IVC
    • Left varicocoele after age 40 think about a renal cancer b/c remember, the left spermatic vein drains into the left renal vein; A right varicocoele may mean an obstruction of the IVC; Varicocoeles present as a bag of worms of worms on palpation with pain; indications for treatment are persistent pain, low sperm count and large size; tx: ligation of the spermatic vein and all collaterals
    • If a young women has an indeterminate, large ovarian mass, it is appropriate to remove the ovary on that side, fallopian tube and do a complete staging operation; never perform a complete TAH/BSO; Also , if you see a mass on U/S, you can watch it for 3 menstrual cycles safely and see if it goes away with serial U/S exams;
  • Endometrial cancer: the most common malignancy of the female genital tract; risk factors: no children/obesity/HTN/DM/late menopause; hallmark is abnormal vaginal bleeding after menopause; A malignancy must be ruled out in any postmenopausal woman with bleeding
    • All abnormal PAP’s are followed with a colposcopy and biopsy; Any gross cervical abnormality found on exam (even with a normal PAP) should get the same; if no diagnosis, then proceed to cervical conization or LLETZ; Further, all CIN 3 is treated with conization or LEEP
  • Cryptorchidism: Most testes will descend by 9 months, therefore wait at least this long to operate; should be surgically repositioned by 2 years old; decreased fertility and increased testicular degeneration; increased chance of malignancy even after operative repair with bilateral orchiopexy
  • Anterior spinal artery syndrome: Bilat. loss of motor fxn., pain and sensation below the level of the lesion with sparing of position and vibratory sense and light touch sensation; seen with acute rupture of a cervical disc followed by occlusion of the anterior spinal artery
  • Brown-Sequard syndrome: ipsilateral loss of motor fxn. and position/vibratory sense with contralateral loss of pain, temp and sensation below the level of the injury
  • Central cord syndrome: bilateral loss of motor fxn., pain , temp. and sensation in upper extremities with sparing of the lower extremities; usually due to a hyperextension injury
    • There is no benefit to using ABX for basilar skull fractures with otorrhea or rhinorrhea
    • A herniated disc b/t L4 and L5 impinges on the L5 nerve root
  • C1 fracture: Jefferson fracture fx. of lateral masses; Odontoid fracture , type I: tip only, II: across the base (most common), III: across base and extend into the body of the axis; C2 fracture: posterior elements fracture

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COAGULATION

    • von Willebrand’s Disease: Increased bleeding time, PTT can be elevated, PT normal; AD; TX: cryoppt., Factor VIII conc. or DDAVP
    • Protein C deficiency is associated with a warfarin- induced skin necrosis
    • Highest viral risk for blood transfusion is CMV infection
    • Impaired sensitivity of Factor V to protein C is called activated protein C resistance and is caused by a point mutation in factor V (Factor V Leiden); This is prevalent in 3-5% of the general population and may account for up to 30% of all idiopathic venous thromboembolic cases (the most common reason)
    • Hemophilia A: Factor VIII deficiency, X-linked recessive, increased PTT, normal PT and BT
    • Cryoppt. is used primarily to replace factor VIII and fibrinogen, although it also has vWF, F XIII and fibronectin
    • Vitamin K deficiency is caused by antibiotics that kill gut flora (which make it); can see with malnutrition and TPN
  • ATIII: inactivates thrombin, complexes with heparin to remove factor XII, XI, X, IX from blood, made primarily by mast cells, ATIII deficiency = lupus anticoagulant = anticardiolipin Ab that intereferes with phospholipids and lipoprotein
    • Arachidonic Acid PGI2 and TXA2 (enzyme necessary is cyclooxygenase, COX-1); irreversib le inhibition with ASA; TXA2 potent vasoconstriction, decreases cAMP, increases Ca mobilization, increases platelet activation, decreases adenylate cyclase (prostacyclin does all the opposite)

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INFECTIONS /CRITICAL CARE/ TRAUMA/ ICU/ FEN

    • High dose steroids in the trauma patient are only indicated for patients with blunt spinal cord injury (give methylprednisolone @ a bolus of 30mg/kg followed by 5.4 mg/kg for 24 hours); Do not give at all if 8 hours out from the time of the event
    • A parasternal stab wound at or around the 5th ICS mandates a DPL (not a thoracotomy); emergent thoracotomy only if you have a pericardial tamponade, hemothorax of 1.5L initially or hemorrhage of 250ml/hr + shock; perform an anterolateral thoracotomy (not posterolateral)
    • A left subclavian artery injury is best approached via an anterior thoracotomy through the 3rd and 4th ICS, or creating a trap door incision using this approach; A right SCA injury is best approached via a median sternotomy
    • Never do a cricothyroidotomy on a child <12 y/o; for an emergent airway, do a needle cric. or trach.
    • RSBI= breaths/min/L, freq/TV, most sensitive indicator for (un)successful weaning from vent extubation
    • The only absolute CI to MAST trousers is pulmonary edema
    • Tumors cannot usually be detected until about 30 doublings = 1 gm of tumor = 10(9) cells; A lethal tumor burden is only 3 more doublings, 10(12) cells
    • Patient post-op. with drainage from wound 12-24 hours after surgery: don’t forget about Clostridium perfringens: open wound, send G-stain, if GPR’s, give PCN G (high dose) and take back to OR for Wide debridement to healthy appearing tissue with return to OR in 24 hours
    • Cortisol must be present with IL-6 in order to make acute phase proteins
    • Chronically ill patients on TPN get acalculous cholecystitis
    • A-aDo2 gradient is normal with hypoventilation and high altitude, it is increased with V/Q mismatch, diffusion defect and shunt
  • Hypoxemia: most commonly results from V/Q mismatch secondary to shunting with an increase in deadspace ventilation; for diffusion abnormalities, V/Q mismatch and hypoventilation 100% O2 will correct the hypoxemia; this will not correct for shunt
    • Risk factors for the development of an UGI bleed in the ICU: mechanical ventilation and coagulopathy (4% risk with either one or both, <0.5% if neither), SCI, CHI, MSOF, severe burns
    • Risk factors for post-op. pneumonia: 60 y/o, trauma, CHI, Impaired airway reflexes, ETT 48 hours, Upper abd or thoracic operation, low serum albumin, neuromm. disease, use of an NGT, prolonged use of prohylactic ABX
  • Hemorrhagic shock: peripheral vasoconstriction/decreased CO/increased ADH/increased glucocorticoids/ increased A-a gradient
  • Lung compliance: change in volume / change in pressure; compliance is increased with emphysema and decreased with pulm. edema, ARDS, pulm fibrosis, pneumonia
    • RQ= CO2 production/O2 consumption; RQ 1 too many carbs, RQ=0.85 is mixed fat and carbs, RQ=.6 to .7 is fat consumption; a lower RQ in a septic patient reflects impaired glucose metabolism, increased gluconeogenesis and a greater reliance on lipids as an energy source
  • TPN formulation: Any % solution is 1 gram per 100 ml, always. ie: D20 = 20 gm per 100ml or 200 gm per liter; therefore: 500ml of D40W= 500ml x 40gm/100ml x 3.4 kcal/gm = 680 kcal; 500 ml of 8.5% A.A.’s= 500ml x 8.5gm/100ml= 42.5 gm protein; 500 ml of 10% lipids= 500ml x 1.1 kcal/ml = 550kcal; 3-omega fatty acids are better than 6-omega FA’s and reduce inflamm. Mediators; try for a calorie: Nitrogen ratio of 150 kcal per gram of nitrogen; DEKA are fat soluble vitamins; Fat=9/carbs=3.4/protein=4; growth hormone given with TPN results in a positive nitrogen balance and positive phosphorous balance, no effect on potassium, increased wt. gain secondary to H2O and Na retention
  • SBP: Ascites with low protein (<1g/dl) are 10X more likely to develop SBP than those with protein levels 1g/dl; high protein renders resistence to SBP; duration of ABX based on ascitic PMN count check q48 hours when <250 can stop ABX; high recurrence rate after 1st episode (50% @ 6 months); This is a single organism disease with E.coli, step and Klebsiella accounting for 85% of all cases
  • ETT size for a child = 16 + age/4; normal SBP= 70 + (2 x age)
  • Stress ulceration: current indications include pt. on a vent., coagulopathy, SCI, head injury, MSOF and severe burns
    • Coronary perfusion pressure=DBP-CVP (80-8=72); <25 is fatal; 65% of the coronary blood flow occurs during diastole
    • Oxygen extraction ratio (O2ER)= O2 uptake/O2 delivery (=VO2/DO2)
    • DO2 (O2 delivery)= CO x PO2; SVR= (MAP-PCWP)/CO x 80
  • Water deficit: observed Na – 140/140 X 0.6 X body wt. (in kg.)
    • Albumin half life =20 days/pre-albumin=2-3 days/transferrin=8days/retinal binding protein=10 hours
    • 1 gram of nitrogen = 6.25 grams of muscle protein; N2 balance= (protein intake/6.25) – (24 hour UUN + 4)
    • BCAA’s are lysine, isoleucine and valine and preferentially used by muscle for energy; BCAA BCKA alanine, glutamine and glutamate liver glucose (Cori cycle)
    • In starvation, 75% of fuel needs of brain are met by acetoacetate; decrease glucose decreased insulin increased glucagon increased fat mobilization TG’s FFA’s + glycerol liver ketones
    • Increased aromatic AA’s as sepsis worsens and liver fxn decreases causing encephalopathy, hypotension and vasodilatation
    • Arginine enhances wound healing; it is also the precursor for Nitric Oxide (NO)
  • PEEP: increases FRC/improves pulmonary compliance/decreases intrapulm. shunt fraction/ increase deadspace by overdistending the alveoli/ can increase ICP/causes fluid retention and edema secondary to increase in ADH
    • Class II hemorrhage occurs when you lose 750ml -1.5 liter of blood; this is the first time that you see a decrease in the pulse pressure; Class III is the first time to see tachycardia (pulse 120), decrease in SBP and U/O
  • ARDS: major criteria: hypoxemia (increased FIO2), low compliance, decreased FRC, bilat. Pulm. Infiltrates (fluffy), increased deadspace ventilation;
    • Prerenal azotemia: Urine SG<1.020, Na<20, RFI<1, FENa<1%, urine osmol 500, BUN/Cr ratio 15:1
    • In a pt. with a normal PCWP, with a C.I.<2, think about increasing SBP with DA, followed by IABP insertion;
    • Angiography and external fixation is the tx. of choice in a patient with a pelvic fx. that continues to bleed (will usually continue to bleed after external fixation)
  • DPL: positive if you get gross blood, bacteria on G-stain, TB or amylase serum, 500WBC/ml, 100,000RBC/ml (blunt), 20,000 RBC/ml (penetrating)
    • FRC= ERV+RV; VC=IRV+TV+ERV
  • FENa: Urine Na x Plasma Cr / Plasma Na x urine Cr
    • Osmolarity= 2(Na) + glucose/18 + BUN/2.8
    • Pancreatic and duodenal trauma have a mortality of 20% with 75% of duodenal injuries from penetrating trauma; Basically, never do a Whipple for trauma unless it is your last and only option; Intraop pancreatography is often very helpful to define proximal pancreatic ductal injuries and susbsequent stenting across such and injury
    • Important intracellular buffers are proteins and phosphates; for RBC’s the primary intracellular buffer is Hgb; extracellular buffers are primarily HCO3 and H2CO3 system; pH=pK + log (HCO3)/(H2CO3), at ph=7.4, a 20/1 ratio
    • Low magnesium parallels low K; 20-30% Mg is protein bound; too much Mg lose DTR’s
  • Amrinone: phosphodiesterase inhibitor, increases CO, decreases SVR; phenylephrine has pure alpha-1 activity; isoproterenol has pure beta-1, Dobs B- 1, some B-2, NE alpha and beta

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PARATHYROID AND THYROID

  • Secondary HPTH: Occurs in almost all patients with advanced renal failure and on dialysis; Will have bone disease secondary to HPTH; Increased serum PTH causing renal osteodystrophy (kidney loses calcium, keeps phosphate, cannot hydroxylate Vit.D therefore causes decreased absorption of calcium by the gut which in turn causes PTH levels to increase); tx: 1st with oral calcium supplements, restrict phosphate in die t to <600mg/d, increase phosphate bindingresins and Vit D analogues; decrease aluminum in dialysis bath and diet (it accumulates in the bone causing osteomalacia)
  • Indications for surgery: In pts. with symptoms from secondary HPTH or from tertiary HPTH and CRF: hypercalcemia in a renal transplant pt./ pathological fx. secondary to renal osteodystrophy/ secondary symptoms to HPTH like pruritus, bone pain, soft tissue calcification, and calciphylaxis, Calcium x Phosphate product 70: Treatment of choice is a 4-gland parathyroidectomy with immediate autograft in the SCM (fxn. in 87% of pts. @ 20 month f/u)
    • 53 y/o with a 2 cm mass in post. neck, FNAB benign appearing thyroid cells with papillary features, no thyroid masses, what next? Pt. has metastatic papillary cancer of the thyroid from an occult thyroid primary. Due to her age, + mets, she should have a total thyroidectomy, MRND, followed by post-op. RAI ablation
    • If you see a really high calcium ( 15), think about parathyroid cancer; Death from tumor growth is rare, death usually from uncontrollable hypercalcemia therefore aggressive reoperation required with maximal tumor debulking (often including the thyroid lobe on the involved side); the only certain sign of tumor recurrence is a re-occurrence after resection
    • Hyperthyroidism during pregnancy is usually due to Grave’s disease; treat with
    • PTU (not B-blockers, not surgery, not RAI)
    • Parathyroid glands: the superior glands are from the 4th branchial pouch, blood supply for both from the inferior thyroid artery; superior gland is anterior to the recurrent nerve
  • MCT: R/O MEN IIA; Treat the pheo. 1st; increased calcitonin/siblings are at risk/abnormal pentagastrin stim. Test; only the differentiated thyroid cancers take up RAI (I131), MCT does not
    • If you see amyloid on pathology, it is diagnostic of MCT
  • Hurthle Cell Cancer: 3-10% of thyroid cancers/ As size increases, malignant risk does as well, tumors 4cm 65%, 6-10cm 80%; very difficult to differentiate b/t benign and malig. on FNAB; Has a poorer prognosis compared to follicular and papillary, more aggressive and metastasizes earlier; Does not take up I131; total thyroidectomy is appropriate treatment for all Hurthle cell cancers and adenomas 4cm
    • Injury to the superior laryngeal nn. (external branch) will produce a lowpitched voice and you lose the ability to produce high-pitched singing (weakened high pitch control)
  • Recurrent laryngeal nerve injury: paramedian location of the ipsilateral cord; if permanent, can try teflon injections into cord
  • Thyroid storm: 20-30% mortality, fever, hypotension, CHF, circulatory collapse; tx. with KI to suppress thyroid fxn., steroids to tx, assoc. adrenal insuff., Bblocker for tachycardia and PTU to suppress thyroid hormone synthesis and conversion of T4 T3; PTU can cause agranulocytosis and aplastic anemia
  • AMES criteria for high or low risk: Age 45 has a poorer prognosis, Mets. at the time of dx. poor prognosis, Extent and Size : larger size has poorer prognosis; females have an improved survival compared to males
    • Primary treatment for MCT is a total thyroidectomy and central node dissection; you can treat a recurrence with an octreotide scan which detects calcitonin

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HEPATOBILIARY

    • Sickle cell/chemotx./prosthetic valves/hereditary spherocytosis all are assoc. with an increased incidence of cholelithiasis
  • Pyogenic liver abscess: Very often presented with an Asian person who recently has been in Asia and is now back in US presenting with fevers, WBC +/- RUQ pain; commonly follows cholangitis, diverticulitis or appendicitis; treatment is CT-guided needle aspiration and IV ABX
  • Porcelain gallbladder: Anyone with a porcelain gallbladder should have a cholecystectomy b/c there is a 35-65% risk of GB cancer
  • Echinococcal cysts (hydatid cysts): Invariably given a migrant wirker or someone who has traveled to Mexico; treat with surgical resection (tx. of choice) +/- ABX. Be careful to not spill cyst contents into the abdomen; do not do percutaneous procedures
    • Brown pigment stones are most commonly found in the CBD (not black stones)
    • Amoebic liver abscess: caused by E.histolytica; pt. presents with F/C/N/V/D; Flagyl is the mainstay of treatment, however, if no effect, may need open drainage
  • Emphysematous cholecystitis: Any evidence of air in the GB wall and clinical symptoms requires IV ABX and emergent operation
    • There is no reason to perform a lap. chole in a diabetic with asymptomatic cholelithiasis; Current indications for pre-op. ABX for a lap. chole. are: acute cholecystitis, age 60 yoa, obstructive jaundice, CBD stones
    • All hepatic adenomas require resection because of the increased risk of malignancy (10%); Tc99 scan is negative, cold nodule; no Kupffer cells; definitely associated with OCP use; abdominal symptoms are common
  • FNH: central stellate scar; Tc99 hot, + Kupffer cells, possibly assoc. with OCP’s, tx. by stopping OCP’s; no symptoms
    • Treatment of a type I (most common) choledochal cyst is by roux-en-Y hepticojejunostomy and excision of the entire cyst (do not attempt a primary duct anastomosis)
    • Hemobilia following hepatic injury suggests bleeding directly into the biliary tract from a lacerated hepatic artery; the treatment of choice is angiography with embolization
  • Hepatorenal syndrome: Cr 1.5, Cr clearance <40ml/min, no benefit from fluid challenge, urine volume <500ml/day, urine Na<10, urine osmolarity plasma osmolarity
  • Primary sclerosing cholangitis (PSC): 4th leading indication for transplant/unknown etiology/progressive liver failure cirrhosis portal HTN/70% of cases occur in men/assoc. with chronic UC/onion skin changes on biopsy are pathognomonic; ERCP for dx.
  • Hemangioma: Giant ones in kids Kasabach-Merritt Syndrome: children with a palpable abd. mass, high-output CHF and coagulapathy due to sequestration of platelets and fibrinogen
  • Budd-Chiari Syndrome (BCS): The preferred therapy for acute and subacute BCS is a side-to-side portocaval or mesocaval shunt; use TIPS for fulminant hepatic failure (as a bridge to transplant); Usually see acute onset of ascites, with high protein in it
  • Known risk factors for HCC are: HBV, ETOH cirrhosis, any cirrhosis, aflatoxins, vinyl chloride, hemochromatosis (not primary biliary cirrhosis)
  • Kasai procedure: is most successful if performed before 3 months of age (b/c the fibrosis is progressive with biliary atresia)

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PEDIATRIC SURGERY

  • Wilm’s tumor: occurs usually b/t 1-5 years old/primary therapy is surgical resection/good overall prognosis/Bilateral Wilm’s Bilateral nephrectomy with safe renal transplant after 1 year/responds well to chemo./associated with the WT1 tumor suppressor gene/ 3 syndromes: WAGR, Beckwith-Wiedeman and Denys-Drash/ Tx. of Wilm’s is with resection for local control and chemo. (XRT for advanced disease); staging: I: limited to kidney/complete resection, II: still completely resected, extends beyond the kidney +/- capsular extension or invasion, III: residual tumor in abdomen or tumor rupture or peritoneal implants + (+) L.N.’s, IV: hematogenous mets. other organs; V: Bilateral renal involvement; I,II: resection and chemo.; III,IV: resection and chemo and XRT; All anaplstics: resection, chemo and XRT; if ?? unresectable neoadj. Chemo and XRT resection if shrinkage occurs
  • Neuroblastoma: neural crest origin; 40% from adrenal medulla, elevated HVA and VMA (90% have this), increased ratio of VMA/HVA is good prognosis; dx. Requires histologic confirmation by direct tumor biopsy; stage with CT of C/A/P, bone scan classify into high, intermediate or low-risk groups at diagnosis; high risk: 1 year old, stage III,IV, unfavorable histology, increased ferritin, increased LDH, increased NSE; tx. of low risk surgery, high risk neoadjuvant chemo. (with initial surgery for dx. and port placement only) with complete gross resection reserved for a 2nd look procedure after chemo.; N- myc is a protoncogene seen in 30% of tumors
  • Omphalocoele: midline at umbilicus/covered with a peritoneal sac/ assoc. with other congenital abnorm.’s/ may contain eviscerated organs such as liver
  • Meckel’s diverticulum: caused by a persistent omphalomesenteric duct; can contain gastric or pancreatic tissue; usually painless rectal bleeding ~2 yoa
  • Duodenal atresia: prenatal U/S reveals polyhydramnios with fetal distention of stomach and duodenum; double-bubble on CXR do a BE to r/o microcolon +/- obstructing meconium; assoc. with trisomy 21 in 30% of cases, 38% with congential heart defects
  • Intussusception: repeated bilious vomiting usually in the 1st year of life; current jelly stools; use abdominal U/S 1st to dx. (accuracy close to 100%); can dx and tx with BE (30 cm above buttocks)
  • Gastroschisis: prolonged ileus at birth/ defect is lateral and to the right of the umbilicus/no peritoneal sac/inflamm. peel from irritation by amniotic fluid/ only rarely assoc. with congenital abnorm’s
  • Pneumatosis intestinalis: is never an indication to take a neonate to the OR for NEC; portal venous gas, free air, a fixed and dilated bowel loop, abdominal erythema and mass, bacteria in paracentesis fluid, uncontrolled persistent acidosis and thrombocytopenia are all indications for Ex Lap.
  • NEC: Will almost always be presented with a neonate receiving enteral feedings who becomes intolerant of feeds; prematurity plays a major role in the development of NEC; most will survive without an operation with bowel rest, systemic ABX and TPN
  • Testicular torsion: acute, severe onset of testicular pain assoc. with N/V without a cremasteric reflex; must operate within 6 hours or risk testicular necrosis
  • Indications for ECMO: aADO2 diff. 610 for 8 hours; acute deterioration, barotrauma, cardiac failure, does not stabilize on conventional therapy, oxygenation index 40 for 2 hours; delayed CDH repair facilaited by ECMO results in improved overall survival, reduction in pulmonary compliance after surgical repair and decreased barotrauma
    • Neonates are obligate nose breathers
  • Thyroglossal duct cyst: Remnant of thyroglossal duct extending from the foramen cecum of the tongue to thyroid isthmus; Always midline; +/- if it gets infected; tx: Sistrunk procedure (complete excision of cyst including central portion of the hyoid bone)
    • Urachus connects the bladder to the umbilica cord in utero and incomplete closure at birth results in either a persistent fistula, draining sinus or urachal cyst; tx. with I+D followed by elective complete cyst excision

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ANESTHESIA

    • Nitrous (not nitric) causes peripheral neuropathies, megaloblastic anemia and BM depression/ sevofluorane and enflurane produce fluoride ions and can cause ARF/ Isoflurane can cause a coronary steal syndrome/ Halothane can cause a halothane hepatitis, seen in middle age fat women/ pancuronium is a vagolytic/ succinylcholine is a vagotonic/ Atracurium is metabolized by Hoffman degradation (plasma pseudocholinesterase) and therefore does not affect the liver or kidney
  • CO2 embolism: causes acute SVC obstruction; Increased CVP, PAP, CO with decreased SBP with an abrupt decrease in ETCO2; put pt in left lateral decub., trendelenberg
  • Succinylcholine: depolarizing agent (only one); metabolized by plasma pseudocholinesterase; acts on the Ach receptor
  • Ketamine: causes a dissociative state/ causes an increase in HR, SBP and CO with bronchodilatation, increased CBF and increased O2 consumption/ should not use in pts. with increased ICP’s or uncontrolled CAD and HTN; does not depress respiration; can cause acute intermittent porphiria; produces amnesia and analgesia
    • Malignant hyperthermia: the earliest and most sensitive and specific sign is an unexplained rise in the ET CO2; this is rapidly followed by tachycardia, PVC’s, hyperkalemia, increased CPK, mm. rigidity, respir. and metabolic acidosis, cardiovascular collapse; known triggers are all inhalational agents and succinylcholine; abnormal Ca release in skeletal mm. causes sustained mm. contractures; tx: stop surgery, stop inhalational agents, 100% O2, protect the kidneys from myoglobinuria and rhabdomyolysis, cool pt., IV dantrolene whichs interferes with Ca release from the sarcoplasmic reticulum
    • All esters have only one I in their name; broken down to PABA, Very allergenic, safer than amides, shorter half- life

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MISCELLANEOUS

  • GI bleeding: technetium sulfur colloid scan: can detect a LGI bleed as low as 0.5 ml/min, but patient has to be actively bleeding/ tagged RBC scan detects at 1 ml/min and remains in circulation for up to 24 hours and therefore you can bring the patient back and look again/ mesenteric angiography detects at 1ml/min; can infuse vasopressin which stops the bleeding in about 85% of cases, however high chance for re-bleeding within 48 hours
    • IMA superior rectal artery; IIA middle rectal artery; IIA internal pudendal inferior rectal artery
    • Inguinal ligament is the most inferior part of the external oblique aponeurosis; All hernias have a defect in the transversalis fascia;
    • Left vagus anterior hepatic branch; right vagus posterior celiac branch and criminal nerve of Grassi
    • Ventral pancreas uncinate process and inferior portion of head; dorsal pancreas remainder of the pancreas; uncinate is to the left and behind the portal vein and SMA, in front of the aorta and IVC, below and ventral to the left renal vein
    • Give Vit. A to overcome steroid- induced healing impairment (25,000 IU/ml) or GHRF or anabolic steroids
    • Arginine is a conditionally essential AA that promotes collagen deposition, wound healing, immune function, NO production
    • Glutamine decreases the risk of infectious complications and increases nitrogen balance overall
    • P. vera: primary has a low EPO, secondary has high EPO (physiologic response to high altitude)
  • Arterial supply to the adrenal: superior adrenal artery (from inferior phrenic a), middle adrenal artery (from aorta), and inferior n artery (from renal artery); venous drainage is usually via 1 main vein; left adrenal vein left renal vein; right adrenal vein IVC
    • Triglycerides are broken down into monglycerides and (2) FFA’s which combine with bile salts and fo rm micelles (single most important step in fat absorption); micelles (FFA’s, monglycerides, phospholipids, cholesterol, bile salts) are broken up at the brush border and TG’s are re-synthesized in the cells of the gut with formation of chylomicrons which are absorbed by the lacteals and transported to the thoracic duct bloodstreams
    • Metoclopramide is a DA antagonist, increases LES pressure, increases gastric contraction, Ach augments release, used for delayed gastric emptying/gastroparesis
  • Collagen: accumulates in the scar until 21 days, it shows up in a wound at day #3, only fibroblasts before this, peaks at day #7; unique b/c of hydroxyproline which requires ascorbic acid and oxygen; once in ECM, collagen cross- linking occurs; inhibited by D-penicillamine and beta-aminopropionitrile
    • Endothelial cells, macrophages, neutrophils L-arginine NO converts GMP to cGMP causes PKC to dephosphorylate myosin light chains muscle relaxation and vasodilation
    • IMA (internal thoracic artery): arises from the 1st portion of the subclavian artery medial to the anterior scalene; posterior to the clavicle and one fingerbreadth lateral to the border of the sternum; gives off anterior intercostals and cutaneous branches and terminates as the musculophrenic and superior epigastric arteries
    • Subclavian artery Thyrocervical trunk suprascapular artery 1st then the transverse cervical artery, continuing on as the inferior thyroid artery
    • NaNitroprusside NO vasodilatation of both arterioles and venules; decreased myocardial O2 consumption/increased HR/causes hypotension/cyanide toxicity after 24-48 hours severe lactic acidosis; tx. of cyanide toxicity is with NaThiosulfate; use nipride for acute aortic dissection but must use with Bblocker concomitantly (decreased BP inc reases contractility worsens dissection)
    • The most reliable independent predictor of a poor outcome after surgery is low albumin (<2.6g/dl)
  • Pro-inflammatory cytokines: released by tissue macrophages: TNF and IL-1 (first wave) IL-6 (second wave) Splenic artery gives off: great pancreatic artery, left gastroepiploic and the dorsal pancreatic artery transverse pancreatic artery caudal pancreatic artery
    • GDA/SMA anterior and posterior pancreaticoduodenal arteries; inferior pancreaticoduodenal artery is the first branch off of the SMA
    • Busulfan and bleomycin pulmonary fibrosis; cyclophosamide hemorrhagic cystitis (can prevent with mesna); dacarbazine and nitrosourea can enter CSF b/c they are lipophilic; cisplatin peripheral neuropathy; mithramycin platelet dysfxn., decreases clotting factors; doxorubicin (adriamycin) cardiomyopathy, dose limit is 550 mg/m2, causes red urine (this is not blood); L-asparaginase hepatotoxicity
    • Etoposide inhibits topoisomerase II; topotecan inhibits topoisomerase I; use tretinoin to treat pro-myelocytic leukemia (M3)
    • 1st lumbar nerve root lumbar plexus ilioinguinal nerve travels under the aponeurosis of the external oblique superficial inguinal ring supplies sensation to the inguinal region, inner aspect of the scrotum, medial part of thigh
    • 1st and 2nd lumbar roots genitofemoral nerve mainly sensory; genital branch supplies sensation to the skin and scrotum, medial thigh; femoral branch sensation to the anterior thigh
    • T8 level of diaphragm IVC and phrenic pass through together; T10 level esophagus and vagus; T12 level aorta, azygous and thoracic duct Neuroleptic malignant syndrome: usually presented with a pt. on a vent. Who gets haldol for agitation; this is then followed by fevers, HTN, muscle rigidity and obtundation; centrally mediated process probably due to an imbalance of DA; tx: dantrolene and bromocriptine
    • PPV=a/a+b (TP/TP+FP); NPV=d/d+c (TN/TN+FN); sensitivity=a/a+c, specificity=d/d+b; prevalence=a+d/a+b+c+d; RR=sens./specif.; sd= square root of the variance; SEM=sd/sq.rt.of n; ANOVA is used for comparison b/t the means of 3 variables
  • Nerves: axillary C5-6 ABD shoulder; musculocut C5-6 FLEX elbow; radial C6-8 EXT thumb; median C6-T1 FLEX thumb interph. Joint; ulnar C7-T1 ABD index finger; femoral L2-4 EXT knee; Obtur L2- 4 ADD hip; sup. Gluteal L5 ABD hip; Inf. Gluteal S1 EXT hip; Sciatic (tibial) L4-S3 plantar flexion of toe and ankle; Sciatic (deep peroneal) L4-S2 dorsiflexion of toe
General Surgery Recertification
Our course has been recognized as an excellent general surgery review and recertification course for practicing surgeons.
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An intensive two-day (weekend) review of high yield topics in both the clinical and basic science of surgery.
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Fact 1 - This is the eleventh year for the course making it the oldest and most attended review course of its kind.
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