Benign Perianal Disease

Topics to review:

- Anal Fissures:
1) describe pathophysiology
2) describe preventative, medical and surgical treatment

- Anorectal abscess:
1) differentiate perianal, ischiorectal, intersphincteric, supralevator and horseshoe abscesses;
2) describe drainage technique of uncomplicated perianal and ischiorectal abscesses

- Hemorrhoids
1) differentiate internal, external hemorroids, rectal prolapse
2) describe treatment of external hemorroids
3) describe treatment options for internal hemorrhoids

Miscellaneous perianal and colorectal conditions
1) pruritis ani
2) proctalgia fugax
3) rectal prolapse
4) fecal incontinence

Recommended Reading:
- Lange Current Diagnosis and Treatment - Anorectum
- Corman's Colorectal Surgery - Proctalgia fugax

Breast Disease

Reading Guide: Breast Disease
- Breast Cancer
- Staging breast cancer
- Inflammatory Breast Cancer
- Paget's disease
- Causes of nipple discharge
- Management of Mastalgia
- Breast Cysts, fibrocystic disease, fibroadenoma

References:
Link to UofA Surgery 101 Breast Cancer Lecture  - Podcast #116
NCCN Breast Cancer Guidelines
Lange Current Diagnosis and Treatment: Breast
Paget's Disease: Kurer's Breast Surgical Oncology
ACS Surgery - Benign Breast Disease

Rome criteria for Irritable Bowel Syndrome

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

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

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

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

Laparoscopic Abdominal Wall Reconstruction

Movie link

Definition of hypersplenism

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

Meckler's Triad

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

GAIL model for breast cancer risk assessment

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

"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

"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

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

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

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

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

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

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

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

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.