Gen Surg Study Notes

Rome criteria for Irritable Bowel Syndrome

2011-01-02T18:42:00.001-07:00

The Rome III criteria system was developed to classify the functional gastrointestinal disorders based on clinical symptoms. Each disorder has its own set of criteria. For example, the Rome III criteria for irritable bowel syndrome (IBS) is as follows:

Symptoms of recurrent abdominal pain or discomfort and a marked change in bowel habit for at least six months, with symptoms experienced on at least three days of at least three months. Two or more of the following must apply:

Pain is relieved by a bowel movement
Onset of pain is related to a change in frequency of stool
Onset of pain is related to a change in the appearance of stool.

Classification of Gastric Carcinoid tumors

2010-12-05T21:55:00.003-07:00

Gastric carcinoids are rare tumours.
Clinical setting:
-  Type I  - Associated with chronic atrophic gastritis with or without pernicious anemia.
In autoimmune gastritis progressive destruction of the specialised parietal and chief cell zone leads to atrophy , intestinal metaplasia , hypochlorhydria and hypergastrinemia.
- Type II - In Zollinger Ellison syndrome, particularly in patients associated with multiple endocrine neoplasia type 1.
    - Type III - Sporadic tumours
   - Not related to hypergastrinemia
   - In the antrum or corpus
   - Larger lesion, may be ulcerated.
   - May have an aggressive course.

http://www.ncbi.nlm.nih.gov/pubmed/15362575

Anti fungal therapies

2010-11-29T00:52:00.002-07:00

Amphotericin B
Azoles: block Ergosterol synthesis which is an component of fungal cell wall
Echinocandins: Inhibit glucan synthase which is specific for fungal wall (eg: caspofungin)

Link

Colitis Cystica Profunda

2010-11-17T12:32:00.001-07:00

http://www.ajronline.org/cgi/reprint/131/3/529.pdf

Laparoscopic Abdominal Wall Reconstruction

2010-11-16T20:55:00.000-07:00

Movie link

Definition of hypersplenism

2010-11-15T22:28:00.000-07:00

- Splenomegaly
- cytopenia(s) - usually thrombocytopenia, anemia or neutropenia
- normal or hyperplastic bone marrow
- response to splenectomy

Meckler's Triad

2010-11-15T09:10:00.001-07:00

http://www.ncbi.nlm.nih.gov/pubmed/20935623

Triad of:
- Vomiting
- Chest pain
- SQ emphysema

Symptoms associated with Booerhaave's syndrome

GAIL model for breast cancer risk assessment

2010-11-12T10:28:00.000-07:00

http://www.cancer.gov/bcrisktool/

- age
- age of menses
- age of first child
- first degree relative with breast cancer
- previous breast biopsies
- History of ADH
- race

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Drugs that cause acute pancreatitis

2010-10-31T17:33:00.000-06:00

"DEFEATS"

D: didanosine (anti-HIV drug)
E: erthyromycin
F: furosemide
E: estrogens
A: azithromycin (Imuran)
T: tetracycline
S: sulfa

Drugs Associated with Pancreatitis:

*Definite Cause*
· 5-Aminosalicylate · 6-Mercaptopurine · Azathioprine · Cytosine arabinoside · Dideoxyinosine · Diuretics · *Estrogens* · Furosemide	· Metronidazole · Pentamidine · Tetracycline · *Thiazide* · Trimethoprim-sulfamethoxide · Valproic acid
*Probable Cause*
· Acetaminophen · α-Methyl-DOPA · Isoniazid · L-Asparaginase	· Phenformin · Procainamide · Sulindac

Etiology - Acute Pancreatitis

2010-10-31T17:30:00.000-06:00

"IT HURTS BADLY"

80-90% due to EtOH and gallstones

I: infection
T: trauma
H: hypercalcemia
U: ulcer (penetrating)
R: renal disease
T: tumor (pancreatic, biliary, duodenal)
S: structural (annular pancreas, pancreas divisum)
B: biliary gallstones
A: alcohol
D: drugs ("DEFEATS")
L: lipids
Y: "y"atrogenic

Parenteral Fluid composition

2010-10-26T08:39:00.000-06:00

Solution	Na	K	Ca	Mg	Cl	HCO3
ECF	142	4	5	3	103	27
NS	154				154
RL	130	4	2.7		109	28
D5/0.45%NS	77				77
2/3 & 1/3	56				56

Osmolarity:
Ringer's: 275 mmol/L
Normal saline: 310 mmol/L
Plasma normal range: 300-310 mmol/L

pH:
Ringer's: 6.75
Normal saline: 5.5

Remicade vs. Humira

2010-10-12T09:28:00.000-06:00

Adalimumab (Humira)
- human mAb to human TNF receptor
- 5-7 days until maximal serum concentration
- dosed every week 40mg I'M
- terminal half-life is 2 weeks

Infliximab (Remicade)
- Humanized mouse mAb to human TNF
- terminal half-life is 7-10 days
- dosed every 2-6 weeks 3-10 mg/kg depending on indication
- for Crohns typically 5 mg/kg

Timing after surgery.
- DMARDS can impair healing. For Remicade suggested to wait 6 weeks before elective surgery. For humira ? 2 weeks

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Hinchey 3/4 diverticulitis

2010-10-11T21:15:00.000-06:00

ACS surgery:
- 1-2 resection and immediate anastamosis are suitable.
In setting of perforated, peritonitic diverticulitis, resection with diversion is gold standard.
- other potential options (without great evidence) include on-table lavage and primary anastamosis (more for obstructing colon lesions with minimal contamination), laparoscopic lavage and creation of loop ileostomy (and delayed laparoscopic sigmoid resection)
- one stage resection: argument is that colostomy takedown and reanastamosis associated with 4% mortality and 30-40% never go back for reversal.
In a healthy patient mortality of 4% seems too high. In an elderly and sick patient primary anastamosis would carry too high risk of leak with attendant risks of getting sicker
- diversion: loop ileostomy vs. Transverse colostomy. Higher risk of obstruction with ileostomy but transverse colostomy associated with paying problems, scar issues and harder to reverse.

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Diverticulitis: special circumstances

2010-10-11T20:56:00.001-06:00

Cecal diverticulitis.
- 15% of north American patients. Majority are pseudodiverticula
- medical management is mainstay for uncomplicated disease
- localized diverticulotomy can be performed for very localized and mild disease

Young patients:
- patients younger than 40 yo
- current textbooks suggest treating in same fashion as in older patients.
- elective resection is individualized to the patient but generally does not follow a single attack.

Immunosuppressed patient:
- included in his group are chronic alcoholics, transplant patients, chemotherapy patients.
- incidence is not higher but consequence of a complicated attack is more significant
- corticosteroids cause thinning of colonic wall, suppressed physical exam, attenuated inflammatory response
- are RA patients on methotrexate and IBD patients on biologics considered Immunosuppressed?
- prophylactic colectomy not needed if diverticulosis found but aggressive investigation and treatment of diverticulitis warranted.

Trivia:
- diverticulitis has replaced appendicitis as most common source of liver abscess of portal origin.
- recurrence of diverticulitis after colectomy in the range of 1-10%
- level of anastamosis is only identifiable risk factor.

Classification of Wounds

2010-10-09T22:25:00.003-06:00

Clean:

nontraumatic, no break in technique, no tract entered.
Infection rate: 1.5 – 2.9%

Clean contaminated:

GI or resp tract entered without significant spillage, oropharynx, vagina, or noninfected GU or biliary tract entered, minor break in technique.
Infection rate: 2.8 – 7.7%

Contaminated:

major break in technique, fresh traumatic wound, gross spillage from GI tract, entrance into GU or biliary tree in presence of infection.
Infection rate: 6.4 – 15.2%

Dirty:

pus encountered, traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, or delayed treatment, or from a dirty source. This definition suggests that organisms were present in the operative field before the operation.

Barrett's Esophagus - Surveillance

2010-10-04T00:43:00.000-06:00

4 quadrant biopsies every 2 cm intervals - beginning 1 cm below GE jxn and extending 1 cm above squamocolumnar junction

In absence of dysplasia:
- every 3 years

Low grade dysplasia:
- every 6 months for 1st year, if no progression then every 1 yr

High grade dysplasia:
- confirm by an independent, experienced pathologist. Confirmation of diagnosis warrants agressive treatment
- endoscopic vs. surgical options

Mallampati Airway classification

2010-10-04T00:16:00.003-06:00

Look for soft palate, uvula, tonsillar pillars
Class I: tonsillar pillars and all of uvula (only 0.4% were difficult)
Class II: more than base of uvula but not pillars
Class III: only base of uvula
Class IV: no uvula or soft palate

False positives and negatives do occur

Informed Consent

2010-09-29T22:25:00.000-06:00

http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/ml_guides/consent_guide/com_cg_practicalconsiderations-e.cfm

Adequacy of informed consent is judged by what a "reasonable patient" would want to know about a procedure.

Inguinal hernia tissue repairs

2010-09-16T12:02:00.000-06:00

McVay repair:
- for direct and femoral hernias
- transversalis aponeurosis and fascia sutured laterally to Cooper's ligament.
- sutures are placed beginning medially at the pubic tubercle and extending as far laterally as the femoral vein
- next suture (transition stitch) placed deeply into the pectineus fascia and more laterally through the anterior layer of the femoral sheath
- if conjoined to coopers stitches carried out too far lateral before transition stitch then patient can get femoral vein thrombisis
- treatment of femoral vein thrombosis involves anti-coagulants, recanalization and collateral venous formation usually occurs

Condon Repair:
- anterior approach similar to McVay repair but you are suturing the conjoined tendon to coopers and to iliopubic tract/poupart's ligament
- ?higher risk of femoral vein compression
- double closure of femoral canal
- but does this neccessarily add anything beyond a McVay repair?

Nyhus repair:
- Preperitoneal approach to hernia repair
- from posteriorly similar to a condon repair you close femoral canal by suturing iliopubic tract to cooper's ligament

Poupart's ligament is the reflection of the external oblique aponeurosis
iliopubic tract extends from ASIS to the pubic tubercle

Stages of wound healing

2010-09-15T20:19:00.003-06:00

Physiological Stages

Physiological Stages of Wound Repair

1.) Inflammatory Phase

Initial response to injury
Day 1-4 post injury
Characterized by rubor, tumor, dolor, calor
Platelet aggregation and activation
Leukocyte (PMNs, macrophages) migration, phagocytosis and mediator release
Venule dilation
Lymphatic blockade
Exudative
In wounds closed by primary intention, lasts 4 days
In wounds closed by secondary or tertiary intention, continues until epithelialization is complete

2.) Proliferative Phase

Day 4-42
Fibroblast proliferation stimulated by macrophage-released growth factors
Increased rate of collagen synthesis by fibroblasts
Granulation tissue and neovascularization
Gain in tensile strength

3.) Remodeling Phase

6wks-1 year
Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation
Characterized by increase in tensile strength
Type III collagen replaced with type I
Scar flattens

Imperforate Anus

2010-09-15T16:39:00.002-06:00

Low vs high.
Low perineal procedure.
High colostomy and pull through

Best to wait 24 hrs to define high or low.
- invertogram
>1 cm high
<1cm low High create colostomy then come back in 3 mos. Low cutback anoplasty High posterior sagital anorectal pullthrough Cloaca. Combined uretral and anal opening. Need to separate all and create new openings

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Rectal surgery sexual and bladder function

2010-09-06T16:06:00.001-06:00

Since advent of TME, impotence reported ~10-30% of patients.
- hypogastric plexus. Sympathetic innervation, ejaculation
- Nervi erigentes. Parasympathetic function. Erection and urinary dysfunction.

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Rectal cancer margins

2010-09-06T16:00:00.001-06:00

Distal margins.
- traditionally 5 cm. However no difference in local recurrence rateswhethwr 5, 2 or <2 cm distal margins.

Current recommendations. NCI
- proximal margin 5cm
- distal margin of >= 2 cm
- however, if 1cm margin needed to preserve sphincters then acceptable.
- distal spread beyond 1cm associated with aggressive disease or advanced stage tumors and a longer distal margin will not improve prognosis.

CRM: circumferential radial margin.
- most important determinant of local recurrence.
- TME has largely ensured that adequate circumferential margins routinely obtained.
- preTME era local recurrence was in the realm of 15-30%
- now recurrence rates should strive for 4-7%
- if mesorectal margin involved then local recurrence rates 11 vs 5%

Nodal clearance:
- 12 LNs required for adequate pathological staging. NCCN.
- can be challenging in pts who have had neoadjuvant therapy.

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Other antithyroid medications

2010-08-28T22:32:00.001-06:00

Lugol's iodine (KI)
- short term antithyroid medication
- inhibits thyroglobulin proteolysis (which prevents release of T4/3)
- also prevents organification of thyroid hormone
- effects last 10-14 days

T3 production inhibitors
- major role of beta-blockers is to block the peripheral conversion of T4 to T3
- they do this in addition to treat symptomatic effects of hyperthyroidism.

Radioactive iodine.
- 131I
- trapped by follicular cells incorporated into tyrosine complex and deposited into colloid where beta dray destroys surrounding parenchyma

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Thionamide drugs

2010-08-28T22:24:00.001-06:00

Two common antithyroid drugs used in north America
- propothiouracul (PTU)
- methimazole (tapazole)

PTU is preferred in the treatment of thyroid storm because it acts both on the thyroid and also peripherally

- in the thyroid both drugs inhibit TPO which converts iodide to iodine to be incorporated into thyroid hormone.
- PTU also prevents the peripheral conversion of t4 into the more active T3

Both drugs can cause skin rash. Agranulocytosis is rare but occurs with both
- 0.44% PTU
- 0.12% methimazole

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Amyloidosis Diagnosis

2010-08-12T11:37:00.001-06:00

Diagnosis is via abdominal fat pad biopsy.
- easier and less morbid than biopsy of affected organ
- fat droplet place on glass slide and smeared to single layer
- sent air dried to lab for congo red staining which will allow pathologist to see amyloid deposits within fat

easiest to do an excisional biopsy of fat
core biopsy of fat also described.

http://www.amyloid.nl/investigations.htm

Pathological Subtypes of Breast Cancer

2010-08-10T22:07:00.000-06:00

There are over 12 subtypes of breast cancer - though most of them are rare
- Invasive carcinoma (No Special Type) is by far the most common followed by Invasive lobular
- the remaining subtypes are quite rare

1) Invasive carcinoma: No Special Type
- majority 70-80%
Subtypes:
- Luminal A (ER +ve, HER2/neu -ve)
- Luminal B (Triple +ve)
- Normal Breast-Like (ER +ve, HER2/neu -ve)
- Basal-Like (ER -ve, PR -ve, HER2/neu -ve)
- HER2 positive (ER -ve, HER2/neu +ve; associated with brain mets)

2) Invasive Lobular Carcinoma
- increased bilateral

3) Medullary Carcinoma
- 6th decade of life
- slightly better prognosis than NST carcinomas despite negative histological features
- high nuclear grade, aneuploidy, absence of hormone receptors, high proliferative rate
- rapidly growing with smooth borders and thereforeon imaging can resemble a benign lesion

4) Mucinous (Colloid) Carcinoma
- older women
- grow slowly
- ER +ve, LN mets uncommon
- slightly better prognosis vs. NST

5) Invasive Papillary Carcinoma
- <1% of invasive ca
- ER +ve
- favorable prognosis
- much different outcome compared to micropapillary carcinoma

6) Micropapillary Carcinoma
- ER -ve, HER2/neu _ve
- LN mets
- poor prognosis

7) Metaplastic carcinoma
- rare type of breast cancer (<1% of cases)
- Matrix-producing carcinomas
- Triple negative
- LN mets infrequent but poor prognosis

Source:
Robbins

Neoadjuvant Therapy for Breast Cancer

2010-08-10T21:57:00.000-06:00

Standard of care foe bulky breast or axillary disease:
- primary tumor 2-5cm
- <2cm but metastatic axillary LNs

Early skeptisism for this approach is unfounded: concern initially that pts would have poorer operative outcomes due to wound complications

McCready and Colleagues:
- ALN retains prognostic value after neoadjuvant Rx
- Not clear if neoadjuvant Rx impacts survival (but it's at least equivalent overall survival)
- 80% of pts have ~50% shriknage of tumor
- only 2-3% have signs of progression during neoadjuvant Rx

If there is complete pathologic regression there is a survival benefit

NSABP B-18:
- 4 cycles of doxorubicin and cyclophosphamide
- 5 year survival of complete response pts ~50%
- however, only 12% of pts achieve this kind of response

Advantages:
- Down size tumor in 80% of pts
- Determine which are chemo-responsive

Lower Limb 4 Compartment Fasciotomy

2010-08-05T23:30:00.007-06:00

Compartments:
- Anterior
- Lateral
- Superficial Posterior
- Deep Posterior

Lateral incision: (Over fibula)
- releases anterior and lateral compartments
- watch out for superficial peroneal nerve which can be in lateral but also anterior compartment near intermuscular septum

Medial incision: (2-3 cm medial to edge of tibia)
- releases superficial and deep posterior compartments
- incise superficial compartment then release soleus muscle from posterior edge of tibia to arrive at deep compartment
- watch for saphenous vein which is superficial and runs at the posterior edge of tibia
- watch out for posterior tibial neurovascular bundle and achilles tendon which runs in superficial posterior compartment

http://www.youtube.com/watch?v=-1NDJkFH1vM&feature=related
http://www.youtube.com/watch?v=6c5r5brMOso

MELD score

2010-08-05T15:07:00.000-06:00

MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln INR] + 9.57[Ln serum creatinine (mg/dL)] + 6.43

In interpreting the MELD Score in hospitalized patients, the 3 month mortality is:

40 or more — 71.3% mortality
30–39 — 52.6% mortality
20–29 — 19.6% mortality
10–19 — 6.0% mortality
<9 — 1.9% mortality

Branches of the Internal Iliac Artery

2010-08-03T10:17:00.001-06:00

I Love Going Places In My Very Own Underwear:

Ileolumbar
Lateral sacral
Gluteal (superior and inferior)
Pudendal (internal)
Inferior vesicle (uterine in females)
Middle rectal
Vaginal
Obturator
Umbilical

Branches of the Long Saphenous Vein

2010-08-03T10:09:00.000-06:00

6 tributaries off the long saphenous at the sapheno-femoral junction.
- important clinically when ligating and stripping the long saphenous for varicose veins
- also need to know and likely ligate when doing a superficial groin LND

2 circumflex femoral veins (medial and lateral)
2 circumflex iliac veins (superficial and deep)
superficial inferior epigastric
external pudendal

Endoscopic management of upper GI bleed

2010-07-28T12:29:00.000-06:00

Forrest classification helps to predict who is at high-risk of re-bleed
1a: active, pulsatile bleeding. 50-90% rebleed
1b: active, non-pulsatile bleeding, 10-50% rebleed

2a: no active bleed, visible vessel. high risk rebleed (50-80%)
2b: adherent clot. low risk rebleed

3: no visible stigmata of bleeding. low risk rebleed

If you inject high risk lesions with 1:10,000 epinephrine risk of rebleed ~10-30%
other option is endoscopic coagulation or clips

Reasonable to repeat endoscopy in the case of rebleed

Consider OR if:
- large ulcer
- large bleeding vessel
- eldery >60
- active hemorrhage
- hypotension

angiography plays little role in controlling gastric ulcer bleeding as the vascular network is too rich

Perioperative Cardiac Risk Assessment

2010-07-28T12:17:00.000-06:00

Assessment:
- History, physical
- Resting 12 lead ECG
- should be enough to stratify patients into low, intermediate and high cardiac risk

Risk of cardiac death and nonfatal MI also depends on procedure:
High risk >5%:
- Emergency operations (particularly in elderly)
- aortic, major vascular, peripheral vascular surgery
- Extensive operations with large volume shifts or blood loss

Intermediate risk <5%
- intraperitoneal or intrathoracic
- CEA
- H&N surgery
- Orthopedic
- Prostate

Low (<1%:
- endoscopic procedures
- superficial biopsy
- Cataract
- Breast surgery

Some merit has been shown in perioperative B-blockade to reduce perioperative cardiac risk.
The POISE study was reviewed in EBRS
- at adose of Metoprolol 100mg BID there is cardioprotective effect at this dose (lower doses do not afford same protective effects)
- however, patients need to be aware of the increased risk of hypotension, stroke and death

MAnagement of perioperative MI:
- STEMI: should be revascularized ASAP (within 12 hours). In post-op pt this likely means angiography as early post-op pts may not be eligible for throbolytics
- NSTEMI: stabilize medically and undergo risk stratification when stable
- Therapy with ASA, B-blocker and often ACEi (particularly in pts with low EF or anterior MI)
- Most post-MI pts should also be placed on a statin at discharge.

CHOP

2010-07-28T10:23:00.001-06:00

Chemotherapeutic regimen for treatment of non-hodgkin's lymphoma

CHOP consists of:

Cyclophosphamide, an alkylating agent which damages DNA by binding to it and causing cross-links
Hydroxydaunorubicin (also called doxorubicin or Adriamycin), an intercalating agent which damages DNA by inserting itself between DNA bases
Oncovin (which is the trade name for vincristine), which prevents cells from duplicating by binding to the protein tubulin
Prednisone or prednisolone is a corticosteroid.

Normal cells are more able than cancer cells to repair damage from chemotherapy drugs.

This regimen can also be combined with the monoclonal antibody rituximab if the lymphoma is of B cell origin; this combination is called R-CHOP or CHOP-R. Typically, courses are administered at an interval of two or three weeks (CHOP-14 and CHOP-21 respectively). A staging CT scan is generally performed after three cycles to assess whether the disease is responding to treatment.

In patients with a history of cardiovascular disease, doxorubicin (which is cardiotoxic) is often deemed to be too great a risk and is omitted from the regimen. The combination is then referred to as COP (cyclophosphamide, Oncovin, and prednisone or prednisolone) or CVP (cyclophosphamide, vincristine, and prednisone or prednisolone).

Radiation Proctitis

2010-07-28T10:13:00.000-06:00

Can result from external beam radiation or brachytherapy for cervical or prostate cancer.
Radiation oncologists can try and reduce incidence by using differential dosing during radiation or by using spacer techniques to increase distance between treated organ and rectum.

Complications of radiation proctitis include:
- bleeding
- tenesmus
- stricturing
- incontinence
- fistulas
- diarrhea

Mild radiation proctitis is usually self-limiting and decreases over time
proctitis can be acute or chronic and can present late even in the absence of immediate proctitis

Treatment options include:
- nothing
- enemas (cortisone, 5-ASA); evidence for these treatments is sparse and potentially can even cause more harm
- medium chain fatty acids
- Formalin/methanol topical application
- YAG laser
- thermal cautery
- if severe stricturing or fistulization then procetectomy or diverting colostomy maybe required

Hepatic Abscess

2010-07-25T22:04:00.000-06:00

Potential routes for hepatic seeding are:
1) Biliary tree (currently most common)
2) Portal vein (usually GI source)
3) Hepatic artery (can be from any distant infection site/sepsis)
4) Direct extension (usually from abscess in vicinity of liver)
5) Trauma
Cryptogenic abscesses are very common and often a source is not identified

Microbiology:
most common organisms: E coli, Klebsiella pneumoniae

Antibiotic therapy and percutaneous drainage are currently the mainstays of treatment.
However, when this fails or the pt has a concomitant disease process that requires operative management, surgical drainage is indicated:
- use imaging to help guide site of drainage
- needle aspirate to confirm location and to get C&S sample (aerobic, anaerobic and gram stain - for ameobae too)
- abscess drained and finger dissection to break loculations
- biopsy wall of abscess cavity to rule out amebic trophozoites and presence of necrotic tumor
- biopsy normal liver --> presence of micro-abscesses will warrant a longer course of IV antibiotics
- closed suction drains in abscess cavity

Hypergastrinemia

2010-07-25T21:08:00.000-06:00

Non-Ulcerogenic causes:
- Renal failure
- Atrophic gastritis
- Pernicious anemia
- Previous vagotomy
- Short-gut syndrome
- PPI

Ulcerogenic causes:
- ZES
- Retained or excluded antrum
- G-cell hyperplasia
- Gastric Outlet Obstruction

Gastrinoma

2010-07-25T16:31:00.000-06:00

Most common site of gastrinoma:
- D2: 70%
- D1: 57%
- Pancreatic head: 27%, body: 23%, tail 50%

Gastric Ulcer Classification

2010-07-25T14:50:00.000-06:00

Type I: Lesser curve at or proximal to incisura
Type II: 2 ulcers, Type I and an active or chronic duodenal ulcer
Type III: Located 2cm from pylorus
Type IV: Proximal stomach or gastric cardia
Type V: NSAID induced (diffuse)

Types II and III are associated with high-acid states.

Forrest Classification

2010-07-25T11:38:00.000-06:00

1a: arterial, spurting hemorrhage

1b: Ozzing hemorrhage

2a: Visible vessel

2b: adherent clot

2c: Hematin-covered lesion

3: no signs of recent hemorrhage

Upper GI Bleed presentation:

http://fhs.mcmaster.ca/surgery/documents/gi_bleeding.pdf
Forrest class 2 lesions (Visible vessel or adherent clot will have) ~10% risk of rebleeding in first 24 hours
- risk of bleeding drops significantly in following 48-72 hours

Upper GI premalignant screening recommendations

2010-07-18T17:57:00.003-06:00

American society of gastroenterologists recommendations:

http://www.guideline.gov/summary/summary.aspx?doc_id=9306

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Gastric polyps

2010-07-18T07:48:00.001-06:00

Gastric Polyps are encountered in ~3-4% of upper endoscopies

Hyperplastic polyps
- 80% of all types of polyps
- overgrowth of normal gastric epithelium
- atypic is rare and has no neoplasticism potential

Adenomatous polyps
- premalignant lesions
- risk of malignancy is 10-20% in polyps >2cm
- operative management for sessile polyps >2cm suggested.
- some centers are also using submucosal resection.

References:
- greenfield

Hashimoto's Thyroiditis

2010-07-10T22:44:00.001-06:00

AKA: struma lymphomatosa

- transformation of thyroid tissue to lymphoid tissue

- most common inflammatory disorder of the thyroid

- most common cause of hypothyroidism

Etiology:

- autoimmune process caused by activation of CD4 T cells specific for thyroid antigens. Innate and adaptive immune response against thyroid

Clinical Presentation

Hashimoto's thyroiditis is also more common in women (male:female ratio 1:10 to 20 ) between the ages of 30 and 50 years old. The most common presentation is that of a minimally or moderately enlarged firm granular gland discovered on routine physical examination or the awareness of a painless anterior neck mass, although 20% of patients present with hypothyroidism, and 5% present with hyperthyroidism (Hashitoxicosis). In classic goitrous Hashimoto's thyroiditis, physical examination reveals a diffusely enlarged, firm gland, which also is lobulated. An enlarged pyramidal lobe often is palpable.

Diagnostic Studies

- When suspected clinically, an elevated TSH and the presence of thyroid autoantibodies usually confirm the diagnosis.
- FNAB indicated in patients who present with a solitary suspicious nodule or a rapidly enlarging goiter.
- Thyroid lymphoma is a rare but well-recognized, ominous complication of chronic autoimmune thyroiditis and has a prevalence 80 times higher than expected frequency in this population than in a control population without thyroiditis. Recent studies of clonal similarity indicate that lymphoma may, in fact, evolve from Hashimoto's thyroiditis.14
- Path: FNA sample will show Hurthle cells in conjunction with heterogeneous populations of lymphocytes

Treatment

Thyroid hormone replacement therapy is indicated in overtly hypothyroid patients, with a goal of maintaining normal TSH levels. The management of patients with subclinical hypothyroidism (normal T4 and elevated TSH) is controversial. Treatment is advised especially for middle-aged patients with cardiovascular risk factors such as hyperlipidemia or hypertension and in pregnant patients.15 Treatment also is indicated in euthyroid patients to shrink large goiters. Surgery may occasionally be indicated for suspicion of malignancy or for goiters causing compressive symptoms or cosmetic deformity.

Hypercalcemic Crisis

2010-07-10T22:31:00.002-06:00

Presentation:
- severe dehydration
- hypotension,
- altered mental status
- dysrhythmias

Management:
- hydrate: normal saline at a rate of 300 ml/hr; rehydration promotes calcium excretion in proximal tubule which is associated with Na flux
- Loop diuretics: reduce fluid overload and inhibit calcium resorption in the loop of Henle, thus promoting increased renal calcium excretion.
- Dialysis: Patients with renal failure should be dialyzed with low-calcium dialysate

Pharmacologic agents to be used after rehydration:
- Steroids: Glucocorticoids lower calcium by inhibiting effects of vitamin D, increasing renal calcium excretion, and inhibiting osteoclast-activating factor.
- hydrocortisone is 200 to 400 mg IV per day for 3 to 5 days
- Bisphosphonates inhibit osteoclast activity, thus preventing bone resorption induced by PTH.
- Pamidronate (90 mg IV) or zoledronic acid (4 mg IV initial treatment, 8 mg on retreatment) normalizes calcium levels in most patients
- Calcitonin acts quickly (within 24 to 48 hours) to lower serum calcium levels and is more effective when used in combination with glucocorticoids. It should not be used in patients with salmon allergies.

After patients with PHPT and hypercalcemic crisis are stabilized and serum calcium levels have been reduced to acceptable levels, preoperative localization studies should be obtained expeditiously in anticipation of an urgent parathyroidectomy.

Cameron 9th ed

Parathyroid Hormone

2010-07-10T18:05:00.000-06:00

Single most important regulator of calcium and phosphate homeostasis in the body.

Effects:
Direct effects on bone and kidneys
Indirect effects on intestines (mediated viaVitD)

Effects on Bone:
- complex interaction activating osteoblasts and osteoclasts
- act indrectly on osteoclasts but have direct ligands on osteoblasts
- acts first to mobilize minerals from areas of rapid equilibrium
- prolonged PTH exposure results in further bone mineralization as lysozomal and hydrolytic enzymes are synthesized

Effects on Kidney:
- PTH has 3 effects on kidneys
- increases production of alpha-hydroxolase, resulting in increased hydroxylation of cholecalciferol to calciferol.
- increases reabsorption of calcium in distal nephron (loop of henle and proximal tubule Ca reabsorption is linked to Na and not influenced by PTH)
- prevents reabsorption of both phosphate and bicarbonate

Effects on Intestine:
- indirect and results in increased calcium absorption by increased VitD hydroxylation in kidney

Feedback inhibition is regulated by calcium levels.
- increased calcium normally results in inhibition of PTH secretion
- decreased calcium levels result in increased PTH secretion

Merkel Cell Cancer

2010-07-10T16:55:00.002-06:00

http://theghostofsnotboogie.blogspot.com/2009/12/skin-cancer-merkel-cell-carcinoma.html

Resection with 1-2 cm margins
- SLNB is bare minimum for all patients
- therapeutic LND in patients with positive SLN
- radiation to all primary tumor beds, radiation to LN basin ?depends on LN status
- chemotherapy not very effective and when to start is controversial

Adult Intussusception

2010-07-08T11:19:00.002-06:00

Rare in adults

- risk of malignant lesion as lead point higher if colo-colonic intussusception

- If SB intussusception 60% chance of lead point being benign

Management is controversial:

- reduction of intussusception vs. en bloc resection

- if colonic intussusception then consider en bloc resection as more likely malignant lead point

- if SB intussusception then consider reduction and resection of lead point only

- id ischemia or necrosis then consider en bloc resection

- risk short-gut if extensive SB resection

Cubittal tunnel syndrome

2010-07-02T13:22:00.000-06:00

Potential points of compression of the. Ulnar nerve.

1) Arcade of Struthers:
- thick fascism structure 8 cm proximal to the medial epicondyle between medial head if triceps and medial intermuscular septum.
- present in 70% of pts with ulnar nerve compression

2) medial intermuscular septum
- dense fascia that covers ulnar nerve as it travels in postcondylar groove

3) Osbornes's band
- leading edge of fascia that connects ulnar and humeral heads of flexor carpi ulnaris

4) aponeurosis of flexor-pronator mass
-

Examination:
- 2point discrimination, pinch and grip strength, motor strength for entire upper arm
- tinel's sign through course of ulnar nerve
- brachial plexus: arm raised to stress brachial plexus and observ for parasthesias
- nerve conduction studies. But normal study in the setting f painshould not preclude an operative repair.

Management:
- conduction greater than 40m/sec treat conservatively for 8 wks and or only if still symptomatic
- conduction < 40m/sec should be managed with release electively Conduction may not improve post procedure on basis of permanent axonal injury.
- <30m/sec release within 3 months
- <20m/sec release ASAP

Conservative treatment
- activity modification
- Ulnar nerve loose when arm extended. Therefore avoid elbow flexed positions
- elbowpads at night

Many options for surgical treatment.
- simple decompression
- medial epicondylectomy
- subcutaneous transposition
- intramuscular transposition
- trnasmuscular transposition

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Ulnar nerve compression points

2010-07-02T11:06:00.000-06:00

brachial plexus

2010-07-02T10:44:00.001-06:00

Brachial plexus video

Psammoma Bodies

2010-06-30T00:14:00.000-06:00

Round collection of calcium.
- thought to arise from infarction and calcification of intralymphatic tumor thrombi

Commonly seen with:
- papillary thyroid cancer
- papillary RCC
- serous papillary ovarian adenoca
- endometrial adenoca
- meningioma
- mesothelioma
- prolactinoma
- endosalpingiosis

Papillary thyroid cancer

2010-06-29T23:59:00.002-06:00

Lymph node metastases are most common.
Distant metastatic spread is rare. Lun and bone are two most common sites

- Ground glass nuclei, cellular grooving and psammoma bodies are diagnostic features of papillary thyroid cancer and if seen can be used to confirm diagnosis.

- 30-50% of papillary thyroid cancers are multicentric with a simultaneous cancer in the contralateral lobe.

- this is the reason for endorsement of a total thyroidectomy in cases where the lesion is a papillary thyroid cancer.

- while distant mets to bone and lung are the most common sites for papillary cancer metastases, distant mets are rare. Whereas lymph node mets are quite common with this type of thyroid cancer

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Pediatric thyroid malignancy

2010-06-29T23:51:00.000-06:00

Relativrly uncommon malignancy.
- occurs predominantly in children >10
- males and females affected equally

Pathology:
- 70% are papillary or mixed-papillary-follicular carcinomas
- 18% are follicular
- 4-10% medullary
- 2-5% anaplastic
- hurthle and lymphoma are exceedingly rare in peds

Work-up:
- laryngoscopy to evaluate chords
- thyroid function, anti-thyroid antibody
- ultrasound
- technetium scan; in kids. Warm or. Cold nodules should both be treated as cold nodules, malignancy occurs in 14-40% of solid thyroid nodules in kids not just predominantly in cold nodules
- tissue diangosis: fna and if inconclusive then lobeactomy may be required

Prognosis:
- children with well differentiated thyroid cancer have a better prognosis than adults despite presentation with more advanced disease and high incidence of regional and distant metastases at time of presentation

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Supralevator anorectal abscess

2010-06-29T00:08:00.001-06:00

Relatively rare 2.5% of anorectal abscessess.
- perianal and buttock pain are the most common presenting complaints.
- most with this rare type of abscess have underlying pelvic inflammatory process, prior recent abdominal surgery or crohn's disease.
- can also occur in continuity with cepahalad extension of transsphincteric fistula/abscess

Treatment:
- cause determines therapy.
- transrectal or transvaginal drainage for abscess caused by pelvic sepsis
- if extension if transsphincteric abscess then manage primary trans sphincteric process

Key is to know the patients history.
- crohns or recent abdominal surgery.
- then go to or. Look for crypt abscess
- if absent the internal drainage following a seeker needle with a
Foley/malecot/t-tube in place for 24-48 hrs
- if crypt abscess found the. Drain exteriorly through a large skim incision to adequately drain the supralevator abscess component

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Anorectal abscess

2010-06-28T23:38:00.001-06:00

Drainage is key.
- there is no role for primary antibiotic therapy.
- Some controversy over culturing abscess fluid. Drainage usually sufficient so C&S is redundant. Some Evidence to suggest that presence of gut flora in culture helps to predict who gets persistent fistula.

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Fistula rate after anorectal abscess

2010-06-28T23:14:00.001-06:00

If internal opening recognized in OR at time of anorectal I&D procedure it is reasonable to perform synchronous fistulotomy if low-lying fistula.
- however, usually very difficult to identify the internal opening site.

Anorectal Abscess

2010-06-28T22:53:00.000-06:00

Hemorrhoids

2010-06-28T21:08:00.000-06:00

Ensure you have the right diagnosis.
- cancer
- prolapse
- disordered defecation
- fissure. Hemorrhoidectomy in a fissure patient will result in excessive pain, poor healing. Consider doing lateral sphinceterotomy at the same time.

Treatment options:
- patients with bleeding disorders consider an operative approach to hemorrhoid management
- use of banding in these patients can result in bleeding when the hemorrhoid sloughs off in 5-10 days.

Suture material
- catgut us often used as a suture material because it is absorbed quickly
- potential for infection when long absorbing suture is used.

Infection
- can manifest as pain greater than anticipated, urinary retention and fever.
- manage patient by taking to or, remove elastic band and start on IV abx

Reference:
ACS surgery

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Autonomously functioning "hot" thyroid nodules

2010-06-25T11:34:00.000-06:00

- rate of carcinoma in an autonomously functioning thyroid nodule: 0.7%
(Mizukami et al, Am J Clin Path 1994)

Thyroid MCQ

2010-06-24T14:16:00.002-06:00

1) to prove a thyroid cyst is benign:

a) CT neck

b) cytology and FNA

c) US

d) thyroid scan

2) the best treatment for a women with a thyroid nodule which is hot on thyroid scanning and decreased TSH and increased free T4 is:

a) radioactive iodine

b) thyroid suppression

c) operation

d) FNAB to R/O malignancy

e) Observation

3) thyroid nodule 4cms in size:

a) observe

b) suppress

c) resect

4) what is the best initial investigation for a solid mass in the thyroid:

a) US

b) Thryroid function test

c) FNA

d) Scan

e) serial physical exam

5) 10 yo seen by school nurse, found 3cm mass non-tender inferior aspect of the thyroid:

a) observe and reasses in 6 months

b) thryroid suppression

c) radioactive iodine

d) operate

e) wait until puberty

6) with regards to thyroid ca:

a) lymphatic spread

b) hematogenous spread

c) may be multinodular and encapsulated

d) mets may look normal

Complications of Thyroxine

2010-06-24T13:57:00.002-06:00

What are the complications of Thyroxime?

Atrial Fibrillation
Osteoporosis

- Starting dose is 100 mcg qD

Hyperthyroidism:

2010-06-24T12:29:00.001-06:00

Surgical Management of Hyperthyroid:
- Grave's disease
- Toxic nodular goitre (single or multiple)
- Amiodarone-induced thyrotoxicosis

Preop preparation of patients required to normalize T3/T4 using thioamides. In the past super-saturated potassium iodide or Lugol's solution used to resture thyroid function and decrease thyroid vascularity but does so only temporarily.

Medical management:
- Thioamides (propylthiouracil, methimazole): decrease thyroid hormone synthesis, takes several weeks to take effect. Effective in 90% of patients, but relapses occur in ~80% of pts. Complications: Agranulocytosis rare (0.5%)
- Radioactive iodine 131-I, highly effective in Grave's disease (90%), pt becomes hypothyroid. Can worsen thyrotoxicosis
- 131-I contraindicated during pregnancy or in lactating mothers

Pemberton's Sign:
- facial plethora, inspiratory stridor, venous congestion when arms raised above head
- sign of jugular venous compression (thoracic outlet obstruction can be from large goiter)

Hyperthyroidism Questions:

2010-06-23T21:07:00.002-06:00

1) indications for surgery in hyperthyroidism, all except:

a) childhood

b) pregnancy

c) reoperation for hyperthyroidism

d) toxic adenoma

e) toxic multinodular goiter

2) a 30yo nurse presents with a 3 week history of malaise and weakness. Her thyroid gland is diffusely enlarged and tender. Her ESR is slightly elevated, and her T4 is twice normal. What should be done:

a) total thyroidectomy

b) radioactive iodine ablation

c) treatment with NSAIDS and rest

d) treatment with propanolol and PTU

e) FNA

3) a 35yo male has an asymmetrically enlarged thyroid gland. The ESR is 60. T4 is 180 and iodine uptake is 4%. He most likely has:

a) Graves

b) Ridel’s struma

c) Haschimotos disease

d) subacute thyroiditis

e) toxic multinodular goitre

4) Hashimoto’s thyroididtis may be associated with:

a) follicular thryroid ca

b) papillary thyroid ca

c) lymphoma

d) leukemia

e) Hurtle cell tumors

5) which of the following statements regarding Hashimoto’s thyroiditis is not true:

a) it is the commonest type of thyroiditis

b) there is a familial predisposition

c) the gland is infiltrated with giant cells

d) it occurs mostly in the middle age females

e) antithyroid Ab may be present

Recurrent Laryngeal nerve anatomy

2010-06-23T20:23:00.002-06:00

RLN arises from the vagus nerve
- passes beneath vessel derived from the primitive 4th aortic arch
- on the right it recurs around the subclavian artery
- on the left it recurs around the aortic arch
- 1% of patients have a retroesophageal right subclavian artery and the laryngeal nerve arises directly from vagus to the larynx

Association with the inferior thyroid artery is variable. Most course anterior to all branches, some course between branches and a few course totally behind branches of the inferior thyroid artery.
- text advocates encircling inferior thyroid artery as it arises from carotid and lifting it up to try and help identify the RLN.

Most consistent location of RLN is its insertion between the thyroid and cricoid cartilage. Even in cases of recurrent laryngeal nerves it inserts in this location. Its location relative to the cornu of the thyroid cartilage is quite consistent.
- This is where DCW looks for RLN initially.

External branch of the superior laryngeal nerve runs along the cricothyroid membrane and care should be taken to avoid damaging the SLN.

Silver and Rubin Atlas of Head and Neck Surgery: pg 284

Oral exam: Colon cancer

2010-06-21T22:31:00.000-06:00

46 yo patient presents to you with a biopsy proven adenocarcinoma in the cecum and a 1.5 cm villous polyp 8cm from the anal verge.

What is your workup and management?

Moore Retreat: Pelvic Fracture

2010-06-20T16:57:00.000-06:00

Drive 1st pack deep into the pelvis
- hematoma opens the space up for you
- If laparotomy needed then try to keep fascial defect above the perperitoneal incision

Pelvic Fixator:
- C-clamp used as a pelvic fixator
- can be maneuvered for OR/CT

PPP should be a joint decision with orthopod

Angio:
- if ongoing bleeding pt may still need angio
- angio still needed in 10-12% of patients

Average dates to:
- pack removal: 3d
- ventilator days: 14d
- ICU LOS: 18d

mortality in refractory shock patients:
40-50% mortality without PPP
20-25% mortality with PPP

Moore Retreat: Colon and Rectum

2010-06-20T16:32:00.000-06:00

To Divert or Not?
- 2-3% leak rate with primary repair
- although low leak rate consider whether patient "can take a joke?"

Rectum:
- Pendulum has swung from primarily diverting to observational management more popular now
- A situation where observation might be dangerous is with a massive open pelvic # where diversion can prevent pelvic sepsis/osteomyelitis

Diversion:
- EEM uses loop ileostomy as his primary diversion technique (without on-table lavage)
- sigmoid end colostomy might be done if there is destructive injury to sigmoid where simpler just to take out sigmoid as colostomy
- don't just do a small local exicision: especially in watershed areas
- need to resect from one named vessel to the next! (ie; R hemi/L hemi)tra

Moore Retreat: Liver

2010-06-20T16:18:00.000-06:00

Severe injuries:
- Grade 3 central, Grade IV and Grade V
- treat all as severe liver injuries
- Biliary stent can be used to manage a bilious fistula injury
- Tolerate permissive hypotension and decreased pRBC transfusion if suspect a liver injury

- increased blood pressure can aggravate liver bleeding

- CT very helpful in mapping hepatic injury

Perform pringle early!

- pack and don't keep looking at the liver

- Packing can be used to control even retrohepatic injuries

- EEM also uses veno-veno bypass with a femoral/SMV line feeding into a subclavian line

Moore Retreat: Spleen

2010-06-20T15:21:00.001-06:00

Immunizations:
Boosters given;
- Pneumococcus @ 5yrs
- no boosters given for HIB or meningococcus
- Influenza vaccine given qYr
- EEM ideally gives vaccinations 2-3 weeks post-op; if the patient is unreliable then he will give @ time of discharge
- grade 4-5 and transfused 1-2U pRBC, will give immunizations

Prophylactic Antibiotics:
- Amoxicillin or Erythromycin prophylaxis given from 3-5 yo
- @ UAH pediatricians suggest until age of 7 yo

Unlike liver;
- spleen can bleed in a delayed fashion, even 7-10d out from injury
- Even grade 1-2 injuries can bleed significantly

Conservative Treatment:
Grade 1-3:
- AAT, DAT - let the responsible adult manage and D/C when they see fit.
- D/C pack qD when pt feels fit
Grade 4-5:
- U/S follow-up as outpatient - no need for inpatient CT.

Angio:
- Does a contrast blush mandate angio?
- pts can have either an arterial or venous blush, location of blush matters too
- EEM uses this information to determine if pt to get angio; uses angio selectively
- Global embolization of splenic artery has a propensity to result in splenic abscess formation which can be much more challenging compared to a splenectomy would have been
- when patient hemocontracted what seems like a smaller subsegmental branch can in fact be a larger segmental branch and embolization can result in significant devascularization of spleen

Unstable Patient:
- open the lesser sac and clamp the hilum before mobilizing the spleen
- cut the ligaments 1-2 cm beyond the capsule of the spleen to prevent causing more bleeding by avulsing the capsule
- if you stay right on the the kidney when dividing the splenorenal ligament you avoid getting into the tail of the pancreas

Transfusion triggers to take out spleen:
- recurrent hypotension after 2U pRBC
- EEM aggressive in taking our spleen, risk of OPSS minimal in adult

OPSS:
- rare in adults,
- in children >2 yo rate is higher but salvage rate is 98%
- really of most concern in very young patients < 2 yo

DVT Prophylaxis in pts with splenic injury:
- use of Thromboelastogram? Some pts resistant to LMWH and may need antiplatelet therapy (for upto 4 weeks)
- when deciding to anticoagulate in pt with splenic injury, consider that preventing a PE is probably much more important than preventing the spleen from coming out

Splenic Autotransplantation:
- In Denver they routinely autotransplant splenic fragments into an omental pouch
- there is retrospective data that demonstrates that autotransplanted pts have increased IgA, IgM and Tuftsin levels

Moore Retreat: Pancreas and duodenum injuries

2010-06-20T15:11:00.000-06:00

Retroperitoneal air:
- represents a duodenal injury until proven otherwise
- repeat the CT with a po contrast agent

Examining the pancreas:
- Mobilize the duodenum and pancreas:
- Kocher, take down lig of Trietz
- open lesser sac
- incise the peritoneum above and below the pancreas
- you must get to the posterior surface of the pancereas
- classic missed injury is a posterior disruption of the pancreas where the anterior surface looks normal but if you slip your finger behind the pancreas is fractured where it lies over the spine.

Duodenal Injuries:
- EEM closes the duodenum with a 1 layer continuous suture
- duodenal injuries: most can close primarily unless the ampulla is involved
- if there is extensive blowout of the duodenum options include bringing up a R-en-Y limb and plugging it into the blowout
- ? duodenal diverticulization
- Wide drainage is an option with pyloric exclusion
- should not need to do a Whipple's for duodenal injuries

Pancreatic Injuries:
- Stents in neck of pancreatic duct; better than performing a 90% pancreatectomy with risk of leak
- if do distal pancreatectomy should be able to leave the spleen
- if need to can take splenic artery, just be sure you leave the short gastrics as you are opening the lesser sac
- can also perform intraoperative ERCP - even after having done Kocher - just clamp bowel @ LT and help guide scope down

Moore Retreat: CT imaging in Trauma

2010-06-20T14:47:00.000-06:00

CT imaging of diaphragmatic injuries:

- Collar sign: narrow waist of herniated hollow organs as they herniate through diaphragmatic defect

- Disrupted diaphragm sign

- Dependent viscus sign: posterior wall of stomach lies in contact with posterior wall of the chest (which it normally doesn't)

Use of Triple contrast for colon injuries:

- with multidetector CT, may not need po/pr contrast to detect a colonic injury

- there are usually secondary signs such as a hematoma or air bubbles

- instilling rectal contrast has an inherent false negative rate as well

- pt may still need an exploration if suspicion high enough.

- ?if rectal bleed and penetrating stab or pelvic fracture just explore abdomen, rectal contrast perhaps useful if mechanism present but no clinical suspicion of injury and it may prevent an OR

Houndsfield Units:

- Fresh blood: 20-30 HFU (decreased intensity if old blood, or mixed with ascites, urine)

- Blood with IV contrast: 30-40 HFU

- Fat: <-10 HFU

- Water: 0-10 HFU

- Urine: 0-10 HFU

- Non-contrast (fatty) liver: 10-15 HFU

- Fatty liver contrast phase: 35-40 HFU

- Normal contrast phase liver: 70-80 HFU

- Bone: 400-500 HFU

- Metal: 1000 HFU

- Enhanced aorta: 190

- po contrast: 50-200 (depends on dilution)

Oral contrast can be negative or positive: use of a positive (ie; enhances) contrast agent prevents you from visualizing the bowel wall

- if you want to visualize the bowel wall then water contrast (negative) better

Radiation Exposure:

CT/Abdo/Pelvis:

- old scanners 10-15 mSi

- newer generation of scanners 3-4 mSi

10mSi of radiation carries a 1:2000 lifetime risk of cancer

- consider that everyone has a 1:5 lifetime of risk of caner without any exposure risk

- Therefore if CT is clinically indicated then theoretic risk of inducing cancer should not be a barrier

Moore Retreat: Role of ED Thoracotomy

2010-06-19T17:13:00.000-06:00

Blunt Trauma:
- consider the institutional resources

When is ED Thoracotomy futile?
Blunt trauma:
- CPR > 5 min and no signs of life
- Asystole (without cardiac tamponade)

Penetrating trauma:
- CPR >15 min and no signs of life
- Asystole (without cardiac tramponade)

Once you've done it have an exit plan:
- what are your indications to stop your ED thoracotomy resuscitation?
- was a tamponade present?
- is the heart filling?
- don't let your ED physicians/anesthesiologists get to carried away with transfusion/epinepherine; SBP 90 is enough
- Base deficit >20 is a very, very strong predictor of mortality

Moore Retreat: Thoracic Great Vessels

2010-06-19T17:06:00.000-06:00

Pearls:

- Consider forearm fasciotomies if upper arm ischemia (how?)

- know course of phrenic and vagus nerves as these come into play

Anterior lateral thoracotomy is the defacto incision for any thoracic vascular injury

- if you need access to the other side: Clamshell

- if you need access to proximal great vessels: T-up with a sternotomy +/- supraclavicular trap-door incision

Pneumonectomy in trauma patients is associated with a 95% mortality

- places significant right heart strain that unstable patient won't tolerate

Moore Retreat: Neck Injuries

2010-06-19T16:47:00.003-06:00

Mandatory Zone 2 neck exploration:

- was the surgical dogma dating from Korean and Vietnam war

- This dogma is now changing with improvements in CT imaging and additional diagnostic testing to rule out injuries

- Mandatory exploration carries a 60% negative exploration rate

Selective Zone 2 neck exploration:

- now the approach in most centres

Zone 1 injuries:
- Use CT imaging to determine trajectory of injury
- trajectory helps you to guide further management

Quadroscopy not mandatory anymore
- With improvements in imaging, CT can guide further investigations if the tract is in proximity to other structures

Airway injuries
- Supraglottic injuries: ENT
- Below cricothyroid membrane: general surgery in Denver repairs primarily with 2-0 PDS interrupted sutures
- large injuries can be managed with a tracheostomy tube

Esophageal Injuries:
- rare
- Drain
- place a muscle interposition with SCM flap
- air in the mediastinum more commonly from a tracheal injury
- flexible esophagoscopy is first test: if you make a hole larger it need operative repair anyways
In OR: if unsure
- do an air leak test
- instill methylene blue or charcoal into esophagus and look for leak in neck or chest tube

Carotid Artery Injuries:
- Be wary of using shunts: any debris that flies past shunt can cause a devestating stroke
- Dr. Moore believes ALL carotid artery injuries should be repaired
- doesn't feel risk of hemorrhagic stroke is significant: short presentation times

Internal jugular veins:
- unilateral injury can be ligated

Vertebral artery injuries:
- Angio is primary treatment modality
- if vessel bleeds continuously in ER, can take to OR: make incision at base of neck, place balloon tamponade to get the patient to angio

Moore Retreat: Damage Control Laparotomy

2010-06-19T12:30:00.000-06:00

Identify who needs a damage control lap:
- Temperature, acidosis, coagulopathy
- temperature should be largely controlled: bear huggers in ER, warm fluids; in Denver not an issue as pts rarely get to OR with temp<36. With longer transports most of our pts hypothermic, pre-hospital bear huggers?
- Acidosis can be controlled with bicarb, Denver is quite liberally with use of bicarbonate during trauma resuscitation
- Most significant factor is coagulopathy
- Need for resuscitation should not be indication of damage control. Can resuscitate as well or better in OR vs. ICU

Newer evidence to demonstrate that ARDS is better with isofluorane vs. propofol sedation
- pt in OR on volatile anesthetics may in fact be safer than in ICU from respiratory standpoint

30 Minute Time out:
- pack site of bleeding for 30 mins
- close abdomen with towel clips and then go back and check for further bleeding
- warm patient, resuscitate
- when you go back look for arterial bleeding
- better than sending back to ICU with arterial bleeding

Temporary Abdominal Closures:
- all pts in Denver get abdominal compartment syndrome
- Vac closure is preferred method of closure
- They even apply this to select abdominal sepsis patients
- Relaparotomy in 12-24 hours: especially if shunts used or contamination
- patients very quickly go from being hypocoaguable to hypercoaguable

Abdominal Closure techniques:
- staged tension closure
1) Plastic drape
2) Nylon retention sutures
3) Repeat laparotomy every 48hours and place interrupted sutures each time gradually closing the abdomen
(AJS 2007)

Diuresis:
- Gives a 10mg Lasix trial
- if the patient responds and diureses he then starts a lasix gtt to aggressively diurese for closure
- if pt doesn't respond then he waits

Pearls:
- Chest can also be closed temporarily with plastic drapes

Moore Retreat: Zone I retroperitoneal injuries

2010-06-19T12:01:00.005-06:00

Important aspects of managing retroperitoneal injuries:
1) identify if the injury is arterial or venous?
- arterial: hematoma extends into mesentery, pulsatile

ACCESS:
Supraceliac aortic injury - becuase of dense neural plexus network at celiac plexus unable to really get much above renal arteries with a Mattox maneuver
- therefore a thoracotomy to get supradiaphragmatic control of aorta necessary

"Mattox" maneuver - start incision 1 cm lateral to the white line of toldt: keeps you from damaging ?retroperitoneal structures
- leave kidneys in place generally

Superior Mesenteric Vessel injuries:
Fullen's zones: (1-4) - describes areas of injury to SMA
Zone 1: proximal to infero-pancreaticoduodenal branch
Zone 2: between IPD and middle colic branches
Zones 1-2 are proximal and sit behind the pancreas
- access in trauma situation can be gained by simply cutting pancreas with scissors
Zone 3: between middle and ileocolic branches
Zone 4: distal to ileocolic
Moore advocates repairing ALL SMA injuries with possible exception of most distal SMA where you just accept some dead SB and resect it.
- this is a long process and a temporary shunt can be used

Inferior Vena Cava:
- control: use sponge sticks proximally and distally, a vascular clamp is likely to lacerate the IVC even further
- a posterior IVC injury can be difficult to access, enlarging your anterior injury to gain access to the posterior wall is probably your easiest option.
- try to close transversely as a longitudinal repair is likely to cause hourglass deformity

Pearls: - if you can't find your injury after exploring the hematoma, perform an immediate CTA as the injury is probably temporarily sealed but if it lets loose in ICU it will be catastrophic

Vascular Trauma AHD

2010-06-17T09:27:00.001-06:00

Supraceliac Control
- Insert NG to help locate esophagus
- use mets or scrape with fingers to break through fascia over aorta
- use fingers ot dissect down to spine
- if visceral/aortic penetrating injury, thoracic aorta control much better

Abdo Injury
- Zone 3 injury: explore only if intra-op explanding hematoma
- get another pair of expert hands,

Mesenteric hematoma (expanding)
- Explore take off of SMA
- Can get angio next day to look for bleeding branch and embolize (vs. exploring each branch of SMA)

Packing pelvis:
- open space of retzius and pack anteriorly

CArotid Injury:
- shunts while repairing carotid: in line shunts, baloon shunts
- Safetste ALWAYS to shunt
- if no stents available then use: IV tubing, with bevel but no point
- keep in place with umbo tape
- tie shunt in middle

Indications: to repair carotid
- <4hrs
- hemiplegic
- >4hrs intact function
- otherwisenecrotic when hook up will bleed

14jun10

2010-06-14T08:30:00.001-06:00

-Most common mets to the adrenal gland.
-Benign adrenal lesions.

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ED Thoracotomy

2010-06-13T16:23:00.004-06:00

Source: Cameron

Discussion revolves around definition of Presence of Vital Signs vs. Signs of Life.
- vital signs include blood pressure, palpable pulse and spontaneous respirations
- signs of life include electrical cardiac activity, respiratory effort, pupillary reactivity.

Indications for EDT
1) salvagable post injury cardiac arrest
2) hypotension from
- cardiac tamponade
- intrathoracic hemorrhage
- air embolism
- active intra-abdominal hemorrhage

Relative indications:
1) refractory moderate hypotension from the same reasons as 2) above.

Incision:
- start just lateral to the sternum just inferior to the nipple.
- curvilinear incision following inferior border of pec major
- continue all the way down to the lattisimus dorsi
- using mayo scissors cut intercostal muscles just above the rib

Things you can do after chest accessed
1) pericardiotomy
- open longitudinally, parallel to phrenic nerve
- extend up to root of aorta and down to the apex
2) Aortic cross-clamping
- divide pulmonary ligmament with straight scissors
- bluntly dissect away mediastinal pleura from aorta and esophagus
- dissect away esophagus and prevertebral fascia to the point where you can encircle the aorta.
- with aorta encircled with left hand apply a curves aortic clamp with the right hand.
- be judicious about aortic cross clamping. It increases cardiac work and will result in post-clamp shock when reperfusion occurs.
3) Open cardiac massage
- begin bimanual cardiac massage if arrest has occured
4) control non cardiac hemorrhage
- great vessel damage is almost impossible to repair in ED. Apply pressure and get to the OR
- pulmonary hemorrhage can be controlled with Duvall clamp or vascular clamp
- last resort is to clamp or occlude inflow at the hilum. Which will require division of the pulmonary ligament. Similar to aortic clamping will result in increase in cardiac afterload and may supress cardiac index.

Risks assoated with EDT.
- HIV. Trauma pt 4%. EDT pt 14%
- acutely injured pt. HIV 4% HepB 20% HepC 14%

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Soft Tissue Sarcomas

2010-06-13T07:27:00.002-06:00

Diagnosis:
Tissue diagnosis is the key - need to differentiate from other disease processes
1) FNA is rarely diagnostic
2) Core needle biopsy is the primary modality:
- try to follow straight tract to lesion - remember you'll have to resect the biopsy tract
- prior imaging will help to guide route of biopsy, image guided biopsy may also be useful
3) if core biopsy is not diagnostic then open incisional biopsy may be necessary
- <5cm can consider exicisonal biopsy
- if >5cm do incisional biopsy reducing flaps and ensuring hemostasis

Pathology:
LN Mets are rare (2-3%): Some subtypes do have a higher association with LN mets (~20-30%) and you should resect LNs if positive, some even advocate doing SLNB in these cases:
- Synovial
- Epitheliod
- Clear Cell
- Rhabdomyosarcoma

Most common subtype in Children: Rhabdomyosarcoma
Most common subtype in Adults: Malignant Fibrous Histiocytoma

HER-2

2010-05-30T21:49:00.002-06:00

HER-2
- gene responsible for encoding a transmembrane typrosine kinase (growth stimulating activity)
- when over-expressed in breast cancer causes more rapid growth and aggressive behaviour of tumor cell
- over-expressed in ~30% of breast cancers
- over-expression is an independent predictor of worse prognosis
- Herceptin: monoclonal antibody targetting HER-2 membrane receptor

BRCA

2010-05-30T17:47:00.002-06:00

BReast CAncer 1 and 2
- higher incidence of breast and ovarian cancer
- Autosomal dominant with incomplete penetration
- 85% chance of developing breast cancer over lifetime; majority will present before age 50
- risk of ovarian cancer BRCA-1 40%, BRCA-2 20%
- 10% of males with BRCA-2 develop breast cancer

Li-Fraumeni Syndrome

2010-05-30T17:40:00.001-06:00

mutations of p53 gene
- breast cancer
- sarcoma
- brain tumors
- adrenocortical carcinomas
- leukemia

Breast Cancer in Pregnancy

2010-05-30T13:57:00.002-06:00

Breast cancer 2nd most common malignancy in pregnancy
(1:3,000 pregnancies)
Diagnosis:
- Mammography can be performed if fetus shielded
- U/S
Treatment:
- mastectomy usually operation of choice (radiation contraindicated in all trimesters)
- lumpectomy can be performed very late stages of pregnancy
- Tc99 can be used for SLNB
- avoid isosulfan blue dye and vital blue dyes
- chemotherapy acceptable in 2nd and 3rd trimester but avoid in 1st trimester

Locally Recurrent Breast Cancer

2010-05-30T13:49:00.002-06:00

Local recurrence after mastectomy - 10%
Treatment:
-local excision plus irradiation
- use of systemic therapy is contraversial
Prognosis:
-almost always accompanied by distant metastatic disease
- Long-term prognosis poor 20 yr survival <10%

Male Breast Cancer

2010-05-30T13:36:00.002-06:00

<1% of breast cancers
Risk factors:
- (increased estrogen levels): cirrhosis, Klinefelter sydnrome
- radiation
- BRCA2
most common tumor type is infiltrating ductal cancer
- stage for stage same as female breast cancer but detected later
management:
- mastectomy SLNB +/- ALND
- large majority are ER positive and adjuvant treatment should be offered the same as females

Keys Steps: Parotidectomy

2010-05-29T12:07:00.002-06:00

1) raising skin flaps
2) dissection down to posterior belly of digastric mm.
2) identification of facial nerve

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TMcM - adrenal talk

2010-05-28T18:28:00.001-06:00

Aldosteronoma:
- usually very small tumors
- if larger tumor on one side --> is it a redherring and its actullay another type of adrenal tumor
NP25 scan available at CCI for localizing
Adrdrenal venous sampling
pheo 30% are thought to be genetic
- now all pts get screened MEN2a/b, vHL, NF-1, tuberous sclerosis, SDH mutations
- pheos alpha block 2-3 wks before OR
- fluid load 3L day of surgery
- can tank pressures from other causes

DCW Salivary gland AHD talk

2010-05-28T10:35:00.001-06:00

cystic lesions of minor salivary glands
- due to trauma (biting lip)
- treated by excision of entire cyst and reapproximation of oral mucosa
minor salivary glands can also be biopsied when asked for salivary gland bx for sjogren's diagnosis
salivary duct stones
- can be extracted with baskets by interventional radiologist
sialadenitis
- staph aureus
- hydration
- sialogogues - lemon drops
- antibiotics
- drainage: through stensen's duct or 14G needle aspiration
Parotid lesions:
- parotid glands are now FNA'd whereas in past went straight to OR
rate of needletrack seeding
- 25G - 0.01%
Parotidectomy
1% chance of permenant facial nerve dysfunction
- marginal mandibular branch is long and thin and most likely involved
- 20% of temporary dysfunction
posterior belly of digastric for deptth
- finger on mastoid point to nose
- 1/2 distance at depth of digastric belly
Fascial layers of neck

Making of a surgeon

2010-04-16T10:29:00.001-06:00

Residency is a job. Not a primary educational pursuit.
Residency is a passive system that depends on the patients that come
through the door.
Deliberate practice.
Currently limited in surgical training.
Surgical rotations do not allow development of mental models and
pattern recognition of surgical disease.
Medical school tracks surgery vs medicine.
- move basic science to undergrad.
- more opportunities for lifelong learning

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Laparoscopic Surgery for Crohn's disease

2010-04-15T14:29:00.001-06:00

Possible challenges to laparoscopic surgery in Crohn's disease:
- Inflammatory mass
- abscess
- anatomical orientation: previous operation, fistualous connections
- adhesions
- difficult dissesction
- bleeding high conversion rate

Patient preparation:
- Drain abscess: keep drain until time of surgery
- Optimize nutrition with elemental diet (preferable over TPN)

SB resections:
- if single site can consider intracorporeal anastamosis
- if multiple sites will be faster to exteriorize each site

conversion to open procedure is not associated with an adverse outcome.

Laparoscopic resection only accounts for <10% of crohn's resection
-no impact on Long term QOL or function.

Surgery for Colonic Crohn's Disease

2010-04-15T13:59:00.001-06:00

Segmental vs total colectomy:
- distribution of diseae: previous or concurrent SB disease
- status of rectum
- age of patient
- rate of recurrence

- don't leave your anastaomosis next to the duodenum; if recurrence forms develops a duodenal fistula
- Transeverse colon disease: segmental transverse colectomy results in huge mesenteric defect; better to do subtotal and anastamosis to sigmoid colon
- multisegmental pancolonic crohn's: consider IRA if pts sphincter fxn will tolerate

Immunomodulators and their impact on Surgery in IBD

2010-04-15T13:53:00.001-06:00

Do immunomodulators increase risks of surgery?
- no good prospective studies on this topic
Appau etl al, J Gastrointest Surg 2008: Effects of infliximab on ileocolic resection
- use of steroids in non-infliximab group higher
- rate of sepsis and readmission higher in IFX group
- trend toward leak and reoperation in IFX group
Columbel et al, Mayo Clinic
- no difference in septic complications after use of IFX, AZA/6-MP/MTX, steroids
Kunitake, J Gastro surg 2008
- no significant difference in complication rate.
Therefore, conflicting data on whether they cause complications
- all retrospective and had methodological flaws
- One speaker suggested that pts of on combinations of IFX and steroids are at risk of anastamotic leak.

When should you stop immunomodulators?
- if attenuation to IFX, consider trying a 2nd biologic
- for fibrostenotic disease, will need surgery
- worsens obstruction as quick healing results in worsening of fibrostenotic disease
- stop if develop abscess
- failure of 2nd biologic
- always worry about possibility of malignancy
- stop 1 month prior to surgery: OK to continue AZA/6-MP/MTX until date of surgery

Laparoscopic IPAA

2010-04-15T12:41:00.000-06:00

Options include:
- open laparotomy
- Lap assisted: mobilize colon laparoscopically and use low phannenstiel incision for extraction and creation of pouch
- Hand-assisted procedure
- completely laparoscopic - extraction site through ileostomy site (need normal BMI)
- single incision:

5 step Lap Total Colectomy - IPAA:
- mobilize left colon
- mobilize right colon - preserve ileocolic vessels for pouch
- rectal dissection: - uterus suspended with suture and sponge stick in vagina
- exteriorization of colon through ileostomy site: pt must be thin, bowel must be prepped
- anastamosis

Dr. Marks steps:
- takes infra colic
- takes ileo-colic vessels and divides ileum early so by end of case has sense of blood supply
- mobilize right colon
- middle colic division (branches ~3.5cm from take-off of SMA)
- divide omentum/supracolic dissection
- Closckwise rotation of cecum upto LUQ - allows you to follow the mesentery down to rectum
- pelvic dissection
- uses 30mm stapler coming vertically from supra pubic port site

Gaining length on SMA.
- fenestrate SB mesentery

Medical Management of IBD

2010-04-15T12:06:00.000-06:00

UC Remission:
- Aminosalicylates:
- can give oral or topically or combined
- Pentasa has earlier release in stomach and SB vs. Asacol and sulfasalazime which are activated more in the colon
- ensure that patient has had an adequate dose prior to declaring the patient has failed on this treatment
- Steroids:
- Immunomodulators:
- cyclosporine: small percentage of the population who have fulminant disease as a bridge to early surgery
- azathioprine/6-MP: steroid refractory patients

CD remission:
- 5-ASA
- Antibiotics
- Steroids: Budesonide - 9 mg: long-term therapy has fewer cushingoid SE but still at risk of osteoporosis

infliximab:
- SE: lymphoma, TB, death
- Present, Et al NEJM 1999; infliximab for fistulizing crohn's disease
Methotrexate:
- complication profile is significant and not generally used often

Indications for surgery:
- failure of medical management: make sure pt just doesn't need better monitoring of taking meds
- obstruction
- bleeding
- perforation
- CD: not operating for cure; managing complications and QOL

Risk of Malignancy:
- UC after 10 years needs 4 quadrant biopsy every 10 cm
- DALM: unless adenoma like then likely requires resection.

Laparoscopic Resection for IBD

2010-04-15T11:50:00.000-06:00

General Principles:
- Ensure that you review pathology to differentiate CD from UC

- Perianal disease is a red flag for CD.

- however, may be coincidental, biopsies of local fistula may not differentiate

- increased perioperative morbidity in pts on Remicaide

- Safest approach would be to perform total colectomy to get better pathology and return to fight another day.

Chronic Crohn's Colitis:
- NEVER do a segmental resection
- Controversy regarding reconstruction, IRA can be considered in select patients with rectal sparing. Pt must be informed that inevitable re-resection of rectum is likely.

Chronic Groin Pain After Hernia Repair

2010-04-15T09:12:00.004-06:00

Definition: Pain that lasts > 3 months after a hernia repair
- 5-7% with groin pain will go to litigation

Management of inguinodynia:

- NSAIDs

- Pain clinics

- nerve blocks

Ref: Palumbo et al, "for algorithm for management of persistent groin pain

Risk factors for groin pain:-Recurrent hernia
- high pain scores at 1 and 6 weeks

Types of Post-op Pain:

- Nerve pain. Burning

- Somatic pain. Gnawing

- Testicular pain

Nerves to take into consideration:

Considerations in Inguinal hernia repair:

- Type of mesh. Heavy vs light weight

- Fixaton: Fibrin sealant vs. Staples vs. no fixation

- Most studies have not shown a difference in chronic pain scores based on type (if any) fixation

Use as few tacks as possible and stay above iliopubic Tract

References:
- Courtney BJS 2002. Large Scottish population study
- Grant BJS 2004. Open vs lap hernia numbness and pain is initially lower in the laparoscopic group but equalize at 5 years
- Eklund. BJS 2010. Chronic pain: At 9 years tep group few have residual pain compare to open group. Low BMI, improvement in function pre to post op lower risk of groin pain.
- Matthews. Am j Surg. 2007. Followup va study. Chonic groin pain

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Loss of domain defects in obese patients

2010-04-15T09:00:00.000-06:00

Ching Surg endoscopy 2008
Comparison of early outcomes
Recurrence is not influenced by obesity. Recurrence related to defect
to mesh size.

Conflicting data.
Some think recurrence rate higher in obese

Concept of end stage hernia.

Options
Open inlay or onlay
Stoppa
Component separation
Laparoscopic
Combined with bariatric procedure

Contraindicatipmd to laparoscopy:
Loss of domain
Vet large defect >20 cm
Past or present mesh infections
Contraindicatipmd to synthetic mesh
Skin changes over hernia sac
Need to remove old mesh

chang archives ofaurgery 2007. Autologous recontruction.
- compontent separation 3% recurrence rate.

Should ventral hernia repair be delayed in obese patients.
- attempted medical weight loss.
- bariatric procedures.
Not known at this time.

Eid. Surg endocopy. 2004.
Repair of ventral hernia in morbidly obese.
-primary repair high 22%
- biological mesh no recurrences at 1 year
- high rate of sbo if adhesiolysis performed in hernia sac.

Staged repair may improve outcomes
Obesity is a contraindication.

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Difficult Ventral Hernias

2010-04-15T07:13:00.002-06:00

Principles of hernia repair:
- Mark grid on skin to keep you honest where pulling out anchor stitch.
- Grid markes 4 corners of defect making sure that they bisect the defect in half.

- Most accurate defect measurement is with abdomen insufflated and form inside. Large BMI makes external measurement more inaccurate.

- Lower risk of infection laparoscopically.

- # of anchoring sutures: 4 corner sutures is sufficient usually. Larger luminous hernias probably need more tacking sutures. They are the only full thickness transabdominal fixation. Make no apologies to pt that it causes pain.

Subxiphoid hernia:
- secondary to cardiac surgical incisions
- difficulty arises in achieving adequate overlap of mesh over defect due to rib cage and diaphragm.
- May need to compromise lateral suture bc limited by costal margin.
- order of placing tacking transabdominal sutures: sup, far lateral, inf, near lateral
- may have difficulty passing superior tacking suture: Gore suture passer can be placed through the xiphoid process.

Suprapubic hernias:
- Trocar placement from above
- 3 way foley to fill and drain bladder. May need to talk to pt about bladder mobilization and injury
- 4 cm over lap below pubis
- Anchor inferior, far lateral, superior then near lateral.
- Cardinal suture into pubis periosteum. Overlap below pubic bone.
- Four bone anchor sutures placed through the pubic rami and tack down around circumference of mesh

- Bone anchor drilled. Same as flank hernia. Permenant bone anchor stitch with #2 polyester u stitch through pubic bone and mesh.

Flank hernias:
- Mobilize retroperitoneal sutures to bring out lumborum suture.
- Bone anchors into iliac crest.
- PTs on immunoauppressants may not hold bone anchor.
- PTs may get neuralgia.

Chronic pain:
Waits 6 weeks before doing anything
Injects marcaine. Usually from a tacking clip they have never had to remove stitch.