CAGS review

·       Workup of paraesophageal hernia/gastric volvulus

·       CT abdo/pelvis vs. Gastro

·       TPN

·       Brachial plexus

Stress ulceration

Gastric pH needs to be >4 to prevent stress ulcer formation
- incidence of bleeding is 2-3%
- most common indication for stress ulcer prophylaxis is respiratory failure (followed by shock/hypotensions, sepsis and neurotrauma)

Agents used for prophylaxis are:
- H2 blockers
- sucralfate (higher incidence of bleeding compared to H2 blocker)
- PPIs

- H2 and PPIs are equally effective in stress ulcer prophylaxis and have no difference in nosocomial pneumonia

Sucralfate vs. Ranitidine:
- RCT performed NEJM 1998
- ranitidine has 50% decreased ulcer rate (1.7 vs 3.8%) compared to sucralfate
- does not significantly increase ventilator associated pneumonia rate (16 vs 19%)

Inverse Ratio ventilation

Technique of reversing length of inspiration:expiration from 1:2 to 2:1
- increases the time for positive-pressure inspiration

- what clinical scenarios would this be beneficial?
- decreased expiratory time can lead to permissive hypercapnia and reduce barotrauma

Consequence of this type of ventilation:
- positive intra-thoracic pressure can result in decreased pre-load
- can be uncomfortable and cause anxiety for pt (requiring increased sedation)
- may not allow for adequate expiratory time resulting in stacked breaths and auto-PEEP

Adrenal Metastases:

Most common cancer metastasizing to the adrenals:
- Lung ca
- RCC
- melanoma
- breast ca
- gastrointestinal ca
- HCC
- lymphoma

Work-up:
- patients with a solitary adrenal mass and symptoms suggestive of malignancy should have screening colonoscopy, mammography and CXR to try and identify the primary tumor
- PET scan may be helpful to identify the primary disease
- FNA can be performed: but only after a pheo has been ruled out

Presence of a solitary met - may benefit from adrenalectomy
- usually small and contained within capsule.
- lap adrenalectomy has been shown to have an equally effective outcome as open adrenalectomy
- 5 year survival 25%

Virilizing and Feminizing Adrenal Tumors

- Rare
- usually symptomatic

>80% are malignant
- almost all feminizing tumors malignant
- 50% of virilizing tumors are malignant

- because they are so rare, testing for sex hormone excess during work-up of incidentaloma should only be done if there are clinical signs of virilization or feminization

Diagnosis:
- Virilizing tumors: serum testosterone, serum dihydroepiandrostenedione, 24 hr urine 7-hydroxysteroid, 24 hr urine 7-ketosteroids (serum androgens and 24 hr urine keto-steroids suppressed if ovarian cause)
- dexamethasone suppression test can differentiate between adrenal and ovarian cause
- Feminizing tumor: serum estrogen and suppressed FSH, LH and gonadotropins confirm feminizing adrenal tumor (as opposed to testicular tumor)
- CT scan can generally localize a tumor

Consider that most are malignant when deciding if going to attempt laparoscopically

Adrenal Cushing's syndrome

Cushing's syndrome: caused by glucocorticoid excess
- central obesity, hypertension, moon facies, easy brusibility, weakness, depression, polyuria, glucose intolerance and diabetes

Gluccocorticoid secreting lesiosn:
- adrenal: adenomas, hyperplasia, adrenocortical carcinomas
- pituitary: adenomas, hyperplasia
- ectopic: SCLLC, bronchial carcinoid tumors, thymomas, pancreatic islet cell tumors

Diagnosis:

- elevated 24-hour urinary free cortisol most sensitive and specific test

- if 24 hour urine is negative formal low-dose dexamethasone suppression test can be performed

Important distinction during work-up:
- ACTH dependent or independent (adrenal adenoma and candidate for resection)
- measure plasma ACTH levels: should be low in ACTH independent tumors
Imaging:
- CT or MRI both can be used for localizing the tumor
- if pituitary or ectopic lesion suspected then imaging of head/chest may be warranted

Pre-op considerations:
- treat with stress-dose of steroids: taper slowly (the contralateral adrenal will be suppressed from pre-operative excess steroid secretion)
- pre-op antibiotics (due to immunosuppression from steroids)

TReatment:
- surgical resection of bilateral hyperplasia is indicated in this disease
- patient will requirer lifetime glucocorticoid and mineralocorticoid replacement (Florinef 0.1mg qD)

Aldosteronoma

Classic triad of Conn's syndrome:
- Hypertension
- Hypokalemia
- Polyuria

Diagnostic test is PAC:PRA >30
- PAC: plasma aldosterone concentration
- PRA: plasma renin activity
- second confirmatory test is an aldosterone stimulation test (positive if urinary aldosterone level elevated during a saline infusion)

Workup: adenoma vs. hyperplasia
- important step in working patient with suspected aldosteronoma is to determine if you are dealing with a unilateral adrenocortical adenoma (2/3 of patients) or bilateral hyperplasia
- other very rare causes include adrenocortical carcinoma, angiotensin II responsive adenomas, familial hyperaldosteronism type I and type II
- this can be done by imaging - CT scan may show a solitary lesion

Indications for selective adrenal vein catheterization:
- sampling of adrenal vein may be necessary to localize adenoma.  placement of catheter confirmed by increase in cortisol concentration as compared to IVC
- looking for ~5 fold increase in aldosterone compared to the other side
- indicated with there is adrenal hypertrophy, bilateral nodules, no lesions

Pre-operative considerations:
- patient begins spironolactone pre-operatively to control hypertension and normalize potassium levels.
- other antihypertensives are added as needed
- stop spironolactone immediately post-op

Iliac Aneurysms

Isolated ilaic aneurysms are rare
- most commonly associated with other aneurysms : found in 10-20% of patients with AAA

Difficult to detect clinically
- usually detected late and as a result mortality rates high

Recommendation is to repair iliac aneurysms once they are >3cm in size
- endovaascular options exist

Colonic Volvulus

Recurrence rate after endoscopic detorsion ranges from 30-90%.  Morbidity and mortality increases with each successiev detorsion.
- mortality of elective resection is low (1-5%), recurrence rate after resection low (~5%).
- If operative risk is too high - consider percutaneous endoscopic transcolonic tube placement

- recurrence rate of cecal volvulus is also high (20-40%): cecopexy or resection with primary anastamosis are eqully safe with similar recurrence rates (5-15%)

Antibiotic AHD

Pre-op Antibiotics:
- Ancef - for procedures not involving distal ileum, appendix, or colon (alt clinda + gent)
- for colon/

medical post article for antibiotic recommendations

- ancef provides gram positive prophylaxis, some gram neg coverage (but not great)
- for prophylaxis don't need to kill all bacteria

Colorectal prophylaxis
Ancef& Flagyl
If allergy
- clinda & Cipro or Gent and Flagyl
- cipro or gent & flagyl

SSI treatment:
Mild-Moderate community acquired infection ((SSI)
- Cefzaolin/flagyl
- ceftriaxone/flagyl
-cipro/levo and flagyl
-cefoxitin
-Moxifloxacin
Do NOt need enterococcal coverage, candida coverage, aminoglycocides

Severe community acquired infection:
- meropenem
-piptazo
-cipro/levo and flagyl
- ??

Healthcare associated intraabdo infections:
- meropenem/imipenem/doripenem
-piptazo
- ??

When do you need antifungal treatment:
- C. albicans - fluc
- other spp. - need caspofungin
- treat if you grow out of wound

anti-enteroccal
- if you grow from healthcare related infection
- amp, piptazo, or vancomycin

Appendix abx:
- with adequate source control, no need to extend abx beyond 4-7 days

Forearm compartments

Forearm has 3 major compartments:
- anterior (volar)
- posterior (dorsal)
- mobile was (includes brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis)

Mesenteric venous thrombosis

- Treatment in symptomatic patients is anticoagulation with heparin and fluid resuscitation.  Surgical exploration is reserved for patients with peritonitis
- in asymptomatic patients anticoagulation must be weighed against patient co-morbidities
- Hematologic assessment for hypercoagulable state is recommended

Thromboangitis obliterans

AKA Buerger's disease:
- chronic arterial inflammatory condition (can also affect veins)
- leads to arterial occlusion in medium and small extremity arteries
- Unknown etiology
- M>F
- complete abstinence from tobacco is the only known effective treatment
- cessation of tobacco can reduce rate by 50%

Phyllodes Tumor

·      Varying malignant potential

·      Round, may be indistinguishable from fibroadenoma

·      Comprised of epithelial elements and connective tissue stroma (like a fibroadenoma)

Classification:

·      Benign

·      Borderline

·      Malignant

·      Based on cellular atypia

·      Mitotic activity

·      Overgorwth in stroma

·      Phyllodes tumors have increased cellular activity compared to fibroadenomas

·      If malignant treat with adjuvant therapy like a sarcoma

Treatment:

·      Excise with a 1 cm margin of normal breast tissue

·      Re-excision is often necessary to achieve this margin

·      LN dissection is not necessary

·      LN mets <5% of cases

·      If LN mets to axilla then pt has a very poor prognosis

Extracolonic manifestations of Ulcerative Colitis

Pyoderma gangrenosum
Erythema nodosum
Ankylosing spondylitis
Sclerosing cholangitis

Left sided portal hypertension

From thrombosed splenic vein after pancreatitis.
- arterial inflow but no outflow.
- results in isolated gastric varices

Solution. NOT gastectomy
- splenectomy or angioembolizayion



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Access to lessser sac

Paucher
Foramen of Winslow
Through transverse colon mesentery
Through stomach
Arid maneuver- mattox and come yo pancreas laterally at tail.



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