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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Management of Asymptomatic Gallstones

Few predictive factors for symptomatic progression of gallstone disease:
- Bariatric surgery - 30% develop gallstones
- post-colectomy - 20% will develop symptoms within 5 years
- prolonged TPN use

Despite these risk factors, there are few indications for prophylactic cholecystectomy:
- Expectant Management of Cholelithiasis is the accepted treatment despite low morbidity of lap chole
- Diabetes is not an indication for prophylactic chole.  Diabetics do not have any significant difference in prevalence, presentation or complications compared to nondiabetics

Post-Transplantation:
- Cyclosporine leads to gallstone formation.
- Need for prophylactic chole has been shown to be of benefit in cardiac transplant patients if screening u/s shows stones (Milas et al, Mayo clinic)
- in renal transplant patients, majority (~90%) remain asymptomatic

Hemoglobinopathies:
- at risk of developing pigmented stones.
- sickle cell: 70% of pts
- hereditary spherocytosis: 85%
- thalassemia: 24%
- Gallstones in sickle cell patients can pose a problem. ~50% will become symptomatic within 3-5 years. Presence of gallstones can be diagnostically challenging due to possibility of abdominal sickling crisis.
- Hemoglobinopathies are an indication to perform prophylactic lap chole, lap chole should also be performed if doing a lap splenectomy

Bariatric Surgery:
- incidence of gallstone formation after rapid weight loss:
- general population: 10-20%
- bariatric surgery population: 30-40%
- if gallstones documented at time of bariatric surgery - lap chole recommended
- Ursodiol - can decrease incidence if patient compliant (prevents cholesterol absorption, expensive (~$1.50/d), BID). Suggested for patients undergoing bariatric surgery without prior evidence of stones.

Incidental Cholecystectomy - Controversial:
- During AAA: controversial due to the presence of graft material.  Review of incidental chole - shown to be safe as long as performed after retroperitoneum is closed
- Other abdominal surgeries: One study (Watemberg et al) showed that in pts >70 yo with cholelithiasis, M&M was higher if you DO NOT do incidental chole during laparotomy for other reasons.... yet we do not routinely do this in practice - why?
- most were small studies - only Watemberg was larger study