The Concise Surgery

Review Manual
FOR THE ABSITE & BOARDS

2ND EDITION

Tommy Alan Brown, II

MD | GENERAL SURGERY iii

Uploaded by MEDBOOKSVN.ORG
 The Concise Surgery Review Manual
for the ABSITE & Boards

The purpose of this text is to have one unified source for reference during surgical
rotations & to serve as a base text to prepare for the surgery in-service & board
exams. It has been compiled over the course of seven years & represents notes
taken during academic lectures & various readings in preparation for the surgery
in-service examination as well as the written & oral boards. The information
contained herein should serve as a reference only & is not a substitute for clinic
judgement. Italicized content is considered very high-yield for examination
purposes. Text in purple denotes potentially helpful mneumonics. Commonly
quoted oral board topics are listed in maroon. While this review follows the
SCORE curriculum in general, the author has no direct affiliation with SCORE,
the American Board of Surgery, or the American College of Surgeons.

This book is dedicated to my wonderful wife, son, parents, and all of those who
have taught me the way I should go. None of this would be possible without you.
Thank you for your wisdom, patience, and love.

i
Contents
1. Cell Biology & Hematology........................................................................................... 1
2. Immunology, Inflammation, & Cytokines ..................................................................... 8
3. Infection & Antibiotics ............................................................................................... 10
4. Anesthesia, Medications, & Pharmacology................................................................. 17
5. Fluids, Electrolytes, & Nutrition ................................................................................. 22
6. Oncology ................................................................................................................... 28
7. Transplantation ......................................................................................................... 31
8. Wound Healing .......................................................................................................... 35
9. Trauma...................................................................................................................... 36
10. Critical Care ............................................................................................................... 55
11. Burns......................................................................................................................... 62
12. Plastics, Skin, & Soft Tissues....................................................................................... 67
13. Head & Neck.............................................................................................................. 72
14. Pituitary .................................................................................................................... 78
15. Adrenal ..................................................................................................................... 79
16. Thyroid ...................................................................................................................... 83
17. Parathyroid ............................................................................................................... 89
18. Breast........................................................................................................................ 92
19. Thoracic................................................................................................................... 100
20. Cardiac .................................................................................................................... 106
21. Vascular .................................................................................................................. 108
22. GI Hormones ........................................................................................................... 118
23. Esophagus ............................................................................................................... 120
24. Stomach .................................................................................................................. 125
25. Liver ........................................................................................................................ 135
26. Biliary System .......................................................................................................... 143
27. Pancreas.................................................................................................................. 150
28. Spleen ..................................................................................................................... 157
29. Small Bowel............................................................................................................. 160
30. Colorectal ................................................................................................................ 166
31. Anal & Rectal........................................................................................................... 175
32. Herniae, Abdomen, & Surgical Tech ......................................................................... 180
33. Urology ................................................................................................................... 188
34. Gynecology.............................................................................................................. 192
35. Neurosurgery .......................................................................................................... 196
36. Orthopaedics ........................................................................................................... 197
37. Pediatric Surgery ..................................................................................................... 201
38. Statistics & Pt Safety ................................................................................................ 210
39. MIS ......................................................................................................................... 213
40. Abbreviations .......................................................................................................... 214

ii

Uploaded by MEDBOOKSVN.ORG
iii 0
1. Cell Biology & Hematology
A. Coagulation Factors
1) All from liver minus f VIII (f VIII & its cofactor vWF [from endothelium]).
2) Extrinsic → f I (tissue factor) & VII.
3) Intrinsic → collagen (exposed), f XII, kininogen, & prekallikrein.
4) Vit K dependent cofactors → f II, VII, IX, & X (Also proteins C & S).
a. Warfarin inhibits these.
5) Factor VII → shortest ½-life.
6) Fibrin → binds Gpllb/llla → cross-links PLTs.
7) Prothrombin (Xase) complex f II, V, & X + Ca++ + PF3. Is on PLTs.
a. Catalyzes f IIa (thrombin).
8) Thrombin (f II, Key for coag) →→ fibrinogen → fibrin + FSPs.
a. Activates f V & VIII, PLTs. Fibrin + PLTs → hemostatic plug.
9) Anti-thrombin III (Key for anticoag). Binds & inhibits f IIa, IX, X(MI), & XI.
a. Heparin ↑ AT-III activity 1000 x.
10) Protein C → degrades f V, VIII, & fibrinogen.
11) FFP → ↑all factors, protein C & S, & AT-III. Immediate effect (thaw 1st).
a. Corrects coagulopathy 2/2 liver dz or warfarin (↑PT).
b. FFP INR is 1.1 on avg, but will not significantly ↓ INR to ≤ 1.6.
12) Cryo → Highest vWF-VIII concentration, also ↑ fibrinogen.
a. Used in vWB dz & hemophilia A (f VIII def).
13) DDAVP → vasopressin analogue → release of f VIII & vWF from endothelium →
corrects bleeding time. Use for acute uremic bleeding & acute DI.
B. Procoagulant agents (anti-fibrinolytics)
1) ε-Aminocaproic acid (Amicar) Inhibits plasmin →↓fibrinolysis.
a. Txs→ bleeding s/p bypass, DIC, thrombolytic overdose.
2) Tranexamic acid (TXA) → Lysine analog.
a. Binds plasmin & prevents fibrin break down.
C. Anticoagulation
1) Coumadin → Prevents vit K–dependent glutamic carboxylation of f II, VII, IX, X, &
proteins C & S.
a. SEs → skin necrosis, liver injury, & teratogen (crosses placenta).
b. ↑Needs ↑ dose if on barbiturate/other cytochrome p450 inducer.
c. Bridging
i) D/c 5d before surgery & restart 24hrs s/p surgery.
ii) Bridge for → mech heart valve, high-risk Afib, prior CVA/TIA, acute
embolism, or high risk for VTE.
A) NO CKD → LVX (d/c 1d preop, resume 1-2d post-op).
B) CKD → UFH (d/c gtt 6hrs preop, resume 1-2d post-op).
C) No bridge→ low-risk/chronic Afib, bicuspid Ao, or VTE w/<2RFs
iii) Semi-urgent reversal (1-2d) → give vit K (2.5-5.0 mg PO or IV).

Uploaded by MEDBOOKSVN.ORG
 iv) Immediate reversal → 4f-PCC or plasma products (eg. FFP or PF24) + vit K.
4f-PCC has all needed factors.
A) 3f-PCC needs added f VII (usually via FFP).
B) ↑thrombotic risk → only use for life-threatening bleed w/↑INR.
v) Vit K → 2.5-5.0mg PO or IV (onset 6hrs).
vi) 4f-PCC (aka Kcentra)→ 25-50 u/kg IV. Immediate onset, lasts ~6hrs.
A) Stored at room temp, quick, & small volume.
2) Heparin
a. 80u/kg bolus, 18u/kg/hr gtt. Titrate ↑or↓25% per aPTT/anti-Xa goals.
b. ½ -life→ 60-90min (want aPTT 60-90sec OR anti-Xa 0.3-0.7 IU/mL).
c. Binds/activates AT-III (↑activity 1000×) → Inhibits f II, IX, X, & XI.
d. Reticuloendothelial system clearance.
e. Reversed w/protamine. Long-term SEs → osteoporosis, alopecia.
f. Doesn’t cross placenta (OK for pregnancy).
g. Pre-op: If tx dose/gtt → d/c 6hr pre, restart 12-24hrs post-op.
h. Protamine→1mg per 100u UFH (general rule, depends on dose time).
i) Cross-rxn w/ prev exposure or NPH insulin (~1%→↓HR, EF, & BP).
i. Low molecular weight heparin (eg enoxaparin) → ↓HIT vs UFH.
i) Activates AT-III, but ↑neutralization of just Xa → NOT reversed w/protamine.
Stop LMWH 24h preop, restart 24-48hrs postop.
3) Ancrod – derived from snake venom → tPA release.
4) Thrombolytics → All activate plasminogen. Follow fibrinogen lvl (<100 →↑bleeding
risk/severity).
a. Streptokinase (has ↑antigenicity), urokinase, & tPA (tissue plasminogen
activator). D/c these within 24hrs.
b. OD Tx → ε-aminocaproic acid.
5) Antiplatelets
a. ASA → Irreversibly inhibits COX in PLTs & ↓TXA2 →↑bleeding time. PLTs lack
DNA → can’t resynthesize COX.
i) Continue through most surgeries. If bleeding risk > risk of holding ASA → stop
ASA 7d before surgery.
ii) Can emergently reverse effects w/PLTs.
b. NSAIDs
c. P2Y12 Inhibitor
i) Clopidogrel (Plavix) → ADP antagonist. D/c 5d before surgery.
A) OD or reversal → PLTs.
d. GpIIb/IIIa Inhibitors → abciximab (ReoPro), eptifibatide (Integrilin), & tirofiban
(Aggrastat).
e. Wait times before elective surgery s/p PCI. (No heparin bridge.) Can’t wait →
switch to IIb/IIIa inh.
i) Coronary Angioplasty
A) on ASA/Plavix → 2wks not on ASA → 4wks

2
 ii) Bare Metal Stent
A) on ASA/Plavix → 4wks not on ASA → 8wks
iii) Drug-Eluting Stent
A) on ASA/Plavix → 6mns not on ASA → 1yr
6) Thrombin Inhibitors/DOACs can follow aPTT.
a. Argatroban → reversible, direct inh. CI in liver failure (cleared by liver), ½ life →
40-50min, used in HITT.
b. Dagibatran (Pradaxa) → CI in CKD. Cleared by HD or Praxbind (idarucizumab;
~$4,200).
c. Bivalirudin (Angiomax) → reversible, direct inh. Cleared by blood proteases. ½-
life → 25min.
d. Lepirudin → ½ life 60-90min. Load w/0.4mg/kg then 0.15mg/kg/hr gtt. Cleared
renally.
e. Hirudin (Hirulog; from leeches) → irreversible, most potent → ↑bleeding Cxs.
7) Xa Inhibitors/NOACs Reverse w/andeXanet alfa (AndexXa). Xa false receptor;
800mg bolus, 960mg infusion (~$58k/tx).
a. RivaroXaban (Xarelto)
b. ApiXaban (Eliquis)
c. BetriXaban
D. Hypercoagulation Disorders Can be arterial or venous.
1) Acquired – CA, IBD, infection, inflammatation, MPDs, OCPs, pregnancy, post-op,
rheumatoid arthritis, & tobacco (MCC).
2) Antithrombin III Def → Can develop s/p prev heparin exposure. Heparin doesn’t
work. Pts get fresh red thrombi.
a. Tx → recomb AT-III conc or FFP (highest AT-III conc), heparin bridge to coumadin.
3) Anti-Phospholipid Antibody Syndrome (APAS) → Procoag (but ↑ PTT) 2/2
cardiolipin/mitochondrial membrane Abs & SLE anticoag (phospholipids). Not all
will have SLE.
a. Dx → ↑PTT despite tx w/FFP, + Russell viper venom time, false-positive RPR
(syphilis). Tx → heparin bridge to coumadin.
4) Cardiopulmonary Bypass Activates f XII (Hageman factor)→ hypercoag.
a. Tx → heparin to prevent.
5) Dysfibrinogenemia, Dysplasminogenemia
a. Tx → heparin bridge to coumadin.
6) Factor V Leiden Leads to activated protein C resistance (but mut is on f V). Causes ~
30% of spont VTE.
a. MC congenital hypercoag d/o (MC overall & MC acquired → smoking).
b. Tx → heparin bridge to coumadin.
7) Hyperhomocysteinemia Tx → folic acid & B12.
8) Polycythemia Vera PLT function defect → thrombosis.
a. Keep Hct <48 & PLTs <400 before surgery.
b. Tx → phlebotomy, ASA.
9) Protein C or S Def AD. Tx → heparin bridge to coumadin.
3

Uploaded by MEDBOOKSVN.ORG
 10) Prothrombin Gene G20210 A Def AD. Tx→ heparin bridge to coumadin.
11) Warfarin-Induced Skin Necrosis →2/2 starting coumadin w/o heparin 1st. Relative
protein C def pts are very vulnerable.
a. Short relative ½-life of proteins C & S → 1st to ↓vs. procoag factors →
temporarily hyperthrombotic.
b. Tx → heparin. To prevent start heparin prior to coumadin. MI when starting
coumadin for the 1st time.
12) Key for arterial thrombosis → endothelial injury.
13) Keys for venous thrombosis → endothelial injury, hypercoag, & stasis (Virchow’s
triad).
14) Venous ThromboEmbolism (VTE) LLE 2x DVT vs RLE.
a. RFs → hypercoag, stasis, & venous injury.
b. VTE Tx: 1st → 3-6mn, 2nd → ½-1yr, 3rd/sig PE → life.
c. H/o previous DVT → place SCDs + ppx for subsequent surgeries.
d. UE DVT 2/2 PICC in pt w/ICH → just pull PICC.
i) Don’t give tx-dose anti-coag or place SVC filter.
e. Most abd/pelvis CA pts need 4wks VTE ppx post-op.
f. Greenfield filter indicated for →
i) Anticoag CI, PE on anticoag, free-floating IVC/ilio-femoral/deep femoral DVT,
recent pulm embolectomy.
g. Temp IVC filters → pts w/↑DVT risk (eg head injury, prolonged bed rest).
Place filter below right renal vein.
15) Portal Vein Thrombosis Tx→Tx cause, start LMWH then NOAC for 6mns.
a. Usually post-partum or s/p umbilical cath→ above + abx 7-10d.
E. Bleeding Disorders
1) Incomplete Hemostasis MCC of surgical bleeding.
2) von Willebrand’s Disease MC congenital bleeding d/o.
a. Prevalence → 1:100, clinically sig bleed → 1:10,000.
b. vWF links GpIb on PLTs to collagen. Nml PT, nml/↑PTT.
c. ↑ bleeding time (ristocetin test).
d. Type I – AD, ↓ amount (Diminished); MC (70%). Mild sxs.
i) Tx → recomb f VIII:vWF, DDAVP (1st line), cryo.
e. Type II – AD, defect (Defective), vWF doesn’t work well.
i) Tx → recomb f VIII:vWF, cryo (1st line), DDAVP.
f. Type III – AR, total def (rare; Deficient) → most severe bleeding.
i) Tx → recomb f VIII:vWF (1st line); cryo; (DDAVP won’t work).
3) Factor VII Deficiency →↑PT, nml PTT→ bleeding tendency.
a. Tx → recomb f VII or FFP.
4) Hemophilia A (f VIII Deficiency)
a. MC inherited coagulation factor d/o (prev → 1:5000 M).
b. Sex-linked recessive. Nml PT, ↑PTT. Crosses placenta → may not bleed
w/circumcision, but can be 1st sign.
c. Pre-op → need 100%; keep 80%-100% 10-14d post-op.
4
 i) 25 u/kg of recomb f VIII = 50% nml f VIII level.
d. Joint bleeding (DON’T aspirate).
i) Tx → ice, range of motion, DDAVP (mild) vs f VIII/cryo (severe).
e. Epistaxis, ICH, or hematuria. Tx → recomb f VIII or cryo.
5) Hemophilia B (IX Deficiency) / Christmas Disease → X-linked recessive.
a. Nml PT, ↑ PTT.
b. Need level 100% pre-op & 30%-40% 2-3d post-op.
c. Tx → recomb f IX or FFP.
6) PLT Disorders → bruising, epistaxis, mucosal bleeding, petechiae, purpura.
a. Acquired– 2/2 heparin, H2 blockers, Zosyn.
b. Bernard Soulier GpIb (has 1 “b”) PLT receptor def (b/w PLT & vWF/collagen).
vWF binds GpIb to collagen. Tx → PLTs.
c. Glanzmann’s Thrombocytopenia GpIIb/IIIa (has 3 “a’s”) receptor def b/w PLTs.
Fibrin binds GpIIb/IIIa to GpIIb/IIIa b/w PLTs. Tx → PLTs.
d. Uremia usually 2/2 ESRD → vWF down-reg/↓vWF release → ↓PLT function.
i) Tx → hemodialysis (best for non-acute;
corrects uremia, but only transiently
PLT fxn), DDAVP (quickest, best for
acute; effective w/in 1hr, lasts 4hrs,
dose 0.3µg/kg), PLTs.
e. Wiskott-Aldrich Syndrome → X-linked.
Eczema; &↓PLTs, B & T cells.
f. Heparin-Induced Thrombocytopenia (HIT)
i) 4T Score is predictive of likelihood of
HIT.
ii) Type I → ~2d s/p heparin/LMWH. PLTs
↓ 50% then normalize, non-immune, 2/2 direct heparin effect.
iii) Type II →2/2 antiPLT Abs (IgG PF4 Ab [MC], neutrophil-activating peptide 2
Ab, IL-8 Ab) → immune-mediated PLT destruction.
iv) Tests → 1st PF4 Ab, 2nd serotonin release assay (SRA).
v) Can also → PLT aggregation → thrombosis (HITT; T = thrombosis).
vi) White clot (PLT rich, ↓fibrin & RBC), can → skin necrosis.
vii) MC Cx of long-term heparin → osteopenia.
A) Can occur w/low heparin dose.
viii) LMWH → ↓ HIT risk vs UFH.
ix) Tx → d/c heparin; start dagibatran or argatroban (direct thrombin inh) for
anticoag/HITT Tx.
A) DVT ppx if hx of HITT→ fondaparinux (indirect Xa inh. NOT a LMWH, but
similar).
g. Disseminated Intravascular Coagulation (DIC) → ↑PT & PTT.
i) ↓PLTs & fibrinogen, ↑ fibrin split products & D-dimer.
ii) Initiated by exposed tissue factor.
iii) Tx → tx underlying cause.

Uploaded by MEDBOOKSVN.ORG
 7) Anemia in Jehovah’s Witness →Give 300u/kg EPO + IV iron (limiting factor in RBC
synthesis). Need transferrin sat ≥ 15% + ferritin ≥ 50 mg/mL.
a. Will produce equivalent of 1u pRBCs in ~3-5 days.
6. Hemorrhage Resuscitation
i) All products have → HIV & hepatitis risk except Alb & serum globulins (heat
treated).
ii) Screen for → HIV, HepB & C, HTLV, syphilis, & West Nile.
iii) MCC death from TXF → TRALI (previously ABO incompatibility 2/2 clerical error).
iv) Type AB → both A & B Ags (universal recipient, universal plasma donor → no A or
B Abs).
v) Type O → universal RBC donor (no A or B Ags).
vi) pRBCs → ↓2,3-DPG on shelf (→ left shift [↑oxygen affinity]), ↑K+ (2/2 leaking), &
↓Ca++ (2/2 citrate → preservative).
vii) CMV-neg blood → indications - LBW infants, BMT & TXP pts.
viii) EPO → 200mL RBC produced w/in 7 days. Transferrin sat >15% or ferritin
>50mg/mL → expect adequate Hgb response. Will likely need IV Fe as well. Men
make more RBCs w/EPO. Not dose dependent. Retic count NOT correlated w/RBC
production.
ix) PLT TXF → < 10K, < 20K + bleeding, < 50K + needs OR.
x) Thromboelastography (TEG) → best test for specific factor needs.
(1) Newer test has a triple assay. CRT-MA = MA (↓→ give PLTs).
CFF-MA has replaced K time & α-angle (CFF-MA↓→ give cryo).

7. Transfusion Reaction
i) Acute Hemolysis → Ab-mediated ABO incompatibility
(1) ↑HR & temp, lumbago, chills, & hemoglobinuria → ATN, DIC, & shock.
(2) ↑ indirect bili, free Hgb > 5 g/dL, haptoglobin < 50 mg/dL (binds Hgb.
(3) Tx → d/c txf 1st, IVF, diuretics, HCO3−, pressors, histamine blockers (Benadryl).
ii) Delayed → Ab-mediated vs minor Ags Tx →obs (usually).
iii) Nonimmune → 2/2 mech RBC destruction Tx → IVFs & diuretics.
iv) Febrile Nonhemolytic → Recipient Abs vs donor WBCs
(1) MC txf rxn. Use WBC filters for future txfs.
(a) Tx → slow vs d/c txf, supportive care.
v) Anaphylaxis → Usually recipient Ab vs donor IgA in IgA-def pt

6
 (1) →bronchospasm, ↓HR, ↓BP, ↓EtCO2, urticaria.
(2) Tx → d/c txf & IM epi 1st then IVFs, Lasix, pressors, steroids, histamine blockers
(Benadryl).
vi) Urticaria → Recipient Abs vs donor plasma proteins (or IgA in IgA-def pt)
Nonhemolytic.
(1) Tx → histamine blocker, supportive care.
vii) Transfusion-Related Acute Lung Injury (TRALI) → Recipient WBCs vs donor Abs
→ clot in pulmonary capillaries, rare.
(1) MC product asso w/TRALI → pRBCs.
viii) PLT Alloimmunization → from previous TXF
(1) Post-TXF purpura & ↓PLTs. Tx → IVIg, plasmapheresis.
8. Other Transfusion Problems
i) MC bacterial contaminate → #1 skin flora (Staph epi), then GNRs (usually E. coli).
ii) MC contaminated product → PLTs (2/2 to not being refrigerated, GPCs).
iii) Autotransfusion (Cell Saver) → best way to ↓ txf rxn risk (relative CI in CA surgery,
absolute CI → contamination [ie. bowel entry, abscess, etc]).
iv) Chagas’ disease → can be transmitted w/TXF.
v) Cold → ↓ clotting, 2/2 cold products or ↓body temp.
vi) Diffuse bleeding from trauma pt → ensure 1:1:1 pRBC:FFP:PLT ratio &
normothermia.
vii) Dilution → occurs s/p ~10u of pRBCs.
viii) HypoCa++ → ↓clotting (it’s required for clotting cascade). Occurs w/massive txf
2/2 citrate in products (preservative).
(1) Tx →10-20mL 10% Ca++ gluconate per 500mL WB/pRBC (per SCORE).
9. Topical Hemostatic Agents
i) Surgicel / Fibrillar → Oxidized regenerated cellulose → RBC lysis → artificial clot.
↓’s local pH. Poss antimicrobial.
ii) QuickClot → Kaolin → activates f XII.
(1) Previously contained zeolite → exothermic rxn.
iii) Gelfoam / Surgifoam → Large surface area for clot. Possible ↑ infection rate.
iv) Avitene / Microfibrillar Collagen → Scaffold for clot. Effective even s/p UFH given.
PLTs must be >20.
v) Thrombin → Uses circulating fibrinogen → clot. (As does FloSeal & Surgiflo).
vi) Fibrin → Usually contains both fibrinogen & thrombin.
vii) Arista → Absorbs H2O → concentrates PLTs & clotting factors.
viii) HemoCon → Lyophilized chitosan (a glutaraldehyde cross-linked peptide) bandage
→ seals when wet.
(1) ChitoFlex → A flexable form.

Uploaded by MEDBOOKSVN.ORG
2. Immunology, Inflammation, & Cytokines
A. Major Histocompatibility Complex Classes
1) MHC I (One letter for MHC 1)
i) Activates CD8+ T-cells. All nucleated cells. Inh NK cells (if cell doesn’t express
it is destroyed by NK cell. Innate immunity.
ii) There are three loci → HLA-A, HLA-B, HLA-C.
2) MHC II (Two letters for MHC 2)
i) Activates CD4+ T-cells. On Ag presenting cells (macrophages, dendritic [MI], &
mast cells). These APCs bring phagocytized material to thymus &
lymphocytes. Cell-mediated immunity.
ii) The HLA loci are HLA- DP, DQ, & DR. These are MOST important for matching
a donor & recipient.
3) DAMPs (from injured tissue) & PAMPs (from infection) → interact w/TLRs in
infection/injury → cytokine release → SIRS.
i) SIRS → gene expression is ↑ for innate & ↓ for adaptive.
B. Antibodies
1) Constant Region – recognized by PMNs & macrophages.
2) Variable Region – Ag recognition. (Fc fragment does not carry variable region.)
3) Monoclonal Abs → only 1 binding site to 1 epitope.
4) Polyclonal Abs → multiple binding sites to Ag at multiple epitopes.
5) IgA → secretions, Peyer’s patches & breast milk (newborn immunity); prevents gut
adherence & invasion.
6) IgD → membrane-bound, B cells (Ag receptor).
7) IgE → allergic reactions, parasites.
8) IgG → MC Ab. 2° immune response. Crosses placenta. Opsonin → fixes complement
(requires 2 IgG).
9) IgM → 1st Ab s/p exposure. Largest Ab. 5 domains (10 binding sites). Opsonin →
fixes complement (requires 1 IgM).
C. Inflammation
1) IL-1 → Fever, released by macrophages, activates CD4+ T-cells, potentiates TNFα.
2) IL-2 → Cell-mediated immunity w/LAKs, stimulates formation of memory B-cells &
Treg cells.
3) IL-4 → Differentiation of naïve T-cells to Th-cells.
4) IL-6 → ↑ hepatic acute phase proteins.
5) IL-8 → PMN chemotaxis.
6) IL-10 → Down regulates immune response.
7) L-selectins → located on leukocytes, bind to E- (endothelial) & P- (platelets)
selectins. Rolling adhesion.
8) Beta-2 integrins → CD 11/18 molecules on leukocytes, bind ICAMs, etc. Anchoring
adhesion.
D. Acute Phase Reactants
1) Positive (go ↑ w/infxn) → CRP, complement, serum amyloid A, ferritin.

8
 2) Negative (go ↓ w/infxn) → transferrin, transthyretin, RBP, albumin.
E. Innate Imunity – Humoral
1) Classical Complement Pathway → Ag:Ab complex.
2) Alternative Pathway → activated by C3 hydrolysis or Ag alone.
3) Mannose-Binding Lectin Pathway
i) C3a,4a,5a → anaphylatoxins. C3b → opsonization/phagocytosis. C3a & C5a
→ potent chemoattractants C5b-9 → MAC complex.
F. Immunonutrition (Studies flip-flop widely. Below is per SCORE.)
1) Arginine → Best immunonutrient in elective pts.
i) Pros: ↑growth hormone, IGF-1, prolactin, insulin, T-cells (& function).
Improves wound healing.
ii) Cons: ↑’s mortality in elderly male septic pts.
2) Glutamine → MI nutrient in stress overall/in general.
i) Pros: Major carrier of skeletal m N, MC AA, conditionally essential, MI
substrate in ammoniagenesis by kidney, helps cell-mediated immunity,
protects/maintains gut mucosa.
ii) ↓ mortality & LOS in ICU pts.
3) Omega-3 Fatty Acids →
i) Pros: anti-inflammatory, ↓IL-6, IL-8, & TNF-α. Improves oxygenation &
↓vent days in ARDS pts.
4) MCC of immune def worldwide & in surgical pts → malnutrition.

Uploaded by MEDBOOKSVN.ORG
3. Infection & Antibiotics
A. General
1) Gram pos → exotoxins Gram Neg → eNdotoxins
2) Stomach → almost sterile; few GPCs & yeast.
3) Jejunum → 105, GPCs.
4) Ileum →107, GPCs, GPRs, GNRs.
5) Colon → 1011, anaerobes + few GPCs & GNRs.
6) Anaerobes → MC flora in GI. In colon, ratio is 1,000 anaerobes : 1 aerobe.
a. Bacteroides fragilis → MC overall (anaerobe, colon).
b. Escherichia coli → MC aerobe in colon.
7) Bacteria require ferrous Fe. Transferrin→↓ ferrous Fe. MetHgb→↑ ferrous Fe
(↓pH & O2 tension, ↑ferrous Fe→ infection).
8) Gram-neg → LPS (Lipid A → most potent stim for TNFα).
B. Bites
1) Human Bites: Strep pyogenes, staph, Eikenella corrodens, fusobacter,
peptostreptococcus, prevotella, porphyromonas; likely in that order from MCC to
lesser common; virus most likely transmitted is Hepatitis C.
2) Dog Bites: Polymicrobial, MC are Eikenella corrodens, staph, & strep. Rabies chance
low, but possible.
3) Tx → broad-spectrum abx (Augmentin/Unasyn, don’t close).
a. PCN allergy → use doxy + clinda.
b. Infected bite → Tx: I&D, abx [1Unasyn, 2Zosyn, 3ceftriaxone+Flagyl, or
4Levaquin+Flagyl], splint in extension if digit).

4) Snake Bites: 25% are “dry” (no envenomation).

a. Viperidae (copperhead, cottonmouth, rattlesnake) → DIC & rhabdo.
i) Significant swelling, ↑PT, ↓PLTs or fibrinogen → 4-6 vials CroFab.
ii) Shock/significant bleeding → 8-12 vials CroFab & call 1-800-222-1222 (Poison
Control).
b. Elapidae (coral snake – red touches yellow = dead fellow) → irreversible ACh
binding. Antivenom & supportive care.
5) Spider Bites:
a. Brown Recluse (fiddle on head) → cytoxic/tissue necrosis. I&D/wound care.
b. Black Widow (hourglass on abd) → affects neuromuscular jxn. Benzos, IVFs, ±
antivenom.
C. Clean Lacerations 1° intention = close 2°= leave open 3°= DPC
1) <18hrs → w/o & 1° closure. >18hrs → w/o & DPC @ 48hrs.
2) Face → 1° closure w/in 24h. Close Galea w/abs sutures.
D. CLABSI
1) MCC → poor aseptic technique (MC bug → staph epi).
2) Overall fewest Cxs w/IJ CVC placed under U/S guidance.
a. SubClav → least CLABSI, most PTX.

10
 b. Use a high frequency (better shallow resolution) linear probe.
CLABSI in TPN line → BS abx + antifungals (candida coverage).
3) If ERSD → change over wire & give abx (80% salvage rate).
4) Tunnel cath infection → 70% salvage (d/c if permacath, but not if PD cath [see
Hernia/Abd/Surg Tech section on PD caths]).
5) Exit-site (superficial only) → >95% salvage (if mild → topical abx).
E. Soft Tissue Infections
1) If cx + for Strep bovis or Clostridium septicum → need CSP (↑ association w/CRCa).
2) Necrotizing Soft Tissue Infections (NSTI) (80% are polymicrobial).
a. Types → cellulitis, myocytis, & fasciitis.
b. LRINEC → CRP (≥150=4), WBC (15-25=1, >25=2), Hgb (11-13.5=1, <11=2), Na
(<135=2), Cr (>1.6=2), Glucose (>180=1).
i) ≥ 6 is a reasonable cut-off to rule in necrotizing fasciitis, but a LRINEC < 6 does
not rule out the dx.
c. Tx of pleomorphic gram-positive rods (C. perfringens) & gas in soft tissue
infection → STAT debridement, 1vanc + clinda + imipenem/meropenem/Zosyn
OR 2high-dose PCN-G (10-24million U/d) + clinda (blunts exotoxin effects)
i) Infection w/bullae → Best tx is radical debridement, also need broad
spectrum abx & IVF.
ii) Prognosis related to time to OR (mortality goes from 32% to 70% if >24hrs).
Debride to viable tissue.
iii) Requires re-exploration w/in 24-48hrs to check for progression.
3) SSIs
a. MC source is pt (MC isolate → same as Cx from pt’s nares).
b. Failure/leak rate w/single glove @ ~3.5 hrs → 51%, double glove → 7%. (clinical,
in OR). Single glove perf ↑ 4x vs double. (clinical Chochrane review).
c. MRSA → virulence 2/2 horizontal gene txf of mut PCN binding prot (SCCmec,
mecA), a-toxin, & coagulase (all S. aureus).
i) MRSA from draining sinus after bowel resection → Tx: I&D if abscess +
bactrim (or clinda [PO] or vanc [IV]).
ii) Best tx for MRSA if allergic to vanc/Bactrim/clinda → linezolid.
d. Actinomyces → yellow sulfur granules, forms sinus tracts.
i) Tx → high dose PCN (or ticarcillin).
e. Prevention
i) Give pre-op abx 1 hr pre-op (2hrs for vanc or fluoroquinolones) until closure of
incision (except for implant/cardiac → may get up to 24hrs post-op).
ii) Normothermia → likely MI to prevent SSI other than abx.
iii) Prevention of SSI in diabetics
A) Standard glucose control (160-180) → ↓hypoglycemia, no change in
mortality vs. tight control (80-120). NICE-SUGAR
iv) Best pre-op ppx w/mech heart valve → nml SSI ppx abx (per IDSA).
v) Best preop abx ppx against SSI prior to bowel surgery if β-lactam allergy →
clinda + gent.

11

Uploaded by MEDBOOKSVN.ORG
 A) Best pre-op prep is mechanical + abx (typically neomycin).
vi) Pre-op abx in penetrating colon injury reduces risk of SSI.
4) Pilonidal Disease – acute pilonidal infection → I&D.
a. Never make/leave incision midline. Chronic → consider GIPS.
F. Nosocomial (#1UTI, #2SSI, #3PNA; #1 nosocomial c/o mortality is PNA).
1) VRE Tx → Linezolid.
a. Greatest risk factor for VRE colonization → poor hand hygiene.
2) C. diff Contact precautions → gown, gloves, wash hands.
a. Hand sanitizer NOT effective vs C diff.
b. Greatest risk factor for C. diff colonization → recent abx.
c. Ppx abx > 24hrs → ↑ C. diff x3, may ↑ SSI as well.
3) ESBL E. coli Tx → Meropenem.
4) PNA
a. CAP MCC are Strep pneumo, viral, H. flu, Moraxella, MSSA.
i) Occurs out of the hospital or w/in 1st 48hrs of admission.
ii) Tx → Augmentin + Azithromycin (best per IDSA), or Levaquin x7d.
b. HAP
i) Occurs > 48hrs s/p admission & did not appear to be incubating at the time of
admission.
ii) The most significant risk factor for HAP → mechanical ventilation.
iii) BAL <10,000 oral flora or procalcitonin < 1 → d/c abx.
iv) Best dx for PNA → BAL w/ >105 organisms.
c. VAP BAL > 100K → think VAP. MCC overall → pseudomonas.
i) Develops > 48 hrs s/p ETT. Risk ↑ as vent days ↑.
ii) MC infectious c/o mortality in surgical pts.
iii) Early: likely 2/2 aspiration → Staph, H. flu, Strep. pneumo. (MC GP [20-25%
mort] → staph). Tx w/abx x 8d.
iv) Late: Pseudomonas & Acinetobacter (MC GN [50% mort] → pseudomonas).
Tx w/abx x 8d.
5) UTI → MC hospital-acquired infection.
a. SCIP measure to ↓ UTI → d/c foley after 24-48hrs if able.
b. Prevention → Maintain closed system/daily CHG baths in ICU→↓ UTI.
G. NSQIP ACS & SIS Guidelines (CR = colorectal)
-no smoking 4-6wks preop -CHG bath(+/-)
-glucose control -MRSA screen(+/-)
-mech + abx bowel prep (CR) -clip hair (PRN; no razors)
-hand scrub -proper OR attire
-new closure instruments (CR) -abx (see below)
-normothermia -wound protector
-triclosan suture (abd cases) -double glove
-shower OK 12hrs post op -topical mupirocin
-purse-string >1° ostomy closure -80% FiO2
-NPWD on top of staples (CR, vasc groin incision)
12
H. SCIP Core Measures
-abx w/in 1hr before incision -d/c abx w/in 24hrs (Grade Ia recc)
-d/c foley by POD2 -hair removal by clipping
-other “beneficial” → VTE ppx w/in 24hrs & standard glucose control (<180).
I. Healthcare Workers/Exposure/Needle-stick
1) MC Hep B (20-30%) > Hep C (1.8%), > HIV (0.3%)
2) Transmission: blood to open wound > hollow needle > solid needle > blood to eye
[ML in this order].
3) HIV → start 2 or 3 drug ART within 72hrs, continue for 28 days.
4) Hepatitis B → healthcare workers who contact body fluids/sharps need
vaccinated. If Ab & HBsAg negative→need HepB IG w/in 24hrs.
5) Hepatitis C Transfusion transmission rare (0.0001%/unit). 1-2% overall prevalence.
a. Rare for fulminant liver failure to occur.
b. Risks: Cirrhosis → 15%; chronic hepatitis → 60%; HCCa →1-5%.
c. IFN may ↓ progression to cirrhosis.
d. Needle stick from known Hep C positive pt → get anti-HCV Ab test w/in 48hrs.
Negative → antiHCV Ab & ALT lvls 4-6mns s/p exposure, if negative → done.
J. Antibiotics
1) Ppx abx → any implant or aerodigestive entry.
a. IHR w/ or w/o mesh → cefazolin.
IHR w/mesh + h/o MRSA → vancomycin.
2) A mild allergy to PCN is NOT a CI to cephalosporins/β-lactams.
a. 1st gen are good surgical ppx w/GP & some GN coverage. Give w/in 1hr of
incision & redose q3h intraop if cephalosporin.
3) “Buy AT 30, CEL at 50.”
a. Aminoglycoside, Tetracycline → 30S; Clindamycin, Erythromycin, Linezolid →
50S.
4) Anaerobics → clinda above diaphragm, flagyl below.
5) TB tx → “RIPE” Rifampin, Isoniazid, Pyrazinamide, ± Ethambutol.
6) Flouroquinolones → stop DNA gyrase bacterial DNA synthesis.
7) Tetracyclines → stop tRNA binding w/mRNA:ribosome complex.
8) Ertapenem → good solo agent for intra-abd infxn; covers GPs, GNs, & anaerobes.
Has q24hr coverage/dosing.
9) Levamisol → immunostimulatory, antihelminthic. Adj tx for CRCa. Can cause SJS.
K. Mechanisms
1) Aminoglycosides →irreversible ribosomal binding, bactericidal.
2) Bacteriostatic abx → reversible ribosomal binding (tetracycline, clindamycin,
erythromycin), Bactrim.
3) Inhibitors
a. Cell wall synthesis → PCNs, cephalosporins, carbapenems, monobactams, vanc.
i) β-lactams most effective when level is > MIC more than 50% of the time.
ii) Penicillin
A) ✓GPCs → anthrax, β-hemolytic Strep, C. perfringens & N. meningitides
(GPRs), strep, syphilis.
B) Ø Staph or Enterococcus.
13

Uploaded by MEDBOOKSVN.ORG
iii) Ampicillin & amoxicillin → above, + ✓enterococci.
iv) Oxacillin & nafcillin → Anti-staph PCNs (ie. MSSA only).
v) Augmentin (amoxicillin/clavulanic acid) & Unasyn (ampicillin/sulbactam)
A) Broad → ✓ GPCs (staph & strep), GNRs, ± anaerobic coverage.
B) ✓enterococci.
C) Ø Acinetobacter, Pseudomonas, & Serratia.
vi) Sulbactam & clavulanic acid → β-lactamase inhibitors.
vii) Ticarcillin & piperacillin (antipseudomonal PNCs).
A) Timentin (ticar-/clavulanic acid) & Zosyn (pipera-/sulbactam).
B) GNRs → ✓enterics, Acinetobacter, Pseudomonas, & Serratia.
C) Broad spectrum → ✓GPCs (staph & strep), GNRs, & anaerobes.
D) SEs → ↑ NaCl load; can ↓ PLTs & WBC counts.
viii) 1st gen cephalosporins (cefazolin, cephalexin).
A) Cefazolin (Ancef) → longest ½-life → ✓ ppx, GPCs.
B) Ø Enterococcus.
ix) 2nd gen cephalosporins (cefoxitin, cefotetan, cefuroxime).
A) Cefotetan → longest ½-life → ✓for ppx.
B) ✓ GPCs, community-acquired GNRs, ± anaerobes. ↓ effectiveness vs
staph.
C) Ø Enterococcus, Acinetobacter, Pseudomonas, & Serratia.
x) 3rd gen cephalosporins (ceftriaxone, ceftazidime, cefepime, cefotaxime).
A) ✓GNRs ± anaerobic coverage Acinetobacter, Pseudomonas, & Serratia).
Crosses blood/brain barrier.
B) Ø Enterococcus.
C) SEs → cholestatic jaundice, gallbladder sludge w/ceftriaxone.
xi) Carbapenems (meropenem, imipenem).
A) Broad – ✓ anaerobes, GPCs, & GNRs.
B) Ø MEP: MRSA, Enterococcus, & Proteus.
C) Cilastatin → prevents renal hydrolysis of the drug & ↑ ½-life (“keep it
lastin’ w/cilastatin”).
D) SEs → seizures.
xii) Monobactam (aztreonam)
A) ✓GNRs + Acinetobacter, Pseudomonas, & Serratia.
xiii) Vancomycin (glycopeptides) → Cell wall protein binding.
A) ✓ C. diff (PO/PR), Enterococcus, GPCs, & MRSA.
B) 15-20mg/kg (actual wt) q8-12hrs (nml renal fxn & MIC =1mg/L).
C) Peak → 20–40 μg/mL; trough → 5–10 μg/mL.
D) AUC target of 400-600mg/hr w/in 24-48hrs → safest & most accurate way
to dose per IDSA.

14
 E) Resistance 2/2 cell wall–binding protein change. SEs→ HTN, Redman
syndrome (histamine release), neph- & ototoxicity
b. 30s ribosome & protein synthesis → aminoglycosides, tetracycline.
i) Aminoglycosides (gentamicin, tobramycin)
A) ✓GNRs, Acinetobacter, Pseudomonas, & Serratia.
B) Ø anaerobes b/c it needs O2 to function.
C) Resistance 2/2 modifying enzymes →↓active transport.
D) ↑killing w/↑ level.
E) Works well w/ampicillin for Enterococcus.
1. β-lactams (ampicillin, amoxicillin) facilitate its infiltration.
F) Gentamicin → peak 6–10 μg/mL; trough < 1 μg/mL.
G) SEs → reversible nephrotoxicity, irreversible ototoxicity.
ii) Tetracycline → ✓ GNRs, GPCs, & syphilis.
A) SEs → tooth discoloration (kids).
c. 50s ribosome & protein synthesis → macrolides, clindamycin, linezolid,
Synercid.
i) Clindamycin → ✓Anaerobes, some GPCs, asp PNA, C. perfringens.
SEs → C. diff.
ii) Macrolides (azithro-, clarithro-, erythromycin, & fidaxomicin)
A) Erythromycin SEs → nausea (PO), cholestasis (IV).
1. ✓ GPCs. Best vs CAP & atypical PNAs.
2. Binds motilin receptor → prokinetic.
iii) Linezolid (oxazolidinones) → ✓GPCs (esp MRSA, VRE).
iv) Synercid (streptogramin + quinupristin-dalfopristin)
A) ✓GPCs (MRSA, VRE).
d. DNA helicase (DNA gyrase) → quinolones.
i) Quinolones (ciprofloxacin, levofloxacin, norfloxacin)
A) ✓GNRs, few GPCs. Best when AUC/MIC > 25.
B) ✓Acinetobacter, Pseudomonas, & Serratia.
C) < 40% of MRSA are susceptible. = PO/IV efficacy.
D) Ø Enterococcus SE → tendon rupture.
e. RNA polymerase → rifampin.
4) Oxygen free radical production (→ breaks up DNA)
a. Metronidazole (Flagyl) → ✓Anaerobes
b. SEs→disulfiram-like rxn, peripheral neuropathy (long-term).
5) Trimethoprim → ↓dihydrofolate reductase →↓purine production.
6) Sulfonamides → PABA analogue, ↓purine production.
a. Bactrim (Trimethoprim/sulfamethoxazole)
i) ✓GNRs ± GPCs.
ii) Ø Enterococcus, Acinetobacter, Pseudomonas, & Serratia.
iii) SEs (many): teratogen, allergic rxns, renal, EM/SJS, hemolysis (G6PD-def).
15

Uploaded by MEDBOOKSVN.ORG
L. Resistance
1) Aminoglycoside → 2/2 modifying enzymes. → ↓ active transport.
2) Methicillin-resist. S. aureus (MRSA) → d/t cell wall–binding protein mut.
3) PCN resistance → 2/2 plasmids vs β-lactamase.
4) Transfer of plasmids → MC method.
5) Vanc.-resist. Enterococcus (VRE) → d/t cell wall–binding protein mut.
M. Drug Levels
1) Peak high → ↓ dose amount.
2) Trough high → ↓ dose frequency (↑time b/w doses).
N. Fungal Infections (can present w/myalgias, rash, fevers → need to r/o invasive fungal
infection).
1) Aspergillus → septate hyphae, narrow branching. Tx → voriconazole.
a. Aspergilloma → Monad sign (lung mass w/in cavity w/air that stays non-
dependent on repositioning).
i) Tx (only if bleeding) → angioemb + resect.
b. Allergic BronchoPulmonary Aspergillosis (ABPA) → non-invasive, a
hypersensitivity. Can cause fibrosis. Tx sxs w/bronchodilators + steroids, f/u
serial CXRs, IgE, & PFTs.
c. Chronic Necrotizing Aspergillus PNA & Invasive Aspergillosis → IV voriconazole.
2) Candida Need 2 Cx sites or eye involvement (need ophtho exam).
a. New tests for invasive fungemia → β-D-glucan & galactomannan.
b. Candidemia Tx → fungins (eg. Anidulafungin).
c. C. albicans – common respiratory tract flora.
i) Tx→ Fluconazole (non-albicans sp. often resistant); Anidulafungin for severe
infections; Amphotericin for eyes, CNS, & heart infxn (nephrotoxic & ↓ K+).
d. C. glabrata → caspofungin/anidulafungin ($), amphotericin (↑dose→more
effective, but ↑oto- & nephrotoxicity).
3) Mucor → non-septate hyphae, broad branches.
a. Tx → aggressive debridement + amphotericin B.
4) TPN is a RF for disseminated fungal infections (at least in burn pts).
O. Antifungals
1) Anidulafungin (Eraxis) → blocks cell wall glucan.
2) Amphotericin – binds cell wall sterols → alters permeability.
a. SEs → nephrotoxic, fever, hypoK+, hypoTN, anemia.
b. Liposomal type → ↓SEs.
3) Voriconazole & itraconazole → blocks ergosterol which is required in cell
membrane.
4) Prolonged broad-spectrum abx + persistent fever → itraconazole.
5) Fungal sepsis other than candida & aspergillus → liposomal amphotericin.
P. Bacillus anthracis
1) INH anthrax 1-6d incubation → malaise, myalgia, fever → resp depression, chest
pain, & diaphoresis. pPx → Cipro.
2) Tx → Cipro + clinda + rifampin.
Q. HIV ↑ risk of opportunistic infxn → CD4 < 200 (need ppx Bactrim).
1) MCC b/l PNA in HIV pt w/CD4 <200 → Pneumocystis jirovecii PNA.

16
4. Anesthesia, Medications, & Pharmacology
A. Rapid Sequence Intubation The 7 P’s
1) Plan → Equipment (IVs, O2 sat, BVM, suction, ETT, back-up plan).
2) Posistion → C-spine precaution vs “sniffing” position.
3) Preoxygenate → w/100% O2.
4) Premedicate → midazolam 0.1-0.3mg/kg diazepam 0.2mg/kg (20 max)
ketamine 1-2mg/kg etomidate 0.3mg/kg
a. < 2yo → add atropine 0.02mg/kg to block reflex bradycardia.
5) Paralyze (on/off in min)→ succinylcholine 1-1.5mg/kg (1/10)
rocuronium 0.6-1.2mg/kg (1-2/80) vecuronium 0.1mg/kg (3/35-115)
6) Placement → EtCO2 (best to confirm ETT placement), direct visualization (1st thing
seen → Arytenoids), distance, listen, CXR. Can’t see glottis → “BURP” Backward,
Upward, Rightward Pressure on thyroid cartilage.
7) Post-ETT Management → Secure,
NG/OG, vent setting, VAP pPx (HOB
up, oral swab, cuff pressure 20-
30mmHg).
a. Stable then sudden change
(especially after transfers) →
recheck ETT & circuit 1st.
B. NMBs
1) Depolarizing
a. Succinylcholine → CI in hyperK+,
burns, spinal cord injury. Quickest
onset of all NMBs, only irreversible & depolarizing NMB.
i) Malignant hyperthermia Presents up to 24hrs post-op. Brief trismus nml,
but >30 sec think MH (cancel OR, obs 24hrs).
A) AD mutation of the ryanodine receptor gene (RYR1), 2/2 succinylcholine &
volatile anesthetics.
B) 1st sx → ↑EtCO2 → muscle rigidity, lactic acidosis, & ↑K+. If only needs
↑ventilation (↑RR or TV) not likely MH, but if CO2 not improving + rigidity
& fevers → likely MH.
C) Tx → Dantrolene 2.5mg/kg q5m PRN x4 doses, prevents release of Ca++
from sarcoplasmic reticulum (Call 1-800-MH-HYPER).
2) Non-Depolarizing → Inh neuromuscular junction, competes w/ACh. ↑ action time
w/myasthenia gravis.
a. Cis-atracurium → cleared by Hoffman degradation in blood (0.3-0.6mg/kg, lasts
20-30m).
i) Can be used in liver & renal failure. → histamine release.
b. Pancuronium → slow acting, long-lasting; renal clearance (0.1-0.15mg/kg, lasts
60m).
i) MC SE → tachycardia.

17

Uploaded by MEDBOOKSVN.ORG
 c. Rocuronium → fast, intermediate duration; hepatic clearance.
d. Vecuronium → fast, hepatobiliary clearance, no histamine release (0.1mg/kg,
lasts up to 115m w/0.4mg/kg).
e. Reversing drugs for nondepolarizing agents.
i) Sugammadex → chelating agent for rocuronium.
ii) Edrophonium → inh acetylcholinesterase → ↑ ACh.
iii) Neostigmine – inh acetylcholinesterase → ↑ ACh.
A) Used in Ogilvie’s (2mg push over 3-5min), MG & glaucoma.
B) CI in pts w/prior 2nd degree heart block.
iv) Adjuncts → Atropine (0.5mg [kid], 1mg [adult]) or glycopyrrolate given
w/neostigmine or edrophonium to counter effects of ↑ ACh.
3) General anesthesia → hypoglycemia in DM pts.
4) Halothane → hepatitis, INH anesthetic w/highest cardiac depression.
5) MCC of intra-op brady → INH anesthetics.
C. Sedation
1) Benzodiazepines
a. Midazolam (Versed) → Anxiolytic (0.5-1mg), muscle relaxant, anticonvulsant
(1mg until status epilepticus breaks, max 0.2mg/kg), hypnotic, & amnestic (2mg).
NO analgesic activity (like other benzos).
b. CIWA Protocol → n/v, tremor, sweats, agitation, tactile/auditory/visual
disturbances, HA, AMS/clouding. Tx w/benzos usually at scores of >8-10.
2) Dexmedetomidine (Precedex) → central α2 agonist → sedation, analgesia,
axiolysis, & amnesia. Caution in heart block. No resp depression. SEs bradycardia,
hypoTN (may be ↑’d in elderly).
3) Etomidate → ↓hemodynamic changes. Fast (for RSI). No analgesia. Continuous
infusions → adrenocortical suppression.
4) Ketamine → thalamic/limbic dissociation → cataleptic state (amnesia, analgesia),
good for short-term sedation & for kids. No resp depression. SEs → hallucinations &
↑catecholamines → ↑SBP, ICP(?), HR & EtCO2.
5) Propofol → no analgesia. Rapid on/off. Contains lipids. SEs → hypoTN (MC), resp
depression, & Propofol Infusion Synd (PRIS).
a. PRIS → @rates >80 → met acidosis, ARF, & cardiac failure → death. High
mortality. ↑risk in young & w/↑ catacholamines.
i) Monitor w/serial CPKs, lactates, & triglycerides.

LEVELS OF SEDATION & THEIR EFFECTS

Min Mod/Conscious Deep General Anesthesia
Airway OK OK Probably OK Not OK
BP NML Typically NML Typically NML ↓
Purposeful to repeated
Response NML Purposeful None
/ noxious stimuli
Ventilation NML OK Probably OK Not OK

18
D. Analgesics
1) Somatic
a. Opioid
i) Morphine → analgesia, euphoria, resp depression, miosis, constipation,
histamine release (causes hypoTN), ↓ cough.
A) MC opioid w/↑ SEs in renal failure → morphine (also demerol &
meperidine).
ii) Demerol → analgesia, convulsions/seizures, euphoria, fasciculations, miosis,
respiratory depression, & tremors.
A) No histamine release.
B) Seizures (normeperidine analogue buildup → avoid in renal failure).
iii) Meperidine → ↑ SEs in renal failure 2/2 active metabolites.
iv) Methadone → like morphine w/↓ euphoria.
v) Hydromorphone
vi) Fentanyl → fast; 80× morphine (NO cross-rxn w/morphine allergy). No
histamine release/mast cell degranulation. IV form needs no hepatic or renal
dose adjustments.
A) Can cause chest wall rigidity & ↓responsiveness → give Narcan (0.4-
2.0mg q2-3m PRN, >10mg → ? the dx).
1. Monitor for at least 2 hours s/p narcan given its ½ life of ~1 hour .
vii) Sufentanil (most potent) & remifentanil (very fast).
viii) 72% of opiates prescribed s/p IHR, lap chole, & lumpectomy are “left over.”
ix) 6-10% of pts s/p common surgeries like above continue to fill opiate Rxs 3-
6mns post-op.
x) Decrease post-op opiod requirements by → giving ketorolac & using
regional/neuraxial anesthetics.
xi) In geriatric pts, reduce opiate to “lowest effective dose” → ~ 25-50% of nml
adult dose.
b. Local Anesthetics
i) Act on Na+ channel of nerve membranes & stabilize them so they no longer
conduct signals.
ii) Types
A) Ester → 1 “I” in name (eg. procaine, cocaine), PABA analogues →
↑allergic rxns.
B) Amides → 2 “I’s” in name (eg. lidocaine, bupivacaine).
iii) Add bupivacaine to lidocaine for both a long & short term block.
iv) Don’t use epinephrine for digital blocks.
v) Dosing 1mL = 1gm = 1,000mL (@ 100% conc).
A) 1% Lidocaine W/O epi (aka plain) → 4-5 mg/kg of 1% = 0.4-0.5 mL/kg,
max total: 300 mg [30 mL of 1% or 60mL of 0.5%]) ~1hr duration.
B) 1% Lidocaine W/epi → 7 mg/kg of 1% W/epi = 0.7 mL/kg, max total: 500
mg [50 mL of 1% w/epi or 100mL of 0.5%]).

19

Uploaded by MEDBOOKSVN.ORG
 C) For ↑ safety, 80% max dose if <8yo or 50% if elderly w/severe liver or
kidney dz.
vi) Max bupivacaine → (0.25% = 1 mL/kg, 0.5% = 0.5 mL/kg) ~4-12hr duration.
A) General rule → mLs of 0.25% = pt wt in kg
B) Max 1% bupivicaine w/o & w/ epi → 0.2mL/kg / 0.3mL/kg
C) Max 2% bupivicaine w/o & w/ epi → 0.1mL/kg / 0.15mL/kg
vii) Local anesthetic toxicity → tinnitus, tachy, HTN, dizziness, PO numbness,
seizure, hallucinations → → then brady +hypoTN.
A) Tx → 20% Lipid emulsion (if seizures → midazolam).
B) 20% lipid bolus of 1.5-4 mL/kg then 0.25-0.5 mL/kg/min infusion for 10-
60min.
C) Distiguish from vasovagal which has → immediate brady + hypoTN.
1. Tx → atropine.
2) Visceral
3) Neuropathic → Gabapentin → not metabolized, excreted in urine.
4) Chronic Regional Pain Syndrome/Sympathetic Reflex Dystrophy
a. Tx → Local blocks, NSAIDs, gabapentin, tricyclics, topical lidocaine, cognitive
behavioral therapy.
5) Regional Anesthesia
a. Blocks
i) Cervical → Brachial & Cervical blocks can cause Horner Syndrome.
ii) Interscalene → commonly leads to phrenic nerve temporary paralysis (Sxs →
SOB w/nml bilateral breath sounds).
iii) Digital → Inject just distal to MCP at base of finger, 4 nerves →
1.5-3mL of 1% plain lidocaine.
b. Epidural
i) CIs → cirrhosis, hypertrophic cardiomyopathy, & ↑ICP.
ii) Morphine → resp depression (use dilaudid to avoid this). NO opiate-related
hypoTN w/epidural.
iii) Bupivacaine → hypoTN.
iv) Laparotomy → block T8-L1.
v) If enters intrathecal space, can spread caudally & → total spinal anesthesia
(SOB, hypoTN, difficulty swallowing, hoarseness).
vi) Wait at least 6hrs after d/c’ing epidural before restarting anticoagulation. If
restarted w/epidural in place → wait 3 days off anticoag to d/c cath.
c. Subarachnoid/Intrathecal/Spinal
i) Blocks sensory & motor at that spinal level.
E. Diuretics
1) Lasix Tinnitus & acute hearing loss → d/c furosemide.
F. P-450 → Meds that will need ↑ warfarin dose (P-450 inducers, e.g. barbiturates).
G. Perioperative Assessment
a. Med recs → For most surgeries, continue 81mg ASA, statins, & β-blocker peri-op
(but don’t start new β-blocker).
a. These are commonly held → benedryl.
20
 2) Mallampati 1x Hydrocortisone
a. Class I: Soft palate, uvula, fauces, pillars. 4x Prednisone, prednisolone
5x Methylprednisolone
b. Class II: Soft palate, major part of uvula, fauces.
30x Dexamethasone
c. Class III: Soft palate, base of uvula.
d. Class IV: Only hard palate.
3) ASA Classification
(OR mortality %) → Best general indicator of all surgical complications EXCEPT
LEAK.
a. Class I (0.1%): no systemic PRE-OP STEROID RECS
disease. Pre-op Prednisone Type of Recs
Equivalent surgery (AM / Induction)
b. Class II (0.2%): mild disease. < 10 mg/d (or Nml
Nml AM dose
c. Class III (1.8%): severe systemic >3mn off steroids) response
AM dose /
dz; diabetes, stable angina, & Minor
25mg hydrocortisone
CKD. AM dose /
Mod 50mg hydrocortisone
d. Class IV (7.8%): severe systemic 10-59 mg/d then 1d taper
AM dose /
dz constant threat to life: dialysis, 100mg
Major
cirrhosis, symptomatic CHF. hydrocortisone then
1-2d taper
e. Class V (9.4%): actively dying & Adrenal 80mg hydrocortisone
≥ 60 mg/d
Suppression Q8H then taper
won’t survive w/o surgery w/in
24 hrs.
f. Class VI: organ donor.
4) Cardiac Clearance Determines risk of MACE using RCRI.
a. If pt has current angina/ACS or < 4 METS → stress test.
b. Best cardiac clearance prior to major vascular surgery.
i) Exercise stress if able, pharm if not.
A) Dobutamine CIs: LBBB, V-paced, V-arrhythmia, Ca++ or β-blocker, ACS/prior
MI.
B) Thallium CIs: asthma, SBP <90, sick sinus, caffeine.
c. Best pre-op clearance s/p CABG: good fxn→ ECG, poor/ukn fxn → get stress test.
d. New dyspnea (or worsening if known h/o CHF) → need preop ECHO.
e. No sxs → no PCI needed pre-op.
f. Acute Coronary Syndrome (ACS) → needs PCI pre-op.
B. Intraoperative Monitoring
1) Mandatory → VTOC (Vent, Temp, Oxygen, Circulation).
2) Intra-op allergic rxns:
a. Adults → MCC NMBs (58%) > latex (20%) > abx (13%).
b. Kids → MCC latex > NMBs > abx.
c. Rarely 2/2 inh anesthetics or hypnotics.
C. Reversal Agents for drugs
1) Tylenol → N-acetylcysteine (150mg/kg over 1hr loading dose).
2) Opioids → Narcan (0.4-2.0mg q2-3m PRN).
3) Benzodiazepines → Flumazenil (0.2µg/kg [up to 3µg/kg])
4) β-Blockers → Glucagon (50mcg/kg LD then 1-15mg/h).
5) Nondepolarizing paralytics → Neostigmine (2mg push over 3-5min).

21

Uploaded by MEDBOOKSVN.ORG
5. Fluids, Electrolytes, & Nutrition
A. Crystalloids OSM = (2Na+)+(glucose/18)+(BUN/2.8)
Insensible losses → 10mL/kg/d hypotonic (75% skin, 25% lungs).
B. Sodium Chloride → resus IVF for losses from mouth to duo.
1) ¼ NS → Na+ 38.5, Cl- 38.5 ½ NS → Na+ 77, Cl- 77
NS/0.9% → Na 154, Cl 154
+ -
HTS/3% → Na+ 513, Cl- 513
C. Lactated Ringers → resus IVF for losses past duo & burn resus.
Na+ 130, K+ 4, Ca++ 2.7, Cl- 109, HCO3- 28.
1) Plasmalyte →Na+ 140, K+ 5, Mg++ 1.5, Cl- 98, Acetate 27, Gluconate 23.
D. Hetastarch → coagulopathy.
E. Acid/Base (CO2 ↔ H+ + HCO3-)
1) Respiratory Acidosis ↑PCO2 2/2 ↓MV.
2) Respiratory Alkalosis ↓PCO2 2/2 ↑MV.
a. MV = RR x TV.
Goal MV ~5-10 L/min.
3) Metabolic Acidosis pCO2 = 1.5(HCO3-)+8
a. Δ-Gap (or “delta-delta”)=(pt’s AG - 12) – (24 - pt’s HCO3-) =Na+- Cl-- 36
i) <-6 → non-AG + AG. -6 to 6 → just AG >6 → multiple AG sources
b. Anion gap = Na+ – (HCO3- + Cl-). Nml is < 10–15.
i) + Anion gap
A) MUDPILES = Methanol, Uremia, Diabetic ketoacidosis, Par-aldehydes,
Isoniazid, Lactic acidosis, Ethylene glycol, Salicylates.
B) Lactic Acidosis: TYPE A → 2/2 tissue hypoxia
TYPE B → not 2/2 hypoxia (eg. 2/2 meth, cocaine)
ii) Non-gap “Meth LAB” Meth = Lactic Acidosis type B
A) Normal anion gap acidosis → usually lose Na+/HCO3− (RTA [proximal &
distal], hypoaldosterone, diarrhea, ileostomies, small bowel fistulas). Resus
w/LR (has HCO3− & less Cl- than NS).
B) Tx → tx 1° source; can ↑pH if < 7.20 w/HCO3−.
C) Cl- responsive (uCl- < 15) → 2/2 emesis, diuretics, H+ loss via aldosterone
stimulation.
D) Cl- resistant (uCl- > 25) → 2/2 ↑mineralcorticoids or hypoK+.
E) Urine gap can tell b/w renal & non-renal causes of HCO3− loss (eg.
diarrhea). uAG = uNa+ + uK+ -uCl-.
1. + value = renal loss (eg RTA). - = non-renal HCO3− loss.
c. Compensation: pH 7.3, pCO2 25, HCO3- 18 best represents → metabolic acidosis
w/comp resp alk.
4) Metabolic Alkalosis pCO2 = 0.7(HCO3- - 24)+40
a. Typically 2/2 contraction.
b. NGT suction → hypochloremic, hypokalemic, metabolic alkalosis, & paradoxical
aciduria 2/2→
i) ↓ Cl−& H+ ions 2/2 NGT (hypochloremia & alkalosis).
ii) ↓H2O→ renal Na+ reabsorbtion for K+ (Na+/K+ ATPase) → ↓K+ (hypokalemia).
iii) Na+/H+ exchanger activated →reabsorb H2O + K+/H+ exchange in an effort to
reabsorb K+ → results in paradoxical aciduria.
c. Tx → NS (need to correct Cl- deficit).

22
 d. Hypochloremic, hypokalemic metabolic alkalosis → 2/2 emesis, excessive NGT
suctioning, pyloric stenosis.
e. Primary loss of K+ w/ gastric losses → 2/2 renal exchange (renal Na+/K+
ATPase).
C. Sodium Corrected Na+ = Na+ + 0.016(glucose – 100)
1) Obtain BMP + urine lytes/OSM to determine etiology.
DI Dehydration SIADH CSW 1° Polydispia
UOP ↑ ↓ ↓ ↑ ↑
uOSM ↓ ↑ ↑ ↑ ↓
pVol ↓ ↓ ↑ ↓ ↑
pOSM ↑ ↑ ↓ ↓ ↓
+ ↑/nml ↑/nml ↓ ↓ ↓/nml
pNa
2) Hypernatremia Water Deficit = TBW ([Na+ - 140]/140)
TBW : M = 0.6 x kg / F = 0.5 x kg
a. Iatrogenic → Babies & elderly more prone w/NS as IFV resus. Look for high serum
(& uOSM, diff from DI).
b. Rapid correction → cerebral edema. Correct < 8mEq/L/24hrs.
c. HyperNa+ Hypovolemia → 2/2 burns, diarrhea, fistula, renal dz, osmotic
diuretics, post-obstruciton. Tx → isotonic IVFs.
d. HyperNa+ Euvolemia → 2/2 DI, insensible losses, hypodipsia.
i) Diabetes Insipidus
A) ↑/nml pNa+ conc (> 142 mEq/L, 2/2 water loss) points toward DI,
particularly if uOSM < pOSM. (uOSM should = pOSM; nml is 275-295).
B) Nml pNa+ not helpful, but if uOSM >600mOSM/kg, excludes DI.
C) Acute → give DDAVP Chronic → give free H2O.
e. HyperNa Hypervolemia →2/2 Cushings, 3% HTS, 1°hyperaldosterone.
+

3) Hyponatremia Na+ Deficit = (140- Na+)(wt)(0.6 for men, 0.5 for women)
a. General tx w/2L NS. Responder → likely hypoNa+ hypovolemia.
Non-responder → likely euvolemic hypoNa+ 2/2 SIADH or diuretics.
i) Central Pontine Myelinolysis → 2/2 rapid correction of hypoNa+ (Correct
<0.5mmol/L/hr). Sxs → dysarthria, dysphasia, extraocular muscle palsies,
abnml pupils, tremor, incontinence, & seizure.
b. HypoNa+ Hypovolemia → 2/2 emesis, CSW, diuretic, diarrhea. Tx → NS. Correct
≤ 1 mEq/L/hr (HTS only considered if Sxs).
i) Cerebral Salt Wasting (CSW) → classically s/p SAH 2/2 ↑ANP & failure to
release aldosterone & ADH. Similar to SIADH (both have ↓pNa+, ↑ uNa+), but
↑UOP & hypovolemia w/CSW.
A) Tx → NS, salt tabs.
c. HypoNa+ Euvolemia → 2/2 adrenal insufficiency, exercise, SIADH, polydipsia,
hypothyroid, pseudohyponatremia (↑glucose).

23

Uploaded by MEDBOOKSVN.ORG
 d. SIADH (”Sodium Is Always Down Here”)
i) Type A ↑↑↑ ADH, NO response to OSM change. Plasma ADH > lvl
needed for max antidiuresis → ↑↑↑ uOSM . ADH > physiologic range
→ectopic ADH (MCC → bronchogenic carcinoma).
ii) Type B Lowers OSM threshold for ADH release ("reset osmostat”). ADH
secretion will stop once OSM gets below threshold.
iii) Type C No change in ADH ↑ or ↓ OSM (stays in nml range). Can be 2/2
ectopic ADH.
iv) Type D Nml ADH reg, but ↑uOSM even w/↓ADH. 2/2 germline mutation
→ constituently activated V2 receptor. Others → other antidiuretic &
postreceptor aquaporin-2 defect (mediates ADH antidiuresis).
v) Type E ↓ plasma ADH as sNa+ ↑w/HTS. Poss 2/2 abnml baroreceptor fxn
despite normovolemia → minor BP or vol ↓→ ↑↑↑ ADH. Likewise,
minor BP or vol ↑w/NS → ↓↓↓ADH.
vi) SIADH Tx → Acute → Tolvaptan or democlcycline.
Sub-acute/Chronic → 1st restrict water, 2nd diuretic.
vii) Suspect if hypoNa & ↓pOSM, & uOSM > 100 mOSM/kg. SIADH → uNa+
+

conc usually > 40 mEq/L, pK+ conc nml, nml acid-base, & ↓plasma uric acid
conc.
viii) Primary Polydipsia → ↓ pNa+ conc (< 137 mEq/L) w/ ↓uOSM (eg. < ½
pOSM) → usually water overload.
ix) Pseudohyponatremia 2/2 ↑glucose/triglycerides (every 100 gluc > nml →
add 1.6 to measured Na+), Multiple Myeloma. Tx → obs.
e. HypoNa+ Hypervolemia → 2/2 CHF, cirrhosis, renal dz/nephrotic synd.
i) Cirrhosis → ↑ADH & aldosterone → nml Na+, excess TBW.
A) EtOH → ↓osm pressure response → inhibits ADH,↑diuresis.
D. Potassium salivary K+ / colon > gastric > bile, panc, duo, & ileum.
1) Hyperkalemia EKG → Peaked T waves, can be 2/2 ESRD.
a. Tx →"C BIG KD" (Ca++, Bicarb, Insulin, Glucose, Kayexalate, Dialysis/Diuretic).
i) Ca++ gluconate (stabilizes cardiac membranes → prevents Vtach) → 1st Tx.
2) Hypokalemia MCC of sig hypoK+ → overdiuresis.
a. Ø T-waves→ U-waves. May need Mg++ prior to K+ correction.
b. ↑cardiac m. sensitivity & ↓ skeletal m. excitability (esp w/resp alkalosis).
E. Calcium
1) Hypercalcemia
a. Ca++ >13 or ionized >6-7 → lethargy.
b. Breast CA MC malignant cause, ↑ in lung SCCa 2/2
PTHrp, highest Ca++ levels seen. w/malignancy.
Parathyroid CA has highest associated frequency.
c. MC benign cause → Hyperparathyroidism.
d. No LR (contains Ca++) or thiazides (retain Ca++).
e. Tx 1st → NS at 200-300mL/h. 2nd add Lasix (loop
diuretic).
24
 i) Malignancy→ alendronic acid, calcitonin, HD, mithramycin.
f. Familial Hypocalciuric Hypercalcemia
i) Nml/high PTH, no/min sxs, 24hr U Ca++ <200mg/d.
ii) Tx→ observe (no subtotal parathyroidectomy).
2) Hypocalcemia MCC of sig hypoCa++→prev. thyroidectomy.
MC overall → ↓ albumin.
a. Ca usually <8 or ionized Ca++ <4 for Sxs → hyperreflexia, Chvostek’s sign
2+

(tapping on face → twitching), perioral tingling & numbness, Trousseau’s sign

(BP cuff up 3min → carpopedal spasm), ↑QT interval. Can occur s/p
parathyroidectomy.
b. Replace Mg++ if Ca++ doesn't respond to replacement.
Albumin adjustment → add 0.8 to Ca++ for every 1g ↓in albumin.
F. Magnesium
1) Hypermagnesemia → similar to hypercalcemia (flacid paralysis, lethargy, coma,
hypoTN). Seen in renal failure + antacid/laxative use. >10 → compete heart block,
>13 cardiac arrest.
a. Tx: 1st → Ca++ gluconate, 2nd → diuretics, HD.
2) Hypomagnesemia → CNS irritability, tetatny, seizures, torsade de pointes.
HypoCa++ won’t correct w/Ca++ → give Mg++.
G. Phosphate
1) Hyperphosphatemia → usually 2/2 PO43− moving extra to intracellular, 2/2 renal
failure or w/Fleet’s phospho-soda or enema, hypoK+ Sxs.
a. Tx → sevelamer, low PO43− diet (no dairy), dialysis.
2) Hypophosphatemia (2/2 Refeeding Syndrome → MCC of sig ↓PO43−).
a. 2/2 normal feeding s/p prolonged starvation/malnutrition.
b. ↓K+, Mg2+, & PO43− (MC & most important) →cardiac dysfunction, profound
weakness, AMS. Seizures MC asso w/↓ Mg2+, but very ↓ PO43− will also cause
them. Alcoholics → high risk.
c. Prevent this by starting to re-feed at a low rate (10–15 kcal/kg/day).
d. Cardiac dysfunction (MCC of death), profound weakness, encephalopathy, CHF,
& vent wean failure.
e. MC electrolyte def w/refeeding syndrome → Hypophosphatemia.
H. GI Losses
GI LOSSES
+ - + -
L/d Na Cl K HCO3
Saliva 1.5 50 40 20 30
Gastric 2 100 140 10 -
D- 10
Small Bowel 3 80-150 60-115 5
I- 30-50
Bile 0.5-1 140 100 5 25
Pancreas 1.5-3 140 60 5 80-115
Colon varies 120 90 25 45
25

Uploaded by MEDBOOKSVN.ORG
I. Fuel sources
1) Colonocytes → short chain fatty acids (i.e. acetate, butyrate, & propionate).
Phenylalanine
2) Enterocytes & Neoplastic cells → glutamine.
Valine
3) MC amino acid in blood & tissue → glutamine. Threonine
4) Proteins absorbed as di-/tripeptides by PEPT1 in jejunum.
5) MC & MI AA for gluconeogenesis → alanine. Tryptophan
Isoleucine
6) Essential AA’s → “PVT TIM HiLL”.
Methionine
7) SCFA & MCFA → absorbed via portal vein.
8) LCFA & TAGs/cylomicrons → lymphatics (cleared from blood by LPL). Histidine
Leucine
K. Stress & Starvation Lysine
1) Obligate glucose users
a. Adrenal medulla, RBCs, Peripheral Nerves, WBCs.
2) Brain → Switches to ketones in starvation.
3) Kwashiorkor → squishy, 2/2 protein malnutrition w/nml kCal → edema.
4) Glycogenolysis is primarily from liver in starvation (early/1st 6hrs; gluconeogenesis is
then from skeletal m AAs → glucose by the liver).
L. TPN (must have ≥100gm glucose or → ketone production/protein catabolism)
1) TPN = glucose based, max is 3 g/kg/hr. PPN = fat based.
a. Add selenium to prevent cardiac Cxs.
2) Severe malnutrition (>15% ↓wt/6mns) → preop TPN → ↓non-infectious Cxs. (If
<15% ↓wt TPN will → ↑infections).
3) Enteral → preferred if able → ↓all Cxs.
a. Standard TFs →1-1.5 kCal/mL.
4) Start distal feeds @ 20mL/hr on POD 0 & CLD by POD 2/3 s/p UGI surgery.
5) CIs to G-tube → ascites, coagulopathy, gastric AVM, gastroparesis, GOO, severe
GERD.
6) CIs to PEG specifically → can’t access (esophagus obstruction, prior surgery, etc),
esophageal varices/AVMs.
M. Nutritional Status
1) Best indicator of preop nutritional status → Nutrition hx.
2) Best indicators of acute nutritional status
i) Prealbumin → 2-3 days; nml 15-35
ii) Transferrin → 8-9 days
iii) Albumin → 2-3 wks; nml 3.5-5.5 (<3.5→ ↑M&M).
3) Basic needs → 25kCal/kg/d + 1.5 g/kg protein.
a. Using actual wt will lead to overfeeding in obese pts.

26
 4) Respiratory Quotient (CO2 out / O2 in) RQ ∝ kCal/g
Carb (1.0/3.4) Prot (0.8/4) Fat (0.7/9)
i) >1.0 → overfeeding / lipogenesis
ii) 1.0 → Pure carb utilization (↑EtCO2)
iii) 0.825 → Balanced
iv) 0.8 → Pure protein utilization
v) 0.7 → Pure fat utilization
vi) 0.6 - 0.7 → Starvation/EtOH (0.67)
5) Nitrogen balance
a. N balance = (Nin-Nout) = ([protein/6.25] – [24-hour urine N + 4g]).
i) Positive N balance = protein in > out (anabolism).
ii) Negative N balance = protein out > in (catabolism).
iii) 6.25gm protein contains 1gm of nitrogen
A) Quick formula → need 1gm N per 150 kCal in TPN.
6) Severe malnutrition + emergent surgery→early TPN if NUTRIC score >5.
7) Indirect calorimetry → better measure of nutritional needs than Harris-Benidict &
similar equations.
8) Enteral nutrition is relatively CI in pts needing vasopressors.
N. Vitamin & mineral deficiencies
1) B1 / Thiamine → Beri-Beri (met acidosis, DI, ↑bili, ↓PLTs), cardiomyopathy,
peripheral neuropathy, Wernicke encephalopathy, ataxia.
2) B3 / Niacin → Diarrhea, Dermatitis, Dementia (Pellagra). “B3 = D3”
3) B6 / Pyridoxine → Glossitis, peripheral neuropathy, sideroblastic anemia.
4) B9 / Folate → Megaloblastic anemia, glossitis.
5) B12 / Cobalamin → Megaloblastic anemia, beefy tongue, peripheral neuropathy.
6) Copper → Pancytopenia, ataxia, spasticity, ↓ceruloplasm.
7) Chromium → Encephalopathy, hyperglycemia, neuropathy.
8) Essential FA (linoleic & linolenic) → Dermatitis, ↓hair, ↓PLTs, patchy dry red rash,
brittle nails, ↓healing, ↑infections.
9) Phosphate → Encephalopathy, weakness, cardiorespiratory failure.
10) Selenium → Cardiomyopathy.
11) Vitamin A → Xerosis, night blindness, & keratomalacia.
12) Vitamin C → Scurvy, poor wound healing.
13) Vitamin D → Osteomalacia, rickets, proximal myopathy, hypoCa++,& fxs.
14) Vitamin E → Peripheral neuropathy, myopathy, ataxia, ↓PLTs, anemia.
15) Vitamin K → bleeding (↑ PT).
16) Zinc → ↓wound healing & taste, acne, hair loss, eczema (esp. perioral & anal),
diarrhea.

27

Uploaded by MEDBOOKSVN.ORG
6. Oncology
A. MC Cancers
1) Overall
#1 breast(F)/prostate(M)
#2 lung
#3 colon
2) Death
#1 lung
#2 breast(F)/prostate(M)
#3 colon
B. Lymphoma → needs Ex Bx
for architecture.
C. XRT works best in the M
phase of the cell cycle.
D. CA w/best 5YS w/1°
resection, liver met resection,
& CTX-XRT → Colon.
E. Overall 5-year survival
rates:
-Thyroid 98% -Non-Melanoma skin >90%
-Melanoma 90% -Breast 89%
-Oral/small bowel/anorectal 66% -Other endocrine/colon 65%
-Stomach 30% -Gallbladder/esophagus 18%
-Lung/liver 17% -Pancreas 7%
F. Chemotherapeutics
1) Adriamycin/doxorubicin → cardiotoxic @ >500 mg/m2.
2) Alkylating agents
a. Examples → Cytoxan, ifosfamide.
b. Uses → lymphoma, sarcoma, NonGI adenoCA.
c. Cxs → severe pancytopenia, pulm fibrosis, 2° CAs, hemorrhagic cystitis.
3) Antimetabolites
a. 5FU
i) Uses → any adenoCA, sensitizing for XRT.
ii) Cxs → PO ulcers, diarrhea, SJS.
b. Methotrexate
i) Uses → “liquid” tumors.
ii) Cxs → hepatitis, encephalopathy, nephrotoxicity.
4) Plant alkaloids
a. Vinca
i) Examples → cisplatin, carboplatin, oxaliplatin.
ii) Uses → lung, SCCa, ovarian, germ cell, CRCa (oxaliplatin).

28
 iii) Cxs → nephro/oto-toxicity, hypocalcemia/magnesemia, neuropathy (MC
dose-limiting SE w/oxaliplatin), emesis.
b. Taxanes
i) Examples → taxol, taxotere.
ii) Uses → breast, ovarian, lung.
iii) Cxs → pancytopenia, cardiotoxicity (w/Adriamycin), neuropathy, allergies,
edema.
c. Podophyllotoxins
i) Examples → etoposide, temisopide.
5) Antitumor antibiotics
6) Hormonal
a. Examples → tamoxifen, arimidex, letrozole, exemestane, somatostatin,
Herceptin (SEs → cardiac [f/u w/ECHOs], diarrhea).
7) Immunotherapy & Antibodies
a. Avastin (Bevacizumab)
i) VEGF → MI for tumor neovascularization.
ii) anti-VEGF monoclonal Ab, use in CRCa if + KRAS mutation (“AB+”
[Avastin/Bevacizumab w/ KRAS + mutation]).
iii) A 1st line agent for CRCa per SCORE.
b. Cetuximab
i) Blocks phrosphorylation, ↑apoptosis, ↓cell growth/EGFR/ VEGF/matrix
metalloprotease.
ii) Chimeric (mouse/human) mAb against EGFR, txs metastatic CRCa (w/wild-
type KRAS; ie w/o KRAS mutation), metastatic NSCLC, & H&N SCCa (“C is
average” = wild type KRAS).
c. Infliximab & adalimumab antiTNF abs.
d. Ipilimumab
i) anti-CTLA4 Ab, FDA approved for melanoma in 2011, can be used in adjuvant
setting.
e. Nivolumab, Pembrolizumab, & Atezolizumab
i) Monoclonal Abs against PD/PDL 1, used for unresectable/ metastatic
melanoma, NSCLC, RCCa, & urothelial Ca.
f. Sorafenib Multikinase inhibitor for HCC.
G. Tumor Lysis Syndrome
1) Breakdown of tumor cells leading to ↑ K+, Phos, Mg++, Urea; ↓Ca++.
2) Tx → IVF, urate oxidase (fewer SEs vs rasburicase).
H. AFP → most specific tumor marker (76-94%).
I. Notable Nodes
1) Sister Mary Joseph – umbilical, carcinomatosis, asso w/gastric CA.
2) Virchow – Left supraclavicular, aka “Troisier sign”.
3) Irish – Left axillary, asso w/gastric CA.
4) Rotter – b/w pec major & minor.
5) Lund/Mascagni – in Calot’s triangle.
29

Uploaded by MEDBOOKSVN.ORG
6) Cloquet/Rosenmuller – at/under inguinal lig, is the highest groin/lowest external
iliac LN.
7) Blumer Shelf – drop mets in pouch of Douglas, anterior on DRE.

ABDONMIAL EXPLORATION FOR CANCER

1. Angled laparoscope & 2 ports triangulated on
target.
2. Organ(s) involved, peritoneal dz, amount of
mets, & draining LN basins should be
evaluated/Bx’d.
3. Gastric/GEJ tumors
- Look at GEJ, anterior & posterior (via lesser
sac) stomach, liver, sample hepatogastric lig. &
subhepatic LNs, & do pelvic & subphrenic
washings.
4. Liver tumors
- Assess surface of liver w/mobilization PRN.
5. Pancreatic tumors
- Assess peritoneum & lesser sac + peritoneal
washings.
6. Biliary tumors
- Assess liver w/intra-op U/S, sample
perihepatic LNs, & do peritoneal washings.

CANCER GENES
Gene Function Cancers
Serine/threonine kinase
ATM Neuro/vasc, leukemia, lymphoma
→ DNA repair/apoptosis
BRCA1 Transcription via RNA polymerase Breast, ovary
DNA repair (direct
BRCA2 Breast, ovary, prostate, pancreas
action/binding)
CDH1 Cell adhesion via cadherin Stomach, breast
Serine/threonine kinase
CHEK2 Bladder, breast, CRCa
→ DNA repair/apoptosis
p16 Tumor suppressor, slows
Breast
(FAMMM) progression from G1 to S phase
p53 Adrenal, brain (GBM), breast, blood,
Regulates cell division
(Li Fraumeni) lung, sarcoma
PALB2 dsDNA repair Breast, pancreas
PTEN Phosphatase → cell cycle
Breast, endometrial, RCCa, thyroid
(Cowden) regulation
STK11 Endometrial, GI, HCC, ovarian,
Serine/Threonine Kinase
(Peutz Jeghers) pancreas

30
7. Transplantation
A. Still potential organ donor
1) UTI (but NOT urosepsis)
2) Low grade visceral malignancies (case by case)
3) Low grade brain tumors
4) H/o abd surgery for benign dz
B. General absolute CIs to organ donation
1) HIV & Hepatitis (unless for + recipient)
2) Cirrhosis
3) Active systemic infection w/+ BCxs
4) Melanoma (even if indolent for many yrs)
C. Kidney
i) Indications MCC → ESRD 2/2 diabetes.
ii) Anatomical considerations (Panc+Kidney txp has ↑ quality of life vs kidney txp
alone).
(1) Left renal vein is longer than right → use left as donor.
(2) Take ureter at pelvic brim/near its crossing of iliacs.
iii) Absolute CI to be a living donor → donor has DM.
iv) Improves → DM/renal fxn, reverses neuropathy, reverses autonomic dysfxn, &
halts retinopathy progress.
v) Not improved → vascular disease.
vi) If living donor & recipient have different blood type → 2 options
(1) ABO incompatible donation (need rituximab + plasmapheresis OR
(2) Paired kidney exchange
vii) Complications
(1) Dx → U/S → can evaluate vascular flow, fluid collections (urinoma,
lymphocele), hydropnephrosis.
(2) MCC → Urine leak → Hrs-days. Have IR place a percutaneous drain & have
urology stent open ureter.
(3) MCC post-op Oliguria s/p Kidney TXP → DGF/ATN (path: dilation + loss of
tubules). 2/2 prolonged organ ischemia/reprofusion.
(4) MCC post-op Diuresis s/p Kidney TXP → High urea & glucose before TXP.
(5) MCC new Proteinuria s/p Kidney TXP → Renal vein thrombosis (Dx → U/S).
(6) MCC new onset Diabetes s/p Kidney TXP → S/E of steroids.
(7) MCC acute donor death → PE.
(8) MCC acute recipient death → MI.
(9) MCC long-term in young female kidney donors → pregnancy issues
(↑gestational HTN & pre-eclampsia).
(10) MI RF for ↓ survival (graft & pt) → COPD.
(11) ↑age @ txp (>60) → ↑hospitalizations.
(12) 1° Non-fxn/Delayed Graft Fxn (DGF) → ↓graft survival.
↓ risk of 1° Non-Fxn/DGF w/cold, pulsating machine recirculation.
(13) MC vascular cx s/p Kidney TXP → Renal artery stenosis (or thrombosis).

31

Uploaded by MEDBOOKSVN.ORG
 (14) MCC of external compression s/p Kidney TXP → Lymphocele (MC 3 weeks
after TXP).
(a) Tx → 1st perc drain, 2nd → peritoneal window.
(15) MCC nephropathy leading to graft loss → BK polyomavirus.
(a) Inc → 5%, but 80% of those → graft loss.
(16) Acute rejection → tubulitis on Bx.
(a) Tx → pulse dose steroids (follow Cr).
D. Liver
1) Indications MC → Hep C.
2) Lamivadine + adefovir ↓HepB reinfection to <5%.
3) Contraindications → Current EtOH/subtance abuse, active sepsis or UC, recent
IVH, irreversible poor cardiopulmonary dz (eg. pulm HTN).
4) Anatomical considerations
a. Differences in anastomoses b/w RIGHT liver vs deceased donor.
i) R liver (dR to Main)→ dRHV to IVC, dR portal v to R portal v/CPV, dRHA to
RHA/CHA, dR bile duct to R bile duct/CBD.
ii) Deceased donor (Main to Main)→ dIVC to IVC, dCPV to CPV, dCHA to CHA,
dCBD to CBD.
iii) Split/reduced size grafts → good for 1 adult txp or 1 adult & 1 pediatric (Poor
outcomes if used for 2 adults).
5) Complications (MC w/living donor)
a. Diagnosis U/S- Can evaluate for portal vein/hepatic artery/hepatic venous flow,
IVC patency, biliary dilatation.
b. Biliary leak (MC) → percutaneous drain + stent w/ERCP.
E. Heart
1) Indications → cardiac disease w/life expectancy < 1 yr.
2) Complications
a. Persistent pulmonary HTN → asso w/early mortality.
b. Acute rejection (<1yr) → perivascular lymphocytic infiltrate.
c. Chronic allograft vasculopathy/Progressive diffuse coronary atherosclerosis →
MCC of late (>1yr) & overall mortality.
i) CMV infxn → accelerated coronary atherosclerosis.
F. Lung
1) Indications → pulmonary disease w/life expectancy < 1 yr.
a. Cystic fibrosis → main indication for bilateral lung transplant.
2) Complications
a. Reperfusion injury → similar to ARDS, MCC early death.
b. Acute rejection → perivascular lymphocytosis.
c. Chronic rejection → bronchiolitis obliterans, MCC late & overall mortality.
G. Pancreas
1) Indications → CKD4/ESRD + DM or frequent metabolic Cxs + failure of insulin tx.
2) Anatomical considerations → need both celiac & SMA + portal vein, attach to illiacs.
3) Complications
a. Venous thrombosis → MC complication s/p pancreatic transplant, difficult to tx.

32
 b. Rejection → difficult to diagnose w/o concomitant kidney transplant, can see
increased glucose, amylase, WBC, & fevers.
c. MCC of perioperative failure → technical error (venous thrombosis).
H. Small Bowel
1) Indications → short bowel syndrome w/failure of TPN or life-threatening Cxs.
2) Contraindications → active infection or CA.
I. Complications
1) Rejection
a. Hyperacute → Preformed Abs to HLA Ags (min to hrs).
i) MC 2/2→ABO incompatibility. Type II hypersensitivity.
ii) Tx → Retransplant.
b. Acute → T cells (minimum 7 days).
i) Can be Ab or Cell-Mediated.
ii) Tx → ↑immunosuppression (generally w/steroids).
c. Chronic → mediated by T & B Cells (mns to yrs).
i) Tx → ↑immunosuppression. Most need re-transplant.
d. Chronic Allograft Vasculopathy → Chronic rejection → fibrosis of blood vessels.
i) MC s/p cardiac txp.
ii) Tx → Steroids. Eventually re-transplant.
e. Anti-rejection medications
i) Induction
A) ATG → Anti-thymocyte
globulin, from rabbits or
horses.
B) Basiliximab → mAb to α-chain (CD25) of IL-2 receptor on T-cells.
C) OKT1 → mAb, induction & acute rejection.
D) Steroids → inhibit IL-1, IL-6, & macrophages; → thin skin, poor healing,
bruising, Cushingoid.
E) Tacrolimus → Binds FK protein, then inhibits calcineurin protein,
downstream effect → inh IL-2, IL-4, INF-γ. Sim to cyclosporin (= graft & pt
survival, ↓rejection).
1. SEs → Seizures (>10%), neuro- & nephrotoxic.
ii) Maintenance
A) Steroids & Tacrolimus
B) Sirolimus → Binds FK protein like Tacro, but instead inh mTOR → blocks
response to IL-2.
1. Not nephrotoxic like Cyclo & Tacro. However, does → oral ulcers,
thrombocytopenia & poor wound healing (consider holding
perioperatively).
C) Mycophenolate → ↓purine synthesis. NOT nephrotoxic.
1. Pancytopenia & GI sxs. 50% get early profuse diarrhea w/↑ WBC w/o
shift, & usually afebrile.

33

Uploaded by MEDBOOKSVN.ORG
 D) Cyclosporine → Enterohepatic recirc (PTC removes 90%).
1. SEs →N/V, seizures (1-5%), arrhythmia.
2. ↑dose if on anti-TB tx (2/2 cyto p450).
2) General Complications
a. Cancer
i) Skin #1 SCCa → MC CA s/p solid organ transplant.
ii) PTLD #2, 2/2 EBV (present w/fever, LAD, distension, emesis).
A) Monoclonal B-cell. MC s/p heart/lung txp. ↑w/CMV+ pts.
B) Tx → gangcyclovir or acyclovir, rituximab, CHOP-R.
b. Infection (EBV MC than CMV)
i) CMV → inclusion bodies. Diarrhea. Asso w/↓survival (graft & pt).
A) Tx → gangcyclovir.
ii) pPX → TMP/SMX for 6mo s/p TXP against PCP/PCJ.
iii) Wound infection → MC complication in a living kidney donor.
iv) PE → MCC of acute death in a living kidney donor.
c. Neutropenic Typhlitis
i) Follows chemotherapy when ↓ WBCs (@nadir).
ii) Can mimic surgical disease (e.g. appendicitis).
iii) Can often see pneumatosis intestinalis (not a surgical indication here).
iv) Tx → abx & bowel rest. Patients improve when WBCs ↑. Surgery only for
free perforation.

34
8. Wound Healing
A. Phases (Cells in order of arrival)
Injury → vasoconstriction → PLT adhesion → thrombin generation.
1) Inflammatory (Injury-1wk)
a. PLTs
b. PMNs (MI for ischemia/reprofusion → superox & clotting).
c. Macrophages → Phatocytoses bacteria.
i) MI cell for healing, initial remodeling, & recruitment.
d. Lymphocytes
2) Proliferation (4d-3wks)
a. Lymphocytes
b. Fibroblasts ↓damage to fibroblasts by irrigating with 0.9% NaCl.
H2O → hypotonic → cell lysis. H2O2 → oxidative damage.
c. Myofibroblasts → wound contraction.
3) Remodeling (3wks-1yr)
a. Lymphocytes
b. Fibroblasts
B. Max collagen @ 3wks, max tensile strength @ 8wks.
C. MI growth factor for healing → PDGF.
D. MI stimulant for angiogenesis → hypoxia.
E. MI for healing by 1° intention → tensile strength.
F. MI for healing by 2° intention → epithelial integrity.
G. Problems Vit A → ↓ neg effects of steroids on healing (25,000 U/d).
1)Age → ↓ wound strength, elasticity, & healing. (↑dehiscence, MMPs).
2)Deficiencies Vit C → Impairs healing by ↓ collagen cross-linking.
3)Malnutrition → Poor healing in HIV pts (check nutrition, Alb, & PreAlb).
4) Hypertrophic scar → stays w/in original incision border.
5) Keloid → outside original incision border. Tx → excise + steroid injection.
6) Risk of delayed epithelialization is ↑ in infection > hypertrophic scar.
7) Tamoxifen ↓wound healing. Digoxin & NTG may ↑ healing.
8) HyperBaric Oxygen Therapy (HBOT) → ↑O partial pressure gradient (→↑O
diffusion) & ↑ VEGF (→ angiogenesis).

35

Uploaded by MEDBOOKSVN.ORG
9. Trauma
ATLS Operative Triage Order: ResuscitativeThroracotomy → Ex Lap → Burr Hole → TEVAR.

1° survey → ABCDE CXR ± FAST

2° survey → Head-to-toe exam ± Pelvic xray (esp if hypoTN)
3° survey → full re-exam, obtain add’l imaging, & f/u all consult recs/imaging.

Best measure of adequate resus → Not trauma → UOP >0.5mL/kg/hr.

Trauma → lactate <2.5 (>2.5 → more resus).

Regions below are listed in order of precedence for the treatment of active hemorrhage
from A - G.
A. Neck
1) Penetrating Neck Injury Zones
a. Zone I
i) Clavicle to cricoid cartilage.
ii) No sxs & HDS → CTA, bronchoscopy, esophagoscopy, & barium swallow; a
pericardial window may also be indicated.
i) NOT HDS → median sternotomy to reach injury (almost always needed for
vascular injuries to obtain prox control).
b. Zone II
i) Cricoid to angle of mandible.
ii) “Hard” signs/indications for OR → pulsatile/expanding hematoma, brisk
bleeding, not HDS, & massive subQ emphysema.
A) Lateral neck incision, anterior to sternocleidomastoid, collar incision if
possible bilateral injury.
iii) In absence of “hard” signs can manage non-op w/obs, neck CTA, & upper
endoscopy/esophagram (per SCORE). OR if w/u + for injury.
c. Zone III
i) Angle of mandible to base of skull.
ii) Need CT angiogram (& laryngoscopy once stable).
iii) May need: 1) jaw subluxation, 2) digastric & sternocleidomastoid muscle
release, 3) mastoid resection to reach injuries.
d. During neck exploration, raise subplatysmal flaps to decrease injury risk to
marginal mandibular nerve.
2) Imaging
a. Asymptomatic blunt → neck CT angio.
b. Asymptomatic penetrating → controversial; see neck zones.
c. Symptomatic → hypotension, pulsatile bleeding, expanding hematoma, palpable
thrill, audible bruit (all are “hard” vascular signs), crepitus, stridor, hemoptysis,
neurologic deficit (eg. hemiplegia) → all need OR neck exploration.

36
3) Airway
a. 1st in order of treatment if airway compromise (A of ABCDEs). Treated at the
same time as chest if for breathing (B) or hemorrhage (C) once airway is secured.
b. Indications for a surgical airway (aka cricothyroidotomy)
i) Significant upper airway distortion, laryngotracheal disruption, midface
trauma, & inability to visualize the airway secondary to hemorrhage,
edema, or anatomic disruption. BLUF → cric if unable to intubate.
c. 1st ETT failed → BVM + GEB; 2nd attempt failed or unable to raise sats w/BVM →
cric (convert to trach w/in 24-48hr to prevent subglottic stenosis).
d. Facial fxs → try oral ETT 1st (nasal ETT is CI), then cric if unsuccessful.
i) Cric is done through cricothyroid membrane, above cricoid cartilage & below
thyroid cartilage.
e. MCC long-term s/p crichothyroidotomy → subglottic stenosis.
f. Tracheostomy
i) After incising the 2nd/3rd tracheal cartilage, slowly back out ETT under direct
vision while inserting the trach.
ii) Early (<7d) tracheal dislodgement → 1st re-intubate from above.
iii) Minor site bleeding early → hemostasis + bronch; if effecting sats → RTOR for
hemostasis (don’t bronch).
iv) Major site bleeding/massive hemoptysis → Tracheo-innominate fistula
(occurs 3d-6wks post-op).
A) <1% risk. 50% mortality.
B) Acute → < 2wks. Chronic → > 2wks.
C) 1 → overinflate,
st 2 → oral ETT past trach & overinflate,
nd 3rd →
finger through hole to lift up sternum (Utley maneuver) to compress + oral
ETT. ALL OF THESE ARE EN ROUTE TO OR.
D) R supraclavicular collar incision + upper median sternotomy w/extension
through 2/3rd ICS. Expose innominate, RCCa, RSCa, & trachea. Get proximal
& distal control. Compare SBP & sat b/w RUE & LUE. If w/in 30mmHg &
10% sat → ligate/oversew w/running 5-0 prolene. If not, autologous
interposition. Leave fistula seg of artery in situ for trachea closure.
Interpose muscle flap/healthy tissue b/w trachea & arterial repair.
4) Laryngeal & Tracheal Injuries → airway emergency!
a. Sxs → crepitus, respiratory compromise, stridor.
b. Get airway in ER (cric PRN; SCORE recs OR for tracheostomy if stable).
c. Tx → 1° repair w/PDS, strap muscle for airway support; tracheostomy necessary
for most to allow edema to subside & to check for stricture (convert cric to
trach).

37

Uploaded by MEDBOOKSVN.ORG
 5) Blunt CerebroVascular Injury (BCVI)

a. Vertebral Artery → See table for tx.

b. Carotid Artery Injury
i) IV UFH (100 U/kg) if complex repair (resect
w/end-to-end anastomosis or interposition
graft) or basilar. Shunt (argyle or Sundt) if
prolonged repair or inadequate back-bleeding.
ii) Interrupted 6-0 prolene suture repair in
children or in internal carotid artery in all
patients to prevent stenosis. Flushing
sequence after verifying back-bleeding is externally, & then into external
carotid artery, and, finally, flow is reestablished into internal carotid artery.
A) Lateral defect → min debridement & lateral arteriorrhaphy w/interrupted
6-0 prolene.
B) Loss of one wall → patch w/GSV, thin-walled PTFE, or bovine pericardium.
C) Through-and-through injuries or segmental disruption → seg resect &
end-to-end.
D) Undue tension → seg resect & GSV or
PTFE interposition graft.
c. External Carotid & Internal Jugular → can
ligate, especially if unilateral.
6) Esophagus (See below)
7) Thyroid Injuries (hemostasis vs excision)
B. Chest
1) General
a. Penetrating Chest Injury
i) Start w/CXR if HDS (chest tube for PTX or HTX)
ii) Pericardiocentesis → only temporizing (eg. Before transfer to higher level of
care).
iii) Penetrating “box” injuries → borders are clavicles, xiphoid process, nipples →
CXR, pericardial window, bronchoscopy, esophagoscopy, barium swallow.
iv) Penetrating chest wound outside “box” without pneumothorax or
hemothorax.
A) Need chest tube if patient requires intubation.
B) Otherwise follow patient’s serial CXRs.

38
 v) Pericardial window: if blood → median sternotomy to investigate heart &
great vessels. Leave a pericardial drain.
vi) Ant-med to midaxillary line & below nipples penetrating inj.
A) Eval for “box” inj pending inj site (FAST vs window).
B) OR for dx lap vs ex lap.
b. Approaches
i) If HDS → endovascular if able.
ii) Proximal L SCV → 2nd ICS trapdoor + sternotomy.
iii) Mid-distal L SCV → L ant-lat thoracotomy.
iv) Proximal L CC → median sternotomy.
v) Proximal R CC → claviculectomy.
2) Mediastinum
a. Heart
i) Hole in heart → repair with plegeted 5-0 Prolene; atria → running, ventricle
→ horizontal mattress.
A) Can use pericardium to repair atrial defect.
B) Ligate distal coronary artery injuries, bypass proximal ones w/rSVG (Ao to
distal w/GSV).
b. Thoracic Aorta
i) Ao dissection → laparotomy 1st if indicated (eg. +abd FAST & pt not HDS) +
double product control (keep HR x SBP <10,000) + delayed repair PRN.
c. Blunt Cardiac Injury (BCI)
i) Negative ECG & troponin → 99% NPV.
A) As single screening test, ECG → best (NPV → ~95%), then troponin & CK-
MB.
ii) V-tach & V-fib MCCs of death.
iii) BCI can → cardiac contusion or rupture. Risk highest in 1st 24hrs. Need
monitoring for 1-2d.
iv) SVT → MC arrhythmia overall (SCORE says PVCs).
v) Internal defibrillation paddle setting → 20J (up to 40J).
d. Hemopericardium
i) Cardiac Tamponade
A) +pericardial FAST w/stab to box w/Beck’s Triad (hypotension, distended
neck veins/JVD, muffled heart sounds).
1. If FAST is initially negative, but pt later develops sxs c/f tamponade →
repeat FAST & tx as below.
B) Stable→ OR for diagnostic subxiphoid pericardial window. If blood, convert
to median sternotomy.
C) Unstable→ OR for emergent median sternotomy (also for unstable
precordial injury).
D) In extremis→ Resuscitative (“ED”) thoracotomy (left, even if inj on right).
1. 1st → mobilize inf pulm lig, 2nd → open pericardium ant. to phrenic n.,
3rd → clamp Ao.

39

Uploaded by MEDBOOKSVN.ORG
 ii) Pneumopericaridum 2/2 Macklin effect
A) Stable → bronch & EGD, most resolve on own if no injuries seen.
B) Unstable → aspirate air then pericardial window.
3) Lungs
a. Aspiration → may not produce CXR findings immediately.
b. Hemothorax
i) > 1,500mL s/p placement, > 200mL/h for 2-4 hrs, > 2,500mL/d, or bleeding +
not HDS → thoracotomy indications.
ii) Drain w/in < 48 hours to prevent fibrothorax, lung entrapment, infected
hemothorax, lung entrapment.
iii) Unresolved s/p 1(per EAST) or 2 well-placed tubes→ VATS.
iv) >300mL → blunts costophrenic angle on CXR.
v) >500mL → detect on exam via percussion.
c. Pneumothorax
i) Spontaneous PTX
A) 1st time w/ small air leak on H2O seal → clamp 4hrs & CXR (no PTX → pull;
PTX → suction [persistent PTX on CXR → 2nd tube, persistent after 4-5d →
VATS]).
B) Persistent large PTX after chest tube → 2nd tube.
C) SpontPTX, CTs w/persistent air leaks → pleurodesis + blebectomy.
D) Best tx for pilot/diver/etc w/spont PTX 2/2 bleb → apical blebectomy +
mech pleurodesis.
ii) Tension PTX
A) One-way valve effect causes air entry & pressure build-up; occult PTX can
→ tension w/ETT & positive pressure.
B) Hypotension, ↑ airway pressures, ↓ breath sounds, bulging neck veins,
tracheal shift.
C) Can see bulging diaphragm during laparotomy.
D) Cardiac compromise secondary to ↓ venous return (IVC, SVC
compression).
E) Tx → chest tube (Place in 5th ICS at mid-axillary line).
iii) Traumatic PTX → Usually 2/2 rib fxs. No sxs & apex-to-cupola <3cm → ED
obs for 6hrs w/repeat CXR (stable→ home).
iv) Open PTX (“sucking chest wound”)
A) Significant if > ⅔ diameter of trachea.
B) Three-sided dressing for lung expansion + prevent tension PTX.
v) Indications for surgery → Persistent air leak (> 3 days), lg air leak, lung not
fully expand w/chest tube, recurrent PTX, negative pressure environments job
(eg. pilot/scuba diver), work/live in remote areas w/limited access.
A) Either an open (muscle-sparing posterolateral thoracotomy) or VATS
approach can be used.
1. Examine upper lobe & superior seg of lower lobe for blebs.

40
 2. No bleb ID’d → sm wedge resection of upper lobe & superior seg of
lower lobe.
3. Mech pleurodesis/pleurectomy → creates adhesions b/w visceral &
parietal pleura → obliterates pleural space.
4. Two chest tubes (28 Fr) placed → angled in costophrenic sulcus &
straight posterio-apically.
d. Tracheobronchial injuries MC on right.
i) May ↓SaO2 s/p chest tube placement.
ii) Rare indication for chest tube clamping.
iii) Mainstem ETT contralateral side.
iv) Dx → bronchoscopy.
v) Tx → repair if: 1) large leak → pulm. compromise or 2) air leak > 2 weeks.
A) Right thoracotomy → trachea, R mainstem, & prox L mainstem injuries.
B) Left thoracotomy → distal L mainstem.
e. Persistent PTX despite 2 well-placed CTs → bronch (could be 2/2 mucous plug,
foreign body, or lg tracheobronch inj).
f. Bleeding pulm injuries → tractotomy. Can enter pericardium anteriorly to
control bleed at hilum.
i) Trauma pneumonectomy → 80% mortality.
ii) If rapid exsanguination/immenant death → clamp hilum vs hilar twist to buy
time for hemorrhage control.
4) Diaphragm Injury
a. AAST Grades
i) 1 → contusion
ii) 2 → lac < 2cm
iii) 3 → lac 2-10cm
iv) 4→ lac > 10cm or < 25cm2
v) 5 → > 25cm2
b. ML on left & ML to result from blunt trauma.
c. CXR → see air/fluid lvl in chest 2/2 stomach herniating (diagnostic).
d. Laparoscopy is better than CXR & CT for dx.
e. < 1 wk → Transabdominal approach. If HDS → start lap.
f. > 1 wk → Per EAST PMG either Abd or Chest (can have pleural adhesions
difficult to lyse trans-abd).
g. Tension-free repair w/horizontal mattress 0 Prolene. May need mesh (must be
permanent & NOT porous), right counter incision, or incising lat/ant/post
border & moving up 2-3 ribs if large. Stear clear of central portion (phrenic).
5) Sternal Fracture → high risk for BCI, get ECG & troponin.
a. Can plate if → chronic pain, associated PNA, unstable fx.
6) Rib Fractures
a. Many rib fxs, severe pulm contusions, lg flail seg. 1st tx → thoracic epidural (NOT
plate 1st or externally stabilize).

41

Uploaded by MEDBOOKSVN.ORG
 i) Rib fracture pain management with failed epidural placement → block +
multi-modal analgesics.
b. Can plate if → flail, deformity, during thoracotomy for another reason, chronic
pain, non-union.
i) CI for rib plating → mod-sev pulm contusions (now disputed). Infection in field
more universal CI.
c. Flail Chest → ≥ 2 consecutive ribs broken at ≥ 2 sites → results in paradoxical
motion.
d. Underlying pulmonary contusion → biggest pulmonary functional impairment
in pts w/rib fxs.
7) Biliary-Pleural Fistula → bilious fluid in chest.
a. Tx → chest tube + ERCP w/sphincterotomy.
8) Scapulothoracic Dissociation → complete disruption of shoulder girdle, can →
massive bleeding. Tx → reduce, immobilize, & IR embolization.
C. Abdominal Consider using Cell-Saver early in ex lap!
1) General
a. Diagnostic peritoneal lavage (DPL) → 1L NS then drain (supraumbilical if pelvic
fx).
i) Used in hypotensive patients w/blunt trauma.
ii) Positive if > 10mL blood, > 100,000 RBCs/mL, food, bile, bacteria, > 500
WBC/mL, or can’t read through it.
iii) Need laparotomy if DPL +. DPL misses → RP bleeds, contained hematomas.
b. FAST scan (Focused Abd Sonography for Trauma).
i) Used in lieu of DPL. Checks for fluid in perihepatic & perisplenic fossae, pelvis,
& pericardium.
ii) Examiner dependent. Can be difficult w/obese pt. May not find < 50–80 mLs
of ascites/blood/succus.
iii) Need ex lap if FAST + & not HDS (go to OR 1st, not CT scanner).
iv) Can miss → hollow viscous & RP injuries.
v) Initial FAST neg, but then pt becomes hypotensive → repeat ABCs, repeat
FAST, & resus.
vi) HDS pt w/+FAST→CT to define injuries. HDS pt w/+ FAST &/or CT(abd fluid
w/o solid organ/vasc injury) → dx lap.
c. Intra-Abdominal Hypertension
i) Grade I → IAP 12-15mmHg Grade II → IAP 16-20mmHg
Grade III → IAP 21-25mmHg Grade IV → IAP > 25mmHg
ii) Abdominal Compartment Syndrome
A) Tx → if IAP ≥20 + new organ dysfunction → decompressive ex lap & leave
open (if not then obs + sedate).
B) Indication for decompressive ex lap s/p abd closure →IAP >20 despite pt
relaxed, AKI/oliguria, resp failure/↑Peak airway pressures, ± APP <60.
C) FAST to look for peritoneal fluid. If large amount of fluid/ascites →
paracentesis may obviate ex lap need.

42
 d. Ex-lap closure → monofilament, slowly absorbable (eg PDS), running, 4:1, 5 mm
bite (STITCH trial).
e. Hierarchy of open abd closure techniques:

1st: 1° fascial closure (w/o ↑ airway pressures→ c/f ACS), SOC ok per EAST
↓
nd
2 : Biologic bridge + skin closure
↓
3rd: Skin closure only/planned ventral hernia
↓
4th: STSG

f. HDS Trauma pt w/+ RUQ FAST + abd pain → CT 1st.

2) Esophagus
a. Perforation (mortality doubles if >24hrs [14→27%]).
i) Best tx for cervical esophagus injury → 1st NPO, IVF, broad abx/antifungals.
A) Contained → drain + NPO & abx. If NOT→ OR, need to see extent of
mucosal inj so must open, consider muscle buttress.
B) At exploration for penetrating zone II → 1° repair + leave drain.
C) Stent ok for → 1small, contained, & HDS pt, 2poor surgical candidates, &
3for small leaks s/p repair (per SCORE).

1. Stent has = mortality, significantly less morbid/LOS/time to PO/costs).

Malignant perf is a good indication for stent.
D) Leak + hypoTN → open exploration, drain, abx, T-tube.
ii) Best tx for thoracic esophagus injury →
A) OR, need to see extent of mucosal inj so must open, consider muscle
buttress (impt on entry if using intercostal mm).
B) Grillo → pleural flap to buttress esophageal repair.
b. Dx → gastrograffin esophogram/UGI (a dynamic study) is better than CT w/PO
contrast (static snapshot) per SCORE.
c. MC site (spontaneous) → Left distal 1/3.
d. MC site (post EGD) → cricopharyngeus.
e. Approaches
i) MC approach for upper 1/3 esophagus → Left oblique neck inc.
ii) MC approach for middle 1/3 esophagus → Right posterior lateral
thoracotomy @ 4/5th ICS.
iii) MC approach for distal 1/3 esophagus → Left post/lat thoracotomy @ 6/7th
ICS ± ex lap.
iv) Steps:
A) Extend myotomy → debride non-viable tissue → close mucosa (4-0 PDS) →
close muscularis (4-0 vicryl) → poss intercostal flap.
3) Stomach
a. 1° repair in 2 layers vs wedge resection.

43

Uploaded by MEDBOOKSVN.ORG
 i) 1° repair of pylorus → Heineke-Mikulicz transverse pyloroplasty.
b. Resecting proximal greater curve may lead to → delayed emptying (Vagal injury).
4) CBD Injury <50% → 1° repair over stent 10% leak so
>50% → HJ leave drains
5) Pancreaticoduodenal
a. Dx → CT w/contrast initially, UGI contrast best.
b. MC blunt mech (eg. seatbelt/handlebar).
c. Pancreas
i) Must open gastrocolic to see panc body, post stomach, & splenic a.
ii) Trauma Whipple → only consider if injury already did the resection + young,
healthy, & stable pt. >50% mortality.
iii) May obs Gr I & II pancreatic injuries (no duct involvement). Must explore if
duct is involved (Gr III-V). Distal panc injury (left of SMA) → save spleen if
HDS & no other major injuries, if not → DPS.
iv) Panc duct inj → stent. Transection → DPS.
v) Like eating crawfish, w/ pancreas injuries → “suck the head & eat the tail.”
A) Pancreas injury left of SMV that is likely involving main duct → Resect distal
pancreas.
1. If not involving main duct → just leave drains.
B) Fistula, panc leak s/p trauma distal panc, Tx → ERCP w/stent.
d. Duodenum
i) MC location for hematoma → 3rd portion (over the spine).
A) Explore for penetrating or blunt > 2cm (see below).
ii) MC to tear → duo (2nd portion near ampulla). Also at LoT.
iii) 1° ± seg resect w/end-to-end anastomosis PRN except for 2nd portion
(attempt 1° repair for most → txs 80%).
A) 2nd portion w/ampulla intact → 1st 1° repair, 2nd jejunal serosal patch, 3rd
or if >75% inj Roux-en-Y & leave drains.
B) 2nd portion not intact → resect, staple, drain→ stablize in ICU→ staged
reconstruction.
e. Paraduodenal Hematoma
i) Can present as proximal high grade SBO 12-72hrs s/p injury (eg. n/v), MC in
children.
ii) Dx → PO CT or UGI study (best) → “stacked coins” or “coiled spring” in 3rd
portion of duo w/o extravasation.
iii) On imaging
A) Intraperitoneal free air/leak → OR for repair.
B) Retroperitoneal air/leak → non-op (NGT, NPO, consider TPN if ↓ gastric
emptying on UGI [get on HD 5-7], bowel rest, & abx cures 90% over 2-3
weeks). If persists >10-14d → consider OR (last resort for non-op failure).
iv) IntraOP
A) Kocher → check for bile, hematoma, succus, saponification/fat necrosis, &
panc inj.

44
 1. Hematoma < 50% → leave. >50% → I&D + 1° repair.
B) Duodenal Wall Compromise
1. 1st, 3rd, or 4th portion GSW → Resect, Roux-en-Y, & leave drains.
Stab → attempt 1° repair as above.
2. 2nd portion, ampulla, or pancreatic head → Damage control, drain, &
2nd look.
a) If HDS, 1° repair if < 50% & ampulla intact. Always place jejunal
feeding tube.
3. Duo leak rate = 6%, ↑ if w/pancreas injury.
6) Bowel Injuries in General → repair transversely vs resect, irrigate copiously (8L
warm NS), & < 24h abx (unless s/s of infxn).
7) Small Bowel → MC injured hollow viscus in penetrating abd inj.
a. Lumbar Chance fx → up to 50% association w/bowel injury.
8) Colorectal
a. Right & trans → R med visceral rotation (Cattal-Brasch).
i) 1° repair, resect & anastomosis if destructive (ie > 50% circumference or asso
w/sig devasc). No diversion.
b. Left → L med visceral rotation (Mattox).
i) Blaisdell → same as Mattox, but kidney stays in situ.
ii) 1° repair w/o diversion if < 50% & no devasc.
iii) Resect if destructive lesions. Open all paracolonic hematomas.
iv) If on pressors, > 6hrs s/p injury, sig comorbidities, gross contamination, ≥ 6u
pRBCs, or can’t 1° repair → end colostomy & Hartman pouch vs 2nd look.
v) Enterotomy + destructive left colon injury & pt is HDS → seg resect w/1°
anastomosis.
c. Rectum
i) MC w/penetrating v. blunt.
ii) Bloody DRE w/pelvic fx → rigid proctosigmoidoscopy (80-95% accuracy).
iii) Intraperitoneal
A) 1° repair w/o diversion if < 50%, LAR & diverting loop colostomy if > 50%
(end colostomy if shock).
iv) Extraperitoneal (SCORE→ add diversion w/loop colostomy for all)
A) Upper 1/3 → 1° repair w/diverting loop colostomy (LAR PRN).
B) Middle 1/3 → Often inaccessible, end colostomy, fix in 6-8wks.
C) Lower 1/3 → Most repaired 1° w/transanal approach. If unable → end
colostomy only (not APR).
9) Abdominal Vascular Injuries
a. Don’t ligate or bypass aorta unless infxn. Rather, insert temp shunt & do a 2nd
look. Repair w/autologous, Dacron or PTFE graft.
b. OK to ligate infrarenal IVC/veins caudal to it if must, but ↑swelling.
10) Liver If not HDS → go to OR, not IR.
a. Ok to ligate CHA/RHA if must (GDA collaterals, also take GB).
b. Must repair portal vein & SMV (DON’T ligate).

45

Uploaded by MEDBOOKSVN.ORG
 c. Cont bleeding s/p packing → Pringle. Still bleeding → angio.
d. MCC s/p hepatic embo → necrosis (15%), abscess (7.5%), & bile leak.
e. Infected post-trauma biloma → 1st perc drain (source control 1st), then abx, etc.
11) Spleen
a. HDS
i) No extravasation or PSA → observe w/serial exams & CBCs.
A) Failure → 6-15% (up to 33% w/Gr IV & 75% w/Gr V).
ii) Extravasation or PSA → angio.
b. Not HDS → OR for splenectomy.
c. MC early Cx s/p splenectomy → hemorrhage from short gastrics (>>> panc leak,
95% resolve w/drain alone).
d. Early ligation of splenic artery → open lesser sac.
e. CT w/grade V spleen & pt NOT HDS → OR for splenectomy.
f. Vax 2wk s/p OR or before d/c if sooner (23v Pneumo + repeat in 4-6y +
meningococcal q5y + HiB x1).
g. Post-op thrombocytosis → only treated when > 100K (Tx → ASA).
12) Bladder
a. MCC → blunt trauma (>95% asso w/pelvic fractures - MC associated injury).
Hematuria → best indicator (but not specific).
b. Sxs → perineal hematoma, blood at meatus.
c. Dx → retrograde cystourethrogram (best test).
d. Extra-peritoneal bladder rupture → starburst appearance on cystogram (for CT
fill w/300mLs or until pt discomfort).
i) Tx → catheter for 7-14d (no surgery). Reimage in 7-10d.
ii) Only repair if → bone fragment, persistant clot, open pelvic fx, or other
pelvic fx requiring open repair.
e. Intra-peritoneal bladder rupture → often in kids. Cystogram shows intra-abd
contrast leak.

46
 i) Tx → laparotomy & 1° repair (3-0 PDS or vicryl) of defect & cath for 7-14d.
Reimage in 7-10d before d/c’ing cath.
f. Pelvic fx, extraperitoneal bladder rupture, nml urethrogram → cath (unless fx
needs op, then fix bladder before bone).
13) Ureters
a. Ureteropelvic Junction (UPJ) inj → MC in kids. Tx→ stent.
b. IV methylene blue can help ID injury intra-op.
c. Injury > 2cm & proximal/above pelvic brim (aka “high/middle”)→ tie off + perc
nephrostomy (delayed recon).
d. Injury < 2 cm & above pelvic brim → End to end re-anastomosis over double-J
stent w/ abs suture (5-0 PDS).
i) 50% ureter injury 6cm above bladder during R hemi/partial transection →
repair over double-J stent.
e. For any location, if found during damage control laparotomy in pt w/lethal
triad → drain proximal end & get to ICU for resus.
f. Injury in pelvis to ureter/below pelvic brim → Re-implant ureter to bladder,
possibly w/ Psoas hitch.
g. Never answer these →
i) Transuretero-ureterostomy (connect damaged ureter across abd into healthy
ureter), technically very difficult & can damage the ureter.
ii) Autotransplant (remove kidney & re-implant into pelvis).
14) Urethra
a. Best signs → triad of 1meatal blood, 2hematuria, & 3free-floating prostate gland.
Usually asso w/pelvic fxs.
b. Dx → Blood at meatus (or perineal lac + pelvic fx) → Don’t place cath! Get a
Retrograde urethrogram (RUG) 1st.
c. If serious generally place suprapubic cath & reconstruct in 6mns.
d. Membranous portion most at risk for transection.
e. Anterior injury (2/2 saddle injury) → distal membranous urethra.
f. Posterior injury (MC; 2/2 pelvic fx) → membranous > prostatic urethra.
15) Testicle Rupture → OR to debride & repair.
16) Uterine Laceration → repair w/chromic.
17) Retroperitoneum
a. Zone 1 → Must explore all hematomas in zone 1.
i) Abdominal Ao (expose w/Left MVR) & IVC (expose w/Right MVR).
b. Zone 2
i) Kidneys
A) In general, avoid operating on blunt
→ ↑ preservation w/no-op.
B) Trauma + microscopic or gross hematuria → abd CT.
C) Indications for nephrectomy → ongoing bleeding in an unstable patient.
Always check for contralateral kidney 1st.

47

Uploaded by MEDBOOKSVN.ORG
 1. All others likely temporized w/packing or IR (can angioembolize & drain
collecting duct injuries).
D) Per SCORE, the only absolute indications for OR are 1known injury + not
HDS & 2expanding/pulsatile hematoma. Otherwise closely observed +
repeat CT (regardless of mechanism).
E) Hematoma over kidney = Zone II.
1. Blunt → don’t explore unless rapidly expanding.
F) Bleeding from RIGHT superior renal pole in OR & not HDS → complete
nephrectomy.
ii) Retroperitoneal Muscles
c. Zone 3 See Pelvis below
D. Pelvis
1) Classification → Vertical shear (binder may worsen bleed), Lateral & AP
compression. Binder centered on fem head. Pelvic fx+not HDS → binder.
2) Anterior Pelvic Fxs Bleeding ML 2/2 → venous from pelvic venous plexus (MC
source in pelvic fxs).
3) Posterior Pelvic Fxs Bleeding ML 2/2 → arterial injury.
4) Intra-op Pelvic Hematomas
a. Penetrating Tx → open v. angio.
b. Blunt Tx → leave; if expanding or patient unstable → stabilize pelvic fracture,
pack pelvis if in OR, & go to angiography for embolization; if packs are placed
intra-op, remove after 24–48 hours when patient is stable.
5) Bleeding pelvic fx & HDS/IVF responsive → angio.
6) Unstable & not responsive to fluid → pack (last resort → ligate hypogastric
arteries.)
E. Extremities
1) Upper
a. Arterial → repair brachial (or rad/ulnar if no arch signal).
b. Venous → ligate vast majority.
c. Orthopaedic

48
 i) GSW to distal humerus, comm Fx, neurovasc deficit → shunt, then ex fix,
then definitive repair.
ii) Finger amputations
A) Reimplant if → thumb, multiple involved, child, 5th digit.
B) Reimplanting Zone II (PIP joint) injuries often doesn’t work.
iii) Jersey finger → RDS tendon rupture → needs repair.
2) Lower
a. Arterial
i) Amputation rate ↑ w/pop & tib injury vs femoral injury.
ii) Popliteal injury → Best conduit → contralateral GSV.
iii) ABI > 0.9 → duplex + obs (>99% NPV). ABI < 0.9 → CTA.
b. Venous If pt not HDS w/multiple serious injuries → ligate.
c. Orthopaedic
i) Femoral shaft fx → IM rod w/in 24h.
ii) Eldery pt on coumadin w/fem fx → emergent OR for fx s/p reversal.
3) Compartment Syndrome
a. Leg Compartments; >30mmHg → consider fasciotomy.
i) Anterior → ant tibial artery, deep peroneal nerve (1st interspace webbing).
MC missed compartment in fasciotomy.
A) Muscles → ant tibialis, ext hallucis longus, ext digitorum longus, &
communis.
ii) Lateral → superficial peroneal nerve (foot dorsum).
A) Muscles → peroneal muscles.
iii) Deep Posterior → post tibial artery, peroneal artery, & tibial nerve.
A) Muscles → flex hallucis longus, flex digitorum longus, & post tibialis.
iv) Superficial Posterior → sural nerve.
A) Muscles → gastrocnemius, soleus, & plantaris.
49

Uploaded by MEDBOOKSVN.ORG
 b. Occurs s/p restoration of blood flow (reperfusion inj).
i) Compartment pressure > capillary filling pressure edema → ischemia &
rhabdomyolysis.
ii) Essentially any injury resulting in interruption & then restoration of blood flow
can result in reperfusion injury (PMN mediated) & compartment syndrome.
c. Rhabdomyolysis & Myoglobinemia - myoglobin release; also release of K+, H+, &
PO4-.
i) Tx → crystalloid for volume. Keep UOP > 1mL/kg/hr (or >100-200mL/hr) for
24h or CK peaks & renal function improves.
A) No difference in ARF w/crystalloid vs HCO3- or mannitol.
ii) Best next step to minimize renal damage s/p 4-compartment fasciotomy →
aggressive IVFs.
d. High risk → tibial plateau Fx, elbow dislocations, supracondylar humeral fx
(→→Volkmann's contracture), calcaneus fx, & crush injuries.
e. Occurs in any muscle compartment → MC in ant.
f. Sxs →Fx or dislocation w/ ↓blood flow, repair (> 4-6hrs s/p inj), pain & swelling
after blood flow restoration.
i) 1st finding → pain w/passive motion.
ii) Swollen & tense extremity.
iii) Numbness in webspace between the great & 2nd toe (dee p peroneal nerve).
iv) Distal pulses can be present → last thing to go.
g. Dx → based on clinical suspicion (if suspected → fasciotomy).
i) Pressure > 20 - 25 mmHg abnormal
ii) Δp = diastolic - compartment pressure
h. Tx → 1st →fasciotomy, 2nd → IVF resus (>100mL/hr UOP ± alkalinize urine
w/bicarb.
i) For leg → medial incision for superficial posterior+ deep posterior
compartments & lateral incision for anterior + lateral compartments.
A) You are through the fascia when muscle bulges
B) Incise total length of compartment
C) Remove all dead tissue
ii) MC injured nerve with lower extremity fasciotomy (via ant/lat incision)→
superficial peroneal nerve (foot eversion).
4) Open Fractures / Gustilo Classification
I → <1cm II → 1-10cm III → >10cm or farm/dirty/extensive damage
i) IIIA → good coverage IIIB → needs flap IIIC → needs vascular repair
b. I & II→ Ancef until closed III → add GN coverage Farm → add PCN
c. Dirty open fxs require abx, washout, & temporary stabilization (ex fix preferred
per OrthoBullets) prior to formal fixation.
F. Head MCC of death if pt reaches ED alive. SBP >90 & O2sat >90% → each double
mortality. Spleen + head inj → splenectomy.

50
1) Calculate GCS
a. Motor Verbal Eyes
6 = follows commands 5 = oriented 4 = spontaneous
5 = localizes 4 = confused 3 = on command
4 = withdraws 3 = inappropriate 2 = opens w/pain
3 = flex/decorticate 2 = incomp 1 = absent
2 = extend/decerebrate 1 = absent
1 = absent
b. GCS score
i) Burr hole → place in frontal bone 5cm ant & 5cm sup to ear canal.
ii) ≤ 14 → head CT.
iii) 8-10 → Consider ETT (prior to head CT).
iv) ≤ 8 → Def ETT, consider bolt v. EVD.
v) ICP monitor if GCS ≤8 + abnml CT or 2 of the following (>40yo, hypotension, or
posturing).
vi) MI exam for prognosis → motor.
vii) Penetrating → worst survival of head injuries.
viii) Lowest score is 3; ETT pts are given a verbal score of 1T (even if writing or
mouthing words).
2) Indications for head CT
a. Suspected skull fx, CSF or blood leak from wound or ear.
b. Hemotympanum.
c. LOC, AMS, or focal neurologic deficit.
d. Can’t examine (eg. going to OR).
e. External inj + other trauma, intoxication, on “blood thinner” (eg. ASA, Plavix,
warafin, Xarelto, Eliquis, Pradaxa, etc).
3) Epidural Hematoma (EDH)
a. MC 2/2 arterial bleeding → middle meningeal artery.
b. Lenticular shape on head CT.
c. LOC → lucid → rapid AMS w/agitation, emesis, LOC.
d. OR if ↓ GCS or midline shift > 5 mm.
4) Subdural Hematoma (SDH)
a. MC 2/2 venous plexus avulsion (“bridging veins” b/w arachnoid & dura). Can be
chronic, esp in elderly.
b. Crescent shape on head CT. OR if ↓ GCS or mass effect > 10 mm.
5) Intracerebral Hematoma (ICH) Frontal or temporal MC.
6) Intraventricular Hemorrhage (IVH) hydrocephalus → ventriculostomy.
7) Cerebral Contusion Coup or contrecoup.
8) Diffuse Axonal Injury Seen better on MRI.
Very poor prognosis. Tx → supportive. May need crani if ↑ ICP.
9) Cerebral perfusion pressure (CPP = MAP - ICP).
a. Quickest way to ↓ ICP → hyperventilate
b. To ↑MAP → volume & pressors.

51

Uploaded by MEDBOOKSVN.ORG
 i) NGT side effect → ↑ ICP
c. To ↓ICP (nml is 10, > 20 usually needs Tx).
i) Sedate, paralyze, head of bed > 30°.
ii) Hyperventilation (but → cerebral vasoconstriction).
iii) Na+ 140-150 mEq, some even say 145-155.
iv) 3% (if other trauma) vs mannitol (if no other trauma).
v) Barbiturate coma, ventriculostomy, craniectomy.
vi) Fosphenytoin or Keppra.
vii) Consider starting DVT ppx if HCT stable for 48hrs.
10) Basal Skull Fxs Battle sign → mastoid ecchymosis (mid fossa).
Raccoon eyes → periorb ecchymosis (ant fossa).
11) Temporal Skull Fxs → MCC of CN VII/facial n inj.
12) Skull fx displaced below inner table → OR for craniotomy.
13) CSF Leak +nasoethmoid fx. Tx → conservative.
14) Dilated Pupil aka “blown” 2/2 CN III compression.
15) Cerebral Edema DAI → poor prognosis.
16) Maxillofacial trauma → ↑ C-spine fx risk (1 facial fx → 5-8% C-spine fx.
a. >1 fx → 7-11% C-spine fx).
17) Orbital Blowout MC orbital fx → maxillary/orbital floor.
a. Diplopia w/looking up v ↓ upward gaze → repair.
18) Lefort Fractures

19) Epistaxis
a. Anterior → Kiesselbach’s plexus. Tx → packing.
b. Posterior → 5 arteries (sphenopalantine, ant/post ethmoids, greater palatine,
sup labial), hard to manage; try balloon tamponade 1st.
c. May need angioemb of int maxillary or ethmoidal artery.
20) Mandibular Injury → MC sign → malocclusion.
a. Dx → fine-cut facial CT scans w/recon.
b. Tx → IMF (ORIF v upper & lower arch bars
x 1-2mns).
21) Tripod Fracture → zygoma. Tx → ORIF.
G. Spinal Cord
1) Fall w/fx'd heel + back pain→ CT T & L-spine.
2) Cervical Spine
a. C-1 burst/Jefferson fx – 2/2 axial loading.
i) Tx → rigid collar.

52
 b. C-2 Hangman’s fracture – caused by distraction & extension.
i) Tx → traction & halo.
c. C-2 odontoid/dens fracture
i) Type I → above base (stable)
ii) Type II → at base (unstable)
iii) Type III → into vertebral body (unstable)
d. Facet fxs/dislocations → can inj cord
w/rotation + hyperextension, & ligament inj.
e. Clearence Criteria (NEXUS) → “no NSAIDs”
(Neuro def, Spinal process ttp, Altered, Intoxicated, Distracting injuries).
i) Obtunded pt w/negative CT C-spine & likely prolonged ETT → clear C-collar
(per EAST PMG).
3) Thoracolumbar Spine
a. 3 columns
i) Anterior – anterior ½ of the vertebral body + ant longitudinal lig.
ii) Middle – posterior ½ of the vertebral body & post longitudinal lig.
iii) Posterior – facets, lamina, SPs, + interspinous ligament.
b. > 1 column inj → unstable.
i) Burst fx → > 1 column, unstable.
ii) Chance fx (flexion-distraction) asso w/intra-abd injury (33-50%).
A) MC → small bowel (2nd MCC pancreas).
iii) Wedge/compression fx → only anterior column, stable.
iv) Fall onto feet → at risk for calcaneus, thoracolumbar, & wrist/forearm fxs.
c. MRI if Sxs but no injury on CT (SCIWORA).
4) Emergent spine surgery if:
a. Cord compression, evolving neurologic deficits, or open fx.
5) ↑ inj level → ↑ M&M.
H. Pediatric Trauma
1) IV site pref order <5yo → 1) AC fossa, 2) saphenous, 3) prox tib IO, 4) dist femur IO.
2) MCC of childhood death.
3) Trauma bolus → LR 20 mL/kg x 2, then give blood 10 mL/kg.
4) ↑risk of hypothermia (high BSA compared with weight) & head injury.
5) Tachycardia → best indicator of shock in kids.
a. Others → tachypnea, AMS (eg lethargy).
b. BP not a good indicator in kids → last thing to ↓.
6) When closing tubular structures in children, especially vessels, run the back row &
interrupt the front→allows growth/prevents stenosis.

53

Uploaded by MEDBOOKSVN.ORG
I. Trauma in Pregnancy
1) Continuous fetal monitoring if → ≥24 WGA (viable).
a. Late decels→2/2 ↓fetal O2 (↑lactate → resus. Nml → c-section).
b. Can stop after 4hrs if ALL are met:
i) Uterine contractions < 1 per 10 min.
ii) NO vaginal bleeding
iii) NO abd/uterine pain
iv) Category 1 fetal heart rate tracing
v) Mom is AFVSS & WNL.
c. Continue for 24hrs if ANY:
i) Abd bruising/other obvious injury
ii) Regular contractions (>1 in 10 minutes)
iii) Vaginal bleeding
iv) Abnormal fetal heart rate tracing
v) Abdominal/uterine pain
vi) Coagulopathy (eg, low platelets or fibrinogen <200 mg/dL).
2) Pregnant Rh- female w/abd trauma → determine Rh status of baby.
3) Kleihauer-Betke Testing
a. Used to detect fetal-to-maternal hemorrhage in excess of that which can be
treated with a standard dose of 300 mcg of Rho(D) immune globulin
(RhoGAM). Standard RhoGAM dose (300 mcg) covers up to 15 mL of fetal red
cells (30 mL fetal whole blood). In major trauma, add’l fetal red cells may contact
maternal blood, & the Kleihauer-Betke test helps to determine how much add’l
RhoGAM to administer.
J. Facial Lacerations
1) MI to line up on lip → vermillion border.
K. Geriatric Trauma
1) Frailty
a. Sarcopenia, as determined by psoas
muscle density, is predictive of poor
outcomes.

54
10. Critical Care
A. Equations
CO = HR x SV CaO2 = 1.34 x Hbg x SaO2 + (PO2 x 0.003)
O2 delivery = 10 x CO x CaO2 VO2 = CO x (CaO2 - CvO2)
Compliance = VT / (PIP-PEEP)
B. Ventilation
1) Volume Control
a. Continuous Mandatory Vent (CMV)→ MV decided entirely by set RR & TV. NO
pt initiated breaths/additional work. Only RR & TV.
b. Assist Control → RR & TV set. Extra breaths → full TV → breath stacking (auto
PEEP). Better if pt needs full vent support. Lowest WOB.
c. Pressure regulated volume control (PRVC) → like AC, but Ti & flow modified to
↓ PLAT-P.
i) Sim to AC. The main diff is vent able to autoreg insp time (Ti) & flow so TV →
smaller ↑in plateau pressure (PLAT-P).
d. Intermittent Mandatory Vent (IMV) → RR & TV set. Can take UNsupported,
spont extra breaths at whatever TV they can generate.
e. Synchronized Intermittent Mandatory Vent (SIMV) → RR & TV set, but vent
tries to sync w/pt effort. If min/no pt effort → basically just = to AC/CMV. Vent
will sync & support breaths until set MV reached.
i) CO, MAP, PCWP, & VO2 → ↑when SIMV only supported < 50%. Modify
support if NOT HDS 2/2 pos pressure vent.
ii) SIMV (vs AC) → ↑pt-vent synch, ↑ability to control support, preserved resp
muscle fxn, ↓mean airway pressures, & possibly ↓ auto-PEEP.
2) Pressure Control (or Cycled or Limited) → Can be delivered using same modes VC
uses but set Pi instead of TV.
a. Set Pi, insp to exp ratio (I:E), RR, PEEP, & FiO2. Insp ends when set Pi reached.
b. Variable TV based on → Pi, compliance, resistance (pt & circuit).
c. Peak airway pressure → constant. Peak = Pi + applied PEEP.
d. General Advantages → ↑O2 dist & oxygenation, ↓ peaks for same volume & ↓
barotrauma.
e. General Disadvantages → TV depends on lung compliance.
f. Pressure Control Vent (PCV)/PC-CMV → set RR & Pi. NO pt initiated
breaths/additional work.
g. PC/AC → set RR & TV. Extra breaths → full Pi.
h. PC-IMV → set RR & Pi. Can take UNsupported, spont extra breaths at whatever
Pi they can generate.
i. PC-SIMV → set RR & Pi, but vent tries to sync w/pt effort.
j. Tube compensation → Automatically gives pos pressure to overcome work of
moving air through tube dead space. Often used in SBTs (ML to tolerate SBT
w/tube comp vs CPAP).
k. Continuous Positive Airway Pressure (CPAP) → cont pos pressure, like PEEP. Pt
must initiate all breaths.
i) MC used for sleep-related breathing problems, obesity hypovent synd, &
cardiogenic pulm edema.

55

Uploaded by MEDBOOKSVN.ORG
 l. Bilevel Positive Airway Pressure (BPAP)
i) A type of noninvasive positive pressure ventilation (NPPV). Set inspiratory
positive airway pressure (IPAP) & expiratory positive airway pressure (EPAP).
TV ≈ IPAP - EPAP. A backup RR can be set on most.
ii) BiPAP ≠ BPAP. BiPAP → a specific brand of portable vent that delivers BPAP,
but there are others that can as well.
m. Airway Pressure Release Ventilation (APRV)→high cont pos pressure (P
high→max’s alveolar recruitment) is delivered for a long time (T high) then ↓to
P low for a short time (T low). P high for T high = insp time. P low for T low = exp
time.
i) From P high to P low (diff = driving pressure) → lungs deflate → eliminates
CO2. From P low to P high → lungs inflate.
ii) P high - P low = driving pressure. TV ≈ driving pressure & compliance.
iii) Adjust Flow-Time waveform to optimize settings. Ideal exp time adjusted to
stop exp flow during release at ~ 75% of peak exp flow rate (PEFR).
iv) Spont breathing poss at P high & low (most spont at P high b/c more time
spent). Distinguishes APRV from other inverse ratio ventilation (IRV) modes.
v) If ↑ autoPEEP, ↓RR or I:E (1:3-1:5) for more time to exhale.
A) May → ↑CO2, ↓O & pH → ↑PVR & hemodynamic instability. If this
occurs ↑peak pressure & inspiratory flow may help, but will →↑
barotrauma risk.
vi) APRV NOT shown to ↓mortality, may ↑other important clinical outcomes.
A) ↑oxygenation & compliance, ↓ PLAT-P, ↓ days on vent, & ↓ICU stay.
May ↓peak pressure, ↑alveolar recruitment, & ↑dependent lung vent.
Results are mixed in lit.
B) Hemodynamically well tolerated → prob 2/2 ↓airway pressures +
allowing spont breaths.
C) Theorhetically ↑’s recruitment → ↑oxygenation.
vii) DON’T use if severe COPD or high vent needs 2/2 → hyperinflation,
↑alveolar pressure, & barotrauma.
3) Oxygen dissociation curve
a. Left (↑O2 affinity, ↓delivery)
i) ↓temp, CO2, & 2-3DPG; alkalosis; CO
b. Right (↓O2 affinity, ↑delivery) “CADeT face RIGHT”
i) ↑CO2, Acidosis, 2-3DPG, Temp
4) Veturi mask: high-flow, specified FiO2, air-entrainment. Works by jet-mixing. ↑FiO2
→ ↓total L/min flow.
5) Vent settings for bronch → keep same settings, but pre-ox w/100% FiO2
6) White out of left lung, c/f aspiration → likely mucous plug.
a. Tx → bronch + suction/lavage.
7) Best vent wean strategy → SBTs & sedation holidays. Successful SBT more
predictive of successful extubation than RSBI.
8) PaCO2 >> EtCO2 → alveolar dead space (ventilated, but not perfused).
a. EtCO2 should normally nearly = PaCO2 (minimal dead space).
9) ARDS w/in 1wk of insult, not 2/2 to CHF, CXR w/bilateral infiltrates.
a. Mild PaO2 ≤ 300-200 Moderate ≤ 200-100 Severe ≤ 100
b. Acute/Exudative (<6d) alveolar/interstitial edema & inflammation.
c. Subacute/Proliferative (7-14d) ↓edema, ↑type II pneumocytes & fibroblasts.
56
 d. Chronic/Fibrotic (>14d) ↑macrophages & mononuclear cells → repair.
e. Best way to ↓ARDS mortality → low TV 6mL/kg > paralysis & proning.
C. Shock Definition → inadequate tissue perf (most basic). CVP doesn’t always = IVF
response.
1) Neurogenic → 2/2
TBI/SCI.
Sympathetic/vasomotor
tone loss → peripheral
blood pooling (aka
↑venous capacitance).
a. SCI → brady, hypoTN
(vagally mediated). Tx
→ atropine.
b. Sxs → ↓HR/BP/SVR,
& warm skin.
c. Tx→ 1st IVF resus.
Phenylephrine (↑’s
SVR) if cont ↓BP.
2) Cardiogenic → 2/2 MI, tamponade, or CHF exacerbation.
a. Sxs → dyspnea, pulmonary edema, ↓CO & UOP.
b. Ineffective contraction → pulm congestion → over distends → worse
contractility.
c. Tx → dobutamine (inotropic). Consider IABP to stabilize. If pulm edema →
diuretics.
d. IABP → use MAP (not SBP) to assess perfusion. ↑cerebral & coronary flow,
↑diastolic BP:time index, ↓ myocardial O2 demand & LVEDV.
i) Absolute CI → Aortic regurg/AI, aneurysm, dissection, sepsis, & uncontrolled
coagulopathy.
e. Temp pacing for → High grade AV block, acute RV MI w/brady & hypoTN sxs,
endocarditis w/brady sxs, complete block w/ventricular early repol.
f. Sudden hemoptysis s/p Swan placement → leave ballon inflated & go to angio.
g. Cardiac tamponade Sxs→Beck's triad (hypoTN, JVD, & ↓heart sounds). HypoTN
2/2 ↓right vent filling 2/2 pericardial fluid.
i) Dx→1st ECHO sign → ↓ right atrial diastolic filling.
ii) Tx → IVF resus to temporize until pericardial window/pericardiocentesis
(pericardial blood usually doesn’t clot).
h. PE Tx → anti-coagulate all (unless CI).
i) tPA ± Trendelenburg procedure (median sternotomy, bicaval + aortic
cannulation for bypass, open PA, massage lungs towards hilum, extract clot).
ii) If right ventricular failure → 1st IVF. 2nd Norepi (less tachycardia, won’t
exacerbate hypoTN).

57

Uploaded by MEDBOOKSVN.ORG
 3) Hypovolemic
a. Initial sign →↑ diastolic pressure → narrow pulse pressure.
b. Tx → IVF resus (Non-trauma → LR; trauma → blood).
c. Hemorrhage → GI vasocon 2/2 angiotensin II & vasopressin → large arteriole
vasoconstriction, small arteriole vasodilation → preserved mucosal flow, but
↓muscularis propria flow.
i) Pentoxifylline & heparin/LMWH→↑microvasc patency & ↑ survival.
4) Septic Early triad → Hypervent (→ resp alkalosis), AMS, & hypoTN.
Hyperglycemia → often just before clinical sepsis.
a. Early → ↓ insulin, ↑ glucose (impaired utilization).
b. Late →↑ insulin, ↑ glucose (insulin resistance).
c. HypoTN in sepsis related to inducible NOS.
d. Optimal glucose in sepsis → 140-180 (NICE trial). May need insulin gtt.
e. Tx → 1st abx & IVF resus. 2nd norepi, 3rd vasopressin, 4th empiric steroids for
relative adrenal insuff for cont hypoTN.
i) Norepi → 1st pressor in sepsis for hypoTN refractory to IVF resus.
f. Predictors of mortality (2017 Sepsis-3)
i) SOFA (better in ICU) → PaO2/FiO2, PLTs, GCS, dBili, MAP/ pressors, &
Cr/UOP.
ii) Quick SOFA (better outside ICU).
GCS < 15 = 1 RR ≥ 22 = 1 SBP ≤ 100 = 1
A) 0-1 = Not high-risk 2-3 = high-risk (M&M ↑ 3-14x).
5) Adrenal Insufficiency (Acute)
a. MCC→steroid w/d (also→adrenalectomy or B/L adrenal hemorrhage [MC 2/2
sepsis, eg Waterhouse-Friderichsen synd]).
b. Sxs → n/v, abd pain, fever, hypoTN (esp. if refractory to IVF+pressors), lethargy.
c. Dx → ↑ACTH & ↓cortisol (Leads to ↓glucose, ↓Na+, & ↑K+)
i) Best test → corticotropin stim test (give ACTH 250 μg & measure cortisol @
30 & 60 mins after).
ii) Baseline cortisol < 15 or changes < 9 ug/dl s/p stim = adrenal insufficiency.
iii) Tx → Dexamethasone 2 mg IV q6h 1st (Does NOT interfere w/test).
iv) + stim test → give hydrocortisone 50 mg IV q6h (DOES interfere) +
fludrocortisone 50 μg PO qd → ↓d/c & 180d mortality, ↑ vent & pressor-free
days vs hydrocortisone alone (APROCCHSS trial).
6) “Spine Shock” → 2/2 SCI w/absent spinal cord reflexes including NO
bulbocavernosus reflex.
a. NOT actually shock (NOT hypoTN w/impaired end-organ perfusion).
b. Once bulbocavernosus reflex returns → deficits likely permanent.
D. Neurologic Concerns
1) Brain Death → complete & irreversible loss of cerebral & brainstem fxn. Usually
considered = to cardiopulm death.
a. Dx → usually made by neuro exam alone if the following prerequisites met:
warm, nml vitals & lytes, underlying cause understood & able to cause neuronal
death, & confounding intox/poisoning r/o.

58
 i) Neuro exam → coma, NO brain-generated response to external stimuli, & NO
brainstem reflexes.
ii) Apnea test (done once all other criteria met & pt is HDS enough to perform).
iii) Ancillary tests → used when can’t use clinical criteria or as a supplement in
young children.
A) Tests of brain blood flow, especially those of brain perfusion, are the most
reliable "stand-alone" laboratory examinations when clinical criteria cannot
be applied.
B) Definitive dx (best single test, not in combo w/PE) → brain radionucleotide
scan.
2) Alcohol withdrawal Sxs→ agitation, tachy, & RASS = 2 → CIWA protocol-based
benzo tx.
3) Delirium → Always reorient pts 1st, esp elderly. Haldol/restraints should be used
cautiously (Haldol maybe neurotoxic).
E. Cardiac
1) Medications
a. AntiHTN / Vasodilators
i) Nipride → NO-mediated arterial vasodil.
A) Cyanide (CN-) tox when >3mcg/kg/min for 7hrs. Check for metabolic
acidosis & thiocyanate lvls.
1. CN- binds mitochondrial cytochrome C → stops electron transport chain
→ can’t use O2 → left-to-right shunt (↑SvO2).
B) Tx → amyl nitrite, then Na+-nitrite. Also hydroxocobalamin (B12).
ii) Nitroglycerin → NO mediated → mostly venodil → ↓pre-load → ↓ventricle
wall tension. Also a coronary artery vasodilator.
iii) ACE inhibitors →↓angiotensin II → mostly vasodil & ↓aldosterone.
Sxs → cough & angioedema.
A) ↓’s post-Ml mortality & prevents CHF.
B) Absolute CIs → previous angioedema & renal artery stenosis.
C) Relative CIs → ↓renal fxn, hypovolemia, & aortic stenosis.
iv) Nitric Oxide → binds soluble guanylate cyclase receptor → ↑cGMP →
vasodil. Arginine NOS Nitric Oxide
A) Aka endothelium-derived relaxing factor (EDRF).
B) Inhaled → selective pulm a vasodil.
v) Sildenafil (Viagra) → NO-mediated selective pulm a vasodil.
b. Pressors → ↑SVR & MAP (NE is also inotropic).
i) Angiotensin II → ↑ aldosterone & vasopressin synthesis. $1200/bag (~1d).
↓AKI & pressor req vs NE, no mort diff (Athos).
ii) Phenylephrine → α1 (vasocon).
iii) Norepinephrine (NE, Levophed) (1-40 µg/min)→Mostly α1 + α2 (vasocon,
most potent in GI). Some β1 (contractility).
iv) Vasopressin (0.04 U/min) → V1 → arterial vasocon.

59

Uploaded by MEDBOOKSVN.ORG
 c. Inotropes → ↑ cardiac output. Used in cardiogenic shock.
i) Dopamine (1-20 µg/kg/min)
A) Low (1-5) Renal D (↑renal & GI flow).
B) Medium (6-10) β1 + β2 (↑contract & ↑HR).
1. Like low dose epi or dobutamine → ↑ SV & CO.
C) High (>10) α1 (periph vasocon, ↑MAP).
1. Like phenylephrine.
ii) Dobutamine (1-20 µg/kg/min) → β1 (contractility). Some β2 (vasodil) at
↑doses (>15 µg/kg/min).
iii) Milrinone → cAMP PDE inh →↑ cAMP → Ca++ influx →↑ myocardial
contract. Also pulm vasodil.
A) NO down-reg like other inotropes → better for use long-term (eg awaiting
heart TXP).
iv) lsoproterenol → β1 (↑HR & contractility) + β2 (bronchon/vasodil).
A) SEs → ↑heart metabolic demand & arrhythmias. Rarely used → may ↓BP
(β2).
v) Epinephrine (Epi, 1-20 µg/min)
A) Low Dose (1-5) β1 + β2
1. Can ↓BP 2/2 β2> β1 activity.)
B) High Dose (> 5) α1 + α2
d. Rate control
i) Afib → Common early s/p lobectomy.
A) Afib & not HDS → LMWH + emergent cardioversion.
B) New onset, HDS → 1st β-blocker (metoprolol 5mg q5m x3; CCB if +COPD).
Can try amiodarone + LMWH. Cardiovert if refractory.
e. Pacing
i) Can’t advance cath while placing wires → use fluoro.
ii) CI to transvenous pacing → mechanical valve.
iii) Transvenous pacing → pt unresponsive, EKG w/only tracer spikes + brady
ventricular escape rhythm → 1st reposition wires, 2nd trans-cutaneous pacing,
& 3rd replacement.
iv) Failure to Sense → indiscriminant pacing artifact.
v) Failure to Capture → pacing artifact w/o QRS.
vi) Electromagnetic Interference Issues (eg. w/electrocautery).
A) Cautery → EMI → brady/asystole.
B) Ways to ↓EMI → reprogram to asynchronous mode, apply magnet
(forces asynchronous mode), interrogate pre & post-op, use bipolar,
ground pad away from pacer, use short bursts.
F. GI
1) Stress gastritis → ppx w/H2-blocker for coagulopathic or vent pt.
a. PPI if taking at home.
2) Enteral nutrition w/in 36h for open abd → ↓ PNA.
a. Absolute CI → hemodynamically unstable.
60
 3) PEG slips out early, dx to see if back in → gastrograffin KUB.
G. Renal
1) Rhabdomyolysis Initial Tx → IVF resus to UOP >100mLs/hr.
2) Contrast Induced Nephropathy Best
preventive → prehydration w/crystalloid. RIFLE /
Cr/GFR UOP
AKIN
3) MI factor to calc eGFR→ #1-Cr, #2-sex, Risk / ↑ Cr 1.5x < 0.5mL/kg/hr x
#3-race, #4-age (depends on formula). AKIN I ↓ GFR > 25% 6 hours
4) FeNa =
Injury / ↑ Cr 2x < 0.5mL/kg/hr x
[(U/P Na)/(U/P Cr)] x 100 AKIN II ↓ GFR > 50% 12 hours
5) Acute Kidney Injury
< 0.3mL/kg/hr x
a. If prerenal → isotonic IVF. Failure / Cr 4mg/dL
24 hours or
AKIN III ↓ GFR > 75%
b. Keep HCO3- > 12, pH > 7.15. anuria x 12hours
c. Keep Phos < 5 & K+ nml. Loss AKI > 4 weeks
ESRD AKI > 3 months
d. Don’t ↓protein. 1-2 g/kg/d is needed
in ICU pts. Avoid phos & K+.
6) Typical indications to begin FENa FEUrea uNa
+
OSM BUN/Cr
renal replacement therapy: K+ Pre < 1% < 35% < 10 > 500 > 20
≥ 6, pH ≤ 7.2, HCO3- < 12, 50-
Renal > 2% > 20 < 350 < 15
PaO2/FiO2 ≤ 200 w/volume 65%
overload, AKI >72hs. Post > 4% - > 40 < 350 > 15
7) Early (<8hrs) initiation of CRRT for AKI → ↓ 90d mortality (39% vs 54%), duration of
RRT, & LOS. More recent data has called this into question.
a. CRRT may filter inflammatory mediators better than IHD.
H. Hemodynamic monitoring
1) Least Cxs during CVC placement → IJ w/US.
2) Can’t get radial a-line BUE in pt on pressors → femoral a-line.
I. ACLS
1) Asystole or PEA → Epi 1mg q3min (vasopressin 40u can replace 2nd Epi).
2) Vtach HDS → amiodarone
Not HDS → shock (cont CPR immediately, rhythm check s/p 2min CPR).
a. Amiodarone 150-300mg load → gtt 1mg/min x6hr→0.5mg/min x18hr.
3) Brady → atropine 0.5mg q3min → epi/dopamine/transcutaneous pacing.
4) Type II 2nd or 3rd Degree heart block → pacemaker.
J. Post-Op Oliguria Sxs → acidosis, hypoxia, & abd TTP.
1) dDx → ARDS, AKI, CHF, MI, ischemic colitis, other acute “itis” (chole, panc, etc).
K. Post-Op MI
1) Don’t mistake an MI as GERD (esp new onset). Get EKG & trops. Revasc PRN.

61

Uploaded by MEDBOOKSVN.ORG
11. Burns
A. 1st Degree/Superficial → Only epidermis
(eg. sunburn).
B. 2nd Degree/Partial TBSA only ≥ 2nd degree.
1) Superficial (papillary) dermis → Painful,
blebs & blisters, hair follicles intact,
blanches. NO skin graft (heals in 2wks).
2) Deep (reticular) dermis → ↓sensation; loss
of hair follicles, slow to blanch (NEEDs skin graft).
C. 3rd Degree/Deep → down to subcutaneous fat (sub-
dermal). Leathery (like burnt parchment).
D. 4th Degree → Down to bone, adipose, tendon, or
muscle tissue.
1) Electrical Injury (~4%) → Needs cardiac monitoring,
can cause rhabdo & compartment synd.
a. Other Cxs → polyneuritis, quadriplegia,
transverse myelitis, cataracts, hollow viscous
perf, liver & panc necrosis.
b. High Voltage → ≥ 1000 V→ deep thermal injury.
i) Lightning → cardiac arrest 2/2 Vfib.
ii) Main Powerline → 110,000 V.
iii) Street Powerline → ≤ 33,000 V.
c. Low Voltage → < 1000 V → arrhythmia.
i) House → 120-240 V.
d. All electrical burns (even w/nml EKG) → admit,
24h cardiac monitoring, labs, & UOP >100mL/hr.
E. Burn Types
1) Thermal → Scald (MC), Flash, Flame, Blast,
Steam/Smoke, & Contact.
2) Chemical
3) Electrical
4) Radiation
5) Friction
F. Chemical (4%)
1) Acid & Alkali → copious H2O irrigation (30-60min).
a. Alkali → deeper burns 2/2 liquefaction necrosis.
i) Stricture (early) &/or SCCa (late). EGD to (but NOT past) injury.
b. Acid → coagulation necrosis. Tx → H2O irrigation x 30min.
2) Hydrofluoric Acid
a. Tx → H2O irrigate x 30 min → neutralize w/topical Ca++ (1amp Ca++-gluconate +
100gm sterile lube) → intra-arterial Ca++ at/near site PRN.
3) Powder Tx → wipe away then irrigate w/H2O x 30min.

62
 4) Mineral Spirits Tx → irrigate w/H2O x 30min.
5) Tar Tx → cool (tar stored @ 250°F → continues to burn pt), then wipe
away w/lipophilic solvent (glycerol/adhesive remover).
6) Phenol → NOT water soluble. Tx → use lipophilic solvent.
G. Desquamating conditions → epidermal detachment from dermis (desquamation).
1) EM → least severe form (self-limited; target lesions).
a. Pt gets a few oral ulcers & skin lesions s/p starting new sulfa drug → d/c sulfa +
local wound care/topicals.
2) SJS → serious (< 10% BSA).
3) SJS/TENs → more serious (> 10 to < 30% BSA).
4) TENs → most severe (> 30% BSA).
5) Staph Scalded Skin Syndrome → 2/2 Staph aureus (asso w/toxic shock synd).
a. Sxs → fever, N/V/D, diffuse erythema, hypoTN, & desquamation.
6) Mouth, lungs, vagina, anus, & GI also involved.
7) 2/2 viruses & drugs (Bactrim [MC now], PCN [MC historically], & Dilantin).
8) Tx → IVF resus, topical abx, Telfa gauze wraps (non-stick → prevents wound
desiccation). IV abx if 2/2 Staph. Poss STSGs.
a. NO steroids & NO silvadene (if 2/2 sulfa).
H. Cold injury
1) Frostbite
a. Need rapid re-warming (40-42°C in circulating water; want sensation to return).
b. Tetanus prophylaxis, topical antibiotic, pain control.
c. Avoid early surgery (even if dry gangrene) → may take 3-4mns to diff b/w viable
& necrotic tissue.
d. Allow time for the necrotic tissue to autoamputate.
e. Avoid pressure on the area & use non-abrasive cleaning.
f. Best way to rewarm frozen feet → 40°C bath.
g. Best tx to prevent tissue loss in frostbite s/p rewarming → tPA.
I. Inhalation injury (9%)
1) MC 2/2 carbonaceous materials & smoke (NOT heat-doesn’t pass glottis).
2) Important prognostic factor in burn → carries up to 50% mortality.
3) Sxs → stridor, facial burn, wheezing, carbonaceous sputum.
4) RFs → EtOH, trauma, closed space, rapid combustion, extremes of age (age< 10 or >
50), delayed extrication.
5) Tracheobronchitis → in minutes to hours s/p burn.
6) ETT indications → upper airway stridor or obs, worsening hypoxemia.
7) Massive IVF resus → worsen Sxs (pulm edema).
8) Dx → bronch (soot, erythema, edema, mucosal sloughing [for up to 5d]).
9) Keep intubated until cuff leak w/balloon down (ie.↓swelling) & nml ABG.
10) Cxs → PNA, airway obs, atelectasis, CO poisoning, & ARDS.
11) PNA → MC infection w/ >30% TBSA burns (up to 70-80% inc).
a. MCC of death s/p sig burn.
b. PNA RFs → #1 inhalation injury, #2 massive IVF resus w/pulm edema.
63

Uploaded by MEDBOOKSVN.ORG
J. Toxin inhalation
1) Carboxyhemoglobin COHgb pts are red CO has 200x Hgb affinity vs O.
a. Most pulse ox will read COHgb as OxyHgb → falsely ↑sats. Need ABG.
i) Pulse ox unreliable in burn until ABG shows COHgb <10%.
ii) New, multispectral pulse ox can differentiate, but not widely used.
b. Confusion/AMS s/p fire → check carboxyHgb. 30%TBSA burns w/18%
carboxyHgb → 100% FiO2 mask.
i) Hyperbaric O2 controversial, may use if CO > 25% or >20% & preg/LOC/pH
<7.1/end-organ ischemia. ABA says NO! (ABLS 2018)
c. Up to ⅔rds also have cyanide poisoning. Initial Tx same → 100% FiO2.
i) If AMS/acidosis → hydroxocobalamin (B12a / Cyanokit).
2) Methemoglobinemia MetHgb pts are blue/cyanotic.
a. Congenital or acquired (dapsone, local anesthetics [benzocaine worst offender]).
b. Asx/MetHgb <20% → obs G6PD def → vit C
c. >20% → methylene blue (if not G6PD def)
K. Burn-specific FEN
1) Enteral nutrition ASAP; H2 blockers = to sucralfate, ↑ infxn w/H2 blockers.
2) Burn wounds lose 4L/m2 per day. Nml insensible loss is ~700mL/d.
3) Historical IVF Resus (MC IVF → LR).
a. Parkland → 4mL x TBSA x wt (in kg)
i) ½ 1st 8hrs, 2nd ½ next 16hrs. Tends to over resus (see Ivy index).
b. Modified Brooke → 2mL x TBSA x wt (in kg)
c. Rule of 10s → 10mL x TBSA. Then titrate q1h to UOP > 1mL/kg/hr (best measure
of resus in burns).
d. Ivy index = 250mL/kg in 1st 24hrs → ↑abd comp syndrome.
4) 2018 ABLS Guidelines LR (& Plasmalyte) preferred over NS.
a. Initial/PreHospital Rate(mL/hr): ≤ 5yr→125, 6-13yr → 250, 14+→ 500.
b. Acutal Resus Rate for 1st 24hrs (½ in 1st 8hrs, 2nd ½ next 16hrs).
i) Flame/Scald
A) <30kg → 3mL x kg x TBSA of LR + mIVF (D5LR, use 4-2-1 rule).
1. Less glycogen reserve → ↑ hypoglycemia. Don’t titrate mIVF.
B) <14yr → 3mL x kg x TBSA of LR.
C) >14yr → 2mL x kg x TBSA of LR.
ii) Electrical All get 4mL x kg x TBSA of LR. (<30kg → add D5LR mIVF).
iii) Titration ↑ by 30% (or 100mL, use bigger #) to UOP using IBW.
A) < 30kg → 1mL/kg/hr. >30kg → 0.5mL/kg/hr.
B) Electrical + myoglobinuria → 75-100mL/hr until clear.
c. HypoTN w/in 1-2hrs s/p burn or despite proper LR resus → likely 2/2
trauma/bleeding, MI, COHgb, or cyanide poisoning.
5) Nutritional requirements: need to add 50-100x RDA of B vitamins
a. 25kcal/kg/d + (30kcal/d x TBSA) OR 35-40kcal/kg/d
b. Burn pts need supra-physiologic protein & kcal (protein = 1.5-2g/kg → adults,
2-4g/kg/d → kids).

64
 c. Large burns ↑ catecholamine by 20-50% → ↓protein. Lasts months.
i) Tx → propranolol 10-40mg TID po + oxandrolone 20mg QD po.
d. MC energy source in burn wound → glucose (WBCs → obligate glucose users).
e. Start nutrition w/in 24hrs.
f. MI nutrient for burn wound healing → protein.
g. MCC of seizure in burn pts → hypoNa+ 2/2 large volume resus.
h. MC electrolyte d/o in burn pt → hyperNa+ 2/2 unreplaced insensible losses or
over resus w/NS (↑’s mortality).
L. Blast Injuries
1) 1° → direct pressure wave (ruptures TMs, bowel, lung, etc).
2) 2° → projectile injury.
3) 3° → injury from pt being thrown by blast (similar to ejection s/p MVC).
4) 4° → other injuries (eg. flames, chemical, radiation, smoke, etc).
M. Wound management
1) Excision “Early excision & grafting”
a. General
i) Best time to excise burns → after acute resus phase.
ii) 3% 2nd degree TBSA to dorsum of foot/3 toes in DM pt. Very edematous, no
palp pulses but monophasic venous signal on doppler → escharotomy then
likely excision.
b. Escharotomy → try 1st since 3rd spacing largely in subQ (unless 4th degree or e/o
comp synd).
c. Fasciotomy → Arm burn, swelling, tense, paresthesia, ↓ pulse → try
escharotomy 1st & proceed to fasciotomy PRN.
2) Skin grafts → survive by 1st 24-48hrs → plasmatic imbibition (osm diff).
After 48hrs → inosculation & neovasc.
a. FTSG → Epidermis & dermis ↓2°contracture.
i) Face & palm need FTSGs. (Face best match → post auricular > thin scalp >
upper back).
b. STSG → Epidermis & variable quantities of dermis.
i) ML to survive. STSG Cx over joint → 2°contracture.
c. MCC of failure → seroma/hematoma.
d. Using saline w/epi tumescence can help ↓ bleeding.
3) Contracture 1°→ immediately after harvest in OR. 2° → long term.
a. Finger contracture s/p burn → z-plasty.
N. Infections
1) Dx of burn infxn → wound bx (NOT Cx/swab → colonization is nml).
a. MCC → Staph aureus (2nd MC → pseudomonas).
2) Topical Antibiotics
a. Silverlon → Best topical dressing that DOESN’T impair STSG take or wound
healing.

65

Uploaded by MEDBOOKSVN.ORG
b. Silvadine → MC topical to cause neutropenia, thrombocytopenia, & CI w/sulfa
allergy (2/2 reactive sulfa group). Poor eschar pen.
i) Silvadine neutropenia Tx → admit, switch topicals, + abx.
c. Silver Nitrate → MC topical to cause hypoNa+/Cl-/Ca++/K+. Poor eschar
penetration. Also → MetHgb.
d. Sulfamylon (Na+ mafenide) → MC topical to cause met acidosis (2/2 carbonic
anhydrase inh) & ↑pain; poss CI w/sulfa allergy (rxn is rare b/c its sulfa group is
not very reactive). Good eschar penetration.
e. Mupirocin → Best topical for MRSA.

66
12. Plastics, Skin, & Soft Tissues
A. Anatomy Strength layer of skin → dermis
Keratin → hair/nails Desmin→ muscle Vimentin → fibroblasts
B. Dermoid Cyst usually intra-abd or sacral, c/f CA, Tx → resect if superficial.
C. Epidermal Inclusion Cysts (EIC) MC cyst, mature epidermal lining, filled w/keratin.
Tx → resect (must include all cyst wall or → recurs).
D. Elastofibroma Dorsi MC in F >50yo. MC on right, infraclavicular.
1) Dx → MRI (fibrous fatty streaks). No CA risk. Tx → excise.
E. Ganglion Cyst at joints, MC wrist, filled w/collagenous synovial fluid.
1) Tx→ asp cures ~50% (if needs excision → remove check valve as well).
F. Glomus Tumor NOT from glomus cells, benign, painful, contains vessels & nerves,
MC @ fingertip/ear. Tx → resect.
G. Lipoma MC mesenchymal tumor, usually on back, neck, b/w shoulders.
1) Dercum Disease/Adiposa Dolorosa multiple, painful lipomas. MC F >50y.
2) Liposarcoma 2nd MC sarcoma. MC RP sarcoma.
H. Neuroma
I. Keratoses
1) Actinic pre-cancerous, tan/pink/red, 2/2 sun exposure, Tx → diclofenac (ex Bx if c/f
CA).
2) Seborrheic NOT pre-cancerous, keratinocytes, trunk, elderly.
3) Arsenical asso w/SCCa.
J. Keratoacanthoma from pilosebaceous gland, grows quickly, rolled edge, crater
w/keratin, 5% CA risk, may involute.
1) Tx → always Bx, excision usually indicated.
K. Paraganlioma (chemodectoma) rarely CA, from glomus cells (neural crest
chemoreceptors, regulate blood flow), secretes norepi, MC in abd overall (MC neck →
carotid body, MC chest → Ao arch).
1) Tx → resect.
L. Trichilemmal Cyst → Scalp, no epidermal lining, filled w/keratin.
1) Tx → resect.
M. Xanthoma benign, yellow, cholesterol, histiocytes, asso w/familial HLD.
1) Tx → resect.
N. Basal Cell Cancer
1) MC skin CA (& overall CA), 80% of non-melanoma skin CA (NMSC), pearly papule,
rolled edges, telangiectasias. MC on upper lip.
2) High risk → any H&N, trunk/extremities >2cm, recurrent, prev XRT site, ill-defined,
morpheaform, aggressive, immunocompromised pt.
3) Tx → WLE 4mm margins (wider margin or MOHS if high risk). Get frozen section of
margin if not using MOHS.

67

Uploaded by MEDBOOKSVN.ORG
O. Squamous Cell Cancer
1) ~20% of NMSC. Well demarcated, scaly patch/plaque to fleshy, soft, granulomatous
plaque/papule/nodule. MC on lower lip.
2) High risk → any H&N, hands/feet, anogenital, trunk/extremities >2cm, >6mm
depth, recurrent, prev XRT site, ill-defined, neurologic sxs, aggressive,
immunocompromised pt. (Very high risk = >4cm).
3) Tx
a. Low/Intermediate Risk
Margins: <1cm → 4mm, 1-1.9cm → 6mm, ≥2cm → 9mm.
b. High/very high risk → MOHS (preferred per NCCN) or “wider margin” 6mm
margins.
4) Ant to tragus → 20% parotid mets (Tx → superficial parotidectomy).
5) SCCa of penis → penectomy w/2cm margin.
6) Bowen’s Disease Cutaneous SCCa in situ → cryotherapy.
7) Marjolin’s Ulcer SCCa that usually rises from chronic, non-healing wounds (esp.
in old burn wounds). Tx → WLE w/2cm margins.
P. Merkel Cell Carcinoma neuroendocrine; 80% have polyomavirus; red-purple nodule
or indurated plaque; very aggressive; skin, +LNs (~30%), MC mets to bone (10%); +NSE,
cytokeratin, neurofilament; perinuclear keratin Ab
1) Tx→1-2cm margin+SLNBx (vs LNDx if +LNs) + XRT (high risk pts), 60% 5ys.
Q. Melanoma ExBx w/1-3mm margins. CNBx if c/f mets (multiple areas if lg).
1) Staging → Chest/abd/pelvic CT, LFTs, & LDH for all melanoma ≥ 1 mm; examine all
possible draining LNs.
2) Melanoma prognosis based on→ #1 Breslow depth (also bad → men, blue,
ulcerated, eye, +LNs, ↑mitotic rate, & mucosal).
3) Melanoma stains positive for S100.
4) Melanoma of Unknown Primary (MUP) → 2-6% of melanoma, 2/2 regression of 1°
vs melanin nodal rests.
a. Get ophtho exam if visceral or liver involvement; found in 1axilla (need lvl 1-3
ALND) > 2groin > 3H&N.
b. Get PET & brain MRI. MUP has same or better prognosis as 1° dz.
5) Resections
a. WLE Margins
i) Melanoma in situ 0.5-1 cm
ii) < 1mm depth 1 cm
iii) 1.1-2mm depth 1-2 cm
iv) >2mm depth 2 cm
b. Excision includes skin & subQ down to, but NOT including, fascia.
c. Small bowel mets common → resect if able. If SBO w/asso mass in pt w/hx of
melanoma → ex lap (NOT serial exams).
d. 1° ant to tragus → 20% parotid mets → superficial parotidectomy.
e. In-transit melanoma = St III → get PET, then resect ± isolated limb infusion ±
intra-lesional tx.

68
 6) LNs
a. Clinically - → SLNB if ≥ 0.75-0.8mm, consider if < 0.8mm + ulceration especially
if >2/mm2 mitosis, young, +LVI, or combination of these.
i) -SLNB → f/u w/H&P q3-6mn x5yrs, consider q1y imaging in 1st 5yrs.
A) MSLT-I → just doing a SLNB ↑ 10yr DFS & DSS.
ii) +SLNB → Surveillance U/S q4m x2 yrs then q6m x3 yrs.
A) Surveillance is preferred over completion LND per NCCN.
B) MSLT-II → + SLNBx doesn’t require completion LND (NO ↑survival), but is
indication PD-1 inh (+BRAF tx if +BRAF mut).
b. Clinically + → MRND or lvl 1-3 ALND (based on location of 1°).
7) CTX in melanoma → BRAF+MEK inh (vemurafenib & dabrafenib), PD-1 inh
(pembrolizumab, nivolumab) +/- CTLA-4 inh (ipilimumab).
R. Breast CA → MC to met to skin. Do Bx of lesion and re-stage BrCa.
S. Dermatofibosarcoma Protuberans
1) Uncommon exophytic, slow growing, low grade, spindle cell tumor arising in the
dermal & subcutaneous tissues, particularly of the trunk.
2) Tx → MOHS is standard of care (per NCCN) vs complete excision. Re-excise if
margins +. Excellent outcomes (~100% @ 10yrs). Radiosensitive.
a. MOHS ↓ recurrence > WLE (1.1% vs 6.3%).
3) Low grade fibrosarcoma in baseline large breast = dermatofibrosarcoma
protuberans → resect w/negative margins as above.
4) Large low grade fibrosarcoma in baseline small breast = dermatofibrosarcoma
protuberans → mastectomy.
T. Hidradenitis From apocrine sweat glands
1) RFs → Downs, women, African heritage, obese, excessive deodorant.
2) MC 2/2 corynebacter, porphymonas.
3) PASH → Pyoderma gangrenosum, Acne, Suppurative Hidradenitis.
4) Acute hidradenitis Tx → Topical clinda +/- low dose PO abx & CHG baths.
5) Acute hidradenitis w/abscess
a. Tx → I&D deroofing + IV abx (if fever, cellulitis, or abscess).
6) Chronic, refractory hidradenitis
a. Tx → Excising all involved skin & subQ, NPWD, may need STSG later.
7) Another way to classify is by Hurley Stage (1-3)
1) Single or mult w/o sinus tract Tx → topical clinda
2) w/sinus tract Tx → 12wks doxy or
3) Diffuse, covers entire area of body 10wks rifampin+clinda
U. Flaps (esp if refractory to doxy).
1) Types
a. TRAM → Based on superior epigastric aa & periumbilical perforators.
i) CIs → previous upper abdominal scars.
b. Fascial (eg. Tensor-lata flap).
c. Deep Inferior Epigastric Perforator (DIEP) flap → fasciocutaneous, ↑ OR time,
↓ Cxs & LOS vs TRAM.
d. Trapezius flap → based on transverse cervical artery.

69

Uploaded by MEDBOOKSVN.ORG
 e. Pectoralis major flap → based on either the thoracoacromial artery or the
internal mammary artery.
2) Complications
a. MCC of flap failure → venous thrombosis. Presents as blue & congested w/↓cap
refill.
b. Venous congestion → arterial insufficiency → Doppler loss.
V. Decubitus Ulcers
1) Stage 1 – erythema & pain, no skin loss. Tx → pressure relief.
2) Stage 2 – partial skin loss. Tx → local tx & keep pressure off
3) Stage 3 – full thickness skin loss w/exposed subQ fat.
a. Tx → sharp debridement (may need myocutaneous flap).
4) Stage 4 – Exposed bone, muscle, adipose tissue or tendon.
a. Tx → myocutaneous flap.
W. Paronychia
1) Infxn where the skin & nail bed meet. MCC → Staph aureus.
2) Can progress under nail bed (erythema, swelling, pain)
3) Tx → abx; remove nail if purulent underneath; I&D if pus (via lateral incision)
X. Felon
1) Infxn in terminal joint space of the finger usually s/p splinter/cut to fingertip. MCC
→ staph aureus.
2) Tx → incision over the tip of the finger & along the medial & lateral aspects of the
fingertip; prevents necrosis; avoid incision into fingertip pad (key part of fingertip
sensation).
Y. Soft Tissue Sarcomas
1) MC → Malignant Fibrous Histiocytoma (MFH; aka undiff spindle cell).
a. Tx → neoadj CTX then WLE.
2) 2nd MC & MC RP → liposarcoma. MC sarcoma mets → lung.
MC location of osteosarcoma → knee.
3) MC in kids → rhabdomyosarcoma (MC subtype → embryonal. Worst subtype →
alveolar).
4) Spread hematogenously, except:
SCARE (Synovial cell, Clear cell, Angio-, Rhambdomyo-, Epitheliod).
5) Sarcoma prognosis is based on grade.
6) T1 < 5cm T2 ≥ 5cm N1 + regional LNs
G1 well diff G2 mod diff G3 poorly diff G4 undiff
7) MI prognostic factor for RP sarcomas→ complete en bloc resection w/neg margins,
50% local recurrence, 20-30% have mets.
8) Most RP tumors are cancerous (MC RP CA → lymphoma).
9) 1st → CNBx. Ex bx if <3cm & superficial on a limb.
a. Longitudinal incisional bx if concern intraop (or non-dx CNBx).
10) Extraskeletal Ewings, myxoid liposarcoma, & rhabdomyosarcoma → CTX sensitive
→ give neoadjuvant/adjuvant CTX.
11) Get a pre-op MRI. Resect mets if they are resectable.
70
 12) Margins → 1-2cm if possible. Narrower OK if preserves neuro/vasc.
13) Extremity → give neo-adj XRT (& often CTX).
a. AIM → Adrimycin, Ifosfamide, Mesna.
14) Angiosarcoma 2/2 XRT for BrCa → taxane then total mastectomy.
a. XRT → ↑local control, NO diff survival.
15) Sarcoma abutting femoral vessels → neo-adj CXR-XRT then resect (90% don’t
require amputation).
Z. Mycosis Fungoides/Sezary Syndrome → Rash; Bx+ for T-cell lymphoma; needs
imaging to see extent of dz.

71

Uploaded by MEDBOOKSVN.ORG
13. Head & Neck
A. Neurovascular Structures
1) CN V / Trigeminal nerve → V1
ophthalmic, V2 maxillary, & V3
mandibular branches; sensation to
face; muscles of mastication.
a. Injury → chewing difficulties;
facial numbness.
2) CN VII / Facial nerve → temporal,
zygomatic, buccal, marginal
mandibular, & cervical branches;
runs through parotid gland. Motor
function to face.
a. Injury → facial droop.
b. MCC → temporal bone fx. MC
location → geniculate ganglion.
3) CN IX / Glossopharyngeal nerve →
taste to posterior 1/3 tongue;
motor to pharynx.
a. Injury → swallowing difficulties.
4) CN X / Vagus nerve → Gives off the recurrent laryngeal (→ innervates larynx). B/w
carotid & IJ. ML to be injured exploring carotid sheath.
a. Injury → hoarseness.
b. MCC of vagus nerve injury → CEA.
5) CN XI / Spinal accessory nerve →innervates trapezius, SCM, & platysma. Separates
lvl II A&B.
a. Located ~1.5cm cephalad to GAN & Erb’s point, on posterior surface of SCM,
runs in posterior triangle, often close to lymph nodes.
b. Injury → trouble turning head, shoulder droop & winged scapula, poor shoulder
shrug.
c. MC nerve injury w/cervical LNDx or post neck triangle dissection (eg. Bx, LNDx or
tumor removal in post triangle).
6) CN XII / Hypoglossal nerve → motor to tongue; tongue points to injury.
i) Injury → slurred speech, swallowing difficulties.
7) Phrenic nerve → on anterior scalene muscle (→ diaphragm innervation).
a. Injury → shortness of breath.
8) Long thoracic nerve → behind middle scalene; innervates serratus ant.
a. Injury → winged scapula only (can't raise hands above head).
9) Lingual nerve → located under tongue; taste to anterior 2/3 tongue & floor of
mouth; comes off mandibular branch of trigeminal nerve (has facial nerve fibers as
well). Injury → poor taste sensation.

72
 10) Inferior alveolar nerve → travels inside the mandible & provides sensation to teeth;
is a branch of trigeminal nerve; gives off mental nerve.
a. Injury → jaw numbness, mouth corner droop (mental nerve).
11) Mental nerve → Fibers from both inferior alveolar nerve [Trigeminal] & marginal
mandibular nerve [Facial]. Comes out of the mental foramen → innervates (motor
& sensation) corner of mouth & chin.
a. Injury → droop at the corner of the mouth, chin numbness.
12) Auriculotemporal Nerve → innervates upper ear, from CN V.
a. Frey’s syndrome → s/p parotidectomy; auriculotemporal nerve injury → cross-
innervates sweat gland sympathetics.
i) Sxs→ gustatory sweating. Tx → anti-perspirant.
13) Greater auricular nerve → C2&3, travels beneath platysma to parotid. Injury → ear
lobe numbness & difficulty shaving, 57% resolve by 1yr.
14) Recurrent laryngeal nerve → MC injured on left. Dx → CT chest; innervates all
larynx except cricothyroid muscle.
a. Unilat & Ø neck PSHx → r/o esophageal & lung CA
b. Posterior to thyroid, tracheoesophageal groove. Can track w/inf thyroid a, but
variable.
c. Right RLN loops around subclavian a.
d. Left RLN loops around Ao in Ao/Pulm window.
e. Inj → hoarseness; B/L → obstruct airway → emergency trach.
f. “Ride the Horse, of Course.” RLN, Horseness, Cord collapse.
g. MCC left vocal cord paralysis → CA invasion into left RLN (MC is lung or
esophageal).
h. Confirm pre-op integrity vs dx injury w/ flexible laryngoscopy.
i. Unilat vocal cord paralysis →↑ contralateral FDG avidity 2/2 ↑ compensatory
work.
j. Non-recurrent laryngeal nerve – incidence ~2%; MC on right.
k. ↑ injuries w/non-recurrent laryngeal nerve during thyroid surgery.
15) Superior laryngeal nerve → Int. br. innervates cricothyroid muscle. Ext. br.
inj→voice fatigue & loss of projection MC inj w/thryroidectomy. “Nerve of Amelita
Gulli-Curci.” Injury to Ext br of SLN = “Ex Singer.”
16) External carotid artery → 1st branch is superior thyroid a.
17) Thyrocervical trunk → “STAT”: Suprascapular a, Transverse cervical a, Ascending
cervical a, inferior Thyroid a.
B. Salivary Gland Tumors
1) Parotid (80% benign), submandibular (50% benign), sublingual (50% benign), &
minor (20% benign) salivary gland tumors.
2) Large salivary gland → MC benign.
3) Small salivary gland → MC malignant (↓size = ↑malignant).
4) MC location of minor salivary gland tumor → hard palate.
5) Parotid gland is MC site for a malignant tumor (higher total # of tumors).
6) MC salivary gland tumor in children → hemangioma.

73

Uploaded by MEDBOOKSVN.ORG
 7) MC injured nerve with submandibular gland resection → marginal mandibular
nerve (inferior alveolar nerve branch; motor function to lower lip & chin).
8) H&N mass in HIV+ pt & FNA indeterminate → excision.
9) Benign tumors Often present as a painless mass
“Bad PassWords Make Me Anxious.”
Benign:Pleo(#1), Warthin(#2) | Malignant:Muco(#1), Adenoid cystic (#2)
a. Pleomorphic adenoma MC. MC benign.
i) Malignant degeneration →5% (Tx → total parotidectomy).
b. Warthin's tumor (papillary cystadenoma lymphomatosum)
i) 2nd MC benign. M, smoking (strong RF). 10% bilateral.
c. Tx for both → superficial parotidectomy (total parotidectomy only if deep gland
involved). No enucleation (↑recurrence rate).
i) MC nerve inj w/superficial parotidectomy→ GAN (C2&3)→ lobular, pre &
post auricular numbness; difficulty shaving;. Resolves ~ 1yr.
10) Malignant Tumors
a. Painful mass, facial nerve paralysis, or LAD on presentation.
b. MC metastatic site → lung.
c. Mucoepidermoid CA - MC malignant. Aggressiveness varies.
i) Low grade mucoepidermoid → consider total parotidectomy w/o MRND or
XRT.
d. Adenoid Cystic CA - 2nd MC malignant.
i) Indolent, protracted course. Invades nerves. Extremely sensitive to XRT (non-
resectable → just give XRT).
ii) Deeply invasive adenoid cystic CA → do not resect, just give XRT.
e. Tx for both → Total parotidectomy (superficial & deep lobes), MRNDx, & Post-op
XRT.
f. Preserve facial nerve branches, even if you have to peel tumor off (unless nerve
already out on pre-op exam) then XRT that area post-op.
g. Lymph drainage → anterior cervical & intra-parotid nodes.
h. Melanoma & SCCA skin CA can metastasize to parotid gland.
C. Sialadenitis
1) Acutely inflamed salivary gland 2/2 stone in the duct 2/2 dehydration/ NPO,
trauma/stress, antiACh meds; most are near orifice; 90% are submandibular
(Wharton's duct) or sublingual glands.
2) Tx: 1st hydrate, warm, massage/milk gland, tart candy; if that fails or pt has signs of
abscess → I&D & remove stone. Gland excision may eventually be necessary for
recurrent disease.
D. TB Lymphoma in Neck → MC non-lung loc (cervical LNs, 10% in US).
1) Dx → FNA, ex bx if non-dx or HIV+. Tx→ RIPEx4mns, then RIx2mns.
E. Abscesses
1) Ludwig's Angina → acute oral floor infection (mylohyoid).
a. MCC → mandibular teeth infection.
b. Spreads deep quickly → airway obs. Tx → ETT, I&D, abx.
74
 2) Parapharyngeal Abscess → 2/2 dental infections, tonsillitis, & pharyngitis in all
ages. Vasc & prevertebral/retropharyngeal spread to mediastinum.
a. Tx → I&D via lateral neck & leave drains.
3) Peritonsillar Abscess (Aka “Quinsy”) Children > 10yo.
a. Sxs → trismus (reduced jaw opening) & odynophagia.
b. Usually Ø airway obstruction.
c. Tx → 1st needle asp, 2nd I&D via tonsils if persists >24hrs (may need ETT to
facilitate drainage. Drains w/swallowing s/p I&D).
4) Retropharyngeal Abscess Younger kids (usually < 10yo) or w/Pott's dz.
a. Sxs → fever, drool, & odynophagia. An airway emergency.
b. Tx → ETT, I&D via post pharynx. Drains w/swallowing s/p I&D.
5) Suppurative Parotiditis Sxs → pain, fever, mandible angle swelling.
a. MCC → Staph aureus. Tx → IVF, abx, I&D.
F. Oral & Pharyngeal Cavity Cancer (Above Larynx)
1) Pharyngeal MC, but laryngeal MC c/o death.
2) RFs → ETOH, tobacco, HPV (>90% HPV+ cases are 2/2 HPV 16), & EBV.
3) ↑risk (5%) for lung CA (all need CXR).
4) MC type → vast majority SCCa (ie. epidermoid).
5) CA risk → ↑ w/erythroplakia vs leukoplakia.
6) Division of oral cavity & pharynx marked by → Tonsillar pillars, jxn b/w hard & soft
palate, & tongue papilla
7) Oral cavity includes → ant ⅓ tongue, ant tonsillar pillars, gingiva, hard palate, lips, &
floor of mouth.
8) MC site for oral CA → lower lip (involves mucosa) 2/2 sun exposure.
9) Lip Ca Upper lip → Basal cell MC. Lower lip = MC location (80%) for upper
aerodigestive SCCa (oral, pharynx & larynx).
a. Tx → MOHS ± flap (if ⅓ lip removed), no ppx LNDx.
10) Tonsillar CA → considered an oral cavity CA. Ø sxs until lg, 2/2 EtOH/tobacco; MC
SCCa, 80% LN+. Tx → tonsillectomy.
11) Tongue CA → worse functional outcomes at base. Need 2cm margin.
a. Jaw invasion, early LN invasion (cervical chain)
b. Tx→commando procedure (if invades jaw, removes part of mandible).
12) Oral Cavity CA → spreads to submental + submandibular nodes 1st.
a. Exception → tongue CA goes to cervical LNs early (level II).
13) Pharyngeal CA → spreads to cervical LNs 1st.
a. Nasopharyngeal CA Sxs → MC presentation → painless neck mass. Also,
epistaxis or obs. Asso w/EBV, Chinese pts. Very responsive to XRT (do not
resect). Stage I → XRT. Stage II+ → CTX-XRT.
b. Oropharyngeal CA Sxs → neck mass, sore throat.
c. Hypopharyngeal CA Sxs → hoarseness (early LN spread).
14) Location w/lowest survival rate → hard palate (b/c hard to resect).
15) Need 1 cm margin for all except → tongue (2 cm margin required).

75

Uploaded by MEDBOOKSVN.ORG
 16) Tx:
a. Stage I + II oral cavity (< 4 cm, no nodal or bone invasion) → Resection.
b. Stage I + II pharyngeal (< 4 cm, no nodal or bone invasion) → XRT.
i) Include neck nodes w/XRT; hard to resect.
ii) Note → nasopharyngeal SCCA is very sensitive to XRT (Stage I - XRT;
Stage II - CTX-XRT).
c. Stage III oral cavity or pharyngeal (> 4 cm or nodal or bone invasion)
i) All get: 1) Resection, 2) MRND, & 3) post-op chemo-XRT
ii) Exception → nasopharyngeal CA gets CTX-XRT only (no resection; include
neck nodes in XRT field).
d. Stage IV (mets) → palliative CTX-XRT (5-FU + cisplatin).
G. SCCa in LN of unknown primary
MC CA dx’d on FNA of neck LN→ <50yo → lymphoma | ≥50yo → SCCa.
1) H&N exam, FNA palp LNs, fiberoptic exam. PE + pan-endoscopy will ID 80% of 1°
H&N CA dx’d on LN FNA.
2) CT H&N & chest ± PET.
3) DL, esophagoscopy, ipsil. tonsillectomy, ipsil. MRND + b/l XRT.
4) Primary MC in → tonsil, 2nd MC → base of tongue.
H. H&N Melanoma (Same margins unless on critical structure. Need neg margins before
recon. MOHS if absolutely required.)
1) Melanoma w/ Unknown Primary ~2-6% of time. If MUP in H&N → H&P, FNA, PET-
CT, Brain MRI.
a. MUP w/visceral mets → do eye exam (esp w/liver mets).
2) Scalp/face/ear→parotid→cervical LNs.
a. Regional LN recurrence w/o e/o mets→resect.
b. SLNB if >1mm & NO clin. + LNs
3) If on scalp, face, ear → resect + superficial parotidectomy + cervical LNDx (only if
palp dz; if none → SLNB).
a. Ant to tragus → ant LNDx. Post to tragus → post LNDx.
b. Adj Tx → IFNα (many SEs), XRT (↓ LR, but not survival).
I. Verrucous Ulcer → Low-grade, well-differentiated SCCa, usually inner cheek/buccal,
presents w/leukoplakia, asso w/tobacco, mets rare, NOT aggressive.
1) Tx→full resection w/5mm margins ± flap, NO SLNBx/LNBx/CTX-RTX.
J. Acoustic Neuroma/Vestibular Schwannoma (CN VIII) → benign, slow, asso
w/NF2, tinnitus/hearing loss/vertigo. MRI best.
1) Usually @ cerebropontine angle. CN VII @ risk.
2) Tx→crani + resect sup & inf vestibular nerves. XRT an option.
K. Maxillary Sinus CA Tx → maxillectomy.
L. Laryngeal CA → Vocal cords. MC → SCCa. Sxs → hoarseness, dysphagia, asp, &
dyspnea.
1) Tx → Vocal cord only → XRT More than cords → CTX-XRT
If +LNs(St III) → CTX-XRT & ipsilateral thyroid + MRND.

76
M. Septal Hematoma Tx → drain (prevents necrosis & infection).
N. Mastoiditis → Can destroy bone; 2/2 acute suppurative OM, ear pushed anteriorly;
MCC Streptococcus pneumoniae.
1) Tx → typmanectomy + abx (masteroidectomy next step).
O. Esophageal Foreign Body → Dysphagia, most stuck distal to cricopharyngeus (95%).
Tx → rigid esophagoscopy.
P. Torus Mandibular → Benign, congenital mass. Ant lingual mandible, DON’T
OPERATE!
Q. Torus Palatini → Benign, congenital mass. Upper palate, DON’T OPERATE!
R. Sleep Apnea → Can lead to cor pulmonale, MI, arrhythmia.
1) Tx → CPAP best, Uvulopalatopharyngoplasty (UPPP) best surgical option.
S. Hemangioma → MC benign H&N tumor (& MC overall tumor in kids).
T. Cystic Hygroma → Congenital lymphatic malformation. Benign. Post to SCM.
Tx → resect.
U. NIMS → Best indication is re-operative field (thyroid/parathyroid > CEA) or PHx of
XRT
1) Incidence of nerve inj ~0.2-0.8% for thyroid surgery. No difference in RLN inj using
NIMS/IONM vs intra-op RLN visualization (gold standard).
2) PPV 33%, NPV ~100%.
V. MRND → Ant cervical LNs, omohyoid, cervical br of CN VII, & submandibular gland.
W. RND → Above +: CN XI, SCM, & IJ. No diff in survival compared to MRND.

77

Uploaded by MEDBOOKSVN.ORG
14. Pituitary Incidentaloma → 10-15%
A. Hypothalamic-pituitary Axis
1) Hypothalamus
a. 1CRH, 2dopamine, 3GnRH, 4GHRH, & 5TRH → median eminence → post pituitary
→ ant pituitary. green = stimulates, red = inhibits
b. Dopamine → constitutively inhibits prolactin secretion.
2) Anterior Pituitary/Adenohypophysis (Makes up 80%).
a. 1ACTH, 2prolactin, 3FSH, 3LH, 4GH, & 5TSH.
b. Prolactinoma MC are micro-adenomas.
i) MC pituitary tumor.
ii) Sxs → infertility, poor libido, amenorrhea, galactorrhea, headaches, &
bitemporal hemianopsia. “Dry men & juicy women.”
iii) Dx → ↑prolactin (> 150 usual); MRI & visual field testing.
iv) Tx → most don’t require surgery.
A) Asx & micro-adenoma (< 10 mm) → follow w/Brain MRI.
B) Sx or MACRO-adenoma (> 10 mm) → Bromocriptine or cabergoline
(dopamine agonist) → 85% success (safe w/pregnancy).
C) Trans-sphenoid surgery (for failed med tx, hemorrhage, ↓vision, wants
pregnancy, or CSF leak) → 85% successful (15% recur).
c. Acromegaly MC are MACRO-adenomas.
i) ↑↑GH (>10) → insulin-like growth factor-1 (IGF-1) secretion.
ii) Sxs → jaw enlargement, macroglossia, HA, HTN, amenorrhea, DM,
giganticism, ↓ vision (2/2 size), cardiomyopathy, & valve problems.
iii) Dx → ↑IGF-1 (Best test. Random GH NOT useful). Brain MRI.
iv) Tx → No invasion → trans-sphenoid resection.
A) Octreotide & bromocriptine → shrink tumor & relieve sxs.
B) Pegvisomant (GH antagonist).
3) Posterior Pituitary/Neurohypophysis (20% of gland).
a. Supraoptic (→ ADH) & paraventricular (→ oxytocin) nuclei.
B. Craniopharyngioma Benign, MC kids 5-10yo.
1) Calcified cyst ~ ant pituitary. Rathke’s pouch remnant.
2) Sxs → HA, growth failure, bi-temporal hemianopsia, endocrine problems,
hydrocephalus.
3) Tx → surgery for sxs. Frequent Cx post-op → diabetes insipidus.
C. Sheehan’s Syndrome → ↓ lactation & hypoTN post-partum → pituitary ischemia
→ Can lead to adrenal insuff. Tx → HRT.

78
15. Adrenal Incidentaloma → ~4%

A. Anatomy (External to internal)

1) Granulosa (Salt)
2) Fasciculata (Sweet)
3) Reticularis (Sex)
4) Medulla (Sympathetics)
B. Adrenal Incidentaloma
1) Workup → lytes, PM cortisol (↑sens) or 24h urine (↑spec) cortisol, plasma
aldosterone:renin ratio, 24h urine metanephrines.
C. Hormonal Effects
1) Preop hydrocortisone dosing (see table in Anesthesia chapter).
2) Hypercortisolism (Cushing Syndrome) MCC → exogenous.
a. 1st test → 24hr urine cortisol.

LD Dexa → Is cortisol abnormally ↑? No → done. Yes →

Is ACTH↑? No → adrenal source. Yes → HD Dexa.
Is cortisol ↑ s/p HD Dexa? No → pituitary. Yes → ectopic.
b. Pituitary Adenoma (Cushing's Disease) Mostly microadenomas
i) MC non-iatrogenic cause of Cushing's syndrome (80%).
ii) Cortisol is suppressed w/dexamethasone.
A) ↑ACTH & cortisol, but suppresses w/HD dex.
B) HD dex → 2mg dex PO q6h x2d → urine cortisol on day 2.
iii) Best initial localization → Brain MRI.
iv) Best overall localization → Petrosal sampling (invasive).
v) Tx → trans-sphenoidal resection. Unresectable/residual dz → XRT.

79

Uploaded by MEDBOOKSVN.ORG
 c. Ectopic ACTH
i) #2 MC non-iatrogenic c/o Cushing's syndrome.
ii) Cortisol not suppressed w/LD or HD dexamethasone.
A) ↑ACTH & cortisol s/p HD dex.
iii) Best test to localize ↑ACTH source → Chest (#1) & abd CT → (MCC→ small
cell lung CA).
iv) Tx → resection 1°. Medical suppression if inoperable.
d. Adrenal Adenoma
i) #3 non-iatrogenic cause of Cushing's syndrome.
ii) ↓ACTH & ↑cortisol (unregulated adrenal production).
iii) Adrenal CT → best initial localization for suspected adenoma.
iv) Tx → adrenalectomy.
e. Adrenal Hyperplasia (macro or micro)
i) NP-59 scintigraphy → best test for 1)equivocal CT, or 2)suspected
hyperplasia. Solves adenoma vs. hyperplasia question.
ii) Tx → metyrapone & aminoglutethimide (→inh steroid production).
A) Bilateral adrenalectomy if fails med Tx.
iii) S/p bilateral adrenalectomy → need hydrocortisone & fludrocortisone
(mineralocorticoid) replacement.
f. Adrenocortical CA → Rare. Bimodal (< 5yo & > 50yo).
i) Usually > 6 cm & advanced at dx (ie mets).
ii) Sxs → abd pain, HTN, ↓wt, weakness.
A) 60% functional → cortisol (MC; Cushing's), aldosterone (HTN, ↓K+), & sex
steroids (virilization, feminization, masculinization).
iii) Adrenal CT → best test to localize; differentiates adenoma vs CA; can usually
make dx by CT scan (necrosis, hemorrhage, invasion).
iv) Tx → radical adrenalectomy (include kidney) -open ant approach.
A) Debulking helps Sxs & prolongs survival.
B) Mitotane (adrenolytic) if R2 resection, recurs, or mets → ↑DFS.
v) 5-year survival (all patients) → 20%.
3) Hypocortisolism (Adrenal Insufficiency; Addison's Disease)
a. MCC → withdrawal of exogenous steroids (a 2° cause).
Others → pituitary disease, h/o bilateral adrenalectomy.
b. MC 1° cause → autoimmune dz in US (TB in 3rd world).
Others → adrenal infection, hemorrhage, mets, or fibrosis.
c. Acute / Addisonian Crisis
i) HypoTN, fever, lethargy, abd pain, N/V, ↓ glucose, ↑ K+, ↓Na+.
ii) Tx → 1st dexamethasone & IVF (empiric). 2nd cosyntropin test to confirm
(dexamethasone doen’t interfere).
A) 250 µg IV ACTH, check plasma ACTH & cortisol @ 30 & 60 min.
1. 1° insufficiency → ACTH > 200 & cortisol < 10.
2° (pituitary) & 3° (hypothalamus) → ACTH < 200.

80
 d. Chronic Adrenal Insufficiency → hyperpigmentation, weakness, ↓wt, abd pain.
Tx → hydrocortisone + fludrocortisone.
i) ↓cortisol, ↑ACTH (unless pituitary dz), & ↓aldosterone.
e. Fever, N/V, abd pain, & hypoTN s/p thymectomy for myasthenia gravis or
splenectomy for ITP → Addisonian Crisis (Tx → dexamethasone).
4) Hyperaldosteronism (Conn’s)
a. Up to 10% of pt’s w/HTN will have ↑aldosterone.
b. HTN, polyuria/-dipsia,↑Na+,↓K+. Tx pre-op w/spironolactone & CCBs.
c. Dx 1° (adrenal source): 1st → aldosterone:renin ratio >20(diagnostic). If
indeterminate → Salt-load suppression w/24hr urinary aldosterone >14mcg.
Can’t localize w/CT → venous sampling (dx if ratio >4:1).
d. Bartter synd → renin-secreting tumor (↑renin → ↑aldosterone).
5) Hypoaldosteronism
a. HypoTN, ↑K+, ↓Na+. Tx → mineralcortocoid (eg. fludrocortisone).
6) Adrenal Androgen Disorders
a. Congenital Adrenal Hyperplasia (enzyme defect in cortisol synthesis)
i) 11-Hydroxylase Deficiency
A) F → virilization. CAH Type BP ↑ before sex. 1 = ↑ Ø1 = ↓
(MC to LC) BP Virilization
B) M→ Precocious puberty.
21 ↓ ↑
C) ↑ 11-Deoxycortisone
11 ↑ ↑
D) Salt saving (deoxycortisone is a 17 ↑ ↓
mineralocorticoid) → HTN.
ii) 21-Hydroxylase Deficiency (90%,MC).
A) F → virilization. M → Precocious puberty.
B) ↑ 17-OH progesterone → ↑ testosterone.
C) Salt wasting (↓Na+ & ↑ K+) → hypoTN.
iii) Tx for both → cortisol & genitoplasty.
b. Feminizing tumors → most malignant adrenal tumor.
7) Pheochromocytoma
a. Adrenal Has PMNT → makes epinephrine (other pheos can’t).
i) Grows slowly, rare. Chromaffin cells from adrenal medulla, sympathetic
ganglia, or ectopic neural crest cells.
ii) 10% rule → malignant, b/l, kids, familial, extra-adrenal. Asso w/MEN Ila, MEN
lIb, Sturge-Weber dz, tuberous sclerosis, von Hippel-Lindau, von
Recklinghausen's dz.
b. Extra-adrenal (2nd MC loc → para-aortic)
i) Lacks PMNT (only found in adrenal) → stops @ norepinephrine.
ii) Organ of Zuckerkandl (3rd MC loc, @ aortic bifurcation)
iii) Locate extra-adrenal pheo with → MIBG (or DOTATATE now).
c. Diagnosis
i) Best test to r/o pheo prior to OR → plasma (99% sensitivity) or urine
catecholamines (usually only one given choice).

81

Uploaded by MEDBOOKSVN.ORG
 d. Preoperative considerations
i) 1st give → α-blocker (Phenoxybenzamine [α1& α2]), then IVF, then β-blocker
[if reflex tachy]).
A) Doxazosin: α2 only (Ø reflex tachy), long acting.
B) Phentolamine: short acting.
8) Angiomyolipoma → benign. Don’t resect based on size if characteristic CT findings.
Only resect for sxs.
D. Adrenalectomy
1) Always test for function prior to removal (metanepherines, BMP, etc).
2) Indications
a. Non-homogenous/complex, >4-6cm, HU >10, <50% washout at 10-15min,
functional, enlarges >1cm while following, +FNA (don’t bx).
3) Right adrenalectomy approach requires → Kocher + mobilize right lobe of liver.
4) Left adrenalectomy → mobilize spleen & tail of pancreas (risk of injury). Phrenic
vein passes medial to gland & into left renal vein near/with left adrenal vein.

82
16. Thyroid

A. Thyroid Function & Anatomy

1) Endodermal origin, from foramen cecum.
2) C-cells from 4th pouch (neural crest origin).
3) T3 is most active & made peripherally.
4) Inferior thyroid a crosses RLN → take arteries at gland to ↓nerve injury.
B. Abnormalities of Thyroid Descent
1) Lingual Thyroid 2% malignancy risk (MC → papillary thyroid CA).
a. Persistent thyroid in foramen cecum (tongue base).
b. 2/2 complete failure of migration.
c. Sxs→ dysphagia, dysphonia, dyspnea. "Strawberry lump" at tongue base.
d. Tx → suppress thyroxine. Ablate w/131I if that fails. Resect if c/f CA or if it doesn’t
shrink s/p med Tx.
e. Only thyroid tissue in 70% (get U/S to check for thyroid gland in neck).
2) Pyramidal Lobe 10% incidence; from thyroid isthmus.
3) Thyroglossal Duct Cyst
a. Midline cervical mass through hyoid bone. Thyroglossal tract arises from
foramen cecum. Can arise anywhere along thyroid descent path (tongue to
pyramidal lobe). Most b/w hyoid bone & thyroid isthmus.
b. Classically moves cranially w/swallowing or tongue protrusion.

83

Uploaded by MEDBOOKSVN.ORG
 c. Sxs→ usually asx; susceptible to infection (MC issue, ~10-70%), dysphagia,
dysphonia, dyspnea, fistula. May be premalignant (MC → papillary thyroid CA).
May be only thyroid tissue.
d. Surgical indications → infection (MC indication), CA, ↑ size.
e. Tx → resection → take mid-portion of hyoid + thyroglossal duct cyst all the way
to tongue base (Sistrunk procedure). Use a lateral neck incision.
f. Recurrence = 10.7%. Re-op for recurrence or infection.
C. Goiter Diffuse enlargement. MCC → iodine def. OR if sxs or c/f CA.
D. Hyperthyroidism Most accurate test to dx → ↓TSH.
1) Best test to distinguish hyperthyroidism type → 123I scan(scintigraphy).
2) Grave’s Disease MCC of hyperthyroidism (80%).
a. Toxic diffuse goiter; often in older women.
b. Sxs only found in Grave's → exophthalmos, pre-tibial edema.
c. 2/2 lgG to TSH receptor (activates it) = thyroid stimulating immunoglobulin (TSI)
& long acting thyroid stimulator (LATS).
d. Dx → ↓TSH, ↑T3/T4. 123I scan → diffuse homogenous uptake.
e. Med tx usually effective (> 95%).
i) Thionamides (50% recurrence).
A) PTU→OK in pregnancy. Methimazole→NOT OK (→cretinism).
1. Both cause agranulocytosis.
ii) 131I (5% recurrence).
iii) β-blocker (helps Sxs only).
iv) Thyroidectomy if med Tx fails. Unusual to have to operate.
A) Pre-op prep → methimazole until euthyroid, β-blocker, 14d of Lugol's (↓
friability & vascularity). OR only after euthyroid.
B) Near total/bilateral subtotal (5% recurrence) or total thyroidectomy (need
lifetime thyroxine replacement).
C) Indications → suspicious nodule (MC), non-compliant, recurs s/p med tx,
kids & pregnant women not controlled w/thionamides (131I is CI in
pregnancy).
3) Thyroid Storm
a. Usually post-op in Grave’s dz; fever tachy, HTN 2/2 no preop β-blocker, PTU, &
Lugol’s.
b. Tx → β-blocker, PTU, & Lugol’s, cooling blanket.
i) Lugol’s (K+-iodine) → Wolff-Chaikoff effect → ↑I →↓T3/4 release.
4) Toxic Multinodular Goiter
a. Older women. Usually non-toxic at 1st.
b. Sxs → insomnia, airway compromise, ↑HR, ↓wt.
c. Chronic low-grade TSH stim → hyperplasia. Path → colloid tissue.
d. Thyroid scan → diffuse non-homogenous uptake.
e. Tx → subtotal or total thyroidectomy preferred.
i) 131I trial can be considered, esp if patient is elderly/frail, but NOT if
compression or suspicious nodule present.
84
 A) 131I is less effective 2/2 non-homogenous uptake.
5) Single Toxic Nodule
a. Younger women. Sxs when > 3 cm. Autonomous fxn.
b. Dx → thyroid scan (localized hot nodule). U/S → may show adenoma.
i) Ultimately 20% of hot nodules cause sxs.
c. Tx → thionamides & 131I (95% effective); lobectomy if med Tx fails.
6) Trophoblastic & TSH-secreting Pituitary Tumors Are rare causes.
E. Hypothyroidism → Wt gain, cold intolerance, fatigue.
1) Tx → levothyroxine.
2) Myxedema coma →↓fT4(<0.8ng/dL), cortisol, glucose, Na+, RR, & temp.
F. Thyroiditis
1) Postpartum/Subacute
a. Palpitations, anxiety, insomnia, fatigue, wt loss, irritability.
b. Hyperthyroid sxs at 1st 2/2 antithyroid Abs, then hypothyroid.
c. Tx → β-blockers, then levothyroxine.
2) Hashimoto’s Disease MCC hypothyroidism in adults. MCC of thyroiditis.
a. Sxs → painless enlarged gland → chronic thyroiditis.
b. MC in F, possible h/o XRT. ESR nml. Path → lymphocytic infiltrate.
c. An autoimmune disease (anti-microsomal & anti-thyroglobulin Abs).
d. No organification of iodine in gland → goiter.
e. Unusual to have to operate unless there is a suspicious nodule.
f. ↑ risk of thyroid lymphoma (Tx → CTX-XRT).
g. Tx → levothyroxine (1st line for most). Thyroidectomy for → ↑size despite
thyroxine, suspicious nodules, or compression.
3) Bacterial Thyroiditis
a. 2/2 contiguous spread w/bacterial URI precursor (staph/strep).
b. Sxs → fever, dysphagia, TTP; nml thyroid fxn.
c. Tx → aspiration, then abx. Rule-out CA if unilateral sxs or not abx responsive
w/lobectomy.
i) Persistent inflammation → total thyroidectomy.
4) De Quervain’s
a. Viral URI precursor; TTP, sore throat, weak, fatigue. Women. ↑ESR.
b. Tx → steroids & ASA. May need lobectomy if unresponsive to med Tx (r/o CA).
Persistent inflammation → total thyroidectomy.
5) Riedel’s Fibrous Struma
a. Fibrous & woody. Can involve strap muscles & carotid sheath, resemble
lymphoma/thyroid CA (Bx). Hypothyroidism & compression.
b. RFs → fibrotic dzs, RP fibrosis, sclerosing cholangitis.
c. Tx→ steroids & thyroxine; Possible isthmectomy (resect just isthmus) or
tracheostomy (for airway sxs). RLN inj w/resection common.
G. Thyroid Nodule
1) Cystic
a. Aspiration alone is sufficient if benign.
85

Uploaded by MEDBOOKSVN.ORG
 b. Lobectomy if >3cm, recurrent, h/o XRT, bloody, or c/f cystic PTC
c. Non-diagnostic→q6-18mn U/S. Resect if >1.5cm or >1cm & suspicious.
1) Asymptomatic Thyroid Nodule W/U → get TFTs & U/S.
Bethesda CA Risk (%
Definition Treatment
Class per SCORE)
I Non-diagnostic 5-10 (17) Repeat FNA
II Benign 0-3 (4) Clinical f/u
AUS or FLUS
III 10-30 (16) Repeat FNA (vs RNA gene
Atypia of Undetermined Significance
Follicular Lesion of Undetermined Significance panel to assess need for
lobectomy)
IV Follicular Neoplasm 25-40 (26)
V Suspicious 50-75 (75) Lobectomy
VI Malignant >97 (99) Lobectomy vs Total
a. Kids → 25--50% nodules are CA. Adults → 5% are CA.
b. ↑CA rate w/ → hypervasc, microcalcs, irregular/heterogenous, taller-than-wide,
hypoechoic.
c. FNA if→ high suspicion & >1cm, mod (eg solid) & >1.5cm, low & >2cm.
FNA PPV for cancer is 97-99%.
d. 14-47% of incidental on PET-CT are CA.
e. For nodules F:M = 8:1, but 2x more likely to be CA in M.
2) Follicular Neoplasia (or just follicular cells)
a. If on FNA → lobectomy (~25% CA). If on path s/p lobectomy → done.
b. MCC Intrathyroid round mass w/outer hypoechoic "halo sign" → follicular
adenoma (PTC has one ~ 24% of the time). Tx w/lobectomy.
3) Lateral Aberrant Thyroid Tissue → Enlarged lateral neck LN w/nml-appearing
thyroid tissue on FNA.
a. Represents PTC w/lymphatic spread → total thyroidectomy, ipsilateral TLNDx,
& I131.
B. Thyroid Cancers
1) Most familial thyroid CA are non-MTC (MC papillary) → FAP, Cowden synd, Carney
complex, Pendred synd, Werner synd, usually AD w/↓prevelance.
2) Papillary (PTC) BRAF-V600+.
a. MC thyroid CA, least aggressive, best prognosis, lymphatic spread, prognosis
based on local invasion (NOT LNs), can be multicentric, Psammoma bodies (Ca++),
Orphan Annie nuclei. Micro-LN+ → still good prognosis & no LNDx unless grossly
involved. Cannot be St III or IV unless >55yo.
b. Tx in pregnancy → Wait until post-partum.
c. Thyroglobulin → marker for recurrence (only if s/p total thyroidectomy). Can be
dx on FNA. C/f recurrence → get US 1st.
d. Tx Do a Targeted Dx (TLND) of grossly/Bx + compartments.
131I post-op for → Mets, >4cm, or >1cm w/high-risk features.

i) Low risk (<1cm & not high risk) → lobectomy.

ii) High risk (≥4cm, T4[extrathyroid extension], cN1, M1) → total
thyroidectomy + central (lvl VI) Dx + TLND.
iii) >1cm, b/l, multicentric, h/o XRT, or + margins → total thyroidectomy
(synthroid to ↓TSH/growth [s/p 131I if getting 131I]).

86
 iv) 1-2wks s/p total thyroidectomy → start levothyroxine (1.6μg/kg)
v) Wait 6-8wks post-op to check TSH levels.
3) Follicular (FTC) PAX-8/PPAR-γ +. Tx → same as PTC.
a. 2nd MC thyroid CA, hematogenous spread (bone MC).
4) Medullary (MTC) CHECK METANEPHRINES PRIOR TO OPERATING ON MTC!
a. RET +. If Bcl2+ = better prognosis. Bx → C-cell hyperplasia & dispersed
plasmacytotic cells w/sudden anisonucleosis. Can be dx on FNA.
b. Can be MEN IIa & MEN IIb (need total thyroidectomy, CNDx, 4-gland
parathyroidectomy w/autoTXP), familial MTC, & sporadic MTC (80%). Asso
w/RET proto-oncogene. Worse prognosis → MEN llb & sporadic.
c. More aggressive than follicular & papillary CA.
d. 1st manifestation of MEN IIa & IIb (1st Sx → diarrhea 2/2 ↑calcitonin).
e. Check metanephrines before OR, if + → CT abd, adrenalectomy before
thyroidectomy if pheo present.
f. Pathology → from parafollicular C cells; C-cell hyperplasia considered
premaliqnant; Amyloid deposition in thyroid gland; Secretes calcitonin, can →
diarrhea & flushing. Most are multicentric (90%).
g. Need to screen all for hyperPTH & pheo.
h. Lymphatic spread → most have +LNs at dx of palpable dz (70%). Often early mets
to lung, liver, or bone (would prevent curative resection).
i. Tx → M0 → total thyroidectomy + b/l central (lvl VI) Dx.
i) M1 → need total thyroidectomy, b/l central (lvl VI) Dx, & ipsilateral MRND (b/l
MRND if both lobes have tumor or extrathyroidal dz).
ii) XRT may be useful if unresectable local dz or mets.
iii) CTX of little benefit (I131 does not work).
iv) Monitor calcitonin for recurrence. ↑CEA, but confounding w/CRCa.
Pentagastrin-stim peak plasma calcitonin → most sensitive lab.
5) Hurthle Cell
a. Most are benign (80%, aka “Hurthle cell adenoma”). Usually elderly. Mets to
bone & lung if CA.
b. Path → Askenazy cells (oncocytic or oxyphilic cells). Can’t dx CA on FNA, need
lobectomy (sim to FNA w/follicular cells).
c. Tx → thyroid lobectomy, total if CA. MRND for clinically + LNs.
6) Anaplastic p53+ Elderly pt w/long-standing goiter.
a. Most aggressive thyroid CA. ↑invasion (eg trachea).
b. 5ys → 0-5%. Usually beyond surgical tx at dx.
c. Path → vesicular nuclei.
d. Tx → total thyroidectomy if resectable (rare). Possible tracheal resection.
Compression → palliative thyroidectomy / CTX-XRT.
7) Thyroid Lymphoma (DLBCL) Need Ex Bx to Dx → irregular lymphoid cells.
a. W/o compression → CHOP. Compression → CHOP + XRT.
i) CHOP → Cytoxan, Hydroxydoxorubicin, Oncovin, Prednisone.

87

Uploaded by MEDBOOKSVN.ORG
C. Post-Op Hypocalcemia
1) Must ID parathyroids on operative side, if accidently removed → visually confirm
presence of other healthy/preserved parathyroid(s).
2) Usually w/in 24-72h.
3) Asx w/Ca ≥7.5 → obs + labs.
4) Asx or mild Sx w/Ca <7.5 →200-500mg PO Ca++ 3-4x/d.
5) Severe sx (ie. carpal pedal spasm, laryngeal stridor) → IV Ca++.
10% CaCl → 270mg, 13.5mEq 10% Ca++-Gluconate → 90mg, 4.5mEq.
6) Hyperventilation → ↓pCO2 → resp alk → ↑ Ca++ binding to Alb → ↓iCa++ →
hypoCa++ sxs.
D. Central Neck Dx Borders superior → hyoid, inferior → thoracic inlet, medial →
midline, lateral → carotid sheath.

88
17. Parathyroid
A. Anatomy
1) MC location of missed
parathyroid at initial surgery →
normal anatomic location.
2) MC location for superior
parathyroid (4th pouch).
a. Lateral/post to RLNs on post
surface of superior gland,
cranial to inf thyroid artery.
3) MC location for inferior
parathyroid (3rd pouch).
a. Medial/ant to RLNs, ant,
caudal to inf thyroid artery.
b. Inf glands more variable &
ML to be ectopic. Occasionally in thymus tail (MC ectopic site), carotid sheath,
mediastinum, & paraesophageal.
i) Can’t find inf gland → focus on carotid sheath & thymus.
4) 3 glands in 3%, 4 glands in 84%, 5 glands in 13%
B. Hyperparathyroidism
1) Primary 4% of pts w/1° hyperPTH will also have thyroid CA!
a. Single Adenoma (80%) → chief cells surrounded by rim of nml tissue.
b. Diffuse Hyperplasia (15%) → diffuse proliferation of clear cells w/very little nml
tissue.
i) Lithium-induced HPT → needs 4-gland exploration.
c. Multiple Adenomas (5%)
d. Parathyroid adenocarcinoma (<1%)
i) Sxs → fatigue, weak, N/V, ↓wt, polyuria, polydipsia, Ca++ > 13.
ii) Bx → ↑mitotic activity, dense fibrous stroma, e/o local invasion. ↑suspicion
if Ca++ > 13 & palp neck mass.
iii) Tx → en bloc resection + ipsilateral thyroid + LNDx.
A) ↑Ca++ 2/2 malignancy. No sxs → bisphosphonate & calcitonin.
Sxs→1st IVF w/NS, 2nd diuretic, 3rd bisphosphonate + calcitonin.
e. Dx → ↑PTH & Ca++, Cl:Phos > 33. Localize w/U/S. PRN SPECT vs 4D-CT.
f. Tx of benign dz → parathyroidectomy (see end of chapter).
g. Hypercalcemic crisis → IV resus w/NS, then lasix.
i) Once Ca++ nml → parathyroidectomy.
h. High Ca++ 1 wk s/p 3 ½ gland excision, nml Ca++ & PTH before d/c, on Ca++ &
calcitriol → 2/2 too much Ca++.
2) Secondary MCC → CKD (Ca++ loss w/HD).
a. Dx → ↑PTH 2/2 ↓Ca++ (maybe low/nml Ca++). Serum PO4- ↑.
b. Sxs → pruritus, bone pain, fxs.
c. Most don’t need surgery (med tx effective in 95%).

89

Uploaded by MEDBOOKSVN.ORG
 d. Tx → Ca++ supplement & sevelamer chloride (Renagel → binds PO4-), calcitriol
(Vit D), control dietary PO4- (limit dairy).
i) Cinacalcet → mimics Ca++, inh PTH release (very effective).
ii) Surgery if → PTH >800 pg/mL + ↑ Ca++ & PO4- or Sxs (calciphylaxis, bone pain,
intractable puritis, persistent anemia, pathologic fxs).
3) Tertiary
a. Corrected renal dz (ie s/p TXP) but continued ↑ PTH.
b. Labs & OR indications → similar as 1° HPT (↑PTH & Ca++).
c. Tx → 1st → med tx like for 2°.
i) Surgical→ subtotal (3 ½) v total parathyroidectomy w/autoimplant.
4) Familial Hypocalciuric Hypercalcemia (FHH) ↑pCa++ w/↓uCa++
a. Need genetics, not OR. FHH → only absolute CI to parathyroidectomy.
C. Hypoparathyroidism
1) Pseudohypoparathyroidism → target tissue resistant to ↑PTH → ↓Ca++/growth &
↑PO4- 2/2 mutation in GNAS-1.
a. Familial, ↓IQ, short/stocky, short 4/5th digit.
D. Multiple Endocrine Neoplasia (MEN)
1) Neoplasms develop synchronously or metachronously. AD.
2) MEN I (MEN1 gene, menin protein; on Ch11) “3 P’s”
a. Parathyroid hyperplasia (90%) ↑PTH & Ca2+ If Vit D↓ → repleat.
i) Usually 1st to have sxs (hypercalcemia, kidney stones).
ii) Tx→ 4-gland resection with autotransplant/subtotal 3 ½ gland + thymectomy
(↑ risk of thymic carcinoid).
A) 4-gland/total resection → 6% permanent hypoparathyroidism.
B) Subtotal 3 ½ gland → 50% recurrence.
iii) Don't leave gland in neck → hard to re-op if recurrence.
b. Pancreatic islet cell tumors (70%)
i) Gastrinoma MC→ 50% mult, 50% CA. 2nd MC→Insulinoma (20%).
A) MCC M&M in MEN I.
c. Pituitary adenoma (70%)
i) MC → Prolactinoma (Tx → Bromocriptine). 2nd MC → IGF-1.
d. For MEN I, correct hyperparathyroidism 1st if simultaneous tumors.
3) MEN IIa (RET proto-oncogene; on Ch10) “2 P’s”
a. Parathyroid hyperplasia (50%) same as above, but last to have sxs.
b. Medullary CA of thyroid (>99%) ML to be Dx’d 1st.
i) Tx → ppx total thyroidectomy ± central LNDx & MRND (if >1cm).
ii) Nearly all patients get this (hallmark of MEN IIa & IIb); often b/l.
iii) Usually 1st part to be sx (MC sx → diarrhea).
iv) MCC M&M in MEN IIa, remove at 2-5yo.
c. Pheochromocytoma (50%) Often bilateral, nearly always benign.
i) Need to remove pheo 1st if simultaneous tumors.
4) MEN llb (RET proto-oncogene; on Ch10) “1 P”
a. Medullary CA of thyroid (>99%) SAA except more aggressive than MEN IIa,
remove at 6mn (if 918T mut) to 1yo. Consider central LNDx & MRND (if >0.5cm).
b. Pheochromocytoma (50%) SAA. Remove pheo 1st if simultaneous.
c. Mucosal neuromas (anywhere in GI tract).
d. Marfan's habitus & musculoskeletal abnormalities
90
 5) Always check Ca++ on MEN I & IIa patients before operating on them.
6) Always check urine metanephrines on MEN IIa & IIb patients before operating on
them.
E. Parathyroidectomy
1) Indications Pre-op localization → U/S ± Sestamibi.
a. Sxs → Refractory bone pain (MC), fxs, pruritus.
i) Indications → “Stones, bones, groans, & psychiatric overtones.”
b. Asx, but refractory to med Tx w/any of following:
i) <50yo, Ca++ > 1 above nml, nephrolithiasis, DEXA T-score < -2.5, urine Ca++ >
400µg/d.
c. 85% get relief with surgery.
d. Surgery involves total parathyroidectomy w/auto-transplantation or subtotal 3 ½
gland parathyroidectomy (or resection of 1 gland if single adenoma).
2) Intraoperative considerations
a. Send gland for frozen to confirm parathyroid tissue.
b. PTH should drop > 50% 10 min s/p excision compared to pre-op levels, if not but
close → wait 5 min & recheck PTH. Not close or PTH still too high → need neck
exploration for ≥ 50% drop.
i) 1st → 4-gland exploration (retro- & paraesophageal focused).
ii) 2nd → Divide middle thyroid vein to better mobilize the thyroid.
iii) 3rd → Resect cervical thymus. Consider PTH from IJs to lateralize.
iv) 4th → close & get Sestamibi scan (>80% sensitivity). Do NOT resect nml glands
or do sternotomy.

91

Uploaded by MEDBOOKSVN.ORG
18. Breast
A. Infection
1) Mastitis
a. Infectious MC asso
w/breastfeeding.
i) Nonlactating women S.
aureus MC 2/2 chronic
inflammation (eg
actinomyces) or
autoimmune dz (eg SLE).
ii) Tx w/abx, if persists r/o a
necrotic CA (incisional bx
w/skin).
b. Periductal (Mammary Duct Ectasia or Plasma Cell Mastitis)
i) Sxs → creamy d/c, erythema, can have nipple retraction. Noncyclic pain.
RFs → smoking, piercing.
ii) Bx → dilated ducts w/inspissation & periductal inflammation.
iii) Tx → if creamy, non-bloody d/c & not asso w/nipple retraction give abx &
reassure. Otherwise or recurs → r/o inflammatory CA (incisional bx w/skin).
c. Granulomatous → idiopathic, inflammatory, “burns out” in 1-2yrs.
i) Multiple abscesses ± fistula at various locations.
ii) Tx→ may respond to steroids (still bx 1st).
2) Abscess Asso w/breastfeeding. MC → S aureus, then strep.
a. Tx → U/S guided-perc asp (try 1st) or I&D, d/c breastfeeding & pump, abx for
cellulitis (Bactrim is safe). Bx if solid or fails to resolve.
B. Galactocele Tx: 1st → reassure + pump 2nd → aspirate
3rd → I&D 4th → incisional bx.
C. Galactorrhea Asso w/amenorrhea.
1) 2/2 ↑ prolactin (pituitary prolactinoma), α-methyl dopa, metoclopramide, OCPs,
phenothiazines, reserpine, TCAs.
D. Gynecomastia pinch test → >2-cm.
1) Recent, >5cm, or painful → send β-HCG, LH, testosterone, & estradiol.
2) 2/2 spironolactone, CCBs, antipsychotics, H2blockers, PPIs, cimetidine, marijuana.
Most are idiopathic.
3) Dx→must get sex hormone levels if no clear etiology (eg meds, BRCA).
4) Tx → Obs vast majority (likely regresses). Resect if deforming or causing social
probs. Tamoxifen 10-20mg/d resolves 60-90%.
5) Pseudo-/ Senescent Gynecomastia Older men, b/l. No TTP, mass, LAD, or nipple
d/c. Tx → observe (benign).
E. Polymastia Accessory breast tissue. Usually in axilla (MC location).
F. Polythelia Accessory nipple. From axilla to groin (MC breast anomaly).

92
G. Mondor’s Disease / Superficial Thrombophlebitis of Breast
1) Palpable, painful cord in breast w/slight skin retraction; in lateral thoracic,
thoracoepigastric, & superior epigastric veins.
2) Tx → warm compress & NSAIDs. Bx only when asso w/mass.
H. Mastodynia / Mastalgia
1) Cyclic MCC is fibrocystic disease.
a. Tx → 1st reassurance, NSAIDs (±wt loss, sports bra). 2nd → Tamoxifen, starting
OCP, danazol (dopa agonist, SEs) & bromocriptine (sig SEs).
b. Evening primrose, d/c caffeine/nicotine not proven to be beneficial in meta-
analysis.
2) Continuous MCC is infection. Tx → abx if infection.
I. Fibroadenoma MC breast mass in young F. “Popcorn” calcs on mammo.
1) Get a CNBx to prove → Broad sheets of cohesive cells w/uniform nuclei /
conspicuous fibrous tissue w/ compression of epithelial elements.
2) Tx → <40, clinically benign (rubbery, firm, rolls, mobile, <2cm, stable size,
Ø↑cellularity), c/w imaging, & bx proven → watch.
a. If not all criteria met → ex bx.
J. Fibrocystic Disease
1) Ectatic duct w/single or double epithelial or myoepithelial cell layer.
2) MCC of cyclic mastodynia.
3) Discharge (yellow-brown), lumpy, TTP varies w/cycle.
4) Types → apocrine metaplasia, duct adenosis, ductal hyperplasia/dilation, epithelial
hyperplasia, fibromatosis, lobular hyperplasia, papillomatosis, & sclerosing
adenosis.
K. Nipple Discharge (Female & Male)
1) Bloody
a. Intraductal Papilloma → MCC unilateral nipple bleeding(no other sxs).
i) Dx/Tx → Mammo 1st, U/S, then ductogram, MRI, + directed excision. Can’t
find → complete subareolar excision.
2) Non-spontaneous 2/2 exercise, stimulation, pressure, tight clothes, etc. Less c/f CA.
Needs ex bx if bloody or other concerns.
a. Periareolar Mammary Duct Fistula 2/2 lg duct obs (MC 2/2 squam metaplasia) →
abscess → fistula (MC at NAC border).
i) Tx → excise entire tract (if not infected) & close primarily.
3) Spontaneous → always ↑ c/f CA no matter color/consistency → Ex Bx.
4) Serous → ↑ c/f CA (↑↑ c/f CA if spontaneous or just 1 duct).
a. Tx → Ex Bx of that ductal area.
L. Fat Necrosis MC idiopathic, or s/p trauma. Bx → loss of adipocyte nuclei, foamy
histiocytes, whorled stroma, ↑macrophage & inflammatory infiltrate.
1) Dx → 1st U/S + mammo. Tx → f/u for resolution.
M. PseudoAngiomatous Stromal Hyperplasia (PASH)
1) Myofibroblast overgrowth/spindle cell. Solid, firm, painless, indolent.

93

Uploaded by MEDBOOKSVN.ORG
 2) Can mimic appearance of CA.
3) Tx → Incidental → none. Tumorous → WLE.
N. Phyllodes Tumor 10% CA (based on mitoses per HPF [> 5-10] & ↑Ki67).
1) No LN mets, hematogenous spread rare. Often quite large.
2) Similar to giant fibroadenoma (stromal & epithelial elements/ mesenchymal tissue),
but has stromal hypercellularity.
3) Dx → CNBx vs Ex Bx. Benign → obs.
a. Tx → Borderline/Malignant → WLE w/neg margins (≥ 1cm). Re-excise if +
margins. No SLNB or ALND (hematogenous spread).
O. Breast Lymphoma B-cell (MC → DLBCL). Can have CNS mets.
1) Tx → localized – excise, diffuse – CHOP + XRT.
P. High-Risk Lesions
1) Non-Proliferative → min ↑ CA risk. Eg. Fibroadenoma, single intraductal papilloma,
fibrosis, & squamous/apocrine metaplasia.
a. Tx → CNBx proven as above → obs.
2) Proliferative w/o atypia → x1.5-2 ↑ RR of CA. Eg. Hyperplasia w/o atypia, radial
scar (<1cm), complex sclerosis lesion (>1cm), papillomatosis, & sclerosing adenosis.
Tx → Ex Bx.
3) Proliferative w/atypia → CA RR ↑x~4.
Tx if CNBx + → Ex Bx + Tamoxifen/ ”risk modifying therapy.”
a. Atypical Lobular Hyperplasia <2mm,↓inc. postmenopause; CA marker, NOT
precursor. CNBx misses CA 2-3%. Tx like LCIS.
b. Atypical Ductal Hyperplasia <2mm, on CNBx→ localized ex bx + Tamoxifen.
Upstaged DCIS/IDC 20-30% (0.5-1%/yr), ↑CA risk x4.
c. Flat Epithelial Hyperplasia
Q. LCIS
1) Uniform population of cells distorting, expanding, & filling lobules.
2) CA risk is 1-2%/yr or 20-25% @ 15yrs (70% IDC, 30% ILC), risk is equal in both
breasts.
3) Pleomorphic LCIS Tx like DCIS, 25% upstaged to CA on Ex Bx.
4) CNBx + → Ex Bx. If margins + for LCIS → tamoxifen (unless pleomorphic or necrotic
LCIS → re-excise). No additional surgery needed for just LCIS.
5) MCC of b/l breast malignancy, ↓incidence post-menopause.
6) Tx → Tamoxifen, raloxifene, or exemestane (↓risk of CA 50% in LCIS+).
R. DCIS a precursor lesion, B/L 10-15%; 16% 10yr local recurrence (50% of which are IDC).
1) DCIS doesn’t extend past basement membrane.
2) Lumpectomy needs 2mm margin if only DCIS on Bx.
3) Types
a. Papillary → well-differentiated, non-pleomorphic.
b. Cribiform → cell polarity & atypia.
c. Comedo → architectural distortion, necrosis, Ca++ deposition.
4) Tx → Lumpectomy + XRT then tamoxifen (- margins on CNBx → XRT + tamoxifen).
No routine SLNBx. If high-grade or doing mastectomy → SLNBx.

94
S. Breast Cancer
1) IDC → Poorly cohesive intact cells w/nuclear size variation/crowding/ prominence,
chromatin clumping, radial dispersion in ↑cellular, monomorphic pattern.
2) MI for prognosis → +LNs.
3) Screening (start @ 40yo)
a. Mammogram
i) BIRADS 0 → Incomplete; follow-up imaging required → repeat / diagnostic
mammo (if on screening mammo).
ii) BIRADS 1 → Negative; routine screening.
iii) BIRADS 2 → Definite benign finding; routine screening.
iv) BIRADS 3 → Probably benign; 6 mn short-interval f/u mammo.
v) BIRADS 4 → Suspicious abnormality, get CNBx.
A) CNBx finding → Radial scar [<1cm → up to 10-20% CA risk]→ sclerosis,
elastosis, stellate architecture. Tx → localized ex bx.
1. Called a complex sclerosing lesion if >1cm.
B) 4a-low 4b-moderate 4c-high suspicion
C) Non-diagnostic, indeterminate, or benign but not concordant with
mammogram → need needle localized Ex Bx.
D) Benign & concordant with mammogram → 6-month follow-up.
E) Malignancy → follow appropriate Tx.
vi) BIRADS 5 → Highly suspicious of malignancy; take appropriate action (95% CA
risk).
A) Malignancy → Tx as below.
B) Discordant → needle localized Ex Bx.
vii) BIRADS 6 → Bx proven malignancy.
b. CNBx → w/o Ex Bx, CNBx allows appropriate staging with SLNBx (mass is still
present) & one-step surgery (avoids 2 surgeries) for patients diagnosed w/breast
CA.
c. MRI (w/contrast → CA screening; w/o contrast → implant integrity).
i) Best use is screening in young female with BRCA mutation.
ii) ↑mastectomy rate, if lifetime risk ≥20-25% (strong FHx, mantle XRT, BRCA+,
1st degree relative w/BrCa)→ MRI OK for screening.
iii) >25% risk 2/2 genetics (BRCA, p53, etc), to check for chest wall involvement,
pts s/p lumpectomy w/+ margins before re-op.
4) Risk Factors (HRT ↑ breast CA rate by 26%)
a. GAIL model ≥ 1.66 → tamoxifen.
b. Genetic syndromes (ATM [neuro/vasc, leukemia, lymphoma], BRCA1&2, PALB-2,
CDH1, CHEK2, Cowden [PTEN – hamartomas, endometrial CA, RCCa, thyroid CA],
FAMMM [p16], LiFraumeni [p53 – sarcoma, GBM, adrenal], NBN, NF1, Peutz
Jeghers [STK11 – hyperpig mucocutaneous, bowel hamartomas, GI CAs, panc CA,
HCC, endometrial & ovarian CA]).
i) BRCA → makes up 5% of all breast CAs.
MC type → ductal Tx → mastectomy + SLNB vs MRM.

95

Uploaded by MEDBOOKSVN.ORG
 A) BRCA I (chrom 17) a TSG
1. Poorly differentiated, ER/PR- (→ worse prognosis).
2. Female breast CA 60% lifetime risk
3. Ovarian CA 40% lifetime risk
4. Male breast CA 1% lifetime risk
B) BRCA II (chrom 13) a TSG
1. Well diff., ER/PR+; ↑CRCa, panc, stomach, GB, & melanoma.
2. Female breast CA 60% lifetime risk
3. Ovarian CA 10% lifetime risk
4. Male breast CA 10% lifetime risk
a) Tx → mastectomy + SLNB vs MRM
C) Screening & Testing
1. 1st-degree relative with bilateral, premenopausal breast CA increases
breast CA risk to 50%, FHx of male breast CA.
D) Ppx mastectomy ↓BrCa >90%.
Ppx BSO ↓BrCa 50-70% and↓ovarian CA 96%
5) Types
a. Ductal MC type (infiltrating ductal, 85%)
A) Epithelial cell nests invading stroma randomly w/tubule formation.
ii) Subtypes
A) Medullary ductal CA ↑ lymphocytes, smooth, better prognosis even though
poor diff. Asso w/BRCA1.
B) Tubular ductal CA Columnar cells w/atypia, small tubules, better prognosis.
+ LNs rare.
C) Mucinous ductal CA Colloid, ↑mucin, better prognosis. Mets rare.
D) Scirrhotic ductal CA Worst prognosis (of ductal).
iii) Groups
1 (Luminal A) → ER +, PR +, HER2 -. Likely benefit from hormone tx & CTX.
2 (Luminal B)) → ER+, PR-, HER2 +. Likely benefit from anti-HER2 & CTX,
possibly hormone tx.
3 (HER2 +) → ER-, PR-, HER2+. Likely benefit from anti-HER2 & CTX.
4 (Basal-like) → TNBC. Benefit from CTX.
b. Lobular Detection better w/MRI vs mammo. Single-file cells.
i) 10-15% of all breast CA. Ø calcifications (usually); very infiltrative. ↑ b/l,
multi-centric & multi-focal dz. Signet ring cells→↓prognosis.
ii) Tx→ MRM or BCT w/post-op XRT.
c. Paget’s Disease needs full thickness bx, CA in 85-92%.
i) Scaly lesion around NAC. Bx→ Paget’s cells (large cells w/pale cytoplasm &
prominent nucleoli).
ii) Usually underlying DCIS or ductal CA → GET MAMMO 1st (DON’T go straight
to OR).
iii) Tx → confined to NAC → excision to neg margins + SLNB +XRT, otherwise
simple mastectomy.

96
 d. Inflammatory A clinical dx. Considered T4/St IIIc dz.
i) Very aggressive → median survival 36mns (median 30-50% 5YS).
ii) Dermal lymphatic invasion → peau d’orange/lymphedema appearance
(pathognomonic).
Erythematous &
warm.
iii) Tx → neoadj CTX,
then MRM, then
adj CTX-XRT (MC
method).
6) Staging (5YS in %)
a. 0 → Tis, N0, M0 T1 ≤ 2cm N1 ipsilateral / 1-3
b. I → T1 (100) T2 >2-5cm N2 clinical/matted / 4-9
c. IIa →T+N=2(N ≤ 1) (92) T3 >5cm N3 clavicle/IMA / 10+
d. IIb →T+N=3(N ≤ 1) (81) T4 chest wall invasion
e. IIIa → T+N = 4-5 (N = 1-2) (67)
f. IIIb → T4 or N3 (54)
g. IV → mets (20)
MC met to axilla → lymphoma, NOT breast CA.
MultiFOCAL → same quadrant.
MultiCENTRIC → different quadrants.
7) Treatment
a. In general needs “margins off ink,” imprint cytology or frozen section ↓need for
re-excision.
i) Stage IIIa-IV need staging chest CT.
ii) Node negative (NN), Low risk (LR), ER- BrCa→no CTX.
iii) NN, LR, ER+ → anti-estrogen.
iv) NN, HR, ER+ → anti-estrogen +/- CTX (pre-menopause → both).
v) NN, HR, ER- (TNBC 12-24% of all BrCa) → CTX.
vi) NP, ER- → CTX.
b. BCT + XRT
i) No XRT needed s/p BCT only if → >70yo, St I, ER+, no other CA hx, & willing to
take anti-estrogen.
ii) Need negative margins. Local recurrence → 10% (usually w/in 2 years).
iii) CIs to BCT → pt who can’t get XRT (prior BCT w/XRT, scleroderma, 1st
trimester pregnancy, multicentric dz).
c. Mastectomy
i) Clavicle→inframam crease, latissimus→lat sternum, incl pec fascia.
ii) Leaves 1%–2% of breast tissue, can preserve the nipple.
iii) Local recurrence ~5%. SCORE recs leaving a drain.
d. Modified Radical Mastectomy
i) Removes all breast tissue, including the nipple areolar complex.
ii) Includes axillary node dissection (except level I nodes)

97

Uploaded by MEDBOOKSVN.ORG
e. SLNB (most accurate [95%] when using dye & tracer).
i) ↓complications vs ALND. False negative rate = 4-12%.
ii) Only for malignant tumors > 1 cm; risk of lymphedema 7% at 6mns.
iii) ACOSOG Z0011
A) BCT + whole breast XRT + CTX for T1-2 & clinically NN, but < 3 LN+ on
SLNBx → no ALND is needed (no survival benefit).
B) Not indicated in patients w/clinically positive nodes (need ALND).
iv) ACOSOG Z1071
A) N1-2 → neoadj CTX → ypN0 → can start w/SLNB. If 3 LNs sampled & all are
negative → no ALND (just axillary XRT).
v) Nerves to pec major are found → medial/deep to SLNBx.
vi) Can't find hot or blue node → ALND.
f. ALND (Cxs→ nerve injury [MC is intercostobrachial], lymphedema, seroma,
↓ROM). SCORE recs leaving an axillary drain.
i) Sup: ax vein Lat: latissimus Med: pec minor Post: subscapularis
ii) Level I→ Inferior/lateral to pec minor.
iii) Level II→ Beneath pec minor.
iv) Level III→ Medial to pec minor (for melanoma, not breast).
g. Radiation
i) Breast XRT (5-6wks) → ≥T3 or N2 or as part of lumpectomy-BCT.
ii) Axillary XRT if ≥4+ LNs, bulky LNs, extranodal extension
iii) Lymphedema Tx for edema s/p ALND → compression.
iv) Stewart-Treves Syndrome
A) Tx → resect (often need amputation).
B) Lymphangiosarcoma → 2/2 chronic lymphedema s/p ALND.
C) Dark purple nodule or lesion on arm 5-10 years after surgery.
h. CTX – usually 4-6 cycles over 4-6mns w/TC or TAC (ddAC + T).
i) T = Taxane, A = Adrimycin, C = Cyclophosphamide.
A) Most effective in sequence: CTX → XRT → hormone Tx.
ii) CTX for→TNBC, HR oncotype DX, T2 or N1 (T2/N1 get neo-adj).
A) High risk (HR) oncotype Dx → CTX (then hormone tx if HR+)
iii) Neoadjuvant CTX if → ≥T2 or N+, TNBC, HER2+, inflammatory.
iv) Neoadj vs adj CTX → no diff in survival, but ↑BCT in neoadj
v) No path CR s/p neo-adj CTX → add capecitabine for TNBC & ado-trastuzumab
emtansine for HER2+.
vi) any HER2+ (3+by IHC) → neoadj CTX + Herceptin/trastuzumab (a HER-2
tyrosine kinase receptor mAb) + pertuxamab for 1 yr.
A) If residual dz → add TDM-1.
vii) If ipsilateral recurrence & ER- → repeat CTX (↑’s overall survival & DFS).
i. Hormonal Therapy → SERMs (eg. Tamoxifen) or Aromatase Inh (eg. Anastrazole
x 5yrs).

98
j. Pregnancy (never give XRT)
i) 1st trimester → MRM vs mastectomy + SLNB (no CTX).
ii) 2nd trimester → MRM vs neoadj CTX w/BCT then postpartum XRT.
iii) 3rd trimester → MRM vs mastectomy + SLNB, or Neo-adj CTX, BCT, &
postpartum XRT.
iv) CTX (except for tamoxifen, taxanes, trastuzumab, MTX, & folates) is safe in 2nd
& 3rd trimesters.
v) U/S is best 1st test for new mass during pregnancy.
vi) No XRT or blue dye while pregnant. No breastfeeding after delivery.
Radioisotope is safe.
k. Males (RFs → BRCA II > I, CHEK2, Klinefelter, ↑ age, hepatic dz, EtOH).
i) MC is ER/PR+, HER2 - IDC
ii) Mastectomy + SLNBx + Tamoxifen if ER+.
l. Reconstruction
i) Tissue expanders
A) Work by local recruitment & thinning dermis/epidermis →→ implant
placement.
B) Subpectoral pocket, minimal inflation. Slowly filled over next weeks &
months →→ space for final implant.
ii) Implants Concerning lesion by capsule → stereotactic CNBx.
A) Breast Implant Asso Anaplastic Large Cell Lymphoma (BIA-ALCL)
1. Rare (1:10-20k). Fluid around implant >1yr after surgery.
2. Dx → U/S asp, send for cyto & CD30.
3. Tx → remove implant w/capsule intact.
iii) Flaps
A) TRAM
1. Smoking, especially >10pk/yr hx → ↑flap necrosis & abd hernia. Need
to stop > 4wks prior to OR.
2. Blood supply of TRAM flap → epigastrics.
3. Best immediate recon s/p MRM, no h/o CABG or XRT → TRAM (likely
DIEP flap now, but usually are delayed).
iv) Post-op concern for seroma (w/o c/f infection) → aspirate to allow for
apposition of tissue (per SCORE).
m. Recurrence (if ER+ → 0.3-0.5%/yr, if ER- →1%/yr (<10% at 10yrs).
i) For new lump/discoloration in mastectomy scar → Bx (restage + excision if pos
for CA).
ii) Recurrence s/p BCT + SLNBx → MRM (can’t give more XRT [needed as part of
original BCT] or repeat a SLNBx [lymphatics disrupted]).

99

Uploaded by MEDBOOKSVN.ORG
19. Thoracic
A. Anterior Mediastinum “6 T’s” Inspiratory Reserve Volume
Inspiratory
1) Teratoma (& other germ cell Capacity
Vital Capacity
tumors) → MC ant. med. tumor
in kids. Tx → resect.
Tidal Volume
2) T-cell lymphoma Tx → CTX.
3) Thymoma → MC ant med Expiratory Reserve Volume
Functional
tumor in adults. Rare in kids. Residual
4) Thymic carcinoid Tx → resect. Residual Volume Capacity
5) Thyroid cancer
6) paraThyroid adenoma 4 Volumes & 4 Capacities (inc Total Lung Capacity)
B. Middle Mediastinum
1) Heart/pericardium, great vessels, trachea, esophagus, hilum.
2) Bronchogenic cysts, neuroenteric cysts, pericardial cysts, lymphoma.
C. Posterior Mediastinum
1) Neurogenic Tumors → MC post mediastinal & MC mediastinal overall.
a. Neurolemma MC; schwannoma, benign nerve sheath tumor.
b. Neurofibroma (nerve sheath) → asso w/von Recklinghausen's (cafe-au-lait
macules, freckles, optic gliomas); 5% malignant. Others → ganglioneuroma
(benign), ganglioneuroblastoma (malignant), neuroblastoma (very malignant, MC
in kids).
2) Esophagus, lymphoma.
D. Lung
1) Preoperative evaluation
a. Most predictive (sensitive) PFT for intolerance to lobectomy / level needed prior
to surgery.
i) DLCO / >10mL/min/mmHg CO or predicted post-op >40%.
b. Most predictive (accurate) PFT for post-op outcomes / level needed prior to
surgery.
i) FEV1 lobectomy / pneumonectomy → >1.5L (>60%) / >2L.
c. CIs to lung resection → FEV1 <800mLs, pCO2 > 50, pO2 <60, VO2 max <10-
12mL/min/kg.
d. Atelectasis → ↓ FRC PEEP → ↑ FRC.
e. PFT most reflective of open & collapsed alveoli → FRC.
f. Aging → ↓DLCO, vital capacity, & ↓↓ chest wall compliance.
i) ↑ Residual volume, FRC, & lung compliance.
ii) ↑ lung compliance + ↓↓ chest wall compliance = ↓ overall compliance.
2) Pulmonary Nodule
a. Solitary Pulmonary Nodule (SPN) → <3cm & well-circumscribed.
i) 2017 Fleischner Guidelines Low-risk & <6mm → no f/u
6-8mm → CT in 6mns >8mm → CT in 3mns vs Bx
ii) >50yo → 50% malignant (lobectomy for dx & tx if good operative candidate).

100
 b. Biopsy (for LNs >1cm) If concerning periph mass + concerning mediastinal LNs →
Bx LNs via closest tube (bronch vs eso).
i) Young F w/calcified mass on R/lateral aspect of middle mediastinum b/w R
bronchus & heart → mediastinoscopy for bx.
ii) Transbronchial EBUS or Mediastinoscopy → Best way to bx central lung mass.
A) EBUS-TBNA→ preferred 1st-step for large, central mass/ suspicious
mediastinal + hilar LNs (2R, 2L, 3p, 4R, 4L, 7, 10R, 10L, 11R, 11L).
B) Mediastinoscopy → VATS vs direct. Can bx upper paratracheal (stations 2R,
2L), right paratracheal (station 4R), left paratracheal superior to the aortic
arch (station 4L), & subcarinal (station 7).
iii) VATS
A) Best for peripheral lung mass/paraesophageal, subaortic (station 5) &
para-aortic (station 6) nodes. Also for azygos (station 4R), paraesophageal
(station 8), or pulmonary ligament (station 9) LNs.
B) LNs extend to chest wall → anterior mediastinotomy instead.
iv) Anterior Mediastinotomy/Chamberlain Procedure: take 2nd rib off angle of
Louis → left paratracheal (4L), subaortic (5), para-aortic (6), & subcarinal
nodes (7) + anterior mediastinum.
3) Hamartomas + calcifications (“popcorn lesion” on chest CT)
a. MC benign lung tumor in adult.
b. Diagnosis can be made with CT. Do not require resection.
c. Repeat chest CT at 6 months for confirmation/ r/o CA.
4) Lung Cancer Pre-op w/u → PFTs, stage mediastinum, PET CT, & bronch.
a. USPSTF/NLST Guidelines → q1y x3 low-dose CT if 55-80yo, ≥30pk/yr.
b. Lobectomy = tx of choice, can consider wedge if <2-3cm & N0.
c. Non-Small Cell Lung Carcinoma (NSCLC)
i) PACCS → Peripheral = Adeno, Central = Carcinoid & Squamous.
ii) Adenocarcinoma
A) More peripheral, MC lung Ca.
iii) Squamous cell carcinoma
A) More central. Paraneoplastic Syndrome → PTH-rp.
iv) Bronchoalveolar carcinoma
A) Looks like PNA; along alveolar walls; multifocal.
v) Tx by Stage
A) I-II (- LNs) → resect. III (+ LNs) → resect + CTX-XRT.
B) IV (+mets) → CTX-XRT.

101

Uploaded by MEDBOOKSVN.ORG
102
 d. Small Cell Lung Carcinoma (SCLC) Neuroendocrine origin.
i) Paraneoplastic Syndrome (PNS) → ACTH & ADH (SCLC is MC to have a PNS;
ACTH MC PNS in SCLC).
A) Lambert-Eaton Synd → prox weakness 2/2 Ab to Ca++ channels. Tx → IVIg,
steroids, 3-4DAP.
ii) 20% of lung Cas. Most are unresectable (< 5%), poor prognosis.
iii) Overall 5-YS → < 5%.
iv) Stage T1, N0, M0 5-YS → 50%.
v) Palliative chemo-XRT for most.
e. Mesothelioma
i) Aggressive local invasion, most malignant lung CA. 2/2 Asbestos.
ii) +LN, & distant mets common at dx.
iii) Tx: if pleural component → extrapleural pneumonectomy best (for local
control, Ø difference in OS).
f. Pancoast Tumor / SVC Syndrome→ best indication for emergent XRT.
i) 65% are 2/2 CA. 35% are 2/2 infection/prior vasc Cx.
ii) Dx → Chest CT.
iii) Tx → 1st stent, 2nd CTX+XRT( > CTX then XRT > XRT alone).
5) Resections
a. Wedge
i) Lobectomy
ii) Afib common s/p lobectomy→1st β-block (or CCB if COPD). If unstable or < 2
days → cardiovert. If > 2 days → ECHO + cardiovert if no clot or delayed
cardioversion (3wks).

103

Uploaded by MEDBOOKSVN.ORG
 b. Pneumonectomy
c. Metastectomy Best indication if in lung → osteosarcoma.
6) Upper Airway Tumors
a. Mucoepidermoid Adenoma & Mucous Gland
i) Slow growth, Ø mets. Tx → resection.
b. Carcinoid Neuroendocrine, central.
i) 5% mets at dx. 50% have sxs (cough, hemoptysis).
ii) Typical → 90% 5-YS Atypical → 60% 5-YS
iii) Tx → resect + LN sampling. Tx like CA. Outcome per histology.
↑ recurrence w/+LNs or tumors > 3 cm.
c. Adenoid Cystic
i) Submucosal glands; along perineural lymphatics past endoluminal elements;
very sensitive to XRT.
ii) Grow slowly. Decent 10-YS even w/R1 resection.
iii) Tx → resection. If unresectable, XRT → decent palliation.
7) Pulmonary Embolus
a. R Pulm artery PE w/R heart strain/dysfunction → mech cath directed
embolectomy.
b. Best localizing test for PE → CTA PE.
8) Pleural Effusion
a. How to darin → sitting/8th ICS b/w post-ax line & spine.
i) To prevent PTX/re-expansion pulmonary edema, stop thoracentesis if chest
pain or vol ≥1000mLs (some say 1500mLs).
b. Malignant effusion (blood-tinged/exudative) → send for cytology.
i) Caking preventing apposition → tunneled pleural catheter.
c. Best way to drain cirrhotic effusion → generally thoracentesis, chest tube if large
or recurrent.
9) Transudate vs Exudate
10) Abscess
a. Necrotic.
b. MC asso w/aspiration & in superior RLL.
c. Chest CT can help differentiate empyema from lung abscess.
d. Tx → abx alone (95% success). CT-guided drain if abx fails.
i) Surgery if drain fails or to r/o CA (ie. >6cm or Ø resolve s/p 6 wks).
11) Catamenial PTX → recurrent PTX 2/2 endometriosis.
12) Rasmussen Aneurysm → Pulm artery aneurysm 2/2 adjacent TB cavity.
13) Empyema Sxs → cough, fever, pleuritic chest pain, SOB.
a. WBCs > 500 cells/cc, bacteria, & Gram +.
b. Exudative phase (1st week) → Tx: abx, chest tube.
c. Fibro-proliferative phase (2nd week) → Tx: abx, chest tube; VATS deloculation.
d. Organized phase (3rd week) →Tx: consider decortication.
e. In the 1st & 2nd week some are using intra-pleural tPA (tissue plasminogen
activator; 10mg) & Pulmonzyme (DNase; 5mg) BID x3d/clamp 1h to try & remove
the collection if chest tube fails.
i) Possible Eloesser flap (open window environment) in frail/elderly.

104
14) Chylothorax
a. Milky, +chylomicrons, ↑ TAGs (> 110 mg/dL) & PMNs. + Sudan red.
b. Infection resistent. >1L/d = High output.
c. 50% 2/2 trauma/iatrogenic 50% 2/2 tumor.
i) Lymphoma MC malignant (2/2 tumor in lymphatic ducts).
d. Above T5–6 → left-sided. Below T5–6 → right-sided.
e. Tx → 2-3 weeks conservative tx (chest tube, strict low-fat diet + MCTs [TPN if
protracted], ± octreotide). No ppx abx.
i) IR for lymphoscintigraphy & embolization before OR.
ii) If fails & 2/2 trauma/iatrogenic → ligate thoracic duct in mediastinum on
right (above cisterna chyli, 80% success).
iii) If 2/2 CA → pleurodesis & possible CTX ± XRT (↓ success).
15) Massive Hemoptysis > 600 mL/d. Bronchial aa - 90% (pulm aa → ~5%).
a. MCC → infection. Death 2/2 asphyxiation.
b. Tx →
i) Bleeding side dependent; mainstem ETT opposite to bleed.
ii) Bronchial artery embolization (can share origin w/ASA &/or supply spinal cord
directly, inj → paralysis).
iii) If fails→ rigid bronch → lobectomy → pneumonectomy for control.
16) Pulmonary AVM
a. Usually lower lobes. Seen in Osler-Weber-Rendu dz.
b. Sxs → TIA/CVA, SOB, hemoptysis. Tx → embo.
17) Tracheo-innominate artery fistula See Trauma chapter.
18) Tracheo-esophageal fistula → 2/2 prolonged ETT asso w/NGT vs OG.
a. Large cuffed ETT below fistula. May need decompressing gastrostomy.
b. Repair s/p vent wean.
c. Tx → tracheal resection, reanastomosis, close esophagus, sternohyoid flap b/w
esophagus & trachea.
19) Tracheal Stenosis At stoma site of trach or cuff site of ETT. 2/2 cuff too high (above
2nd ring).
a. Tx →
i) Minor → Serial dilatation, bronchoscopic resection, or laser ablate.
ii) Recurring/severe → Tracheal resection w/end-to-end anastomosis.
20) 1° Tracheal Cancer → resect + XRT (CTX NOT effective).
21) Thoracentesis Use U/S. Pt sitting upright. Perform 2 ICSs below dullness, but
above 9th ICS b/w scapular spine & post ax line.
a. Prep skin → local → Seldinger 18-20G needle over rib while aspirating until get
fluid → send 50mL for labs (cell #, protein, LDH, pH, glucose, amylase, Gram
stain, Cx, & cytology).
22) Thoracotomy Block → inject b/w innermost & internal intercostal muscles from
2 ICS above to 2 ICS below.

105

Uploaded by MEDBOOKSVN.ORG
20. Cardiac
A. Heart Defects
1) Cyanotic; R → L shunt 5 T’s of right-to-left shunt [1, 2, 3, 4, 5].
a. Truncus Arteriosus (1 vessel)
b. Transposition of Great Vessels (2 vessels transposed)
c. Tricuspid Atresia (3 = Tri)
d. Tetralogy of Fallot (4 = Tetra) Initial Tx → β-blocker.
i) PROVe = Pulm stenosis, R vent hypertrophy, Overiding Ao, VSD.
e. Total Anomalous Pulmonary Venous Return (5 words)
i) Initial Tx → PgE1.
2) Non-Cyanotic; L→R shunt; Others
a. ASD, Ostium Primum asso w/Down synd (+ other endocardial cushion defects) &
mitral insufficiency.
b. ASD, Ostium Secundum MC ASD.
c. Mitral Valve Prolapse Connective tissue d/o (Marfan [aortic root dilation], Ehler-
Danlos, osteogenesis imperfecta).
d. Mitral Stenosis asso w/Rheumatic fever.
e. Aortic Stenosis Asso w/Bicuspid valve &Turner’s synd.
f. Coarctation of Aorta Asso w/Turner’s synd.
g. PDA Asso w/congenital rubella, septal defects, & PA stenosis.
h. VSD MC congenital heart defect.
3) Eisenmenger’s Syndrome Kid w/previous L→R shunt (VSD, ASD, PDA) & cyanosis,
converts to R→L shunt.
a. Repair is CI if PVR is >8 Wood units & irreversible w/vasodilators.
B. Cardiac function preserved w/age → Systolic.
C. Aortic Stenosis Cxs of Aortic Stenosis → CHF, Angina, Syncope.
AoV → replace > repair. MV → repair > replace.
1) MC valve lesion; calcs → stenosis.
2) Cardinal sxs:
a. Dyspnea on exertion – avg prognosis → 5 years.
b. Angina – avg prognosis → 4 years.
c. Syncope (worst of the cardinal sxs) – avg prognosis → 3 years.
3) OR Indications → usually at valve area < 1.0 cm2 & peak gradient > 50.
4) Abx ppx preop for pt w/mech Ao valve.
a. Only for dental or respiratory surgeries. Use amox, amp, ancef, keflex, clinda, z-
pack, or vanc.
D. Ventricular Septal Rupture (Acute VSD)
1) Systolic murmur s/p inferior MI (leads II, III, aVF), O2 step up (L→R shunt).
2) 1st → IABP. 2nd → operative repair + bypass of occluded coronary artery.
E. Mitral regurgitation from rupture of papillary muscles
1) New holosystolic murmur s/p MI, no O2 step up.

106
F. Mitral Stenosis Dx → diastolic murmur. ECHO is diagnostic.
1) Adult immigrant, h/o Rheumatic fever, Afib & pulm congestion.
2) Tx → Percutaneous mitral balloon commissurotomy.
G. Tricuspid Vegetation MC 2/2 IVDU.
H. Strep Bovis Endocarditis → ML 2/2 Colon CA.
I. IABP → ↑ coronary vessel perfusion & ↓afterload.
J. CHF → MI determinant of post-op cardiac morbidity.
K. Coronary Artery Disease → MCC of death in US.
1) CABG for → 1v = Left main, 2v +DM, or 3v dz.
L. Sternal Dehiscence → 2/2 infection (MC Staph) → acute mediatinitis.
1) + Hamman’s sign (crunching over precordium).
2) RFs → B/L IMA grafts (esp in DM), obesity. 30% mortality.
3) Tx → abx, debride, drain, rewire.
M. Pericardium
1) Pericardiocentesis is better than subxiphoid window in effusion 2/2 thoracic
aneurysm.
2) Purulent pericarditis very thick ± loculations → subxiphoid window.
N. Cardiac Tumors MC mets to heart → Lung CA.
1) Atrial Myxoma → Spindle cells. MC overall. MC on Left.
a. Tx if on either side → sternotomy + B/L atriotomies.
2) Rhabdomyoma → MC pediatric cardiac tumor.
3) Angiosarcoma MC 1° malignant cardiac tumor.

107

Uploaded by MEDBOOKSVN.ORG
21. Vascular
A. Cerebrovascular Anti-PLT effect of ASA same at 81mg as 325mg.
1) ↓ Atherosclerotic RF → stop smoking, walk, statins, BP control, antiPLTs.
2) Carotid Stenosis MC CEA nerve inj → hypoglossal (then vagus).
a. Asymptomatic
i) 50-69% → ASA/plavix + statin + anti-HTN (+tx DM if present)
ii) 70-99% → CEA
b. Symptomatic
i) Male
A) < 50%→ASA/plavix + statin + anti-HTN (+tx DM)
B) 50-99% → CEA
ii) Female (same as asymptomatic)
A) 50-69% → ASA/plavix + statin + anti-HTN (+tx DM)
B) 70-99% → CEA
c. Restenosis → 15 % s/p CEA.
i) 1st mn → tech error
ii) Early (< 2yrs) → neointimal hyperplasia.
iii) Late (>2yrs) → atherosclerosis.
3) TIA → CEA in 2wks Crescendo TIA → CEA now
4) Ischemic CVA MI→CEA>CAS (by troponin, no diff longterm)
a. Small → CEA 2wks CVA & death MC CAS>CEA
b. Moderate-Large → CEA 4-6wks CEA: stroke > MI
5) Carotid Body Tumors / Paragangliomas
a. Dx → CTA (wide bifurcation/blush → “Lyre sign”).
b. Tx → resect in periadventicial plane.
B. Kawasaki’s Disease
1) Kids; virus w/fevers + erythematous epidermis & mucosa. Coronary &
brachiocephalic aneurysms → arrhythmia (MC M&M).
2) Tx → steroids, if fails → CABG.
C. Raynaud’s Disease MC F, young; pallor → cyanosis → rubor.
1) Tx → CCBs, warm.
D. Buerger’s Disease/Thromboangiitis Obliterans
1) Smokers, young M. Severe rest pain w/ b/l digital ulceration & gangrene.
2) Angio → “corkscrew” collaterals w/distal dz; looks nml proximal to elbows & knees.
3) Tx → d/c smoking, eventually amputation(s).
E. Hypersensitivity Angiitis
1) 2/2 drug/tumor Ags. Sxs → fever, palpable purpura, organ failure.
2) Tx → stop cause, CCBs, pentoxifylline.
F. Fibromuscular Dysplasia
1) MC F; HTN if involves renals. HA or CVA if involves carotids (ML die from CVAs).
“String of beads.” Medial fibrodysplasia MC variant (85%).
2) MC vessel → Renal artery > ICA > Cerebral > Ext iliac (RICE).
108
 3) Tx → PTA (best); bypass if that fails (no stents → hastens dysplasia).
G. Polyarteritis Nodosa
1) Arthralgia, CKD, HTN,↓wt, rash. Renal aneurysm(MC) →thromb/rupture.
2) Tx → steroids.
H. Temporal Arteritis
1) F > 55yo, blurry vision, HA, fever → blindness.
2) Bx → giant cell arteritis & granulomas in aorta/proximal branches.
3) Angio → Long, smooth stenosic segments w/post-stenotic dilation.
4) Tx → steroids, possible bypass (no endarterectomy).
I. Takayasu’s Arteritis/Pulseless Disease
1) MC F (8:1), Asians. Massive intimal fibrosis in aorta & brs.
2) Carotidynia → pain along inflamed carotid
(pathognomonic).
3) Tx → steroids → PTA → bypass.
J. Subclavian Steal Syndrome
1) 2/2 proximal subclavian stenosis →flow reversal from
vertebral to subclavian artery
2) OR if arm or neuro sxs (MC vertebrobasilar).
3) Tx → subclavian stent; if fails→ common carotid-subclavian
bypass (see figure →).
K. Thoracic Outlet Syndrome
1) (ant) ViP MAN (post) → Vein,
Phrenic, anterior scalene Muscle,
Artery, Nerves.
2) Dx → CXR (1st), duplex U/S.
3) Neurogenic MC, 95%, H&P can dx
most → shoulder, medial arm, & ulnar
(4th/5th digit) pain.
a. Dx → cervical & chest MRI, & EMG.
b. MC abnormality → Cervical rib.
MCC of pain → brachial irritation.
c. Tx → PT/OT 1st.
4) Venous/ Paget–von Schrötter Disease ~5%. Effort-induced thrombosis of subclavian
v. Pitchers &/or swimmers w/unilateral acutely painful, swollen, & blue arm.
a. Dx → venography is “gold standard,” but duplex is quicker.
b. 80% have a thoracic outlet issue.
c. Tx → 1st hep gtt + thrombolytics + repair before discharge (resect cervical + 1st
rib, divide ant scalene) & anticoag (1-3mns total).
5) Arterial (~1%)
a. Compression 2/2 anterior scalene hypertrophy (weightlifters).
b. Sxs → ischemic hand pain & absent radial pulse w/head turned to ipsilateral side
(Adson’s test).

109

Uploaded by MEDBOOKSVN.ORG
 c. Pick Miner Syndrome similar, 2/2 ligamentous compression more distal to
anterior scalene.
d. Dx → duplex or angiogram (gold standard).
e. Tx → surgery (cervical rib & 1st rib
resection, divide anterior scalene muscle;
poss. carotid-subclavian bypass if artery too
aneurysmal/damaged).
L. Aneurysmal Disease
1) Thoracic Aorta (TEE sens. 97-100%)
a. Stanford (based on ascending aorta)
i) Class A – any ascending aortic (MC type
in Marfans dz)
ii) Class B – descending aorta only
b. DeBakey
i) Type I – ascending & descending
Surgery
ii) Type II – only ascending
↓ dp/dt (double-product control = HR x SBP <10,000),
iii) Type III – only descending st
β-blocker 1 to ↓HR/contractility before vasodilators
c. Open Required for Stanford A to ↓SBP. If not, → worsens dissection.

d. Endovascular TEVAR after double-product control is usually best choice (fewest

cxs).
2) AAA ~15% have pop aneurysm.
a. Surgical mortality <4%, 5ys ~30% (2/2 comormidities).
b. RFs → >69yo, smoking, COPD, CVA hx.
c. Tx if → 5.5cm M (5cm F), ↑>0.5cm in 6mn, sxs.
d. Combined AAA (> 5.5 cm) & colon CA.
i) Tx symptomatic issue 1st (eg AAA w/back
pain or obstructing CRCa).
ii) If elective & in OR, fix what you came to fix
& work-up the incidental after.
iii) If both elective & asymptomatic, Tx colon
CA 1st followed by AAA repair in 2-4wks (do
dirty case 1st then place graft).
e. Open (for ruptured AAA → 1st gain control
w/ballon occlusion).
i) Persistent chyle leak s/p open AAA → lymphoscitigraphy (dx & tx).
ii) Best indication for open repair vs EVAR → Aorto-femoral dz w/extensive calcs.
iii) Persistent leaking from groin wound or sxs → explore.
f. Endovascular
i) MCC of Endoleak→ back-bleeding mesenteric/lumbar aa (Type II).
ii) MCC of re-op s/p EVAR → Endoleaks (~15%) vs access site cx (7%).
A) Type I “A’s” Ia – proximal Attachment (Tx all)
“1,2,3,4,5 Ib – distal Attachment(s) (Tx all)
= B) Type II “B’s” Branches, Back-Bleeding MC type.
A,B,C,D,E” 1. If expanding → embolize bleeding vessel (IMA or lumbar).
110
 C) Type III “C’s” Connections (Tx all)
D) Type IV “D’s” Device porosity (blood seeps out)
E) Type V “E’s” Endotension (plasma seeps through)
g. Aortoenteric Fistula
i) Tx → 1st EVAR vs ex lap control, 2nd ax-fem (use arm w/highest SBP)
classically, now most do excision + in situ aortic homograft.
h. Graft Infections 2/2 staph epi > pseudomonas.
i) Tx → extra-anatomic bypass then explant.
3) Splenic
a. MC visceral/splanchnic aneurysm (60%, MC F; 2% rupture [but 50% do in
pregnancy]).
b. Repair if sx, > 2cm pregnant or childbearing F, or is > 3–4 cm.
c. ↑ pregnancy-related rupture (esp. 3rd trimester).
4) Other Splanchnic
a. RFs → medial fibrodysplasia, portal HTN, injury 2/2 inflammatory dz (eg
pancreatitis). If good collateral →coil. If not(eg. PHA)→open rSVG.
b. Rupture %: Gastroepiploic→90%,
Hepatic→60-80%, GDA/PDA→60%.
c. Tx → Repair all > 2 cm at dx (overall 50%
rupture) except splenic. Covered stent
(best); if fails → exclusion & bypass.
5) Renal > 1.5 cm, Tx → covered stent.
6) Iliac > 3.0 cm, Tx → covered stent
7) Femoral > 2.5 cm, Tx → resection
w/interposition bypass.
8) Popliteal
a. MC peripheral aneurysm, ½ are B/L, ½ have another aneurysm (MC AAA),
bounding pop pulses, leg pain 2/2 to compression.
b. Thrombose → embolize distally. Dx → duplex.
c. Tx if sx, > 2 cm, or mycotic → exclusion & bypass (Untreated, 25% need
amputation.)
M. Median Arcuate Ligament Syndrome
1) Compresses celiac a → chronic pain, diarrhea, epigastric bruit, & ↓ wt.
2) Tx → divide ligament; may require reconstruction.
N. SMA Syndrome/Wilkie Syndrome
1) Young pt w/sig rapid ↓wt (usually 2/2 major operation or trauma) → loss of peri-
duodenal fat → Aortic-mesenteric angle < 25° (nml 38-65°) → duodenal (D3)
compression → abd pain, food fear, n/v.
2) Tx → 1st non-op (eat leaning forward, DHT, need to ↑wt (high kCal diet) → ↑ pre-
alb); if fails → duodenojejunotomy.
O. Mesenteric Ischemia
1) Arterial (Jejunal sparing [1st portion] MC w/SMA embolus [lodges at origin of
middle colic]. Thrombotic MC at origin of celiac [2nd MC SMA].)

111

Uploaded by MEDBOOKSVN.ORG
 a. Acute Sudden “pain out of proportion” → hematochezia & peritonitis.
i) MC source → Afib (also endocarditis, recent MI, & angio).
ii) Dx → angio or abd CTA (accuracy → >95%).
iii) Tx → 1st resus + hep gtt, 2nd ex lap + transverse embolectomy ± vein/bovine
patch, resect dead bowel (high-risk pt → PTA + stent).
A) Exposure → divide ligament of Treitz, SMA is right of LoT near base of the
transverse mesentery.
b. Chronic ↓wt 2/2 food fear (visceral angina 30 min post-prandial).
i) Tx → PTA & stent (20% M&M), if fails→ bypass (30% M&M; little/no calcs→
suprarenal Ao-SMA or R CIA-SMA bypass).
2) Venous Thrombosis
a. Short seg of intestine effected → hematochezia, crampy abd pain.
b. Poss h/o vasculitis, hypercoag, portal HTN.
c. Dx → abd CTA w/venous phase (or venogram).
d. Tx → hep gtt. OR for peritonitis (resect dead bowel if present).
3) Non-Occlusive Mesenteric Ischemia (NOMI) ~50% mortality.
a. Vasospasm, ↓ flow, hypovolemia (also digoxin → ↓visceral flow).
b. RFs → CHF, cardiopulmonary bypass, prolonged shock.
c. Sxs → hematochezia, crampy abd pain.
d. Watershed areas most effected.
i) Griffith’s point → splenic flexure Sudak’s point → upper rectum
e. Tx → IVF resus. Catheter-directed NTG or papaverine (anti-spasmotic) into SMA
→↑ visceral blood flow. Also consider dobutamine to ↑ CO/visceral perfusion.
OR for peritonitis.
P. Aorto-Iliac Occlusive Disease
1) Leriche Syndrome → No femoral pulses, Buttock/thigh claudication.
a. Impotence (2/2 ↓ internal iliac flow).
b. Lesion at bifurcation or above.
c. Tx → aorto-bifemoral bypass graft.
2) May-Thurner Syndrome (See image →).
a. Tx → hep gtt, thrombolysis.
b. If chronic stenosis, best tx is endovenous
PTA + stenting per SCORE & ESVS.
Q. Pseudoaneurysms (PSA)
1) Non-infected
a. 2/2 trauma, PTA, or vascular suture line disruption.
b. Tx → If <2cm → obs. >2cm → U/S-guided compression w/thrombin injection. OR
for PSA flow s/p thrombin injection, rupture, total thrombosis, showering
emboli, or at suture line early s/p surgery.
2) Infected Early (<4mn)→ MC staph aureus. Late (>4mn)→ MC staph epi.
a. Late PSA at suture lines (months to years) → suggests graft infection (debride &
reverse GSV graft).

112
R. Popliteal Entrapment Syndrome M, 40s.
1) MC have mild/intermittent claudication. Lose pulse w/plantarflexion.
2) MC 2/2 medial deviation of pop a around medial head of gastroc(Type 1).
3) Tx → resect medial head of gastroc. May need arterial reconstruction.
S. Adventitial Cystic Disease M, 40s; MC area → popliteal fossa.
1) Often b/l. 2/2 ganglia from adjacent tendon sheath/joint capsule.
2) Sxs → intermittent claudication w/knee flexion/extension.
3) Dx → CTA vs angio (“Scimitar sign”). Tx → cyst resection (w/rSVG if occluded).
T. Peripheral Vascular Disease

1) Per SCORE: claudication (ABI 0.5-0.9) → rest pain

(<0.5) → Critical Limb Ischemia (~0.1).
2) Tx → d/c smoking, ASA/Plavix, statin, control BP &
DM.
a. Med tx w/ most sx improvement → cilostazol.
b. Endovascular tx if rest pain, tissue loss, or suspect proximal dz.
c. Wet gangrene/foot abscess → I&D, abx, & then urgent revasc.
i) Watch out for pedal sepsis.
3) Plaques are usually on posterior surface, so clamp dz’d post portion against nml ant
& only grab adventitia.
4) ML to get SFA dz → Smokers. ML to get infra-popliteal dz → Diabetics.
a. No palp pulse s/p in-situ fem-post tib GSV bypass POD7→ 2/2 AVF (2/2 non-
ligated br).
b. Pop branches → Ant tibial, post tibial, peroneal (ML to remain open).
c. Fem-pop rSVG bypass, good flow in rSVG by U/S, no pulse/flow at ankle → dz
distal to pop (eg. AT/TP trunk).
d. MCC rSVG bypass failure Early (<30d) → technical.
Intermediate (30d-2yr) → intimal hyperplasia.
Late (>2yrs) → atherosclerosis.

113

Uploaded by MEDBOOKSVN.ORG
U. Acute Limb Ischemia (ALI)

1) 66-77% from heart (MCC → Afib, valve dz, arrhythmia, recent MI w/left ventricular
thrombus, myxoma, aorto-iliac disease).
2) Ischemic sxs ~10-15cm distal to occlusion.
3) Emboli lodge at aortic or femoral bifurcation & BK pop (AT & TP trunk), NOT at AK
pop.
4) MC site of peripheral obstruction from emboli → CFA.
5) MCC of leg edema s/p fem-pop → disrupted lymphatics.
6) Tx → embolectomy w/postop angio. Fasciotomy if ischemia > 4–6 hrs.
a. Arteriotomy proximal to bifurcations. 2-3F Fogarty past elbow/knee.
b. UPRTOR 2/2 painful, tight LE 4hrs s/p emergent revasc 2/2 acute embolism → 4
compartment fasciotomy.
c. Aortoiliac emboli (NO femoral pulses B/L) → b/l CFA cutdowns w/embolectomies.
d. Can’t pass Fogarty distal → wrap Esmark distal to proximal.
e. Sudden loss of femoral pulse in just one leg → embolectomy.
f. Post-op → ASA (80mg QD = NOAC, but ↓ major bleeding, per BOA).
7) STILE → ALI <14d, tPA vs open revasc→↓amputation w/tPA (6% vs 18%).
tPA 0.5-4.0mg/hr, heparin 300-500 U/hr.
8) TOPAS → at 1yr, pts who had tPA needed ↓ open revasc, but major bleeding
↑w/tPA (12.5% vs 5.5%).
V. Deep Venous Thrombosis MC in calf.
1) U/S → non-compressible or ↓augmentation distally.
2) Sxs → Pain, TTP, calf swelling. DVT MC w/PICC than CVC.
3) LLE 2× MC than RLE (left iliac vein compressed by right iliac artery).
4) RFs → Virchow’s triad → venous stasis, hypercoagulability, intimal injury.
5) Calf DVT → minimal swelling. Femoral DVT → ankle & calf swelling.
6) Iliofemoral DVT → leg swelling → anticoagulate + catheter-directed
thrombolysis/thrombectomy.
7) DVT 2/2 to PICC → d/c line (+ anticoag if able). Hep gtt or pack w/TPA if must have
that access. If line infected → must d/c line.
8) UE DVT tx in setting of PICC line & ICH → Pull PICC (No anti-coag 2/2 ICH; No SVC
filter [controversial]).
9) Phlegmasia Alba Dolens → TTP, pallor, edema. Tx → heparin.
Alba = white. Cerulea = blue.

114
 10) Phlegmasia Cerulea Dolens →TTP, cyanosis, massive edema.
a. Tx → hep + catheter-directed thrombolysis (better than just hep).
11) DVT Tx → heparin, Coumadin.
a. IVC filter indications → CI to anticoag, PE on Coumadin, free-floating ileofemoral
thrombi, s/p pulmonary embolectomy.
b. PE w/IVC filter → from ovarian veins, IVC cranial to filter, or arm/SVC.
12) Post-Thrombotic Syndrome s/p DVT.
a. ↓competence of deep vein valves → venous reflex & HTN.
b. Tx → compression x24mns. Cath-directed thrombolysis & endovasc tx w/in 14d
may ↓ Cxs.
W. Venous Insufficiency Dx → Reflux (retrograde flow >1sec fem/pop, >0.5sec for
others) on U/S.
1) Tumescence → compresses saphenous, anesthetic, & acts as a “heat sink” for RFA.
2) MCC of transient vision changes, HA, & AMS s/p sclerotherapy → sclero embolus in
pt w/structural heart dz (PFO MC type).
3) CI to superficial vein interventions → Deep venous occlusion/dz, infection, ↓
mobility, & acute DVT.
4) Venous ulcer at medial malleolus Tx → compression.
5) Varicose & Spider veins → RFA best.
a. NO RFA if deep reflux → needs valvuloplasty.
X. Diabetes
1) Dialysis Benefit of synthetic AV graft vs autogenous → can use it sooner.
a. MC Cx of radiocephalic AV fistula → vein stenosis (vein needs to be 2.5-3mm
preop to consider using).
b. Order of preference (MI to least).
i) Arm (↑accessibility, ↓infection).
ii) Distal (radiocephalic → brachiocephalic → brachiobasalic → brachioaxillary
graft).
iii) Non-dominant.
iv) Autogenous > prosthetic (↑patency, ↓Cxs).
v) Direct > transposition > translocation.
c. NKF/KDOQI "Fistula First"
i) Try to place peritoneal dialysis cath 2 wks before use.
A) Graft 3-6wks before use (but can use w/in 2-3wks).
B) Fistula 6 mo before use (but can use w/in 6-12wks).
ii) NO LINES in arms if pt will need dialysis access in near future. If temp HD
access needed, don’t use virgin side.
d. MC failure of A-V grafts & fistulae for dialysis → venous obstruction 2/2 intimal
hyperplasia (aka venous stenosis).
e. AV graft infxn → derbide + IV abx. Persists → resect dz’d portion & extra-
anatomic bypass. Entire graft/anastomosis → resect the entire graft.
f. Bleeding at puncture site → purse-string/figure-of-eight + stick new graft site +
wound care.

115

Uploaded by MEDBOOKSVN.ORG
 g. Cimino → radial artery to cephalic vein; wait 6 wks to use → allows vein to
mature.
h. Interposition Graft (eg brachiocephalic loop graft) → wait 2-3 wks to allow
fibrous scar to form.
i. MC nerve injury: Radiocephalic→ superficial radial.
Brachiocephalic→ median.
2) Diabetic Foot Ulcer RF → neuropathy. MC to have SFA/pop dz than Ao/iliac.
a. WIFI Score (see table →)
b. Pt w/diabetic foot ulcer needs
urgent revasc for toe pressures
< 30mmHg (IWGDF).
3) Gangrene
a. Dry
i) NOT infection. Can allow to
autoamputate if small or just
toes.
ii) Amputate large lesions. Also, check for correctable vascular lesion(s).
b. Wet / Diabetic Foot Infections
i) Infection. Need to remove infected necrotic material + abx.
ii) Can be surgical emergency if extensive/pedal sepsis (red swollen toe w/pus &
red streaks up leg + hypoTN) → emergent amputation.
4) Pedal Sepsis → GP, GN, & anaerobes. Tx → debride/amputate + zosyn.
5) Steal Syndrome → cold/pain below fistula, worse
w/HD, better when fistula is occluded.
a. Segmental pressures → quantify better.
b. Nicoladoni-Branham sign →fistula compression
→↑PVR & afterload → ↑BP & ↓HR.
c. Tx → Distal Revasc & Interval Ligation (DRIL) or
Revision Using Distal Inflow (RUDI).
d. Ischemic Monomelic Neuropathy → extreme
pain POD 0 s/p AVF 2/2 nerve ischemia.
i) Tx → immediate ligation of AVF.
6) Central Venous Stenosis → massive swelling/pain,
h/o ipsilateral dialysis graft/AVF or central line (especially subclavian).
a. Tx → PTA ± stent (possible patch angioplasty/revision) to ↑outflow.
Y. Amputations
1) Tx of wet gangrene, large non-healing wounds, or refractory rest pain not amenable
to surgery.
2) 50% mortality w/in 3yrs 2/2 comorbidities (not 2/2 amputation itself).
3) BKA → 80% heal, 70% walk again, ~5% 30d mortality. If for vascular dz,
4) AKA → 90% heal, 30% walk again, ~10% 30d mortality. not trauma.

116
Z. Thrombophlebitis
1) Superficial thrombophlebitis → inflammation (not infxn).
a. Tx → NSAIDs, warm packs, elevation, & ambulation.
2) Lower extremity (A NEW EXCEPTION!) 2021 ESVS Guidelines
a. >5cm long & > 3cm from saphenofemoral junction → 45d ppx w/fondaparinux
2.5mg/d (>lovenox>NSAID).
b. ≤3cm from saphenofemoral junction → therapeutic anticoag.
c. w/stasis/varicose veins→ wait 3+mns before ligation/ablation.
3) Suppurative thrombophlebitis → infxn (fever, ↑ WBCs, erythema, Tx →
resect to nml vein. fluctuance/purulence).
4) Migrating thrombophlebitis → 2/2 pancreatic CA.
5) Pelvic → usually ~ 2-4d post-partum.
a. Tx → heparin gtt + 7-10d abx if septic.
AA. Lymphedema RF → obesity.
1) 2/2 lymphatic obstruction/failure → subQ fibrosis → “woody” edema in toes, feet,
ankle, & leg. Any subsequent cellulitis/ lymphangitis → major issue. MC infxn →
Strep. Congenital lymphedema L > R.
2) Tx → elevation, compression, abx if infxn.
BB. Lipedema → symmetric “swelling” of BLE 2/2 fat. Tx → ↓ wt.
1) Stemmer sign → pinch skin at base of 2nd
toe.
a. Can’t lift → lymphedema. Can lift → it’s just excess fat.
CC. Lymphangiosarcoma Elevated purple-red lesion, asso w/ALND ~10+ yrs prior
(Stewart–Treves Syndrome). Mets to lung early.
DD. Lost wire or port separation → transvenous retrieval.

117

Uploaded by MEDBOOKSVN.ORG
22. GI Hormones
A. Somatostatin
1) From islet, antral, & duodenal δ cells. Stimulated by acid. Inhibits
gastrin/HCl/insulin/glucagon/sectretin/motilin/all pancreatic & biliary output.
B. Gastrin
1) From antral & duodenal G cells. Stimulated by AA, ACh (vagus), Ca++, EtOH,
distention, pH>3. Inhibited by pH<3, somatostatin, secretin, CCK. Works on parietal
& chief cells.
2) ↑gastric acid secretion + ↑gastrin (can be 2/2 → antral G-cell hyperplasia, gastric
outlet obs, retained/excluded antrum).
C. CCK
1) From duodenal & jejunal I cells. Stimulated by AA & fatty acids. ↑GB contraction,
sphincter of Oddi relaxation, & pancreatic enzyme secretion.
D. Secretin
1) From duodenal & jejunal S cells. Stimulated by fat, bile, pH<4. Inhibited by pH>4,
gastrin. ↑ release of bicarb, insulin, pepsinogen, glucagon, PPP, & somatostatin.
Inhibits gastrin (except in gastrinoma).
E. Glucagon
1) From pancreatic α-cells. Stimulated by ↓ glucose, ↑ AA, & Ach. Inhibited by ↑
glucose, insulin, somatostatin. ↑glycogenolysis, gluconeogenesis, lipolysis, &
ketogenesis. ↓ gastric acid secretion & ↓ gastrointestinal motility. Relaxes
sphincter of Oddi.
F. GIP (gastric inhibitory peptide / glucose-dependent insulinotropic peptide)
1) From duodenal & jejunal K cells. ↓gastric acid secretion & ↑insulin release.
G. Insulin
1) From pancreatic β-cells. Stimulated by glucose, glucagon, &CCK. Inhibited by
somatostatin. ↑ glucose uptake & protein synthesis.
H. VIP
1) From gut & pancreas. Stimulated by fat & ACh. ↑intestinal secretions, ↑motility, &
↓gastrin release.
I. Pancreatic polypeptide (PPP)
1) From pancreatic γ (aka PP or F) islet cells. Stimulated by food, ACh, other GI
hormones. ↓ pancreatic & GB secretion.
J. Motilin
1) From gut. Stimulated by duodenal acid, food, & Ach. Inhibited by somatostatin,
secretin, PPP, & duodenal fat. ↑intestinal motility (phase III peristalsis).
K. Bombesin (gastrin-releasing peptide)
1) ↑ intestinal motility, pancreatic enzyme & gastric acid secretion.
L. Peptide YY
1) From TI. Stimulated by fat. Inhibits acid & pancreatic secretion, stomach & GB
contraction.

118
M. Ghrelin (“Grr = hungry”)
1) From stomach, duodenum, & pancreatic ε cells. ↑hunger.
N. Leptin
1) From adipose cells. Acts on the hypothalamus to ↓ hunger & ↑ satiety.

119

Uploaded by MEDBOOKSVN.ORG
23. Esophagus
A. Anatomy (NO serosa)
1) Blood supply
a. Upper 1/3 → Inferior
thyroid a.(+superior thyroid)
b. Middle 1/3 → Superior &
Inferior left bronchial aa,
right bronchial a, & Aortic
branches
c. Lower 1/3 → Left gastric a
& inferior phrenic a
2) Nml UES resting mmHg→60-80
3) Nml LES: >2cm w/>1cm intra-
abd. Nml resting mmHg→ 6-26
B. Diverticula
1) Traction
a. True diverticulum. Most are
in mid-esophagus, lateral
wall. 2/2 inflammation,
granuloma, tumor, or TB.
b. Sxs → regurg undigested food, dysphagia.
c. Tx →VATS excision & 1° closure if sx. May need palliative XRT if 2/2 invasive CA.
ASx → leave alone.
2) Epiphrenic/Pulsion
a. Rare. Asso w/motility disorders (eg achalasia). MC in the distal 1/3rd of
esophagus & ASx. MC Sx → dysphagia & regurg.
b. Dx → Barium UGI & manometry.
c. Tx → diverticulectomy & myotomy on opposite side (if Sxs).
3) Zenker’s
a. False diverticula 2/2 ↑ pressure while swallowing b/c relaxation failure of
cricopharyngeus.
b. Presents w/wt loss, dysphagia, halitosis, regurgitation of undigested food.
c. Best 1st test → Barium swallow (best dx for oropharyngeal dysphagia).
d. Tx → cricopharyngeal myotomy (key); diverticula either resected or suspended
(removal not required).
i) > 3cm → endoscopic resection (transoral stapled myotomy).
ii) < 3cm → open resection (Hard to see/not enough room for EGD) → Left
cervical incision, resect, & leave drains. UGI on POD 1.
C. Dysphagia Dx → EGD (1st r/o mass/web/etc), high-res manometry (2nd).
1) Achalasia Often idiopathic (loss of NO-producing cells at LES / 1° denervation) →
Dysphagia, regurg, ↓ wt, & resp Sxs.
a. 2/2 no peristalsis & LES relaxation failure.

120
 b. Manometry → ↑ LES pressure (IRP >15mmHg), incomplete LES relaxation, & no
peristalsis. Type II has panesophageal pressurization.
c. UGI → tortuous & dilated esophagus w/epiphrenic diverticula, & bird’s beak
appearance.
d. Tx → Heller myotomy + partial fundoplication (left thoracotomy vs MIS,
myotomy [inner circular & outer longitudinal, 5cm on distal esophagus & 2cm on
stomach]).
i) Consider medical tx if pt requests/is not a surgical candidate.
A) Balloon dilatation LES (works 70%), nitrates, Botox (works 50%, but recur in
1-3mns). Balloons & Botox→scar→difficult surgery.
e. T. cruzi can produce similar symptoms
f. Pseudoachalasia → 2/2 something other than primary denervation.
2) Scleroderma
a. Smooth muscle fibrous replacement → ↓LES tone, dysphagia, reflux, &
strictures.
b. Tx → 1st PPI. Severe → esophagectomy.
c. Pre-op Anesthesia concern prior to esophagectomy for scleroderma or achalasia
→ prevent aspiration.
3) Diffuse Esophageal Spasm
a. Chest pain, dysphagia, poss psych hx.
b. Manometry → frequent, high-amp, strong non-peristaltic, unorganized
contractions. LES relaxes nml.
c. Tx → 1st CCB, 2nd nitrates vs Botox. Consider POEM (per SCORE).
i) Surgery less effective for DES vs achalasia.
4) Nutcracker Esophagus
a. Chest pain w/dysphagia. Manometry → high-amp peristaltic contractions. LES
relaxes nml.
b. Tx → 1st CCB, 2nd nitrates vs Botox.
i) Surgery usually less effective for nutcracker than for achalasia.
5) Dysphagia Lusoria (aka “arteria lusoria” or “Bayford-Autenrieth dysphagia”)
a. Dysphagia 2/2 aberrant R subclavian from Aorta distal to L subclavian & then
going behind esophagus → compressive sxs.
b. ↑incidence of non-recurrent laryngeal nerve (incidence of non-RLN is normally
<1%).
6) Jackhammer Esophagus
a. Distal Contractile Integral (DCI) > 8000 (measure of contraction vigor).
7) Isolated Hypertensive LES Tx → 1st - CCB & nitrate, 2nd - Heller.
a. ↑ basal LES pressure. Nml relaxation & peristalsis.

121

Uploaded by MEDBOOKSVN.ORG
 Disease Diagnosis Treatment
st nd
Early contractions on ≥20% of swallows, ↓distal 1 CCBs, 2 nitrates/Botox Consider
DES
latency time (<4.5s), 3°, non-peristaltic, nml LES POEM (vs long Heller)
st nd
Nutcracker High-amplitude (>180), nml LES 1 CCBs, 2 nitrates/Botox
PPI, Reglan, partial wrap (if GERD is
Scleroderma Aperistaltic, low LES mmHg main problem), total esophagectomy
(last resort)
Achalasia No change in esophageal mmHg, 100% failed
(absent I peristalsis, distal esophageal contraction, < 100
mmHg, No pressurization
peristalsis, Heller myotomy (vs dilation).
Integrated Diffuse esophageal mmHg ≥20% of swallowing,
II 100% failed peristalsis, Panesophageal
Relax
pressurization
Pressure
at LES No nml peristalsis, but spastic contractions &
III POEM
DCI >450 on ≥20% of swallows, Premature
>15)
D. GERD (acid + pepsin → ↑↑esophageal damage vs just acid).
1) Best test in pt w/GERD + dysphagia → EGD.
2) Pepsin on BAL → highly sensitive & specific for GERD.
3) 30% of pts w/GERD sx have no esophagitis on EGD
E. Barret’s M:F 2:1, incidence 4-10%, ↑ esophageal CA risk 40-60x.
1) Reflux → squamous → columnar metaplasia. Has goblet cells.
2) No dysplasia → EGD w/Bxs (4 quadrant, q2cm of abn eso) q3y.
a. Is an indication for fundoplication per SAGES.
3) Low-grade dysplasia → EGD w/Bxs (4 quadrant, q1cm of abn eso) q6m.
a. 6-10% CA risk/yr. Tx → 40-80mg PPI.
4) High-grade dysplasia → EMR (w/EGD & Bx in 3mns) vs esophagectomy.
F. Esophagitis
1) Usually better w/PPI. Need EGD w/Bx if not getting better. Consider Nissen if
refractory to ↑ PPI.
G. Eosinophilic Esophagitis Can present w/food impaction.
1) Dx → EGD w/Bxs (>15 eosinophils/HPF).
2) Tx → eliminate food allergens, topical steroids (MDI), ±PPI. Refractory → dilation.
H. Peptic Stricture
1) MCC of benign esophageal stricture → GERD. Usually right above the EGJ
(esophago-gastric junction). Need EGD w/Bx to r/o CA as cause.
2) Medical Tx → PPI + periodic dilatation (95% effective).
3) Surgical Tx → serial dilation (↑2mm each time). All have shortened esophagus &
need Collis gastroplasty w/wrap.
I. Esophageal Shortening RFs → GERD, esophagitis, large hernia, PUD/stricture, &
failed wrap.
1) UGI → EGJ lies 4-5 cm above diaphragmatic hiatus (should be 2cm below hiatus s/p
wrap. If not, → Collis gastroplasty vs PEG to pexy). Insufficient eso length → wrap
herniation (Sx → dysphagia & reflux).

122
J. Leiomyoma Benign. Smooth, round, submucosal esophageal mass.
1) Tx (if 3cm or symptomatic) → thoracic extramucosal enucleation
a. DO NOT bx → scars → surgery more difficult.
K. Caustic Ingestion
1) Acid
2) Alkali Long-term → very high esophageal CA rate.
a. Best 1st step → EGD (if pt gets worse a few days in → CT C/A/P w/ PO contrast).
b. S/p remote caustic eso inj w/narrow tapering at GEJ → EGD w/Bx.
i) If neg for CA → dilate + PPI.
L. Esophageal Foreign Body Sxs → Secretion intolerance, e/o obstruction.
1) Dx → CXR (PA & lat). Tx → emergent endoscopy.
M. Perforation (pleural effusion [usually on left], pneumomediastinum, PTX).
1) Boerhaave’s Syndrome Forceful emesis → chest pain. ML left lateral esophageal
wall 3–5 cm above GEJ.
a. Hamman’s sign → mediastinal crunching on auscultation. Highest mortality of
any perf. Early Dx & Tx → ↑ survival.
b. Dx → Gastrografin swallow. Tx→as eso perf (see Trauma Ch).
2) Mallory-Weiss Tear
a. Mucosal tear only (not true perf), at/near the GEJ. NO follow-up EGD after initial
is required (obs).
3) Iatrogenic MCC of perf. MC at cricopharngeus. Tx → See trauma section.
N. Plummer-Vinson Syndrome IDA, upper eso web, lower eso stricture.
1) Tx → dilation + Fe++, screen for oral CA.
O. Schatski’s Ring (Review EGD & UGI pictures) Sxs → dysphagia.
1) Almost all patients have an associated sliding hiatal hernia.
a. <13 mm: almost always Sx.
b. 13-20 mm: sometimes Sx.
c. >20 mm: rarely Sx.
2) Tx → 50F bougie dilation & PPIs.
P. Esophageal Cancer
1) SCCa (MCC of esopageal CA in the rest of the world).
2) Adenocarcinoma (MCC in the US).
3) Staging Best way to T-stage eso CA → EUS.
a. Best test for resectability → Chest & abd CT. F/u w/FDG-PET CT.
b. T1a → Invades lamina propria/muscularis mucosa
i) Tx → EMR ± ablation (preferred over esophagectomy per NCCN 2.2021
ESOPH-12).
c. T1b → Invades submucosa
Tx → neoadjuvant CTX-XRT,
d. T2 → Invades muscularis propria
resect (if able) + regional
e. T3 → Invades adventitia
LNDx + adjuvant CTX/XRT
f. T4 → Invades surrounding structure
i) T4a – resectable; T4b – non-resectable (Aorta, vertebra, trachea).

123

Uploaded by MEDBOOKSVN.ORG
 g. N1 → 1-2; N2 → 3-6; N3 → 7+
4) Near cricopharyngeus or larynx → neo-adj CTX + 35 Gy XRT then OR.
5) Resection All need 5+ cm margins & 15+ LNs in resection.
a. Types:
i) Ivor Lewis → right chest + abdomen.
ii) McKeown/3 Hole → left neck + right chest + abdomen.
iii) Trans-Hiatal → left neck + abdomen.
b. CI for curative resection → hoarseness (RLN invasion), Horner’s syndrome
(brachial plexus invasion), phrenic nerve invasion, cardiac/aortic invasion,
malignant pleural effusion, malignant fistula, airway invasion, & vertebral
invasion.
c. Conduit
i) Gastric preferred, unless for caustic ingestion (2/2 concomitant gastric injury).
Blood supply → right gastroepiploic.
A) If pt needs pre-op nutrition support, but can’t pass NGT/DHT → feeding
jejunostomy (preserves stomach as a conduit).
ii) Colon #2
d. Complications
i) Neck leak → Open neck incision, NPO, abx, & CT vs EGD.
6) CTX → ECF (Epirubicin, Cisplatin, + 5FU) or carboplatin + paclitaxel.
7) XRT → 41.4 Gy.
8) F/U → H&P q3-6mn x2yr (w/EGD if s/p EMR only) then q6-12mn x 3yr.

124
24. Stomach
A. Anatomy (parietal cells [only in
corpus & fundus] → intrinsic factor).
1) Celiac Axis
a. Left Gastric
b. Splenic
c. Common Hepatic
i) Gastroeduodenal
A) Superior
pancreaticoduodenal
(anterior & posterior)
B) Right gastroepiploic
ii) Proper Hepatic
A) Right Gastric
B. Anti-Reflux Procedures (for GERD see Esophagus)
1) Linx → magnetic ring around LES/cardia.
2) Fundoplications (do a partial wrap if ↓esophageal motility).
a. Nissen 360° around 56F Bougie, 3cm intra-abd esophageal length.
i) CIs → Surgeon inexperience, pt can't tol surgery, portal HTN, achalasia,
Barret's + HGD or CA, poor motility.
ii) MCC of persistent early satiety, dysphagia, & belching s/p Nissen → wrap is
too tight (1-2wk liquid diet to allow swelling to ↓). If 1st couple days post-op
→ likely post-op edema.
A) Tx → NPO & obs unless not tolerating secretions [→ OR].
b. Toupee ~270° posterior partial. Partial thickness esophageal & stomach bites.
c. Dor Anterior partial wrap. Fundal, esophageal, & right crus fixation.
3) Roux-en-Y Gastric Bypass anti-reflux procedure of choice if BMI ≥ 35.
C. Hiatal Hernia
1) Diagnosis (UGI [loc of GEJ + HH; best 1st test], EGD, manometry, pH mon)
a. KUB w/air-fluid level in L chest w/o h/o trauma.
2) Types
a. Type I → GEJ above diaphragm, phrenoesophageal mem intact.
i) Tx → PPI. Repair if significant sxs.
b. Type II → GEJ at diaphragm, stomach herniated through phrenoesophageal
mem.
c. Type III → GEJ above diaphragm, stomach herniated through phrenoesophageal
mem.
d. Type IV → GEJ above diaphragm, stomach + another organ (MC colon) herniated
through phrenoesophageal mem.
3) Repair
a. Repair if type II-IV & good op candidate.
b. Essential steps → complete dissection/reduction of sac, > 3cm intra-abd
esophagus (mobilize distal thoracic portion), close defect, & create anti-reflux
125

Uploaded by MEDBOOKSVN.ORG
 barrier (Nissen is typical). Consider PEG if: 1) large hernia w/extensive
manipulation, 2) short esophagus ± Collis, & 3) w/urgent operations.
c. Lap → ↓pain, incisional
hernia, SSI, LOS.
d. Need >3cm of intra-abd
esophagus, if not → Collis
gastroplasty.
D. Gastric Volvulus
Borchardt triad → epigastric pain,
inability to vomit, can’t pass NGT.
1) Organoaxial around axis made by GEJ & pylorus OR to
2) Mesoenteroaxial distal stomach flips cephalad reduce
3) Combined +pexy
E. Acute Gastric Distension
1) MCC gastric outlet obstruction in adults → gastric adenoCa.
2) Sxs → severe abd distension & pain → brady, hypoTN, tachypnea, & sweating.
Distention → compresses vagus → vaso-vagal.
3) RFs → pancreatitis, recent surgery, psych issues. Can be life-threatening.
4) Tx→ NG tube.
F. Bariatrics
1) Lap Band Excess Wt Loss (EWL) 50%. Deficiency → 0-10%.
a. Nml positioned should be 45° [Phi angle] from spine.
b. Still w/N+V → band too full.
c. Band erosion can present as port-site erythema. NOT a subQ abscess.
d. Dx → CT w/PO & IV contrast.
2) Sleeve Gastrectomy EWL → 55%.
a. Start 6cm proximal to pylorus on greater curve. Use 38F Bougie.
b. LSG leak scenarios
i) Non-HDS pt w/contained or uncontained leak → immediate reoperation.
ii) Fever + tachy, but nml imaging → OR for exploration to r/o a leak.
iii) Stents
A) An option for acute proximal leak that failed conservative therapy in HDS
pt. Wait > 12 wks before reoperating.
B) Limited efficacy if chronic leak (esp. >30 days).
iv) Surgical options → revise over a Bougie vs convert to RYGB (last option for
chronic proximal leaks, converts ↑pressure system to a ↓pressure system →
promotes healing.
3) Vertical Banded Gastroplasty creates small gastric pouch by making a circular hole
below cardia, inserting band through hole and around lesser curve, then vertically
stapling off fundus from cardia (w/o dividing it).
a. MCC of wt ↑→liquid cards. 30% get G-G fistula (Tx→convert to RYGB).

126
 4) RYGB EWL → 60%. Deficiency → 15-25%.
a. Indications
i) BMI >40 (or >35 w/related comorbidities) + failure of non-surgical,
psychologically stable, no drug/EtOH abuse (also no smoking → marginal
ulcers).
b. MC Roux limb length → 100-150cm BP limb → 40-50cm.
5) Biliopancreatic Diversion EWL → 70%. Deficiency → 40-77%.
a. Distal gastrectomy, divide ileum 250cm proximal to IC valve, sew distal end to
stomach & BP limb to ileum 50-100cm proximal to IC valve.
6) Biliopancreatic Diversion-Duodenal Switch (BPD-DS)
a. Create 200mL sleeve gastrectomy, divide D1, divide small bowel 250cm proximal
to IC valve, sew distal end to D1/stomach & BP limb to ileum 100cm proximal to
IC valve.
7) Complications
a. Nutritional → Fe def is MC s/p RYGB (B12 is a close 2nd) & MC in adults overall.
b. Marginal Ulcers → Develops in 10%. RFs → smoking & NSAIDs.
i) Tx → PPI + stop RFs.
c. Stenosis
i) GJ stenosis → EGD dilation, redo if late & dilation fails.
ii) MCC massive distension of proximal bowel s/p RYGB → problem at JJ
anatamosis. Tx → redo JJ.
d. SBO If suspected (even w/neg CT) → dx lap.
i) Adhesions (73%)
ii) Internal Hernia (27%) Mesenteric swirl sign on CT, a surgical emergency.
A) 3 spaces for internal hernia
1) through transverse mesocolic defect,
2) beneath Roux inframesocolic Peterson’s defect,
3) beneath BP limb just proximal to JJ.
G. Phytobezoar → Fiber ball causing obstruction
1) Tx → Chemical dissolution (ie. Coke). EGD if fails & it is in the foregut.
H. Trichobezoar → Hair ball causing obstruction.
1) Tx → EGD removal.
I. Pepic Ulcer Disease / Gastritis . Always ask about NSAIDs, smoking, H. pylori,
previous episodes, & family hx (gastrinoma).
1) GI bleed w/u
1NGT asp (must see bile)

2EGD

3CSP

4capsule or push endoscopy.

5Angio → 0.5-1mL/min. Best test to locate source s/p EGD (dx & tx).

6Tagged RBC Scan → 0.04-0.1mL/min (presence, not loc).

7Meckle Scan

127

Uploaded by MEDBOOKSVN.ORG
2) Gastric Ulcers
a. Best test → EGD (dx & tx).
b. ML to be CA than duo ulcer (↑ risk w/size).
c. MC in 55-65 & M. MCC → perforation.
d. Types (see figure →)
i) I → lesser curve low along body of stomach; due to ↓
mucosal protection.
ii) II → 2 ulcers (lesser curve & duodenal); similar to
isolated duodenal ulcer w/high acid secretion.
iii) III→ pre-pyloric ulcer; similar to duodenal ulcer w/high
acid secretion.
iv) IV → front door = 4, lesser curve high at cardia; ↓
mucosal protection.
v) V → ulcer associated w/NSAIDs (five letters in NSAID).
A) Ketorolac 5x higher ulcer rate vs other NSAIDs.
B) Steroids potentiate NSAID ulcer risk. Misoprostol >
lansoprazole to ↓risk.
vi) Other/Special
A) Curling’s significant burns & duodenal ulcer.
B) Cushing’s head trauma & gastric ulcer.
C) Cameron’s ulcer at diaphragm in pt w/hiatal hernia.
D) Dieulafoy large arteriole in submucosa.
E) Menetrier’s Disease mucous cell hyperplasia, ↑ rugal folds.
F) GAVE/”Watermelon Stomach” Gastric Antral Vascular Ectasia. Radiates
out from pylorus.
vii) Best tx for ulcer refractory to PPI → Triple tx for H. pylori (Esp. if Type II or III).
viii) Persistent ulcer (≥12wks) & H. pylori neg → EGD & Bx (to guide type of
resection) then resect.
ix) Surgical indications → bleeding uncontrolled via EGD + >4-6u pRBCs + not
HDS, perforation, obstruction, & refractory ulcer.
A) Anterior gastrotomy w/oversewing of vessel (rebleed → <5%).
3) Duodenal Ulcers
a. Etiology: NSAIDs & H pylori, then Z-E syndrome (see intractable, recurrent DU →
order fasting serum gastrin).
b. Sxs: sudden onset of epigastric pain (gnawing, burning, stabbing).
c. Anatomy: MC in 1st portion of duodenum. Anterior → perf, posterior → bleed
(GDA). Sharply demarcated w/clean edges & exposed submucosa, most < 5mm.
d. Medical Tx: H pylori eradication (Clarithromycin + Amox/Flagyl + PPI x 2 weeks).
No NSAIDs or smoking.
e. dDx:
i) ↑gastrin & ↑ acid → Gastrinoma, G-cell hyperplasia, retained antrum,
hyperthyroid, CKD, & gastric outlet obs.

128
 ii) ↑gastrin & nml/↓ acid → pernicious anemia, post-vagotomy synd, H2
blockers/PPIs, & chronic gastritis.
iii) ↓gastrin → hypothyroidism.
f. Indications: perforation (upright CXR → free air under diaphragm), hemorrhage,
obstruction. Can manage non-op if HDS & contained.
g. Techniques: Graham (omental) patch + primary closure of defect → tension- free
patch of omentum (absorbable seromuscular sutures, intra-op leak test, leave
NGT & JP drain).
i) Large perforation (>3cm) → Thal patch using jejunal serosa, pyloric exclusion,
& GJ.
h. Perforation: ATLS → resuscitation, NGT, IV PPI (Protonix 80mg bolus then
8mg/hr gtt), broad-spectrum abx, OR if not contained/HDS. Post-op needs triple
tx for H pylori, UGI series on POD3 (if neg → d/c NGT, give diet, remove drain
after diet & no ↑ in output).
i) Valentino’s sign → RLQ pain 2/2 perf duo ulcer mimicking appendicitis.
i. Bleeding DU: ATLS → resuscitation, check airway (hemoptysis), IV PPI. 1st EGD for
clipping, cautery, Epi injection (try x2 before OR if HDS). Surgery → Kocher,
anterolateral longitudinal pyloroduodenotomy incision, U-stitch w/ Vicryl sutures
over bleeding vessel (GDA), close pylorus & duodenum transversely in two layers
(ie. Heineke-Mikulicz pyloroplasty, per SCORE), leave drain + DHT, continue PPI
post-op.
i) Tissue won’t hold stitch → “extraduodenal” control (ligated GDA 1cm above
& below duodenum + medial (transverse pancreatic br).
ii) Recurrent DU bleeding: If young, low-risk, HDS → antrectomy & vagotomy →
↓ acid.
j. Obstruction: NOT emergent if HDS! Sxs → early satiety, bloating, & N/V. Tx like
SBO → NGT, IVF, bowel rest + triple therapy w/IV PPI & UGI (dilated stomach
w/sig narrowing at/near pylorus). EGD (± dilation) to r/o malignancy. Wait for
response before OR if HDS (repeat UGI to confirm persistent obstruction). If
refractory → antrectomy + vagotomy + GJ, leave drains + DHT.
4) Stress Gastritis
a. Ppx PPI Indications → Coagulopathy, vent >48hrs (MCC), recent (<1yr) UGIB, TBI,
spine injury, burn OR 2 minor RFs → ICU >1wk, steroids, occult GIB >6d.

129

Uploaded by MEDBOOKSVN.ORG
5) Surgeries (all vagotomies
↑gastrin).
a. Truncal Vagotomy →
divide ant & post vagus
above GEJ →↓ solid
emptying. Pyloroplasty
w/truncal vagotomy →
↑ solid emptying.
b. Selective Vagotomy →
after hepatic (ant) &
celiac (post) vagal br.
c. Proximal
Gastric/Highly-
Selective
Vagotomy→divides
gastric brs along lesser
curve to incisura (preserves “crow’s foot”); nml solid emptying.
i) MCC recurrence 2/2 → incomplete vagotomy → missed criminal nerve of
Grassi
A) Grassi → post vagus br, comes off before celiac division.
d. Antrectomy & vagotomy→ removes gastrin producing G-cells.
i) Lowest recurrence. But highest complication rate.
ii) Marginal ulcer s/p above → represents inadequate antrectomy.
e. Complications
i) Post-Vagotomy Diarrhea 30-70% will get. Resolves in 3-8mns.
A) 2/2 non-conjugated bile salts (osmotic) → sustained postprandial
organized MMCs.
B) Tx → cholestyramine, loperamide, & ↓carbs/lactose/caffeine.
1. Severe & refractory → reversed interposition jejunal graft.
ii) Dumping Syndrome
A) Early (<1hr) → Hyperosmotic load causes fluid shift into bowel (hypoTN,
diarrhea, dizziness).
B) Late (>2hrs) → Hypoglycemia 2/2 ↑ insulin & ↓ glucose (2nd phase rarely
occurs) → ↑adrenal catecholamines.
C) Tx → small, low-fat/carb, high-protein meals. No liquids w/meals. No lying
down after meals. Octreotide most effective.
1. Surgical options (rarely needed).
a) Convert Billroth I or II → Roux-en-Y GJ.
b) Or ↑ gastric reservoir (J pouch) vs ↑ emptying time (reversed J
loop).
iii) Alkaline/Bile Reflux Gastritis
A) Postprandial epigastric pain asso w/ N/V & pain not relieved w/vomiting.
MC s/p B II than B I.

130
 B) Dx → bile reflux into stomach, histologic evidence of gastritis.
C) Tx → PPI, cholestyramine, metoclopramide.
1. Surgical options → conversion of B I or B II to Braun enteroenterostomy
(↓sx in 53%) vs Roux-en-Y GJ w/afferent limb/JJ >40-60cm distal to GJ
(↓sx in 85%).
iv) Chronic Gastric Atony Delayed gastric emptying.
A) Sxs → N/V, pain, early satiety.
B) Dx → gastric emptying study.
C) Tx → metoclopramide, prokinetics (→→ near-total gastrectomy w/ReY
GJ).
v) Small Gastric Remnant
A) Desired for bariatric patients (↑wt loss).
B) Dx → EGD.
C) Tx → small meals (→→ J pouch reconstruction).
vi) Blind Loop Syndrome
A) s/p Billroth II or Roux-en-Y; 2/2 ↓motility → stasis in afferent/BP limb →
bacterial overgrowth (E. coli, GNRs).
B) Sxs → pain, steatorrhea (bacterial deconjugation of bile), B12 deficiency
(bacteria use it up), & malabsorption.
C) Dx → EGD of afferent limb w/aspirate & Cx.
D) Tx → tetracycline, Flagyl, & reglan/erythromycin (↑ motility), B12 supp
→→ shorten afferent/BP limb to 40 cm.
vii) Afferent Loop Syndrome
A) s/p B II or Roux-en-Y; 2/2 mechanical afferent limb obstruction.
B) Sxs → RUQ pain, nonbilious emesis, steatorrhea, pain relieved w/bilious
emesis.
C) RFs → long afferent limb. Dx → CT.
D) Tx → balloon dilation (→→ shorten afferent limb to 40 cm).
viii) Efferent Loop Syndrome
A) SBO sxs → N/V, abd pain. Dx → UGI, EGD.
B) Tx → balloon dilation if s/p Roux-en-Y (go to OR if B-II, need to relieve
obstruction/herniation at/near anastomosis).
ix) Duodenal Stump Blow-Out → place lateral duodenostomy tube & drains.
J. Helicobacter pylori
1) 75% of gastric & 80-90% of duo ulcers → + H pylori.
2) Best to Dx ulcers → EGD. Best to Dx H. pylori→ antral bx (invasive, vs non-
invasive ELISA serology [serology → best 1st test]).
Best to confirm H. pylori eradication → rapid urease breath test.
3) Tx → PPI + clarithromycin + amoxicillin/Flagyl + Bismuth x2wks.
K. Gastroparesis
1) Best 1st test → EGD to r/o other causes of delayed emptying.
2) Gold standard → Nuc medicine gastric emptying study.
3) Tx → 1st low fat/fiber diet → reglan vs erythromycin → gastric stim.

131

Uploaded by MEDBOOKSVN.ORG
L. Gastric Varices
1) Isolated gastric varices are 2/2 splenic vein thrombosis (usually 2/2 pancreatitis).
Tx → splenectomy.
M. Gastrostomy
1) PEG (Push or Pull technique)
a. Indications → Best nutritional route for long-term neurogenic dysphagia &
aspiration risk.
b. CIs → inability to palpate/transilluminate, obstruction, massive ascites,
coagulopathy, & severe malnutrition.
c. Cxs → comes out (MCC → bumpers are too tight).
d. Can’t transilluminate, get 1:1 ballotment, see needle enter stomach, or get air
prior to entering the stomach → convert to lap (vs open).
e. MCC of UPRTOR → transhepatic placement (> slipped bumper syndrome & PEG
tube falls out at home).
2) Open / Stamm fix @ 3 or 4 points to abd wall+inner & outer purse-string.
N. Gastric Polyps
1) Hyperplastic → atrophic mucosa usually 2/2 PPI.
2) Fundic Gland→ MC type.
3) Adenomatous → 15% risk of cancer. Tx → EMR.
O. Gastric Lymphoma are NHLs (MC extranodal location → stomach).
1) Diffuse Large B-Cell Lymphoma (DLBCL) → MC (55%). Tx → CHOP.
a.CHOP = Cyclophosphamide, Hydroxydoxorubicin, Oncovin, Prednisone
2) MALToma (40%) 2/2 CagA &/or chronic inflammation from H. pylori.
a. Abx → usually cures this CA (90%).
b. F/u EGD+Bx q6mn x5yrs. Persistent/recurrent/high grade → COP.
3) Burkitt (3%), Mantle cell (<1%), & Follicular (<1%) are other types.
4) Gastric CML → BRC-ABL mutation (a tyrosine kinase). Tx → imatinib.
P. GIST → Interstitial cells of Cajal. Hypertrcophic mucosa. IHC c-kit (CD117)+.
1) Sxs → pain, bleeding, bloating, early satiety.
2) Malignant (> 5cm or > 5 mitoses/50 HPF) → needs imatinib (a c-KIT tyrosine kinase
inhibitor).
3) If borderline/unresectable → neo-adjuvant imatinib.
Q. MC solid organ lymphoma in HIV+ pt → stomach (usually NHL).
R. Gastric Carcinoid/Gastric Neuroendocrine Tumor (G-NET)
1) Types (1-3)
1 → Asso w/atrophic gastritis or pernicious anemia (↑gastrin, 85% 5ys).
2 → 2/2 ZES (↑gastrin, 85% 5ys)
3 → Sporadic → malignant until proven otherwise (<33% 5ys).
i) Tx → partial vs total gastrectomy + local LNDx.
2) Type 1 & 2 < 1-2 cm → EMR.
a. Numerous Type 1 → Antrectomy + wedge dominant non-antral tumor.
b. Type 1 rarely needs aggressive surgery unless extensive gastric wall involvement
(↑risk of adenoCa), size >2 cm, or emergent bleeding.
132
 3) High-risk or unresectable C-KIT+ → imantinib.
a. 2nd line→rituximab + fludarabine/cholorambucil.
4) Can resect, or even debulk, most mets – especially liver.
S. Gastric Cancer Best test for gastric CA → EGD + ≥4 Bxs (95% accurate).
1) Hereditary Diffuse Gastric Ca (HDGC)
a. Multiple 1st degree relatives. CA by 80yo. 80% of F & 67% of M have CA (avg age
→ 37). ↑lobular Breast CA (Screen like BRCA).
b. CDH1 (50% of HDGC) mut → E-cadherin loss. Also PALB2, Lynch (MSI → 1CrCa,
2Endo, 3Gastric), Juvinile Polyposis (SMAD4, 20% risk, EGD in teens), Peutz-

Jeghers (30% risk, EGD q2-3yrs in teens), FAP (APC gene).

c. Tx → ppx total gastrectomy b/w 18-40yo.
2) GEJ Cancer/Siewart Classification (based on
epicenter of mass).
a. Type I → 1-5cm above GEJ.
i) Tx → Ivor Lewis esophagectomy
(R thoracotomy + laparotomy) + high
mediastinal LNDx.
b. Type II → 1cm above - 2cm below GEJ.
i) Tx → total gastrectomy w/gastric LNDx. >4cm of eso involved → high
mediastinal LNDx.
c. Type III → 2-5cm below GEJ (Sub-cardial gastric adenocarcinoma).
i) Tx → total gastrectomy w/gastric LNDx. >2cm eso involved → low
mediastinal LNDx.
3) Diffuse (Linitis Plastica/Britton’s dz) MC in low risk areas (West).
a. Young dx (~40). E-cadherin loss. Often @ cardia.
b. Bx → Undiff, scattered fibrous stroma. Tx → total gastrectomy.
4) Intestinal
a. Well-diff (like CrCa). High risk areas (SE Asia). Older dx (~60). Asso w/H. pylori,
smoking, nitrates/smoked foods. Distal.
b. Tx → Subtotal gastrectomy.
5) Important Esophagogastric Cancer Trials
a. MAGIC
i) Gastric > eso CA pts. 3 neo-adj + 3 adj ECF cycles (Epirubicin, Cisplatin, 5FU).
90% w/neo-adj got to OR. 66% who went to OR 1st got adj (& only 50%
finished). 5yr OS 36% neo-adj vs 23% if OR 1st.
b. CROSS
i) Eso > GEJ CA pts (SCCa & Adeno). OR 1st vs neo-adj carboplatin, paclitaxel, +
41.4 Gy then OR. ↑OS w/neo-adj CTX-XRT.
c. FLOT-4
i) Gastric & GEJ CA → ECF 3/3 vs FLOT 4/4 (5-FU, Leucovorin, Oxaliplatin, Taxol).
Path CR 6% w/ECF vs 16% w/FLOT-4. Initial stages =, yp stage ↓ w/FLOT. OS
35% w/ECF vs 50% w/FLOT4. Functional pt → FLOT4, if not → FOLFOX.

133

Uploaded by MEDBOOKSVN.ORG
6) Staging
a. T1a (into mucosa) → EMR or gastrectomy
b. T1b (into submucosa, has lymphatics) → gastrectomy + LNDx
(needs ≥16 LNs)
c. T2+ (into muscularis) or N+ → neoadj 1st then
gastrectomy + LNDx.
d. Stage II → test for MSI, HER2, & PD-L 1.
7) Resection Need 4-5 cm margins (send frozen sections).
a. EUS & staging laparoscopy (if ≥T1b) + intra-op U/S (Left lobe of liver to eval celiac
LNs) before neo-adj CTX & resection.
i) IDs occult mets 23-37% of the time (get sharp Bx).
b. Proximal 1/3 → Total gastrectomy + EJ + D2 LND.
c. Distal 2/3 → Distal gastrectomy + GJ + D2 LND (perigastric [D1 → lvls 1-6] +
hepatic, L gastric, celiac, & splenic LNs [lvls 7-11]).
d. Unresectable w/sx of obstruction → stent vs palliative resection if can tolerate
OR.
8) Follow Up
a. H&P (+EGD if s/p EMR) q3-6mn x2yr then q6-12mn x3yr then q1yr.
b. Monitor nutrition, especially iron (duo) & B12 (intrinsic factor in fundus/body).

134
25. Liver
A. Anatomy
1) Synthetic function
a. MOST helpful to determine liver function → INR/PT. (PTT & Albumin also
helpful).
b. Bilirubin → not reliable 2/2 confounding variables extrinsic to liver.
c. LFTs → markers of inflammation/cell death, NOT liver function.
2) Cantlie’s Line → from gallbladder fossa to IVC. Divides right & left lobes.
3) CVP goal during lobectomy → ≤ 5 cmH2O. 1 mmHg = 1.36 cmH2O
4) Right hepatic a → supplies segments V-VIII.
a. Replaced Right → from SMA posteriorly & to the Right, emerges post. to
pancreatic head, posteriomedial to portal triad, then travels cephalad/to the
Right. Will be to the right of CBD @ lvl of cystic duct.
5) Left hepatic a → supplies segments II-IV.
a. Replaced Left → from Left gastric & runs in gastrohepatic ligament (Don’t
ligate!)
6) Segment I/Caudate lobe → separate Right & Left portal & arterial inflow; drains
directly into IVC via its own hepatic veins.
7) Segment IV is b/w the Middle HV & Left PV.
8) Best vessel to guide right vs left lobectomy → Middle hepatic vein.
9) Portal triad → CBD (ant/Right), PHA (ant/LEFT), PV (post).
10) Portal vein: 75% liver blood flow (50% of O2 flow). Formed by SMV + splenic/IMV,
nml pressure → 3-5 mmHg.
B. Non-surgical jaundice
1) Physiologic jaundice of the newborn → immature glucuronyl transferase;
↑unconjugated/indirect bili.
2) Gilbert’s disease → mild defect in glucuronyl transferase: abnml conjugation.
3) Crigler-Najjar disease → severe glucuronyl transferase deficiency → can’t
conjugate → ↑ indirect bili (life-threatening)
4) Rotor syndrome → deficiency in storage ability; ↑ direct bili.
5) Dubin-Johnson syndrome → deficiency in secretion ability; ↑ direct bili.
C. Liver failure
1) Acute (ALF) → ↑ICP. Don’t correct ↑INR unless bleeding (↑VTE).
a. Drug-induced → Tylenol (MCC in West, give NAC 150mg/kg then 12.5mg/kg
x4hrs then 6.25mg/hr gtt).
b. Viral → HepB (MCC in rest of world), HepE, HIV, HSV (→acyclovir 30mg/kg IV
QD)
c. Postpartum/HELLP → Hemolysis, Elevated Liver enzymes, Low Platelets.
i) Tx → delivery of the baby, then supportive.
2) Chronic / Cirrhosis
a. Etiology → 2/2 EtOH/Hep C/NASH/Autoimmune/Wilson’s Dz (AR ATP7β mut
→↑copper → liver failure).

135

Uploaded by MEDBOOKSVN.ORG
b. Hepatic Stellate/Ito cells in space of Disse store vit A.
i) Ito cell → myofibroblast-like differentiation → fibrosis.
c. Scoring
i) Child’s Score (INR, bili, alb, ascites, encephalopathy)
A) A 5-6 0% 1yr mortality
B) B 7-9 20% 1yr mortality
C) C 10-15 55% 1yr mortality
ii) MELD-Na (predicts 3mn mortality while awaiting transplant).
A) PT/INR, Bilirubin, Creatinine + Na+
B) TXP benefit at MELD = 15 (hepatology referral at MELD = 10).
C) Automatic score of 22 for:
1. HCC
2. Hilar cholangiocarcinoma
3. Hepatic artery thrombosis
4. Hepatopulmonary syndrome
iii) King’s College TXP predictor in ALF
A) Gr III or IV encephalopathy, INR > 6.5, Cr > 3.4.
d. Complications Hepatopedal → flow to liver
i) Ascites HepatoFugal → flow From liver
A) Medical Tx → Lasix, spironolactone, Na+ restriction, ± paracentesis (if >4L
→ replace w/25% salt-poor albumin 1gm/100mL removed).
B) Portosystemic shunts
1. Non-selective
a) These will completely divert portal flow.
b) Conventional (proximal) splenorenal & Eck/end-to-side interposition
graft (>10mm). ↑ intrahepatic & splancnic vein decompression. Best
to prevent rebleed, but ↑ hepatic failure & encephalopathy.
c) TIPS → used for protracted bleeding, progression of coagulopathy,
visceral hypoperfusion, or refractory ascites. Is a bridge to TXP (esp
for hepatorenal synd).
i. Allows antegrade flow, maintains hepatorenal flow. Has ↓ ascites
vs Warren.
ii. TIPS → Best tx to preserve hepatorenal flow in adv cirrhosis (CI if
encephalopathic, Polycystic Liver dz, R heart failure).
2. Selective
a) Warren/distal splenorenal → = effectiveness, ↓re-op, but ↑
difficultly & not suited for emergent tx.
b) ↓ rebleed, encephalopathy, & thrombosis vs TIPS.
c) What shunt decompresses varicies but maintains hepatoportal flow
→ Distal splenorenal shunt.

136
 3. Partial
a) Interposition (<10mm) graft, ↓encephalopathy, = survival vs non-
selective, ↓failure rate vs TIPS. <15% thrombose → most open
w/ballon angioplasty
4. Peritoneovenous shunt / Denver shunt
5. Transplant
C) Chylous Ascites → MCC → lymphoma (33-50%) Can be 2/2 RP dissection.
Dx w/lymphangiogram vs lymphoscintigraphy + aspirate (trig >110mg/dL).
1. Tx → no/low fat diet, med chain FAs, octreotide, possibly NPO ± TPN. If
no resolution → ligate duct.
ii) Hepatic Encephalopathy
A) Development of asterixis → sign that failure is progressing.
B) Rifaximin (antibiotic) → ↓risk of acute hepatic encephalopathy episodes &
severity of encephalopathy.
iii) Hepatorenal Syndrome (HRS) Early alb in SBP to ppx against HRS.
A) Mesenteric vessel dilation & renal constriction.
B) Fast renal failure/oliguria despite nml filling pressures in cirrhotic (no
response to fluid challenge). Same labs as pre-renal azotemia (FeNa < 1%,
BUN/Cr ratio> 20, Urine Na <20). Often has precipitating event (eg GIB,
over-diuresis, infection). Sign of end-stage liver disease → TXP is only tx
(everything else is temporizing).
C) Type I: rapid ↓ in renal fxn, 2 x Cr in 2wks, median survival ~2wks (usually
not > 10wks).
D) Type II: diuretic-resistent ascites, medial survival ~6mn.
E) Dx → 1st volume challenge (main difference b/w pre-renal azotemia &
hepatorenal → volume works in pre-renal & fails in hepatorenal). ↑uOSM
↓uNa+. U/A → no protein or RBCs w/hepatorenal syndrome. Renal Bx →
nml.
F) Tx → midodrine & octreotide (best Tx, but only temporizing), dialysis, d/c
diuretics, consider TIPS. Alb & vasoconstrictors (α1 antagonists) may help.
50% short term mortality. TXP eventually needed.
iv) Esophageal Varices 1yr mortality → 70% in cirrhotics.
A) Dx → generally on EGD. Can also use SplenoPortal Index (SPI).
1. SPI → Splenic v. long x transverse (in cm)/mean PV velocity.
2. 92% sensitive & 93% specific for esophageal varices.
B) Give ppx abx x7d for bleeds. 20% mortality each bleed.
1. 400mg Norfloxacin PO or Cipro IV q12h (or IV ceftriaxone).
C) pPx: small → non-selective β-blocker (propranolol), medium-large → band.
D) Bleeding Tx
1. 1st → Resus, octreotide, & ceftriaxone 1gm IV QD.
2. 2nd & HDS → EGD + band Not HDS → balloon tamponade
3. 3rd & HDS → EGD + band → TIPS
4. 4th & HDS → TIPS.

137

Uploaded by MEDBOOKSVN.ORG
 5. Sengstaken-Blakemore or Minnesota balloon tamponade (90%
effective, 50% recur). D/c w/in 36hrs.
E) ↓Hgb, EGD w/mild esophagogastric varicies w/o bleeding. Tx → band.
F) Rebleeding risk on EGD in general
1. Active, pulsatile vessel → >80%
2. Visible vessel → 50%
3. Adherent clot → 15-25%
4. Clean ulcer → <5%
v) Portal Hypertension
A) Pre-sinusoidal obstruction → schistosomiasis, congenital hepatic fibrosis,
portal vein thrombosis (MCC of portal HTN in kids [50%].
1. Tx → Rex mesoportal shunt).
B) Sinusoidal obstruction → cirrhosis.
C) Post-sinusoidal obstruction → Budd–Chiari syndrome (hepatic vein
occlusion), constrictive pericarditis, CHF.
D) Most accurate estimation of PV pressure → hepatic vein wedge pressure.
E) Octreotide → ↓ pressure by ↓ blood flow (goal <12mmHg).
F) Vasopressin → Not used much, many SEs.
G) TIPS→ for cont bleeding, coagulopathy progression, visceral
hypoperfusion, or refractory ascites. A TXP bridge.
1. Allows antegrade flow, maintains hepatorenal flow.
2. TIPS Cx → ↑ encephalopathy.
H) Distal splenorenal → = effectiveness, ↓re-intervention, maintains
hepatoportal flow, but ↑difficulty & not suited for emergent tx.
vi) Portal Vein Thrombosis
A) Esophageal varices + splenomegaly, but no cirrhosis → think PVT. In kids
look for h/o umbilical vein catheter, omphalitis, or neonatal intra-abd
sepsis (eg. NEC).
B) Dx → duplex US.
C) Tx→ 6mn anticoag. CT for extent & possible infxn, portosystemic shunt if
refractory (Rex shunt = SMV-L Portal vein bypass).
vii) Spontaneous Bacterial Peritonitis Mortality → 20-40%.
A) Fever, abd pain, ascities, PMNs > 250/mm3, & + Cx. No sx→13%.
B) Ppx against HRS w/early albumin (↑ survival).
C) E. coli (#1 adult), Klebsiella, pneumococci (#1 kids w/nephrotic or hepatic
ascites), strep (pyogenes #1 kids overall), & staph.
D) MC → mono-organism (aerobe). Poly → think bowel perf.
E) RFs → prior SBP, UGIB (variceal). Low-protein ascites <1gm/dL + serum bili
> 2.5mg/dL → need ppx abx (usually a fluoroquinolone).
F) Tx → 3rd-gen cephalosporins; most respond in 48 hrs.
e. Acute Care Surgery in Cirrhotics (AGA recs)
i) Elective surgery OK for Child A, OK w/caution for B, & CI for C.
ii) Cholecystectomy Fibrosis d/t liver dz can mimic acute chole on U/S.

138
 A) Not if elective in Child C/awaiting transplant.
1. Also not a candidate for PTC (b/c acites/infxn risk) unless critically ill.
B) If dx of acute chole is certain → 1st ERCP drainage, 2nd refer to TXP center
for lap chole if unable to perform ERCP drainage.
iii) Umbilical Hernia + Ascites
A) Ascites → ↑ abd pressure → ↑ umbilical hernia. Can →
incarceration/infarction → necrosis & perf overlying skin → peritonitis &
death). Don’t wait until ruptured → repair electively with prolene mesh
(↓recurrence vs 1° repair [10% vs 1 %]). If overlying skin is perf’d, infected,
or necrotic → emergent repair (1° closure w/o mesh).
B) Tx → (If ascites refractory to max med tx & paracentesis
→ TIPS 1st before UHR if not strangulated).
1. → Remove ascites (paracentesis; relieves pressure off umbilical hernia)
replace with IV salt-poor albumin (1g per 100mL removed; use 50mL of
25% alb).
2. → Correct coags (↑INR) → Vit K, FFP, & PLTs PRN.
3. → Hernia repair → mesh vs. resect necrosis if present & 1° closure.
4. → Control ascites s/p repair.
D. Budd-Chiari Syndrome MCC in Asia → webs.
MCC in US → Heme d/o (eg. PCV or MPD).
1) Acute, chronic, asymptomatic, or fulminant.
2) Best Dx → Duplex U/S.
3) Hepatic IVC/hepatic vein DVT → RUQ pain, jaundice, ascites (1st sx), enlarged
segment 1, cirrhosis, asso w/hypercoag.
4) Tx → anticoag for life. Angio ± stent if 2/2 stenosis/web. Portosystemic shunt if
patent IVC + anticoag (also TIPS, but less data) vs consider mesoatrial shunt if IVC
not patent.
5) TXP if chronic w/irreversible damage (last resort).
E. Liver masses
1) As an intraoperative finding → CNBx (if no c/f hemangioma).
2) Cystic
a. Simple Benign, Tx → none, unless sx or c/f biliary cystadenoma.
b. Polycystic Liver Disease AD, seen w/PCKD or alone, asx (most), worsens w/HRT.
Multi-septated. Tx → lap fenestration if infected.
c. Echinococcal
i) Forms hydatid cyst. + Casoni skin test & serology.
ii) Sheep → carriers; dogs → humans. ↑ in right lobe of liver.
iii) Don’t aspirate → can leak out → anaphylactic shock.
iv) Abd CT → ectocyst (calcified) & endocyst (double-walled).
v) ↑ LFTs, cholangitis, or jaundice → ERCP (biliary communication).
vi) Tx → pre-op albendazole (x2 wks) & resect (intra-op can inject cyst w/alcohol,
then aspirate). Must remove entire cyst wall.
A) Don’t spill → anaphylaxis.
139

Uploaded by MEDBOOKSVN.ORG
3) Abscess
a. Pyogenic
i) Usually 50-60yo. 80% liver abscesses. MCC → biliary tract
extension/cholangitis. RFs → >50, M, liver TXP, DM, CA hx.
ii) Portal vein pylephlebitis 2/2 diverticulitis, appy, IBD, PID.
iii) Sxs → fever, chills, ↓ wt, RUQ pain, ↑ LFTs, ↑ WBCs, & sepsis.
iv) ↑ in right lobe; 15% mortality w/sepsis.
v) Aerobic GNRs → #1 bug (MC E. coli). Also → Klebsiella & Proteus.
vi) Dx → aspiration.
vii) Tx → CT-guided drainage & abx x 8wks (70-90% effective; CI →
coagulopathy). OR drainage if not HDS/septic or undrained s/p drain d/t
viscous and/or multiloculated.
A) Drain placed well, but no output → upsize/replace (see above).
B) ↑ bile output from abscess drain, 1st → drain cholangiogram, then →
ERCP.
C) 1 undrained pocket → 2nd drain.
b. Amoebic
i) Asso w/trip to Mexico → diarrhea & h/o EtOH; MCC → Entamoeba
histolytica. M >> F. Fecal → oral transmission.
ii) Classic CT finding → single rim-enhancing lesion.
iii) Best Dx → serology for Abs (Cxs are usually negative).
iv) Tx → 1st - metronidazole 7-10d; 2nd - aspiration; 3rd - surgery (or 1st if
rupture).
c. Schistosomiasis
i) Maculopapular rash, fine granular tissue, petechiae, ulcers, variceal bleed, ↑
eosinophils. 1° location → sigmoid.
ii) Tx → praziquantel & control of variceal bleeding.
4) Benign Liver Tumors
a. AdeNOma “Says NO & leaves early.”
adeNOma, NO kupfer cells, NO sulfur/Eovist uptake, Rapid washout.
i) Young F, steroids, OCPs. MC in right lobe. 80% have sxs; 20% have sig
bleed/rupture. Malignant potential.
ii) Sxs → pain, ↑ LFTs, ↓ BP (w/rupture), palpable mass
iii) Dx → NO Kupffer cells in adenomas, thus NO uptake on sulfur colloid scan
(cold), early contrast enhancement on arterial phase.
A) MRI → well-circumstribed hypervascular tumor w/↑ fat signal on T2
(bright).
B) Confirm dx of hepatocellular adenoma → clinical features & MRI
iv) Tx:
A) Asx → >5cm → resect. <5cm → stop OCPs.
1. Regresses → no additional tx. No regression → resect.
B) Sx → resection for bleeding & malignancy risk; embolization if multiple &
unresectable.
C) Best indication for excision of hepatic adenoma → after angioemb for
bleeding or if pt wants to get pregnant.

140
 b. Focal Nodular Hyperplasia (FNH) “Focused, centered, & safe.”
i) Best test to diff b/w adenoma & FNH → sulfur colloid scan.
ii) Hypodense central stellate scar. 2/2 embryonic blood flow disruption. No
malignancy, rupture rare, & usually < 5cm.
iii) Dx → abd CT; Kupffer cells, so will take up sulfur colloid on liver scan; FNA is
safe.
A) MRI/CT scan → hypervascular tumor.
iv) Tx → conservative (safe, no resection).
c. Hemangioma
i) MC benign hepatic tumor. Rupture rare, most asx, & MC in women.
ii) Giant hemangioma, CHF, thrombocytopenia → Kasabach-Merritt syndrome.
iii) > 5cm → yearly survaillence. Avoid biopsy → hemorrhage.
iv) Dx → MRI & CT → delayed peripheral to central enhancement of
hypervascular lesion.
v) Rare Cx → consumptive coagulopathy & CHF. Cx usually in kids.
vi) Tx → conservative unless sx, then surgery ± pre-op embolization; steroids
(possible XRT) for unresectable disease.
A) OR indications → rupture, ↑size, Kasabach-Merritt syndrome.
5) Hepatocellular Carcinoma
a. Best screening in chronic hepatitis → AFP + U/S (only proven beneficial in
Asians).
b. Markers → AFP, alk phos, portal HTN & thrombosis (on duplex).
c. Types
i) AFP negative
A) Fibrolamellar pts are younger (20s) w/well-demarkated mass. May have
hyperdense central scar, better prognosis, but 5ys 45%, + neurotensin,
NEGATIVE AFP.
ii) AFP positive (serum levels >400 ng/mL [nml → 10-20 ng/mL] in ↑-risk pt →
dx for HCC. Specificity >95%).
A) Types: Clear cell, Lymphocytic, Diffuse nodular.
B) AFP level corresponds w/size.
d. Scoring
i) Japan Integrated Score → promising, Child-Pugh (bili, alb, INR, ascites,
encephalopathy) + TMN.
ii) TMN
A) T1 → solid, no vascular involvement.
B) T2 → solid or multiple < 5cm.
C) T3 → multiple > 5cm, vascular involvement.
D) T4 → direct invasion of other organs.
iii) TACE, ablation, & sorafenib are palliative.
Sorafenib→multikinase inh (VEGF2, PDGF, cKIT, MAPKK). ↑survival
iv) Milan criteria for transplant → 1 lesion < 5cm OR 3 lesions < 3cm & NO mets
OR major vascular invasion. Meets criteria → 65-90% 5YS.

141

Uploaded by MEDBOOKSVN.ORG
6) Sarcoma
a. Hepatic → rapidly fatal. RFs → PVC, Thorotrast, arsenic.
7) Hepatectomy
a. Right (V-VIII) vs Left (II-III) vs extended/trisegmentectomy (add IV).
b. Steps
i) Right subcostal vs midline incision (for left).
ii) Mobilize triangular ligament.
iii) Cholecystectomy + cystic duct cannulation.
iv) Vessel loop to control blood supply.
v) Ligate hepatic artery → portal vein → then hepatic vein.
vi) Divide parenchyma.
vii) Use U/S, Cantlie’s line, & middle hepatic vein to guide.
8) Adequate Future Liver Remant (FLR): nml liver → >20%, s/p CTX → 30%, cirrhosis
→ 40%.
9) Metastasis
a. Colorectal cancer U/S → hyper/isoechoic w/hypoechoic rim.
i) MSK Clinical Risk Score (CRS) predicts who would NOT benefit from liver met
excision. LN+, Dz free<12mn, mets #, met >5cm, CEA >200
A) If all neg, 5ys → 60% w/resection.
ii) Solitary CRCa liver met abuts right hepatic vein → can still resect.
iii) Best tx prior to CRCa liver met resection if predicted postop function ≤ 20% →
preop portal vein embolization.
b. Carcinoid
i) Mets to liver (MC site) → Resect if enough liver left post-op.
ii) Best marker to follow post-op → urinary 5-HIAA+CrA
c. No Bx needed for new liver mass if → h/o CRCa + ↑CEA, h/o HCCa + ↑AFP, or
h/o other path w/mass at surgical margin.
i) Place “fiducial marker” (clip) if sive <2cm or >2cm from vessel.
d. Best Dx for small liver mass → intra-op U/S (most sensitive).

142
26. Biliary System
A. Anatomy
1) Lecithin → ↑capacity for cholesterol solubility.
2) Heme → biliverdin → bilirubin (+albumin) → conjugated (liver) → deconjugated (GI
bacteria) → urobilinogen → stercobilin.
3) 1° bile acids → cholesterol + glycine or taurine → cholic & chenodeoxycholic
(conjugated).
4) 2° bile acids → lithocholate & deoxycholate (deconjugated).
5) Bile → 80% bile salts, 15% phospholipids (eg. lecithin), 5% cholesterol. 95%
reabsorbed.
6) Left HD → longer (ML to be dilated).
7) Spiral valves of Heister → not true valves.
8) 75% CBD-pancreatic junctions are extraduodenal.
9) Venous return → liver parenchyma.
10) Motilin → GB contraction b/w meals.
11) CCK → GB contraction w/meals.
12) Gallbladder lies beneath segments IV & V.
13) Rokitansky-Aschoff sinus → asso w/chronic cholecystitis 2/2 mucosal atrophy.
14) Cystic artery from Right HA (RHA>GDA>SMA).
a. Normally posterior to CHD, had superficial & deep branches. Duplicated in 10%.
b. In triangle of Calot (cystic duct [lat], CBD [med], liver [sup]).
i) Node is actually Lund’s or Mascagni’s node (NOT Calot’s node).
15) One of numerous anatomical variants are present ~30% of the time.
16) Right hepatic (lateral) & retroduodenal branches of the GDA (medial) supply the
hepatic & common bile duct from 3 & 9 o’clock positions.
17) Gallbladder concentrates bile 5-10x by active resorption of NaCl & passive H2O.
18) Best test s/p RUQ U/S for biliary complaints in pt s/p RYGB → HIDA.
B. Biliary Colic
1) Transient cystic duct obstruction caused by gallstone passage. Resolves in 4-6 hrs.
C. Biliary Diskinesia
1) Dx → EF < 40% on CCK-CS HIDA (some use 35%).
D. Cholecystitis
1) Diagnosis MC bacteria → E. coli (#2 → Klebsiella).
a. U/S → 85% sens, 95% spec for stones → hyperechoic focus, post shadowing,
focus mvmt w/position changes.
i) Best initial evaluation for jaundice or RUQ pain → U/S. Dilated CBD (> 8 mm)
suggests CBD stone & obstruction.
ii) Suggestive of acute cholecystitis → U/S Murphy sign, gallstones, gallbladder
wall thickening (> 4 mm), & pericholecystic fluid.
b. HIDA scan → technetium taken up by liver & excreted in bile.
c. CCK-CS test (cholecystokinin cholescintigraphy).
i) Most sensitive test for cholecystitis (uses HIDA+CCK).

143

Uploaded by MEDBOOKSVN.ORG
 ii) Cholecystectomy indications s/p CCK-CS test:
A) Gallbladder not seen (likely 2/2 cystic duct stone).
B) Takes > 60 minutes to empty (2/2 chronic cholecystitis).
C) EF < 40% (biliary dyskinesia).
2) Calculus
a. RFs → age > 40, F, obesity, pregnancy, rapid ↓ wt, vagotomy, TPN & ileal
resection → pigment stones.
b. Early chole (< 24hrs) → overall Cx, open conversion, CBD injury, & mortality rate
= to “cooling off,” but ↓hospital stay.
c. IOC → routine use not indicated, but does help ID CBD injuries.
d. Pigment Stones
i) Brown → 2/2 infection (MC E. coli) → 1° CBD stone.
ii) Black → 2/2 heme d/o (Ca++ bili).
3) Acalculus
a. Thickened wall, RUQ pain, ↑ WBCs, no stones.
b. MC s/p severe burns, longterm TPN, trauma, major surgery → 2/2 bile stasis
(narcotics, fasting) & ↑ viscosity (dehydration, ileus, transfusion) → distention &
ischemia.
c. U/S → sludge, gallbladder wall thickening, & pericholecystic fluid.
d. HIDA will be positive (ie. no filling/emptying).
e. Tx → abx & cholecystectomy; percutaneous drainage if patient too unstable
(common scenario: can’t tolerate general anesthesia, severe
bleeding/CHF/COPD, end-stage cirrhosis).
4) Acalculus cholecystitis vs. cholangitis
a. Abnormal GB → acalc → abx + early chole if able (PTC if pt unstable).
b. Abnormal CBD → cholangitis → broad spectrum abx, ERCP w/sphincterotomy,
no chole.
c. Both get PTC if 1st line tx fails/CI/not available. Flush w/10mL NS QD.
i) PTC pts will need interval chole in 6-12 wks once stable.
5) Emphysematous
a. Gas in gallbladder wall on KUB. ↑ in diabetics; MCC → Clostridium perfringens.
b. Sxs → rapid severe abd pain, N/V, & sepsis. Perforation common.
c. Tx → emergent cholecystectomy; percutaneous drainage if not HDS.
6) Gangrenous
a. Best tx for gangrenous chole on lap chole → convert to open & IOC.
7) In Pregnancy → Lap chole is safe in all trimesters per SAGES. Risk of spont
abortion 2/2 dz >> 2/2 anesthesia/surgery.
8) Operative complications
a. Critical view (per SCORE). Injury rate w/ID critical view is < 0.03%
i) Only 2 tubular structures entering GB w/the following exposed:
A) Lower 1/3 of cystic plate cleared of all fibro-fatty tissue.
B) Cystic duct
C) Seg V of liver

144
E. Bile Duct Injuries
1) MC in lap vs open (per SCORE, cites lit from 1993-1996).
a. Lap → 0.26-0.6% Open → 0.1-0.5% (historic data)
2) RUQ pain & hyperbilirubinemia 5 days s/p lap chole → leak.
3) MCC of duct injury → excessive cephalad retraction (puts CBD/CHD/RHD in-line
w/cystic duct).
4) Tx → Thermal injury & clips near CBD → stricture.
a. Found intra-op / Diff lap chole & can’t see critical view → IOC to define anatomy.
i) small branch < 3mm → ligate
ii) branch > 3mm → reimplant
iii) CBD <50% (& not 2/2 Bovie) → repair over T-tube
iv) CBD >50% (or 2/2 Bovie) → debride, 1° repair over T-tube
A) If tension or at bifurcation → Roux-en-Y HJ (choledochoduodenostomy if
distal).
B) SCORE says to stay lap, leave drains, & txf to HB surgeon.
b. Found post-op → PTC & delayed repair. If partial → ERCP for covered stent.
5) Biloma → N/V, jaundice s/p lap chole, US → fluid collection.
a. Tx → Perc drain, if bilious → ERCP + sphincterotomy w/stent.
6) ML also to be injured if CBD injured → R hepatic artery.
7) ML to be injured if unable to laterally retract infundibulum → CBD.
8) Drawback of lap US during chole → air in duo so can't see AoV.
F. Choledocholithiasis
1) Immediate ERCP (c/f CBD stone) → jaundice, cholangitis, U/S w/CBD stone.
a. Pre-op ERCP → AST/ALT (> 200), bili (> 4), or amylase/lipase (> 1,000) for >
24hrs. If < 24hrs then ↓ → lap chole w/IOC.
b. < 5% have retained CBD stone s/p lap chole → ERCP clears 95%.
2) Routine IOC → 10% incidental CBD stones.
3) If retained CBD stones on IOC intra-op:
a. 1st → 1mg glucagon + NS flush (Best tx for retained CBD stone or non-filling of
duodenum on IOC).
b. 2nd → transcystic CBD exploration if cystic duct > 5mm & <8 stones that are all
<6-9mm.
i) MI step → Dilate cystic duct to gain access then initial IOC to assess stone
burden, must remove GB at END of case.
c. 3rd → transductal CBD exploration → cystic duct friable or <5mm, >8 stones or
>8mm.
d. 4th → open CBD exploration → large impacted CBD stone, biliary-enteric fistula,
Mirizzi syndrome, or failed ERCP.
i) 1.5cm vertical choledochotomy on distal CBD + Fogarty.
e. 5th → transduodenal sphincterotomy (see SOD below).
f. 6th → hepaticojejunostomy as last resort.
4) On IOC, if stones >5mm both proximal (PHD) & distal (CBD) to cystic duct →
choledochotomy w/CBD exploration.
145

Uploaded by MEDBOOKSVN.ORG
 5) Jaundice, ↑direct & indirect bilirubin, h/o RYGB, & nml ducts on U/S → MRCP to
eval anatomy b/c no distal obs per U/S.
6) Lap CBD exploration (Try transcystic CBD exploration 1st).
7) Next step s/p repair of cholodocholotomy w/ 5-0 PDS over 14-16F T-tube → transT-
tube cholangiogram.
8) Acute cholecystitis & bile duct stone on U/S 10yrs s/p RYGB. Tx → chole w/CBD
exploration.
G. Hydrops (Gallbladder Mucocele) → Long-standing obs w/o infection → bile
reabsorption & mucous secretion. Tx → lap chole.
H. Adenomyomatosis
1) Thickened mucosal & muscle nodule asso w/Rokitansky–Aschoff sinus. Not
premalignant. Does NOT cause stones, but can cause RUQ pain.
2) Tx → cholecystectomy.
I. Mirizzi Syndrome
1) Compression of CHD by 1) gallbladder infundibulum stone, or 2) gallbladder or
cystic duct inflammation extending to hepatic duct → CHD stricture. Tx →
cholecystectomy, may need HJ for strictures.
J. Lemmel Syndrome
1) Compression of intrapancreatic CBD by a periampullary duodenal diverticulum (aka
choledochocele/type III choledochal cyst).
K. Cholangitis
1) MCC is bile duct obstruction resulting from choledocholithiasis.
a. E. coli (#1) & Klebsiella (#2).
2) Charcot’s triad → RUQ pain, fever, jaundice.
Reynolds’ pentad → Charcot’s triad + AMS & shock (suggests sepsis).
3) Elderly pt s/p major surgery w/↑ LFTs/bili/WBC/fever/NO filling on HIDA → perc
chole.
4) Colovenous reflux occurs at > 200 mm Hg pressure → systemic bacteremia.
5) Tokyo Grade (1-3) & Tx Guidelines
1/Mild → IVF, Cxs, abx
2/Mod (if 2 of these: WBC <4k or >12k, ≥39°C, ≥75yo, bili ≥5, Alb ≤70% nml) →
IVF, Cxs, abx, early drainage.
3/Severe (e/o end-organ dysfunction)→urgent drainage+IVF, abx, Cxs
6) Dx → ↑ AST/ALT, bili, alk phos, & WBCs. U/S → dilated CBD (> 8 mm, > 10 mm s/p
chole) if 2/2 biliary obstruction.
7) Tx → 1st abx (eg. pip/tazo) + IVF resus, need chole in 6-8ks (still obstructed → ERCP
w/sphicterotomy + stent before surgery).
a. Obstructive jaundice → ↓vit ADEK. May need vit K pre-op (>24h best) ± FFP.
L. Hemobilia → 2/2 fistula b/w bile duct & hepatic arterial system. Classically present
w/UGIB, jaundice, & RUQ pain.
1) MC s/p trauma or percutaneous liver procedure (eg PTC tube).
2) Dx → EGD 1st to r/o UGIB, then angiogram.
3) Tx → angioembolization; OR if that fails.
146
M. Gallstone Ileus
1) MCC → fistula b/w gallbladder & 2nd portion of duo → SBO from gallstone (MC →
in TI).
2) Rigler’s Triad → pneumobilia, stone outside gallbladder, & SBO. Best test → CT
w/PO & IV contrast.
3) If duo adhered to GB during lap chole → run entire small bowel for stones to
prevent gallstone ileus.
4) Tx → remove stone from terminal ileum → longitudinal incision proximal to stone
(more dilated portion) → milk back/out → close transversely.
a. Can leave gallbladder & fistula if too sick (usually the case). If NOT sick, perform
chole & close duo (very rare).
N. Bile Duct Strictures MCC → Ischemia s/p lap chole (eg. clips too near CBD). Others
→ chronic pancreatitis, GB/bile duct CA.
1) Sxs → sepsis, cholangitis, jaundice. Strictures w/o h/o pancreatitis or biliary surgery
→ CA until proven otherwise.
2) Dx → MRCP for anatomy & mass → if can’t r/o CA → ERCP w/brushings.
3) Tx → if 2/2 chronic pancreatitis/ischemia → choledochojejunostomy (best long-
term). If 2/2 CA, Tx w/CA.
O. Primary Sclerosing Cholangitis
1) 30-50yo M. Asso w/UC, pancreatitis, & DM.
2) Sxs → jaundice, fatigue, pruritus (2/2 bile acids), ↓ wt, RUQ pain.
3) Progressive fibrosis throughout intra- & extrahepatic ducts → portal HTN & hepatic
failure.
4) Does NOT get better s/p colon resection for UC.
5) Cxs → cirrhosis, cholangiocarcinoma.
6) Tx → liver TXP needed for most; PTC, choledochojejunostomy or balloon dilation →
symptomatic relief.
a. Cholestyramine → ↓ pruritus sxs (↓ bile acids). Ursodeoxycholic acid → same,
+ improves liver enzymes.
P. Primary Biliary Cirrhosis → F. Med-sized ducts. Cholestasis→cirrhosis→portal HTN.
+Antimitochondrial Abs. No↑ CA risk.
1) Sxs → jaundice, fatigue, pruritus, xanthomas. Tx → liver TXP.
Q. Oriental Cholangiohepatitis / Recurrent Pyogenic Cholangitis
R. Porcelain Gallbladder → No longer considered ↑ risk of gallbladder CA (previously
said to be 15%).
S. Gallbladder Polyps (Best test → U/S; found in fundus, ↑wall thickness, anechoic &
NO shadowing; adenomatous polyps are premalignant).
1) MC → cholesterol (95%, ML polyp seen on CT) CA RFs → sxs, >10mm (+ stones,
<3 polyps, ≥50yo), ≥3 polyps, sessile, or e/o mucosal invasion.
2) Tx → ≤5mm (U/S in 1y x1), 6-9mm (U/S q1y), 1-1.9cm (chole), ≥2cm tx like
gallbladder CA.
T. Cholesterolosis → speckled cholesterol deposits on the gallbladder wall.

147

Uploaded by MEDBOOKSVN.ORG
U. Sphincter of Oddi Dysfunction (SOD)
1) Types (1-3)
1. Biliary pain, ↑LFTs, dilated CBD → ERCP.
2. Biliary pain, ↑LFTs or dilated CBD → SOD manometry, if ↑(>40mmHg)
→ ERCP + sphincterotomy.
3. Biliary pain, nml LFTs & CBD → medical tx only (no manometry or
ERCP).
2) Tx → 1st ERCP ± sphincterotomy (see above).
a. Pt may benefit from transduodenal sphincterotomy if + Naidi test (biliary cholic
s/p morphine + neostigmine).
i) Extensive Kocher.
i) Longitudinal duodenotomy, lat @ end of 1st ⅓rd of duo.
ii) ID papilla.
iii) Sphincterotomy at 11 o’clock.
i) Suture mucosa of CBD to duo (5-0 PDS).
i) Close duodenotomy transversely.
B. Choledochal Cysts Concerning findings → cystic, nodularity, type V, e/o invasion or
+ LNs. If peds → better outcomes if resected by 4 wks old.
Type Choledochal Cyst Description Treatment
I Cylindric or fusiform CBD dilation MC, 77-87% / resect w/Roux-en-Y HJ
II Supraduodenal CBD diverticulum Simple cyst excision
Intraduodenal CBD diverticulum (asso Choledochocele / sphincterotomy vs
III
w/ SOD) endoscopic resection
Partial hepatectomy + wide hilar Roux-
IVa Intra & extra hepatic dilations
en-Y HJ. May need TXP.
IVb Extra hepatic dilations Complete resection + Roux-en-Y HJ
Caroli dz (dz + renal cyst = Caroli synd) /
V Intra hepatic dilations
supportive vs TXP
1) Choledochal cyst tx → b/c MC is Type I, MC Tx → resect + Roux-en-Y HJ.
C. Cholangiocarcinoma
1) RFs → PSC, liver fluke, Hep C,
thorotrast, Caroli dz.
2) Subtypes: papillary (best prog),
sclerosing.
3) Resectable → Absence of:
i) Retropancreatic &
paraceliac nodal, or distant
liver mets
ii) Portal vein or main hepatic
artery invasion (although some centers support en bloc resection w/vascular
reconstruction.
iii) Extrahepatic adjacent organ invasion, & disseminated dz.
4) Tx (consider surgery if no distant mets & tumor resectable):
ALL get Portal LNDx (any other LN+ = mets).
148
 a. Upper ⅓ (Klatskin/perihilar tumors)
i) MC, worst, usually unresectable.
ii) Tx → try lobectomy & stenting contralateral bile duct if localized a lobe.
b. Middle ⅓ → hepaticojejunostomy + trisegmentectomy
c. Lower ⅓ → Whipple
d. Palliative stenting for unresectable disease; capecitabine (BILCAP trial) or
gem/cis for CTX, MSI high → pembro.
e. Overall 5ys rate → 20%.
D. Gallbladder Adenocarcinoma
1) Rare, but 4x MC vs
Gallbladder Cancer
cholangiocarcinoma. TNM Depth St Tx
2) 10% dx’d incidentally s/p lap T1a Lamina propria Lap chole (~100% cure)
chole. Muscularis 1A Lap chole + wedge IVb+V
T1b
propria (2cm margins)
3) Dx → 3 phase liver CT/CAP
Perimuscular Lap chole, formal IVb+V,
T2 1B
or MRI, CA 19-9, CEA. tissue portal LNDx (≥3 LNs), CBD
4) RFs → GB wall thickening T3
Serosal/liver/
IIA
resection (send frozen) w/H-
adj organ J, adj gemcitabine + cisplatin
(esp >10mm), +LAD, wall N1 IIB
enhancement (esp mucosal), Main PV, HA, Palliative (gemcitabine +
T4 III
stones >3cm. 2+ organs cisplatin)
M1 IV
5) F/u→U/S + 3-phase liver CT
q6m x2y, then q12m x5y ±LFTs/CEA/CA 19-9.

149

Uploaded by MEDBOOKSVN.ORG
27. Pancreas
A. Anatomy
1) Body/Tail → posterior to gastrocolic lig in lesser sac
2) Uncinate process → rests on aorta, behind SMV
3) SMV & SMA lay behind neck of pancreas
4) Portal vein forms behind the neck (SMV & splenic vein)
5) Blood supply
a. Head → superior (off GDA) & inferior (off SMA) pancreaticoduodenal aa. (ant &
post brs for each)
b. Body → great, inferior, & caudal pancreatic aa (all off splenic artery)
c. Tail – splenic, gastroepiploic, & dorsal pancreatic arteries
d. Venous drainage → portal system
6) Lymphatics → celiac & SMA nodes
7) Ductal cells → secrete HCO3- (via carbonic anhydrase)
8) Acinar cells → secrete digestive enzymes
9) Exocrine function →amylase, lipase, trypsinogen, chymotrypsinogen,
carboxypeptidase, HCO3-.
a. Amylase → only 1 secreted active; hydrolyzes α1-4 glucose chain links.
10) Endocrine function
a. α-cells → glucagon β-cells (islet center) → insulin
δ-cells → somatostatin PP/F cells → panc polypeptide
b. Islet cells → also produce VIP & serotonin.
11) Ventral Pancreatic Bud “Major VW goal → Drive Safe!”
a. Duct of Wirsung (Major, AoV, distal), migrates posterior/right/clockwise to form
uncinate & inferior head
12) Dorsal Pancreatic Bud
a. Duct of Santorini (accessory, proximal), forms body/tail/superior pancreatic
head.
B. Developmental Disorders
1) Annular Pancreas → 2nd portion duo, trapped in panc band; KUB → double bubble;
get duo obstruction (N/V, abd pain).
a. Consider in child w/recurrent abd pain & ↑ amylase.
b. Tx: Asx → nothing.
i) Sx
A) Neonate → DJ.
B) Adult → DJ vs GJ (duo less mobile so unlikely able to do DJ).
C) Adult w/obstructive jaundice → HJ w/biliary stent.
D) Adult w/chronic pancreatitis + obstructive pancreatic stones or
periampullary lesion → Whipple procedure.
2) Pancreatic Divisum Prevalence → 10%.
a. Failed PD fusion → duct of Santorini stenosis.
b. Most are asx; some get pancreatitis.
c. Dx → MRCP – long minor papilla w/large duct of Santorini; major papilla will
show short duct of Wirsung.
d. Tx → ERCP with sphincteroplasty; open sphincteroplasty if fails.
150
 3) Heterotopic Pancreas MC in duo. 2nd MC ectopic tissue in Meckel’s.
a. Tx → Usually asx, Resect if sx.
C. Pancreatitis
1) Acute
a. MCC → 1st = gallstones, close 2nd is EtOH (per NIH). Also → ERCP, trauma,
hyperlipidemia, hyperCa++, viral infection, meds (azathioprine, furosemide,
steroids, cimetidine), genetic (PRSS1, CFTR, SPINK1), & autoimmune (IgG4; Tx →
steroids).
b. Sxs → abd/back pain, N/V, anorexia. Also → jaundice, left pleural effusion,
ascites, or sentinel loop (dilated small bowel near pancreas 2/2 inflammation).
c. Mortality rate 10% (hemorrhagic pancreatitis → 50%). Pancreatitis w/o obvious
cause → need to worry about malignancy.
d. Ranson’s criteria
i) On admission → “GA LAW” - Glucose > 200, Age > 55, LDH > 350, AST > 250,
WBC > 16.
ii) After 48 hours → “Calvin & HOBBS” - Ca++ < 8, Hct ↓ 10%, PaO2<60, BUN
↑5, Base def > 4, fluid Sequestration > 6 L.
iii) 8 Ranson criteria met → mortality rate ~ 100%.
e. BISAP → BUN > 25, Impaired mental status, 2 SIRS, Age >65, Pleural effusion
(sen & spec > APACHE II & Ranson’s).
f. Can see RP hemorrhage:
i) Cullen sign → periumbilical.
ii) Grey-Turner sign → flank.
iii) Fox sign → inguinal.
g. Dx Labs →↑ amylase (clears w/in 2d, low spec), lipase (clears w/in
4+ d), & WBCs.
U/S → gallstones & possibly CBD dilatation.
Abd CT → for Cxs (necrotic pancreas → doesn’t enhance).
h. Tx → NPO, aggressive IVF resus.
2) Chronic Sxs → pain (MC), steatorrhea, malabsorption.
a. MCC → EtOH. Can have pseudocysts (MCC).
3) Hereditary 80% have PRSS1 mutation (cationic trypsinogen gene).
a. 50x more likely to get pancreatic CA.
4) Revised Atlanta Classification of Pancreatic Fluid Collections
a. Non-necrotic
i) Acute Peripancreatic Fluid Collection < 4wks
A) Tx → supportive.
ii) Pseudocyst > 4wks Will have ↑ amylase, ↓CEA & mucin.
A) Most resolve on their own. Only operate at >6wks & 6cm (EGD
w/cystgastrostomy).
1. If pseudoaneurysm → angioemb then EGD.
2. Tx if close to stomach/duo → endoscopic cystoenterostomy (even if
large & thick walled).

151

Uploaded by MEDBOOKSVN.ORG
 3. Tx if far from stomach/duo→ lap vs open cystoenterostomy.
b. Necrotic (liquefactive)
i) Acute Necrotic Collection < 4wks, Tx → supportive.
ii) Walled Off Necrosis > 4wks (tx like pseudocyst per SCORE)
c. Infected Pancreatic Necrosis
i) Air in pancreas, fever, sepsis, + BCxs.
ii) Tx → Abx (imipenem→best panc penetration), IVF, then step-up approach
(PANTER).
A) 1st Perc drain → endoscopic → retroperitoneoscopic → open.
D. Pancreatic Insufficiency Dx → >20gm fecal fat/24h.
1) MCC → chronic pancreatitis (#2 → cystic fibrosis).
2) Tx → low fat, high carb & protein diet, pancrease.
E. Pancreatic Leak / Fistula 5-15% s/p Whipple
1) ISGPF Post-Op Pancreatic Fistula (POPF) Grade
A/biochemical (Not a fistula)
i) Drain amylase >3x nml & aSx on POD3.
B Infected, needs IR/GI procedure, or present > 3wks.
C Above + shock/organ failure/death.
2) Leak Tx → ERCP w/stent. If no communication w/drain → perc drain.
3) Fistula Tx → Abx 1st wk, octreotide; Low output (<200mL/d) → closes
spontaneously, high output (>400mL/d) → NPO+TPN; ERCP w/sphincterotomy &
stent if >6-8wks w/o closure.
4) Octreotide → ↓output, but not time to resolution.
F. Pancreatic Cystic Neoplasms (PCNs)
1) Serous (↓amylase, CEA, & mucin) MC PCN Tx’d non-op.
a. Most are serous cystadenomas, benign, glycogen-rich lining from centro-acinar
cells. Anywhere in pancreas. MC F >60.
b. Types → microcystic (many small cysts), oligocystic (fewer large cysts, sim to
MCN or branch duct IPMN).
c. Multiple cysts w/central calcification → pathognomonic.
d. Tx → conservative (obs), malignant degeneration very rare.
2) Mucinous (MCNs) (↑CEA, ↓amylase)
a. Almost exclusive to F, MC >40. Variable cellular atypia, secrete mucin, ovarian-
like stroma, typically in tail or body, doesn’t communicate w/PD.
b. Malignancy risk → resect.
3) Intraductal Papillary Mucinous Neoplasms (IPMNs) (↑CEA & amylase)
a. M=F. Main duct, branch duct, or mixed. Makes mucin, variable cellular atypia →
dilated PD. Adenoma (mild dysplasia), borderline (mod dysplasia), or carcinoma
(high-grade dysplasia), w/ or w/o invasion.
b. Types (Least malignant [low/mod] to most malignant [high])
i) Branch duct IPMN <1cm → CT q1y, 1-3cm → CT in 6mn then q1y, >3cm →
Whipple.
ii) Main & branch duct (Mixed) IMPN Tx like main duct.
152
 iii) Main duct IPMN →↑malignancy risk (~60%) → resect >5mm &
young/healthy or >10mm. “Fish mouth sign” on EGD. 8% recur.
c. 5YS s/p resection if invasive → 43% non-invasive → 77%.
4) Solid Pseudopapillary Neoplasms (SPNs)
a. Rare, F < 35. MC in body or tail, both solid & cystic components & occasional
calcifications. Malignant risk → resect.
G. Pancreatic Neuroendocrine Tumors (PNETs)
1) 1-2% of panc neoplasms. Functional or non. Spontaneous or genetic. Most
regionally advanced or have mets.
2) Associated gene mutations → MEN1 (menin protein/TSG), DAXX (death-domain
associated protein), & ATRX (α-thalassemia/mental retardation syndrome X-linked),
↑ C-to-G transversions.
3) Can debulk mets for sx relief, including liver (even consider liver TXP).
4) General Dx
a. Labs
i) Chromogranin A (CrA) Best for eval & surveillance, high sens/spec,
corresponds w/tumor burden.
A) False ↑ w/PPIs, atrophic gastritis, & hepatic or renal insuff. Get baseline &
serial values.
ii) Neuron-specific enolase (NSE)
iii) Pancreatic polypeptide
b. Imaging
i) CT-Pancreas +/- MRI (↓T1/↑T2, Hypervasc, occasionally cystic or
w/calcifications, better than CT to eval for liver mets), EUS (res 2-3mm, more
sens than CT/MRI).
ii) 68 DOTATATE scan → ↑affinity for somatostatin receptor vs octreotide,
possibly better than selective Ca++ stim test.
5) Non-functional MC PNET overall.
a. 40% of PNETs have NO hypersecretion, > ½ dx incidentally.
b. MC Sxs → pain, anorexia, jaundice, or ↓ wt.
c. Liver mets at dx 60-85%. Usually have ↑CrA, PP, or + SRS.
d. Median survival → 38 months, 5ys → 43%. Prognosis depends on differentiation
& met status.
e. Tx
i) <3cm & not high-risk or near main duct → consider enucleation.
ii) >3cm, high risk (high-grade dysplasia/ ↑Ki67), near main duct → formal
resection.
iii) Adj CTX → octreotide/lantreotide/everolimus + 5FU + streptozocin.

153

Uploaded by MEDBOOKSVN.ORG
6) Functional (From most benign to most malignant)
a. Insulinoma
(MC functional)
i) Whipple’s Triad →
1Fasting

hypoglycemia
(Prolonged/72h
fasting glucose = gold-standard to dx), 2sxs of hypoglycemia (palpitations,
tachycardia, sweating, syncope), & 3gets better w/glucose.
Insulin : glucose > 0.4 (< 0.3 is nml). C-peptide : insulin should be =.
Throughout, 90% are solitary.
ii) Best localization study → Ca++ stim w/hepatic vein sample (spec for
insulinoma) or Intra-op U/S (best in gen for PNET, 90-95% sen).
A) In OR → 1) palp panc, 2) U/S panc, & 3) Bx panc tail (r/o nesidioblastosis).
iii) Tx → <2cm & >2mm from main duct → enucleate.
>2cm or <2mm from main duct → Whipple v distal panc. Diazoxide (1mg/kg
TID) & octreotide for sx (CA →5FU & streptozocin).
b. VIPoma
i) WDHA (Watery Diarrhea, HypoK, Achlorhidira)
ii) HypoK+, hypoCl-, metabolic ACIDOSIS. In body & tail.
iii) Overnight fasting VIP > 225pg/mL.
iv) Tx → resect, octreotide (CA→ 5FU & α-interferon [diff from rest]).
c. Gastrinoma
i) Refractory PUD & diarrhea (ZES, MC PNET in MEN I); 75-80% sporadic. 60% in
duo wall [1st portion], 50% cured w/resection.
ii) 90% malignant. 1/3rd have sx.
iii) MEN 1 → more aggressive, 0-10% cured w/resection.
iv) Gastrinoma (Pessaro’s) triangle CBD, panc neck, 3rd portion of duo.
v) Dx criteria (off PPI > 2wks)
A) Fasting gastrin >200 (>1000 is diagnostic) & 24h gastric acid >15mEq/hr.
Secretin stim test if fasting gastrin not ↑much (>120-200 rise =
gastrinoma).
1. Baseline gastrin → 2u/kg secretin IV → q5m gastrin x 30m.
vi) Best localization study → octreotide scan.
A) Intra-op → 1inspect triangle, 2U/S panc, 3palp duo, & 4open via lateral
duodenotomy.
vii) Tx → <2cm→enucleation. >2cm→formal resection + regional LND.
viii) Palliation → octreotide & PPI (CA → 5FU & streptozocin).
d. Glucagonoma Fasting glucagon > 1000pg/mL.
i) Necrolytic migratory erythema, rash (face & groin; resolves w/resection), DM,
thrombosis, stomatitis, glossitis, & anemia.
ii) Tail (though some say throughout pancreas).
iii) Tx → resect, octreotide AA, FA, zinc (CA → 5FU & streptozocin).
154
 e. Somatostatinoma Fasting somatostatin > 160pg/mL.
i) DM, gallstones, & steatorrhea. In pancreatic head.
ii) Tx → resect + chole (CA → 5FU & streptozocin).
H. Primary Pancreatic Lymphoma Wt loss, fatigue, anorexia, palp mass (usually
>6cm), Ø jaundice (not obstructive).
1) Dx → ↑LDH & β-2 microglobulin. Nml CA 19-9.
2) Tx → CTX ± ERCP w/stent.
I. Ampullary Villious Adenoma/Carcinoma
1) MC benign periampullary mass → Villous adenoma.
2) Tx → ampullectomy if < 2-3cm, carcinoid or gastrinoma [need portal LNDx], solitary
adenomas/adenomatous polyps.
J. Periampullary Adenocarcinoma
1) If unresectable, but has obstruction → GJ + biliary-enteric bypass.
K. Pancreatic Adenocarcinoma Prognosis based on stage.
1) Male MC, 50-60s. Sxs → ↓ wt (MC), jaundice, pain. 5yr OS 5-8% → 20-25%
w/resection. RF → tobacco #1, BMI, genetics.
2) CA 19-9 → panc CA serum marker (>1000 → likely neoadj CTX benefit).
3) Genetics →
a. Peutz-Jeghers (STK11 mut) → highest risk.
b. p16 mut → 95%. MC, a tumor suppressor, binds cyclin.
c. Others → K-ras (2nd MC → 90%), TGF-β, p53, & C-to-T transitions.
4) Lymphatic spread 1st (If OR 1st → 78% will have +LNs). 70% in head.
5) MC type → ductal. Papillary & mucinous → better prognosis.
6) Dx → Labs → ↑conj bili & Alk phos. MRCP/Panc CT (irregr narrowing,
displacement/destruction, vessel involvement).
a. ↑Bili (>2.5) may falsely ↑ CA19-9.
b. Some pts lack enzyme to make CA19-9 (will be undetectable).
7) At presentation, 20% have local dz (37% 5YS), 20% have regional dz (12% 5YS), &
60% have distant dz (3% 5YS).
8) Tx
a. Boarderline/Unresectable → determined by ABC’s (Abuts vessels, Biology
[?mets, CA19-9], Condition [ECOG]).
i) Mets, aortic involvement, >180° SMA/celiac, unreconstructable SMV/PV,
contact w/1st jejunal br to SMV.
A) → Palliation w/biliary stents or HJ (for biliary obs), GJ (for duo obs), &
celiac plexus ablation (for pain) + local XRT.
ii) Neo-adj FOLFIRINOX (FOLate/leucovorin, 5Fu, IRINotecan, OXaliplatin) to try
to make resectable
b. Resectable → start w/staging lap, prognosis based on clear margins.
i) CTX-XRT usually post-op.
A) Gemcitabine + Capecitabine → ↑DFS x2, don’t use if BRCA+.
B) FOLFIRINOX → ↑DFS x4, OS, & ↓ tox vs gem/cap.

155

Uploaded by MEDBOOKSVN.ORG
 C) Pasireotide → ↓ leak rate (small duct & soft panc→↑leak rate).
D) 40% 3yr DFS w/FOLFIRINOX in adj setting (vs 20% w/ gem/cap).
L. Biliopancreatic Surgeries
1) Kasai (for biliary atresia in newborns) → Jejunum to hepatic plate.
2) Puestow
a. Longitudinal PJ, for ducts > 8mm → open along main pancreatic duct & drain into
jejunum.
3) Beger
a. A duo-preserving panc head resection (DPPHR) + Roux-en-Y PJ.
b. For isolated panc duct dilation in head. Most would just do a pylorus-preserving
Whipple.
4) Frey
a. A partial head resection + Puestow of body & tail.
5) DPS → for nml or sm ducts & distal portion of the gland is affected.
a. MCC of bleeding after → short gastrics.
6) Whipple 40% Cx rate. ML margin to be + → SMA/SMV.
a. MCC → Delayed gastric emptying (35-70%). Tx → erythromycin.
i) Or metoclopramide, but only 20% response + rebound once d/c’d.
b. Inf pancreaticoduodenal a is encountered during Kocher maneuver.
c. Isolated ant abd wall nodule on opening for Whipple → Bx w/frozen section.
Takes antrum → ↓ acid.
d. Steps
i) Explore for mets (send frozen section if concerning lesion).
ii) 270° dissection of SMV & SMA above 1st jejunal br.
iii) Resect panc head & duo (send margin for frozen).
iv) Create Roux limb.
v) End-to-side PJ (Blumgart → stitch post-duo, through panc, ant duo; 1 superior
to PD & 2 inferior). Antecolic if pylorus-sparing to ↓delayed gastric emptying.
vi) End-to-side choledochojejunostomy.
vii) End-to-side GJ.
viii) Cholecystecomy.
7) Whipple vs pylorus-sparing pancreaticoduodenectomy → no sig diff in short or long-
term outcomes. Pylorus-preserving saves gastric antrum (↑acid), pylorus, & prox 2-
3 cm of the duo (DJ). CI if → prox duo, pylorus, or gastric antrum involved (→
standard Whipple).

156
28. Spleen
A. Anatomy
1) Filters, stims humoral & cell-mediated immunity, traps Ags, activates complement,
Ab production, opsonins (tuftsin & properdin).
2) Site of extramedullary hematopoiesis (pathologic).
3) MC location of accessory spleen → splenic hilum (54%, #2 splenic pedicle-25%, #3
pancreatic tail-6%).
B. Infection MCC→ IVDU (Can also spread from endocarditis).
1) Tx → IV abx & splenectomy (gold-standard, esp if multiloculated. Some will try perc
drain + abx if simple.)
C. Post-Splenectomy Sepsis Syndrome
1) 0.1% s/p splenectomy; ↑ in kids (↑M&M). MCC of OPSI → S. pneumonia (also HiB,
Staph, N. meningitides).
2) 2/2 lack of IgM to encapsulated bacteria. Highest OPSI risk in kids s/p splenectomy
2/2 hemolytic do or CA. ML w/Wiskott-Aldrich.
3) Try to delay splenectomy til >5yo→↑Ab formation + vaccines. Kids < 5-10yo →
consider ppx abx (PCN V 125mg BID) x2yrs (Most OPSI w/in 2yrs).
D. Hemangioma → MC splenic tumor, MC benign splenic tumor. Tx → splenectomy if
sx.
E. Non-traumatic indications for splenectomy
1) Auto-immune hemolytic anemias (+Coombs test)
a. ITP → Anti-PLT IgG (↓PLTs) → Petechiae, gingival bleeding, bruising,
ecchymosis. Many causes (drugs, viruses, etc.).
i) Nml spleen. + Coomb’s test. Kids <10yo/ Most resolve w/o splenectomy.
However, ITP MCC non-trauma splenectomy.
ii) Evan’s Syndrome – ITP + autoimmune hemolytic anemia.
iii) Tx → steroids (1° tx); gammaglobulin if resistant (plasmapheresis + 60mg
prednisone/d x10d).
A) Splenectomy → if steroids fail → removes IgG & phagocytosis source. 80%
response. Give PLTs 1hr before OR if < 50K.
B) Best way to prevent recurrence → remove all splenic tissue (including all
accessory spleens, if present).
b. TTP/Moschcowitz Syndrome →↓PLT inhibition → clots & infarction, profound
↓PLT & RBC. Asso w/reactions, infections, inflammation, autoimmune dz.
i) Purpura, fever, AMS, renal dysfunction, hematuria, hemolytic anemia.
ii) Tx → plasmapheresis (1°), immunosupp (80% response). MCC of death → ICH
or ARF. Splenectomy rarely needed.
2) Hypersplenism → hypoTN, abd pain, splenomegaly, & ↓PLTs 2/2 sequestration.
a. Membrane protein defect hemolytic anemias
i) Hereditary spherocytosis
A) MC congenital hemolytic anemia needing splenectomy, AD, neg Coombs
test, pos erythroid hyperplasia.
157

Uploaded by MEDBOOKSVN.ORG
 B) Spectrin & ankyrin deficit (membrane proteins) → abnml RBCs → splenic
sequestration & hypersplenism
C) Pigmented stones, anemia, reticulocytosis, jaundice, &splenomegaly.
D) Tx → splenectomy & chole (after 5yo & vaccines) → curative for cxs of dz.
ii) Hereditary elliptocytosis Like spherocytosis. Less common. Spectrin &
protein 4.1 deficit (membrane proteins).
b. Non-membrane protein defects hemolytic anemias
i) Pyruvate kinase deficiency → altered glucose metabolism → congenital
hemolytic anemia.
A) MC congenital non-membrane protein hemolytic anemia needing
splenectomy (→ ↑RBC survival).
ii) G6PD deficiency Flairs c/b → infection, certain drugs (eg. Benzocaine), fava
beans. No splenectomy usually needed.
iii) Warm antibody autoimmune hemolytic anemia
A) Tx → splenectomy.
iv) Beta thalassemia → persistent HgbF. MC thalassemia.
A) Major → both chains; minor → 1 chain, asx.
B) Sxs → pallor, ↓ growth, ↑head size. MC M&M as teen 2/2 hemosiderosis.
C) Tx → blood transfusions & Fe++ chelators (deferoxamine, deferiprone).
Splenectomy may ↓ hemolysis & sxs.
v) Sickle cell anemia HgbS instead of HgbA. Spleen autoinfarcts & NO
splenectomy needed (usually).
vi) Sideroblastic anemia → No response to splenectomy.
3) Myelofibrosis w/Myeloid Metaplasia (MMM) → Severe splenomegaly w/sxs.
a. Tx → splenectomy (76% response by 1yr, but ↑ bleeding, DVT, & infection
(26%).
4) Felty’s Syndrome rheumatoid arthritis, hepatomegaly, & splenomegaly. Tx →
splenectomy if splenomegaly sxs.
5) Echinococcal cyst Tx → splenectomy (see liver section).
F. Isolated Splenic Vein Thrombosis MC 2/2 pancreatitis.
1) Tx → splenectomy. If occurs s/p splenectomy → anticoagulate.
G. Lymphoma → MCC of chylous ascites.
1) Hodgkin’s Reed–Sternberg cells. Best prog → Lymphocyte predominant. Worst →
depleted. MC → Nodular sclerosing.
a. Staging
i) Stage I – 1 area or 2 contiguous areas on the same side of diaphragm.
ii) Stage II – 2 non-contiguous areas on the same side of diaphragm.
iii) Stage III – involvement on each side of diaphragm.
iv) Stage IV – liver, bone, lung, or any other non-lymphoid tissue except spleen.
v) A – asymptomatic.
vi) B – symptomatic (night sweats, fever, wt loss) → bad prognosis.
b. Tx → CTX

158
 2) NHL MC malignant splenic tumor. 90% → B-cell. Prognosis worse than Hodgkin’s.
Most w/disseminated dz at dx. Stage like Hodgkin’s except no A or B, just E
designator for Extranodal involvement. Tx → CTX.
3) Isolated Splenic Cyst Incidental cyst → 1st get serology to r/o Echinococcus.
H. Splenectomy
1) Vaccines 2wks pre-op (elective) or 2wks post-op (or before pt leaves hospital,
whichever is sooner, if traumatic)
a. Vaccines→ Pneumococcus, Meningococcus, & H. flu.
2) Lap splenectomy CIs→ Massive splenomegaly, portal HTN, unstable pt.
3) Early ligation of splenic artery → open lesser sac. Look sup to pancreas.
4) Best way to ↓ bleeding w/splenectomy for splenomegaly→angioemb 1st.
5) Locate accessory spleen(s) → Not in OR → Get a radionucleotide scan.
In OR → ML in hilum.
6) Smear w/Howell-Jolly bodies → functional asplenia.
7) Early post-op HypoTN s/p splenectomy → bleeding short gastrics.
8) Low-attenuation fluid on CT in LUQ → panc leak (tail).
9) Changes s/p splenectomy
a. Howell-Jolly bodies → nuclear remnants (MC finding).
b. Heinz bodies → denatured Hgb.
c. Pappenheimer bodies → iron deposits.
d. Spur & target (immature) cells.
e. ↑PLTs → only tx if ≥ 1,000K /μL. Tx is ASA.

159

Uploaded by MEDBOOKSVN.ORG
29. Small Bowel
A. Anatomy ~600cm in length
1) MC gut flora → Bacteroides. Gut flora produce vit K.
2) Strength layer → submucosa.
“Dude Is Just Feeling Ill, Bro.” Duo → Iron. Jejunum → Folate. Ileum → B12.
3) Absorbed in Duodenum → Fe, Ca++, B2, B6.
4) Absorbed in Jejunum → B1 & B9.
5) Absorbed in TI → B12, bile salts, Vits ADEK.
B. Duodenum
1) Duodenal Diverticula
a. Must r/o gallbladder-duo fistula.
b. Obs unless perforated, bleeding, causing obstruction (→ jaundice), or ↑↑↑ sxs.
c. Diverticula frequency → duo > jejunal > ileal.
d. Tx → segmental resection for sxs.
i) If into pancreas → duodenotomy, inversion of diverticula, excision.
2) MC periampulary tumor → pancreatic adenoCa.
3) 2nd portion of duo diverticula during OR in pt w/obs jaundice, before ERCP → open
ant duo to assess relation to AoV.
C. Jejunum
1) 100 cm long; long vasa recta, circular muscle folds. Vascular supply → SMA. 95%
NaCl & 90% H2O abs in jejunum.
2) Max abs all nutrients save for B12 (TI), bile acids (non-conj → ileum; conj → TI),
Fe++ (duo), & folate (TI).
D. Ileum TI absorbs → B9, B12, vit ADEK, conj bile salts (as stercobilinogen).
1) Meckel’s Diverticulum
a. Kids → MC, painless LGIB/hematochezia, true diverticulum, 2’ from ICV, bleeding
MC w/gastric.
b. 15-20% heterotopic cells (40-50% if pt has sxs), MC → gastric, 2nd MC →
pancreas.
c. Adults → present w/obs 2/2 band connecting Meckel’s to umbilicus (vitelline).
d. Dx → 99mTc-pertechnetate (Meckel Scan). Only for GASTRIC tissue, not panc. If -,
but ↑suspicion→dx lap.
e. Tx (per SCORE)
i) Found outside OR
A) Incidental on imaging → leave alone.
B) Sxs, palpable, or mass → segmental resection.
ii) Found Intra-Op
A) Adhesive band, but no mass palpable → diverticulectomy.
B) Palpable mass/ulcer or Sxs c/w Meckel’s→ segmental resection.
1. Ulcers are usually located just outside the diverticulum so need
segmental resection to include.
C) Neither A or B → leave.

160
E. Mesenteric Lymphadenopathy → Sim sxs as appy, but also diffuse TTP>RLQ,
preceding URI in kids, CT w/RLQ LAD & nml/non-visible appy. MC infectious cause →
Yersinia (others→Shigella & Campylobacter). Tx → abx only.
F. Appendix
1) Appendicitis
a. Acute 1st anorexia; 2nd abd pain (periumbilical → RLQ gradually w/peritonitis);
3rd vomiting. MC 20-35yo. WBC can be nml.
i) Can be 2/2 Ascaris (MC parasite world-wide).
ii) Retrocecal → 60%, Pelvic → 30%, Retroperitoneal → 10%.
iii) Dx → CT scan → >7mm or wall >2 mm, fat stranding, no lumenial contrast (PR
contrast if able).
iv) Tx → No fecalith→abx alone ok, sim recurrence to baseline. Fecalith→lap
appy (abx alone→↑failure & recurrence).
A) If inflamed @ base → take cecal cuff.
v) Recurrence s/p med tx → 5-38% @ 2yrs.
b. Perforated
i) ML area to perforate → anti-mesenteric border midportion. MC in kids &
elderly 2/2 dx delay.
ii) Kids → ↑fever, N/V. Elderly → min s/s (usually walled-off, need R hemi if c/f
CA).
iii) Is 2/2 to neoplasm up to 20-30% (vs ~1% if non-perf).
iv) Tx → abx, perc drain (if >2cm abscess) ± interval appy if sxs better. Get CSP to
r/o colon CA prior to interval appy.
c. Presumed Nml appy → still take out (unless base is inflamed at cecum) &
explore for alt dxs.
d. In Pregnancy Incidence = in all trimesters, non-perf → 5% fetal loss, perf → 25%
fetal loss. Perform w/Hasson, LL decubitus, ↓insufflation.
2) Appendiceal Tumors
a. Mucoceles Mucous papillary tumor, benign or malignant
i) Tx → resect (consider open to not spill tumor contents → pseudomyxoma
peritonei [Tx → CRS & HIPEC]). Right hemi if malignant.
ii) MCC of death → SBO 2/2 peritoneal tumors.
b. NeuroEndocrine Tumor/Carcinoid MC appendiceal mass.
Enterochromaffin cells. + 24hr urine 5HIAA & CrA.
i) SI (55%) > rectum (20%. ≥2cm, muscularis, or +LN → LAR/APR w/TME) > Appy
(17%) > Colon > stomach (SEER data). Good 10y prognosis.
ii) MC location of 1° for Carcinoid Syndrome → Ileum.
iii) Dx w/DOTATATE PET>octreotide SPECT. Often multifocal. Carcinoid
synd→flushing, diarrhea,+TIPS (Tricusp Insuff, Pulm Stenosis)
iv) Ki67 >2 or mitosis/10HPF > 20 (use highest to determine tx)
A) <2 & 20 → R hemicolectomy.
B) >2 or 20 → octreotide, everolimus, sunitinib (debulk if can resect >80%).
v) Generally for carcinoid: <1cm → 5% mets, >2cm → 50% mets.
161

Uploaded by MEDBOOKSVN.ORG
 vi) Tx PRRT/Lutathera → Tx-dose DOTATATE
A) <2cm & no concerning features (no LVI, < gr II) → appy (good 5 & 10ys even
w/many liver mets)
B) Concerning features, involving base, or ≥2cm → right hemi.
c. Adenocarcinoma Tx like cecal CA → right hemicolectomy regardless of
size/location in appendix. If found on path s/p lap appy → get CSP 1st to check
for other lesions.
d. Goblet-Cell Carcinoma – AdenoCA & NEC features (more like adenoCA, but
worse than both). Tx → like adenoCA.
G. Ileus
1) Causes → Postop, Drugs (opiates, but also α-agonists, antihistamines, anti-ACh &
psychotropics), intra-abd inflam, ischemia, metabolic/electrolyte, RP hemorrhage, &
sepsis.
H. Small Bowel Obstruction SBO + mass on CT, & h/o melanoma → resect.
1) W/o prior surgery: Large bowel → cancer MC.
Small bowel → hernia MC (if h/o melanoma think bowel mets → OR).
2) W/prior surgery: Large bowel → CA MC. Small bowel → adhesions MC.
3) Tx → bowel rest, NG tube, IV fluids → cures 65-80% partial SBO, 40% complete SBO.
a. OR for → ↑ pain, peritonitis, fever, ↑WBCs, (s/o strangulation/perforation), or
fails to resolve.
b. ↓ future SBO → Seprafilm (hyaluronate carboxymethylcellulose sheet) &
Interceed (oxidized regenerated cellulose).
I. Intussusception Intussusceptum → proximal portion (inside)
Intussuscepiens → distal portion (outside), ML to perf.
1) Pediatric Place NGT if stomach needs decompressed (ie. emesis).
a. MCC Peyer’s patches at ileocecal valve, but consider lymphoma & Meckel’s.
b. Dx & Tx→ 1st Air enema w/max 120mmHg, reattempt if no peritonitis or lead
point (if fails [20-40%] or sick → OR to reduce w/gentle distal pressure &
proximal traction). Obs 24hr s/p air enema. 10% recur.
2) Adult
a. MCC pathologic/malignant lead points (colon CA, melanoma mets).
b. Tx → resection.
3) Dx → Target sign or Bull’s eye on U/S (best 1st test in kids) or CT (best in adults).
J. Lower GIB MCC → brisk UGIB (get NGT asp/EGD 1st).
MC lower → diverticula. MCC in HIV+ pt → CMV colitis.
1) Occult → + FOBT & mild anemia, middle age man, EGD & CSP negative → capsule
endoscopy.
2) Brisk w/hypoTN → cont LGIB & not HDS, re-bleeds s/p stabilization, or receives 4+ u
pRBCs → angiography.
a. Angio → invasive, but can also be tx. + localization ML if not HDS or pt receives
4+ u pRBCs/12hrs.
b. Microcatheters → superselective embo of sm target vessels →
↓ ischemia (up to 97% success rate).
162
K. Neutropenic Enterocolitis (Typhlitis) → Diarrhea, then pain + neutropenia (< 0.5
WBC).
1) Tx → NPO/bowel rest, NGT, antiviral, antifungal, zosyn, hold CTX.
L. Acute Radiation Enteritis → Inc = 75% w/XRT to abd/pelvis. Transient.
M. Chronic Radiation Enteritis → 2/2 submucosal obliterative arteritis → strictures.
Worsened by DM, PVD, & CTX. Asso w/>4000 cGy XRT.
1) Tx → Usually obs. If must operate → resect or bypass (NO stricturoplasty b/c very
friable).
N. Crohn’s → intermit abd pain, diarrhea, & ↓ wt; poss SBO & fistulas. Mouth to anus.
Often rectum spared. MC involves → TI.
1) 15-35yo at 1st episode. Earliest finding → aphthous ulxers.
2) ↑ in Ashkenazi Jews.
3) 10-12x ML to get intestinal adenoCA (ML→ileum; duo MC in non-Crohns)
4) MC sites for initial presentation
a. TI & cecum → 40%. Colon only → 35%. Small bowel only → 20%.
Perianal → 5% (MC → skin tag, 2nd → fissure).
5) Path →transmural, segmental (skip lesions), cobblestoning, non-caseating narrow
deep ulcers, creeping fat (pathognomonic).
6) Medical Tx
a. Oral 5-aminosalicylates (eg, sulfasalazine, mesalamine), abx (eg, cipro, flagyl),
glucocorticoids (systemic - prednisone, local - budesonide), immunomodulators
(eg, azathioprine, 6-MP, MTX), & Biologic txs/anti-TNF (eg, infliximab,
adalimumab).
7) Surgical indications → surgery NOT curative (unlike UC).
a. Persistent/blind loop obs, abscess despite perc drain, megacolon (15% perf →
MC TI), bleeding, fissures (NO SILS), persistent ECF, Perineal fistula (unroof),
anorectovaginal fistulas (poss rectal adv. flap/colostomy).
8) Resection vs Stricturoplasty
a. Resect bowel segment w/fistula + 1° repair of other involved organ.
b. Stricturoplasty CIs → intra-abd sepsis, acutely inflamed phlegmon, fistulae,
abscesses, tight/long/thick strictures.
c. Very Short (≤2cm) isolated, or c/f malignant → resect + 1° anastomosis (↓Cx &
r/o CA).
d. Short Stricturoplasty (≤7-12 cm)
i) MC recurrence site → at stricturoplasty (90%).
ii) Heineke-Mikulicz stricturoplasty (longitudinal → transverse)
iii) Judd strictureplasty (SAA, but w/resection of associated fistula tract at
stricture)
iv) Moskel-Walske-Neumayer strictureplasty (Y-shaped)
e. Intermediate Stricturoplasty (>7-12 cm to ≤15-24 cm)
i) Finney strictureplasty (longitudinal → fold bowel onto itself & close; --- → U)
f. Long Enteroenterostomy (>15-24 cm)
i) Michelassi strictureplasty (side-to-side isoperastaltic)
163

Uploaded by MEDBOOKSVN.ORG
 9) SubQ abscess during ostomy takedown → drain abscess & leave ostomy, esp in
Crohn's pt → likely represents a fistula/flare.
O. Short Gut/Bowel Syndrome
1) Sxs → diarrhea, steatorrhea, ↓ wt/nutrition/fat, B12, lytes, H2O.
2) Dx by sxs, not length.
a. Sudan red stain → fecal fat. Schilling test → urinary radiolabeled B12.
3) Need ~75+ cm to live w/o TPN (50cm w/competent ileocecal valve).
4) Tx → ↓fat, PPI, Lomotil (diphenoxylate & atropine)
a. Gattex (teduglutide) → GLP2 analogue, ↑mucosal growth, poss ↑gastric
emptying & secretion.
b. Best nutrient in short gut syndrome → glutamine.
P. MC mets to small bowel → Melanoma (→ SBO).
1) Small bowel diffuse gastric CA mets admitted for SBO → bypass.
2) Matted jejenal mass of mets causing SBO → bypass.
Q. Enterocutaneous Fistula → HIS FRIENDS
1) High output (>500cc/hr; low output <200cc/hr), Intestinal perf, Short fistula tract
(<2.5cm long)
2) Foreign body, Radiation enteritis, IBD/infection, Epithelialization, Neoplasm, Distal
obs, Sepsis.
3) Best Txs→ bowel rest, anticathartics, octreotide, PPI, cholestyramine, endoscopic
stent/plug. Wait > 6mn before surgical tx.
a. Fistulectomy + segmental resection is asso w/↓recurrence.
b. ML to close, colon vs small bowel fistula → colon.
R. Pneumotosis Intestinalis
1) Primay/Pneumatosis Cystoides Intestinalis → thin-walled cysts. MC in colon.
Incidental. Tx → obs.
2) Secondary → asso w/NEC, pyloric stenosis, Hirschsprung’s, COPD (MCC in adults),
immunodef, inflammation, steroids, Celiac dz, collagen vasc dz, Crohns, & ischemia.
a. Tx → OR for perforation or peritonitis. Portal venous gas = ischemia.
S. Ileostomy & colostomy Place through rectus m to ↓ cxs.
1) MC Cx s/p loop ileostomy reversal → SSI.
2) ↑ileostomy output (>1200mL/d) → loperamide.
3) Stoma Cxs
a. Stenosis → 2/2 ischemia. Mild → dilation. Patchy → observe.
b. Prolapse → MC w/loop (vs end). Reverse if able, NOT able→ repair
w/Sugarbaker technique)
c. Retraction → reposition likely needed if fixed.
d. EC fistula → 2/2 full-thickness stitch through both bowel & skin → relocate.
i) If w/synthetic mesh → explant mesh + relocate.
ii) ECF at prior ostomy & if NO distal obs → wound care.
e. Dusky on test tube exam above fascia only → obs
below fascia → re-explore & revise.
f. Hernia → ppx mesh ↓inc from 55 to 8%. MC w/end colostomy. LC w/loop
ileostomy.
i) Tx → Sugarbaker repair (recurrence <10%). Relocating/revising → 24-86%
recurrence.
164
 4) Colostomy
a. Reverse ≥12wks (get contrast enema/flex sig 1st, 30% won’t be candidates), 1st
try lap.
b. ↑ descending colostomy length → divide IMV distal to panc
T. Small bowel primary neoplasms (MC to LC)
MC mets/2° small bowel neoplasm → melanoma.
1) Duodenal Adenoma
a. ≤1cm → EGD polypectomy. 1-2cm → either. >2cm → transduo polypectomy w/
f/u EGDs (40% CA risk >2cm).
2) Adenocarcinoma
a. 30%, ML in duo (80% w/ ulcers duo/prox jejunum). MC 1° malig. sm bowel
tumor. Rare. Sx’s → obs, jaundice, bleeding.
b. Worrisome for CA → ulceration, severe dysplasia, & panc duct/CBD dilation.
i) Tx → resection w/LNDx. 10cm prox & 5cm distal margins.
A) 2nd portion of duo → Whipple. CTX → FOLFOX.
3) Carcinoid
a. EC/Kulchitsky cells → serotonin.
b. Get TIPS → Tricuspid Insufficiency & Pulmonary Stenosis.
i) MC → SI (55%) > Rectum (20%) > Appy (17%) > Colon > stomach (SEER data).
Good 10y prognosis.
c. Tx: see above for appendix, otherwise → segmental resection & LNDx.
d. Recurrence not on CT → Octreotide scan (most sens to localize).
e. CrA most sens (~100%) to detect presence (yes/no, not where).
f. Carcinoid synd → <10%, ↑serotonin→flushing, diarrhea, 2/2 tumor spread past
liver. HypoTN→octreotide(50-100μg IV).
4) GIST Malignant → >5cm & 5mitoses/50HPF → imatinib for 3+ yrs.
5) Lymphoma 70yo M, MC ileal → NHL B-cell (Peyer’s patches), spares duo. ~25%
perf.
a. Asso w/Wegener’s, SLE, AIDS, Crohn’s, celiac sprue.
6) Enteropathy-Associated T-cell Lymphoma Celiac dz w/abd pain & wt loss despite
gluten-free diet + fevers. Celiac also RF for small bowel adenoCA.
U. Witzel → tunneled jejunal tube (obstruction at J-tube → OR → reposition distally).
1) 20cm distal to LoT, 4-6cm serosal Lembert tunnel w/3-0 silk.

165

Uploaded by MEDBOOKSVN.ORG
30. Colorectal
A. Anatomy
1) Secretes K+ & reabsorbs Na+ & H2O (mostly in right colon & cecum)
2) Absorbs vit K, B1, B2, B7.
3) MC site of perf (w/comp ICV) → Cecum.
4) Mucosa (columnar) → Muscularis mucosa (inner muscle layer b/w mucosa &
basement mem) → submucosa → muscularis propria → serosa.
5) Retroperitoneal → Right, left, & sigmoid.
6) Intraperitoneal → Transverse, anterior upper & mid ⅓ rectum.
7) Plicae semilunares → form haustra.
8) Taenia coli → 3 longitudinal bands . Splay on appy & rectosigmoid junction.
9) Denonvilliers fascia (ant) – M → rectovesicular; F → rectovaginal.
10) Waldeyer’s fascia (post) – rectosacral.
11) Vascular supply
a. Colon
i) SMA (ileocolic, right, middle colic) → Right & ⅔ transverse.
ii) IMA (left colic, sigmoid, superior rectal) → ⅓ transverse, left, sigmoid, &
upper rectum.
iii) Marginal artery of Drummond → SMA to IMA collateral along colon.
iv) Arc of Riolan → SMA/middle colic to IMA near base of mesentery.
v) Mucosa & submucosa → get 80% of blood flow.
vi) Veins follow arteries (except IMV to splenic). Splenic + SMV → PV (behind
panc).
b. Rectum
i) Superior rectal ( IMA), Middle rectal ( internal iliac; aka lateral stalks of
LAR/APR), Inferior rectal ( internal pudendal  internal iliac).
ii) Superior & middle rectal veins → IMV → PV.
iii) Inferior rectal veins → internal iliac → IVC.
B. Colonic Inertia Sitz marker test. + if >20% retained s/p 5d.
C. Colovesicular Fistula Sxs → urinary stool/air. 2/2 diverticulitis.
Colovaginal Fistula Sxs→vaginal stool. MC in F vs above. 2/2 OB trauma.
1) Best test → CT w/PO &/or PR contrast only (not IV). Also get CSP & cystoscopy.
a. For colovaginal, best is methylene blue soaked tampon in rectum then vaginal
exam.
2) Tx → close bladder(/vagina), resect colon, reanastomose, diverting ileostomy, & put
omentum b/w bladder(/vagina) &colon.
D. Diverticulosis 2/2 straining (↑ intraluminal pressure), ↓residue/fiber diet, ↑
refined carbs. Prevalence → 35%.
1) Mucosa herniation through sites arteries enter wall, ↑elastin. Colon thickens
around area → narrowing.
2) MC side → Left/sigmoid (80%). MC bleeding side → Right (50%). 10-25% of
diverticulosis → diverticulitis.
166
 3) MCC true LGIB, 2/2 disrupted vasa recta, usually significant, 75% stop, 25% recur.
4) Dx → r/o UGIB w/NGT (MCC hematochezia). Then CSP (best to find & tx w/hemo-
clips).
a. Massive bleed (hypoTN responsive to IVF) → CTA then angio ± vasopressin 1st
(find & coil).
b. OR if hypoTN & not responsive → colectomy where bleeding (can’t find →
subtotal colectomy).
c. Can’t find intermittent bleed → tagged RBC.
5) OR for recurrent diverticular bleed, prior tagged RBC scan 1wk before + Left colon,
no bleeding seen on pre-op endoscopy but tics from transverse colon to recto-
sigmoid junction, tx → L hemi if HDS (if not → subtotal colectomy + end ileostomy).
E. Diverticulitis MC side → Left.
1) Hinchey classification (The 4 “P’s”)
a. I → Paracolonic II → Pelvic III – Purulent IV – Poop
2) Tx
a. Uncomplicated → Tx: levofloxacin & Flagyl; 3-4d bowel rest (mild → out-pt tx),
CSP in 6-8wks to r/o CA.
b. Complicated (persistent obs s/p med tx, perf, peritonitis, can’t drain abscess or
r/o CA). → Take all sigmoid to nml rectum.
i) MC Cx → abscess (→ perc drain). CSP in 6-8wks to r/o CA.
A) Deep pelvic abscess w/o tran-abd window → transgluteal.
ii) STOP-IT trial → w/ source control, 4d abx is = longer abx courses.
F. Angiodysplasia ↑on right, less bleeding vs diverticular, recurs ↑ (80%), venous.
Angio → tufts, ↓emptying. Ao stenosis 20%. Tx→CSP + cautery.
G. Ogilvie’s Syndrome Colon pseudo-obs, asso w/opiate, elderly, major
surgery/infection/trauma. Can perf.
1) Tx → replete lytes (esp. K+); d/c meds w/↓motility (eg. morphine). NGT. > 10 cm (↑
perf) → decomp CSP & neostigmine 2mg IV over 5 mins + continuous EKG (80-90%
effective); if fails & pt HDS → cecostomy (95% effective).
a. CIs to neostigmine → ACS, 2nd/3rd ° heart block, & reactive airway.
b. Not better 1-2 days or worsening or > 10-12cm → ex lap w/subtotal colectomy
w/end ileostomy.
H. Melanosis Coli → benign spotty hyperpigmentation 2/2 laxatives. Tx → obs.
I. Perforation
1) Post-Polypectomy Syndrome Tx: No free air→obs. Free air + aSx→IV abx, NPO, +
serial exams. Free air + peritonitis→OR.
J. Ischemic Colitis
1) Thumbprinting: wall hemorrhage/edema on Barium enema 2/2 ischemia.
2) Ischemic colitis best test→ CTA 1st (some say plain film), then flex endoscopy (no
prep).
3) On CSP → erthymatous & edematous mucosa + small ulcers
4) <1wk s/p major surgery/trauma, CT w/ edematous bowel, C diff neg → 1st empiric
IV abx, IVF, + bowel rest.
167

Uploaded by MEDBOOKSVN.ORG
K. C. diff Colitis
1) Accordion sign: edematous haustra on CT (mostly describes C. diff).
2) Uncomplicated → 10d tx w/PO vanc (125mg QID) or PO fidaxomicin (200mg BID)
(per IDSA). >3 recurrences → consider fecal TXP.
3) C. diff toxic colitis (25% mortality)
a. Tx→ subtotal colectomy + end ileostomy (since pt likely not HDS).
L. Amebic Colitis
1) Entamoeba histolytica; 2/2 contaminated food & water w/ cysts in feces.
2) 1° infection → colon; 2° infection → liver.
3) RFs → travel to Mexico, EtOH; fecal-oral transmission.
4) Sxs → like UC (dysentery); MC chronic (3-4 BM/day, cramping, & fever).
5) Dx →endoscopy → ulceration, trophozoites; 90% have anti-amebic Ab.
6) Tx → Flagyl, di-iodohydroxyquin.
M. Actinomyces
1) Cecal (MC) mass, abscess, fistula, or induration; suppurative & granulomatous.
Often confused for CA. Path → Yellow-white sulfur granules.
2) Tx → PCN or tetracycline, drain abscess.
N. Microscopic Colitis
1) Diarrhea s/p pelvic XRT, sporadic basement membrane thickening, lamina propria
lymphocytic infiltrate. Tx → budesonide.
O. Radiation Proctitis Sxs → bleeding, pain, stricture, fistula s/p pelvic XRT.
1) Tx → 1st sucralfate + Flagyl, 2nd argon/laser coag vs 4% formalin fixation.
P. Ulcerative Colitis Earliest finding → mucosal edema.
1) Sxs → bloody diarrhea, abd pain, fever, & ↓wt. Mucosa & submucosa. Strictures &
fistulae unusual w/UC. Anal sparing.
a. Distal rectum & contiguous (no skips). Friable mucosa (→ bleeding),
pseudopolyps, distorted vascular pattern, & “collar button” ulcers.
b. R/o infection. Proximal dz → backwash ileitis. Barium enema → ↓haustra,
narrow, short, & ↓redundancy w/chronic dz.
2) Medical Tx: sulfasalazine (or 5-ASA) & loperamide for maintenance. Acute flares →
steroids.
3) 5-ASA & sulfasalazine for remission. Cyclosporine or infliximab if steroid resistant.
4) Extraintestinal manifestations → Arthritis, Arthralgias, Pyoderma gangrenosum,
Erythema nodosum, Ocular dz, Growth failure, Megaloblastic anemia (↓folate &
B12), & Stomatitis.
5) Severe UC/Toxic colitis: > 6 bloody BM/d, ↑ HR/temp/WBC, ↓Hgb.
6) Fulminant UC: > 10 bloody BM/d, ESR >30, + above.
7) Toxic megacolon: above + distension & abd pain. ML location of perf w/UC →
transverse colon.
8) Initial Tx → NGT, IVF, steroids, bowel rest, & abx (cipro & Flagyl). 50% will still need
surgery.
a. Follow clinically & w/KUBs. Avoid barium enemas, narcotics, anti-diarrheal
agents, & anti-Ach.

168
 9) Tx
a. UC surgical indications → massive bleed, intractable (>24-48hrs) toxic
megacolon, acute fulminant UC (~15%), obs, any dysplasia (esp high-grade), CA,
poss > 10yrs since dx to ppx vs colon CA.
i) Emergent/urgent resections – total abdominal colectomy & bring up
ileostomy (spares superior rectal a; hook back up later)
b. Total proctocolectomy & IPAA (NO low rectal anastomosis in IBD)
i) Protects bladder & sexual function. Need lifetime surveillance of residual
rectum.
ii) Ileoanal anastomoses often must be resected 2/2 dysplasia/CA, refractory
pouchitis, or incontinence.
iii) Diverting ileostomy for 6-8 wks to heal anastomosis. Infectious pouchitis →
Tx: Flagyl.
iv) MCCx s/p ileal pouch → SBO (11-26%).
A) 2nd MCCx → leak/abscess.
c. 3 Stage → 1) TAC + end ileostomy → 2) proctocolectomy + IPAA + DLI → 3) DLI
reversal.
d. APR w/ileostomy can also be performed
10) CA risk 1%/yr 10 yrs s/p dx if pancolitis. CA throughout colon. CSP yearly 8-10yrs s/p
dx w/random 4 quadrant Bxs (≥32) of UC prox to sigmoid.
a. If UC w/PSC → start screening immediately (↑CA risk).
b. CA Risk: 10yrs → 2.1%, 20yrs → 10%, 30yrs → 50%, 40yrs → 75%.
i) UC w/LGD → 20%. UC w/HGD → 42%.
11) Extraintestinal manifestations.
a. MCC for needing total colectomy in kids → failure to thrive.
b. Colectomy helps → most ocular/oral, arthritis, erythema nodosum, anemia, &
50% of pyoderma gangrenosum. Not PSC & ankylosing spondylitis.
c. HLA B27 → sacroiliitis, ankylosing spondylitis, UC. Thromboembolic dz.
Pyoderma gangrenosum (Tx → steroids.)
Q. Volvulus
1) Cecal
a. Can cause LUQ pain (from RLQ pointing to LUQ)
b. KUB showing cecal volvulus, HDS → go to OR & resect.
2) Sigmoid
a. KUB showing sigmoid volvulus (from LLQ pointing to RUQ), HDS → detorsion
w/CSP then → sigmoidectomy before d/c.
R. Granular Cell Myoblastoma Neural crest origin (poss. Schwann cells). Nearly all
benign, submucosal.
1) MC location → skin/soft tissue, then aerodigestive (MC → tongue).
2) Tx → WLE/CSP excision. + margins → can observe.
S. Colorectal Polyps
1) Types
a. Hyperplastic → MC polyp overall. No CA risk.
b. Tubular adenoma → MC (75%) intestinal neoplastic polyp, generally
pedunculated. <5% CA risk.
c. Tubolovillous adenoma → 20% have CA.

169

Uploaded by MEDBOOKSVN.ORG
 d. Villous adenoma → ML polyp w/sxs. Most are sessile & larger v. tubular. 50%
have CA. Repeat CSP in 3yrs.
2) ↑ CA risk → > 2 cm, sessile/villous lesions, > 3 polyps (>10→get genetics), ≥10mm,
or high-grade dysplasia.
3) Haggitt Levels for Malignant Polyps
1. Pedunculated w/invasion in head.
2. Pedunculated w/invasion in stalk. →Neg. margin polypectomy.
3. Pedunculated w/invasion in neck.
4. Pedunculated w/submucosa (SM1/2)/sessile → ≥ 2mm margin.
High-risk → lower ⅓rd of submucosa (SM3), margin <2mm, +LVI, piecemeal, ±
poor diff → need formal colectomy.
4) MC location → left-side.
5) Tx → CSP for most (esp. pedunculated). Can’t get entire polyp (eg. sessile) →
segmental resection.
6) Tattooing → Don’t tattoo before/at area of submucosal dissection.
a. Tattoo 1mL x4 quadrants circumferentially at distal margin.
7) High-grade dysplasia → intact basement membrane (carcinoma in situ).
8) Intramucosal cancer → into muscularis mucosa (carcinoma in situ → not through
basement membrane)
9) Invasive cancer – into submucosa (T1)
T. Complete Large Bowel Obstruction
1) Send CEA on way to OR → oncologic resection (if doing a 1° anastomosis &
proximal bowel dilated → consider DLI) → stage post-op w/CSP & CT
chest/abd/pelvis.
U. Rectal Carcinoid
1) 15% of carcinoids; carcinoid syndrome rare. ↑ size → ↑ mets (>2cm → 70% mets).
⅔ in colon have local or systemic spread.
2) Tx
a. Colon or high rectal carcinoids → LAR w/TME.
b. Low rectal carcinoids→ < 2 cm → WLE w/- margins.
> 2 cm or invasion of muscularis propria → APR.
c. CTX → 5FU, streptozosin, doxazosin, somatostatin.
V. Colorectal Cancer Mutation order: APC → Kras → DCC → p53
1) Screening
a. Nml risk → 50yo, 40 (or 10 years before youngest dx in fam) for intermediate risk
(eg FMHx of colon CA).
b. LBOs are c/f CRCa.
i) No peritonitis/ischemia → NGT, NPO, IVF, CSP ± stent (time to work up).
ii) Peritonitis/ischemia → ex lap + TAC w/end ileostomy.
c. Screening options
i) High-sensitivity FOBT q1y.
ii) High-sensitivity FOBT (False + → iron, beef, cimetidine, vit C.) q3y & flex sig
q5y.
170
 iii) Double contrast barium enema or CT colonography q5y.
iv) CSP q10y Most sensitive → CSP.
A) No CSP w/recent MI, splenomegaly, pregnancy/fluoroscopy planned.
2) Genetics
a. FAP AD; >90% CA by 50yo. APC gene → ch 5 (>80% of de novo CRCa have
somatic APC muts → no ↑risk to family).
i) 20% of FAP syndromes are spontaneous (germ line muts).
ii) MCC of death → CrCa.
iii) Polyps (1000s) present after birth/in puberty.
iv) No surveillance CSP w/suspected FAP → just flex sig for polyps starting at 10-
12yo. Need ppx TAC by 20.
v) Desmoid tumors → resect if poss (incomplete → 80% recur).
A) Sulindac & tamoxifen help if can’t resect (± doxorubicin/ carboplatin →
50% remission).
vi) Duo Polyps → EGD q2y. 2nd MCC of death (MC s/p ppx colectomy).
vii) Surgery → total proctocolectomy, rectal mucosectomy (controversial), & IPAA
w/J-pouch.
A) Total proctocolectomy w/end ileostomy is also an option.
B) Post-op procto surveillance q2y for life.
viii) Attenuated FAP (100s of polyps, not 1000s)
ix) Gardner’s Syndrome → Colon CA (asso w/APC gene) + desmoids & head/jaw
osteomas (MC extra-intestinal manifestation→get CSP).
A) ML to have skin manifestations → Gardner synd > UC > Crohns.
x) Turcot’s syndrome→ Colon CA (asso w/APC gene) + brain tumors.
b. Mut Y Homolog-Associated Polyposis (MAP) MYH mut 10+ polyps
i) Desmoids & duo adenomas. CAs → Thyroid, Ovary, Bladder, & Skin.
ii) Like attenuated FAP, but MYH not APC + associated TOBS(↑) CA
c. HNPCC
i) 5% prevalence, AD. Asso w/DNA mismatch repair gene, MSI (MLH1, MSH2
[>PMS1 & MSH6)). MC to be on right.
ii) Amsterdam Criteria → “3, 2, 1” → > 3 1st degree relatives, over 2 generations,
1 w/an asso CA < 50yo.
iii) Lynch I → just colon CA risk
iv) Lynch II → also ↑ ovarian, endometrial, bladder, & stomach CA.
v) Need q1-2y surveillance CSP at 25, or 10yrs before youngest dx in fam. Also
surveil for the other HNPCC CAs.
vi) 50% metachronous lesions w/in 10yrs; multiple primaries common.
vii) Test for MSI if → sporatic CRCa, poorly diff, or signet-ring on bx.
viii) Tx → Need total proctocolectomy w/1st CA operation (f/u CSP q1y).
d. Peutz-Jegher’s Syndrome → 90% lifetime overall CA risk. AD STK11 mut,
hamartomas throughout GI (small & large bowel). No need for ppx colectomy.
500x ↑ small intestine CA risk. Get SBOs 2/2 polyp intussuception or obs.
i) Extraintestinal → Mucocutaneous melanotic pigmentation.

171

Uploaded by MEDBOOKSVN.ORG
 A) Other CAs→Breast(MC),cervical(screen@25yo), & stomach/duo.
e. Familial Juvenile Polyposis → AD, SMAD4/DPC4 mutation. 10-38% CA risk. MC
on right. CSP at 10-12yo. If adenoma on CSP → colectomy. Hamartomas can
degenerate into CA.
3) Staging & Treatment
a. CT CAP, EUS/MRI pelvis, CEA, LFTs.
i) ↑↑↑CEA & no obv mets (or indeterminate CT) → PET.
ii) Concerning LNs → indistinct, heterogenous, round, >9mm.
b. Resections
i) Need at least 12 LNs in specimen to stage. Get 5cm gross margins.
ii) Colon (all require high ligation of arterial supply to ensure proper LN staging).
A) Right colectomy → Include TI to right br of middle colic.
B) Extended right colectomy → Include TI & both brs of middle colic up to
splenic flexure.
C) Left colectomy → From peritoneal reflection of rectum to splenic flexure.
1. Ligate IMA near its origin for adequate LN sampling in left
hemicolectomy.
2. Ways to get more length for a tension-free anastomosis.
1IMV high ligation (18cm), 2IMA high ligation + splenic flexure

mobilization (8cm), 3IMA high ligation (5cm).

D) Extended left colectomy → From peritoneal reflection of rectum to
include one/both brs of middle colic.
E) Sigmoidectomy Simple Staging
F) Total abdominal colectomy I - T1-2
G) Total proctocolectomy II - T3-4
iii) Rectum T2 MRI best for depth of invasion & LN III - N+
evaluation (vs U/S)
IV - M+
A) Transanal excision → Submucosal (T1), <3cm,
3mm margins, <30% circumference, low (≤8cm from anal verge), mobile,
well/mod-diff (gr 1 or 2) on bx, & no LVI/PNI. Otherwise needs LAR vs APR.
B) Low Anterior Resection (LAR) +TME if > 2cm from levators.
1. Low rectal CA that extends past submucosa → LAR + TME.
a) Total mesorectal excision (TME). Middle rectal = lateral stalk = lateral
resection border.
b) LAR w/TME → ↑survival, ↓LR vs APR.
c) Op w/best prognosis for rectal CA should include → TME.
2. St II (≥T3,N0,M0) CRCa >2 cm from puborectalis → neoadj CTX/XRT then
LAR.
3. Best next step for BRBPR early s/p LAR → proctoscopy.
4. Need at least 1cm distal margin.
C) AbdominoPeritoneal Resection
1. If < 2cm from levators.

172
 c. Chemotherapy & Radiation
i) St II or III colon CA → OR + 6mns of CTX (no XRT).
A) May perform lung/liver wedge at same time (vs staged).
ii) St II or III rectal CA → Pre-op CTX-XRT x 5wks then OR.
iii) St IV rectal CA → Definitive CTX-XRT (may not benefit from APR).
iv) Preop CTX-XRT may downstage & ↓local recurrence (LR).
A) Wait 5-10wks s/p XRT to assess response.
v) Post-op CTX-XRT may ↑survival & ↓LR
d. Complications
i) Erectile dysfunction → 2/2 pelvic splanchnic inj (PNS).
ii) No ejaculation → 2/2 pudendal nerve inj (SNS).
iii) Retrograde ejaculation → 2/2 hypogastric nerve inj (SNS).
iv) BRBPR → get procto to assess.
v) Leak rates: RIGHT → 5-10%, LEFT → 12-15%.
Ileocolic → 1-3% Colocolonic → 1-10% Coloanal → 10-20%
A) RFs → intra-op hypoTN, low-rectal (<7cm from verge), tumor >5cm,
multiple staple firings, M, intra-op bleed, Ketorolac, prior XRT, ASA 3+,
emergent sg, ↑OR time, poor nutrition, hand-sewn [ultra-low,
controversial]).
B) ↓leak rate by → ↓ RFs above (& in females).
vi) Urine Leak Cr >50, fevers, abd pain. Seen intra-op/PACU→ debride & repair.
Post-op → cystoscopy (dx & tx, perc neph if can’t cysto).
vii) Serosanguinous (“salmon pink”) fluid from wound s/p ex lap, tx → RTOR for
fascial closure.
e. Isolated colon met abutting R hepatic vein → can still resect.
f. Obstructing low rectal CA → loop sigmoidostomy + complete work-up vs pre-op
CEA + oncologic resection w/CSP in 3-6mns.
g. ML recurrence: Colon <2yrs → local=liver, >2yrs → liver. Rectal → local.
4) Follow-up
a. CEAs → q3-6m x 2y then q6m x3y.
OR just say q6mn x5yrs to simplify.
b. CT abd/pelvis → q6-12m (St II-III) or 3-6m (St IV) x 5y.
OR just say q6mn x5yrs to simplify.
c. CSP → 1y, 3y, 5y.

173

Uploaded by MEDBOOKSVN.ORG
 Colon & Rectal Adenocarcinoma
Colon
TMN Stages Rectal
(no XRT)
Tis CIS, into lamina propria 0 Tis All colon CA Trans-anal resection
T1 Into submucosa get segmental Trans-abdominal
I T1-2 colectomy
T2 Into muscularis propria resection
Through propria into
T3 IIA T3
pericolorectal tissues Adjuvant:
T3 → If T3/4 or N1/2 or =
T4a Visceral peritoneum IIB T4a
Capecitabine Neoadjuvant XRT +
T4b Other organs IIC T4b
or
T1-2+N1; 5-FU + Capecitabine
N1a 1 regional LN IIIA OR
T1N2a leucovorin
T3-4a, N1; Infusional 5-FU
N1b 2-3 regional LNs IIIB T2-3, N2a; >T3 → OR
T1-2+T2b FOLFOX FOLFOX
or OR
Deposit in subserosal, T4a, N2a; CapeOX
CAPEOX
N1c mesentary, non- IIIC T3-4a, N2b;
perioclolic tissue T4b+N1-2 +
All for 6mns
Resect
N2a 4-6 regional LN IVA AnyT/N, M1a Neoadjuvant/
N2b >6 regional LN IVB Any T/N, M1b definitive CTX
M1a 1 organ >2cm from dentate → LAR
M1b >1 organ <2cm from dentate → APR

174
31. Anal & Rectal
A. Anatomy
1) Anal canal
a. Anatomical → distal to dentate line.
b. Surgical → Superior border of external sphincter/anorectal ring to anal verge.
2) Anal margin
a. Anatomical → between dentate line & anal verge.
b. Surgical → anal verge to 5-6cm from squamo-mucosal junction.
3) Anal verge → the opening of the anus to the skin surface of the body.
B. Abscess 2/2 obstruction of anal crypts.
1) Supralevator Tx → drained transrectally.
2) Intersphincteric perianal pain, fever, ↑ WBC, no external findings, MCC →
intersphincteric abscess.
a. Tx: Low → drained through the skin if low.
High → through rectal wall.
3) Ischiorectal External to levators. Tx → drained through skin.
4) Perianal Next to anus Tx → drained through skin.
5) Horseshoe wraps around posteriorly & deep to anococcygeal ligament (must
release this to adequately drain).
C. Fistulae
1) Types
a. Extrasphincteric fistulae w/internal rectal openings above levators, descending
through ischioanal fossa. Tx → unroof.
b. Suprasphincteric fistulae w/opening at dentate, pass through internal sphincter,
ascend over puborectalis, passes through external sphincter, & descends into
ischioanal fossa. Tx → advancement flap.
c. Transsphincteric fistulae w/internal opening at dentate, passes through both
sphincters, descends to ischioanal fossa. Tx→see below.
d. Intersphinteric fistulae w/internal opening at dentate, pass through internal
sphincter, & descend through intersphincteric plane w/perianal external
opening. Tx → see below.
2) Don’t need to excise tract. Often found s/p anorectal abscess.
3) Goodsall’s rule Anterior → connects w/ anus in straight line.
Posterior → goes to midline internal opening.
4) Tx → No OR for aSx fistulae in Crohns pts.
a. Lower ⅓ external sphincter → fistulotomy (open tract, curettage, heal by 2°
intention). CIs → incontinence, F w/anterior fistula, Crohns (just non-cutting
seton).
b. Upper ⅔ of the external anal sphincter → seton vs LIFT vs rectal advancement
flap.
i) Ligation of Intersphincteric Fistula Tract (LIFT) → tract b/w external & internal
sphincter is ligated. Used for transsphincteric fistulae.

175

Uploaded by MEDBOOKSVN.ORG
 ii) Incontinence → Most worrisome cx → don’t damage external sphincter (NO
fistulotomy above lower ⅓).
iii) Ok to place cutting setons across sphincter complex & slowly tighten →
fibrosis → reestablish anorectal ring continuity (except in Crohns or
incontinent pts, can lead to incontinence).
5) Ano/Rectovaginal MCC → OB trauma.
a. Simple – low to mid-vagina. Tx → trans-anal rectal mucosa advancement flap.
Many OB fistulas heal spontaneously.
b. Complex – high in vagina. Tx → abd or combined abd & perineal approach;
resection/re-anastomosis of rectum, close vaginal defect, interpose omentum, &
temp ileostomy.
D. Hemorrhoids 2/2 straining.
1) Left lat, right ant, & right post hemorrhoidal plexi.
2) External hemorrhoids → pain w/thrombosis, distal to dentate, sensate squamous
epithelium.
a. Sxs → pain, swelling, & itching.
b. Medical Tx → sitz baths, water hydration, lidocaine jelly, bulk fiber (M→38g/d,
F→25g/d), & stool softeners (↓straining).
c. Thrombosed external hemorrhoid Tx:
i) Do not band external (painful + possible pelvic sepsis).
ii) If< 72 hours of Sxs → hemorrhoidectomy/excision.
iii) If> 72 hours of Sxs → medical tx 1st (surgery pain > hemorrhoid pain at this
point; will fibrose, but ↑recurrence).
3) Internal hemorrhoids cause bleeding or prolapse
a. Types Primary → slides below dentate w/straining.
Secondary → prolapses, reduces spontaneously.
Tertiary → prolapses, manually reduced.
Quaternary → can’t reduce.
b. Tx
i) Surgical indications → recurrent bleeding, multiple thromboses, large external
component, mod-severe pain.
ii) 1° & 2° → banding (in office, stay at least 1-2cm proximal to denate line).
iii) 3° & 4° → 3 quadrant resection (some use stapler, some only 2 columns at a
time 2/2 c/f stenosis). MCC of Stenosis 2/2 → taking too much anoderm.
iv) Milgan-Morgan → open (mucosa). Ferguson → closed.
Whitehead → circumferential stapled.
A) Resect to internal sphincter (NOT through). Take mucosa & submucosa
w/venous plexus.
B) Trans-Hemorrhoidal Doppler → find feeding vessel → ligate.
C) Strangulated 4° hemorrhoids → urgent surgery 2/2 necrosis
1. Sxs → swollen, non-reducible, pain & bleeding.
v) Post-op → sitz baths, stool softener, high-fiber diet, & lidocaine jelly.

176
 4) CXs
a. MCCx → urine retention (20%) 2/2 pelvic spasm after local anesthesia wears off.
Tx → place temporary Foley.
b. Eschar sloughing → light bleeding late (5-10d) post-op (eg blood on TP).
i) Tx → stool softeners, fiber supplements & hydration. Avoid local trauma &
ASA (doesn’t need EUA).
c. Early/significant bleeding (2/2 technical error, rare; eg toilet bowel full of blood)
→ EUA & suture ligation of bleeding.
d. Sepsis → very rare s/p hemorrhoidectomy (Sxs → severe perianal pain, fevers,
urine retention, c/f immunocompromise).
i) Tx → IVFs, broad spectrum abx, & EUA (c/f abscess vs NSTI).
E. Perianal Sepsis
1) Pain, fever, urine retention (can happen s/p rubber band internal
hemorrhoidectomy). Tx → IVF, IV abx, EUA, & I&D.
F. Fissure Split anoderm → pain w/defecation (straining bowel movements);
bright red bleeding. Often h/o constipation.
1) Can be s/p heavy narcotic use, back or perineal surgery.
2) MC location → posterior midline (90%). EUA to confirm Dx.
3) Sentinel piles seen if chronic.
4) Early medical Tx (< 4 weeks of sxs) → sitz baths, bulk fiber, stool softener,
hydration, lidocaine jelly, 6wks topical NTG.
a. Late medical Tx (> 3 months of sxs) → 6wks 2% topical diltiazem (CCB). Indicates
difficult/refractory fissure.
5) Surgical Tx:
a. Surgical indications → No improvement w/2 cycles of CCB; 6mn of medical Tx.
b. Lateral subcutaneous internal sphincterotomy (LSIS)
i) Considered the most effective Tx for anal fissures.
ii) Feel groove b/w internal & external sphincter
iii) 11 blade transverse cut through internal sphincter
iv) Don’t pass dentate, cut external sphincter or mucosa, or perform in Crohns
pt. 90% heal.
v) Most serious Cx → incontinence (1%; pre-op it’s a CI to LSIS).
6) Botulinum toxin injection (40-100u b/w sphincters) → 60% heal.
7) Lateral or recurrent fissures → c/f Crohns (tx →biologic & flagyl), STDs/HIV, &
anal CA → high-res anoscopy w/Bx.
G. Lower GI Bleed
1) FOBT+ up to 3wks s/p bleed.
2) Hematemesis → bleeding from pharynx to ligament of Treitz.
3) Melena→ tarry stools; poss w/as little as 50mL of blood.
4) Azotemia s/p GIB → 2/2 urea from blood broken down by bacteria (↑BUN & total
Bili).
5) Arteriography → bleed ≥ 0.5mL/min. Tagged RBC → bleed ≥ 0.1mL/min.

177

Uploaded by MEDBOOKSVN.ORG
H. Rectal Prolapse (Procidentia) Involves all rectal layers.
1) Tissue is circumferencial/radial.
2) 2/2 pudendal neuropathy + lax sphincters. Starts 6-7cm proximal to anal verge.
3) ↑ in F, straining, chronic diarrhea, s/p pregnancy, & w/redundant sigmoid.
4) Medical Tx → high-fiber diet (Laxatives are CI).
5) Surgical Tx →
a. Old/frail → transanal/perineal rectosigmoid resection (Altemeier).
i) Delorme → Like Altemeier, but only mucosal & submucosal excision.
A) Used if less extensive. Inject submucosa w/dilute epi → aids dissection.
b. Good condition → Frykman-Goldberg Sigmoidectomy & pexy residual colon,
<10% recur, shouldn’t surgically tx post-op incontinence until at least 1yr post-op.
Ripstein → above + mesh.
I. Solitary Rectal Ulcer Syndrome → 2/2 rectal intussusception. Can be mis-dx’d as
CA. Sxs → pain, tenesmus, constipation, BRBPR.
1) Dx → procto w/Bx to r/o CA (usually anterior).
2) Tx → high fiber, stool softeners, & defecation training.
J. Stercoral Ulcer → Elderly, constipated, asso w/NSAIDs & antiACh. MC at
rectosigmoid antimesenteric border.
1) Dx criteria → 1)>1cm, round, anti-mesenteric. 2) colon FOS. 3) multiple pressure
ulcers. 4) absence of other cause (eg. diverticulitis, CA, etc).
2) Tx → resect + end-to-end colo-colonic anastomosis.
K. Anal Incontinence needs EUS.
1) Neurogenic (gaping hole) → no good tx, consider SNS at S3.
2) Abdominoperineal descent → chronic damage to levators & pudendal nerves
(obesity, multiparous women) & anus falls below levators.
a. Tx → high-fiber diet, 1 BM/d limit; hard to tx.
3) Tx of OB trauma s/p 2-3mns max med tx or if asso w/fistula → anterior anal
sphincteroplasty (close in layers if no fistula).
L. Infectious Pouchitis abd pain, fever, bloody diarrhea, urgency/tenesmus. Dx →
procto w/Bx. Tx → IVF + cipro/flagyl.
M. Radiation Proctitis bleeding s/p pelvic XRT.
1) Tx → 1st – sucralfate enema. 2nd – argon beam (90% effective). 3rd – fix w/dilute
formalin (90% eff, but ↑strictures).
N. Pilonidal Disease
1) Sinus/abscess over sacrococcygeal jxn/ gluteal cleft; ↑ in M.
2) Tx → I&D + pack; f/u w/surgical resection of cyst lining (61% recurrence historically)
vs GIPS (resect cyst + punch bx out pits) → ↓recurrence (5.8% at 16mns).
O. Condylomata Acuminata 2/2 HPV. Tx → fulguration (podofilox is an option; from
podophylin, less irritating).

178
P. Anal Canal Cancer
1) Adenocarcinoma
a. Tis = Paget’s Disease of the Anus
b. Tx
i) WLE if < ⅓ circumference, < 3 cm, submucosa (T1 tumors, 2-3mm margins),
well diff, & no LVI. Otherwise → APR.
ii) Adj CTX/XRT → same as rectal CA.
2) SCCa
a. Types → epidermoid, mucoepidermoid, cloacogenic, & basaloid CA.
b. Sxs → pruritus, bleeding, & palpable mass.
c. Staging
i) T
A) Tis = Bowen’s disease, AIN II-III. Tx → high-res anoscopy + fulgaration.
B) T1 = < 2cm
C) T2 = > 2-5cm
D) T3 = > 5cm
E) T4 = Adjacent organs
ii) N (FNA/ex bx suspicious LNs)
A) N1 = Perirectal
B) N2 = Unilateral internal iliac +/- inguinal
C) N3 = Perirectal + inguinal +/- bilateral internal iliac
d. Tx
i) Nigro Protocol (CTX-XRT[5wks] w/5FU & Mitomycin-C [wks 1 &5]), not
surgery. Cures 80%. 50Gy → anus, 35-45Gy → inguinal LNs.
ii) Tx failures or recurs (give it 10-12wks to assess) → APR + myocutaneous flap
(↑wound comp for anal SCCa s/p XRT).
3) Melanoma ⅓ spread to mesenteric LNs at dx.
Anus 3rd MC site for melanoma (Skin & Eyes #1 & #2 – “SEA 1,2,3”).
a. Mets to liver & lung early → accounts for most deaths. Sxs 2/2 sig mets. MC sx
→ rectal bleeding. MC lightly/not pigmented.
b. Tx → WLE (=survival to APR in meta-analysis). Margin dictated by depth as
standard for melanoma. No benefit for LNDx.
Q. Perineal Cancer (was Anal Margin CA; AIN in male → also r/o HIV 2/2).
1) SCCa Better prog vs anal canal SCCa. Asso w/HPV 16, 18, 31, 33, etc (like cervical).
Ulcerating, slow growing; better prog in M.
a. Tx
i) T1 (<2cm) → WLE w/1 cm margins (SCORE says just for T1 well-differentiated)
ii) > 2 cm, sphincter involved, or +LNs → CTX-XRT (5-FU & cisplatin) to preserve
sphincter & possibly avoid APR.
iii) Need inguinal LNDx if +LN clinically.
b. SCCa just outside anal margin → tx like skin CA.
2) Basal Cell CA Central ulcer, raised edges, rare mets.
a. Tx → usually WLE w/3mm margins; APR if sphincter involved.
179

Uploaded by MEDBOOKSVN.ORG
32. Herniae, Abdomen, & Surgical Tech
A. Herniae
1) Inguinal
a. Anatomy
i) External oblique fascia → forms inguinal ligament (shelving edge) at inf
portion of inguinal canal.
ii) Internal oblique → forms cremasteric muscles.
iii) Transversalis fascia → forms inguinal canal floor w/conjoined tendon.
iv) Conjoined tendon → internal oblique aponeurosis & transversalis muscle.
v) Inguinal/Poupart’s ligament → from ext oblique fascia. Travels ant to femoral
vessels from ant sup iliac spine to pubis.
vi) Lacunar ligament → where inguinal ligament splays onto pubis.
vii) Cooper’s/pectineal ligament → post to femoral vessels; against pubis.
viii) Spermatic cord (“Subjective Proof Doesn’t Concern A Good Trial Lawyer”)→
Sympathetics, Pampiniform plexus, Ductus deferens (medial), Cremateric
muscle & artery, Artery to ductus deferens, Genital br of genitofemoral n
(post), Testicular a, Lymphatics.
ix) llioinguinal nerve → Ant & Medial to spermatic cord.
x) Hesselbach’s triangle → rectus (med), inf inguinal ligament (inf), & inf
epigastrics (lat).
A) Indirect hernias → MC; from persistent patent processus vaginalis.
B) Direct hernias → ↓ incarceration risk; rare in F, ↑ recurrence vs indirect.
C) Pantaloon hernia → direct & indirect components.
xi) TAP block → b/w internal oblique & transversus abdominis.
xii) Non-op management of inguinal hernia → 0.3% Cx at 2yrs if min/no sxs.
b. Open → ↓OR time, cost, & maybe recurrence.
A) Mesh types *Need 3-5cm mesh/fascia overlap.
B) Polypropylene → incorporates into tissue.
C) Vicryl → absorbable, useful in contaminated field.
D) PTFE → does NOT incorporate.
E) Macroporous/lightweight → ↑bacterial clearance.
F) Biologic → ↑neovascularization & collegen deposition.
ii) Lichtenstein repair → mesh; recurrence ↓ with use of mesh (↓ tension).
A) 10% overall cx rate & chronic pain, 5-10% recurrence, 1-2% infection,
rarely ischemic orchitis/vas injury/death. Most “watchful waiting” pts will
eventually progress to surgery.
iii) Bassini repair → approximates conjoined tendon & transversalis fascia (sup)
to the free edge of the inguinal ligament (shelving edge, inf).
iv) McVay / Cooper’s ligament repair → incise transversalis fascia →
approximate conjoined tendon & transversalis fascia (sup) to Cooper’s
ligament (pectineal ligament, inf medial) then transition stitch to ileopubic
tract/shelving edge at femoral vessels.

180
 A) Needs 6cm long relaxing incision in external oblique fascia from 1cm
superior to pubic tubercle to the lateral rectus border.
B) Can also use for femoral hernia repair.
c. Lap
i) Order of anatomy medial to lateral in TEPP (Coopers, ext iliac vein, ext iliac
art, vas).
ii) MC nerve injury → genitofemoral nerve injury (MC branch → femoral nerve)
d. 2018 International Groin Hernia Guidelines (Lap vs Open).
i) Lap → ↓wound cx, post-op pain, & earlier return to work.
A) Also ↑ Bowel injury/OR time/cost, seroma, & learning curve.
ii) NO sig 5yr recurrence diff (1.2% open, 2.4% lap, p > 0.05).
iii) 1° & unilateral hernia → no good data/recs for lap vs open.
iv) Difference between open & laparoscopic hernia repair ($$$).
e. Relative CIs to TEP inguinal herniorrhaphy → pelvic XRT, prior/planned surgery in
area, incarcerated, >3cm scrotal hematoma.
i) Absolute → can’t tolerate pneumoperitoneum, active infection, &
strangulation.
f. Best indication for lap IHR → pt s/p prior open IHR w/mesh.
g. Cx MC → Urinary retention
i) Scrotal hematoma 1wk s/p inguinal herniorrhaphy in pt taking NSAIDS → stop
NSAIDs & no strenuous activity.
ii) Continued pain s/p reduction → must consider “reduction en masse”
(peritoneal sac reduction, but bowel still caught in sac).
iii) Nerves at risk
A) Iliohypogastric → suprapubic & lateral thigh pain/numbness.
B) Ilioinguinal → loss of cremasteric reflex, ipsilateral penial base, scrotum, &
medial thigh numbness.
1. Runs on top of cord & MC injured at external ring.
C) Gentiofemoral →Injured w/lap repair.
1. Genital → cremaster (motor) & scrotum (sensory).
2. Femoral → upper lateral thigh (sensory).
D) Lateral Femoral Cutaneous
iv) Glue mesh fixation → less pain vs tacks.
v) Ischemic orchitis → Sxs 2-5d s/p OR. Tx → NSAIDs/pain control.
vi) Chronic inguinodynia → triple neurectomy (genitofem, ilohypo, & ilioing).
2) Umbilical
a. Pediatric umbilical hernias (congenital). RFs → M, African-Americans (8:1).
<2.5cm usually close spontaneously by 2yo.
i) Wait to repair until >5yo unless sxs (rare).
b. Adult umbilical hernias (most are acquired). RFs → F (2/2 pregnancy), obesity,
ascites, aortic aneurysms.
i) Incarceration → adults >>> children. Ok for non-op if → small, asx, & pt
reliable.

181

Uploaded by MEDBOOKSVN.ORG
 ii) Cirrhotic → repair s/p med ascites tx. Thin/at risk skin → TIPS (can repair at
the same time as liver TXP).
iii) For adults, recurrence risk ↓ w/mesh (1% vs 11%).
3) Incisional → ML hernia to recur. MCC → inadequate fascial closure.

a. Rate → 30% s/p emergent ex lap. Otherwise 10-15%.

b. RFs → deep wound infxn, steroids, smoking, XRT, Diabetic nephropathy(↑risk
s/p lap surgery), &SSI (↑rate x2).
c. Separation of Components.
i) Raise subQ flaps from midline to external oblique.
ii) Incise the ext oblique (required) 2cm lateral to linea semilunaris & continue
5cm onto chest.
iii) Separate ext & internal oblique as far as possible.
iv) Need more length (2-4cm), incise → post rectus sheath.
v) Don’t damage nerves going into post rectus running b/w the transversalis &
internal oblique muscles.
vi) Relative CI to SoC → prior DIEP.
d. Retrorectus repair → dissection to semilunaris.
i) Innervation to rectus is b/w transversus & internal oblique.
e. ML to contact bowel → IPOM> underlay ( > retrorectus).
f. Obese, DM, 7cm midline inc hernia, tx → lap preferred to open.
g. Best facial closure → cont, slowly abs suture (PDS), 5mm bites/travel, 4:1
suture:wound length.
h. Recurrence
i) Renal path that ↑ risk of hernia after lap surgery → diabetic nephropathy.
4) Femoral Know how to dx on CT. ↑strangulation → repair all.
a. Anatomy
i) Superior – iliopubic tract/inguinal ligament
ii) Inferior – Cooper/pectineal ligament
iii) Medial - lacunar ligament (attaches to pubic tubercle; connects inguinal &
pectineal ligaments)
iv) Lateral - femoral vein
b. Tx → McVay/Cooper’s/pectineal ligament repair. Mesh OK if NO bowel
compromise (key → close space lateral to lacunar ligament by approximating
iliopubic tract to Cooper's ligament). No mesh w/bowel compromise (eg perf or
necrotic).

182
 i) Unable to reduce → open inguinal ligament.
ii) Direct infra-inguinal incision over bulge also works.
5) Epigastric → through linea abla, superior to umbilicus. MCC → failure of midline
fusion.
6) Obturator → Ant pelvis, herniates through obturator canal (formed from ischium &
pubic bones).
a. MC in F; elderly, multiparous, recent ↓wt. Sxs → tender medial thigh pain/mass
+ SBO.
b. Howship-Romberg sign → inner thigh pain w/internal rotation + adduction
(classic)
c. High risk of incarceration & strangulation. ↑mortality (10%) 2/2 gangrenous
bowel & ↑age.
d. Dx → CT scan (bowel gas below sup pubic ramus). Dx usually during surgery for
SBO.
e. Tx → operative reduction, may need mesh & divide obturator membrane
POSTERIOR to nerves/vessels to reduce bowel; check other side for same defect.
7) Spigelian → b/w internal oblique & external oblique insertion into rectus sheath.
a. Lat border of rectus, adjacent to linea semilunaris, through transversus
aponeurosis, & almost always inf to semicircularis.
b. High risk of incarceration → sepsis 2/2 delay in dx (SCORE says can repair
electively if NO s/s of acute SBO)
c. Tx → lap vs open herniorrhaphy.
8) Amyand → RIH w/appendix w/in hernia sac.
9) Canal of Nuck → Ing canal/patent processus vaginalis extending to labia majora
→→ hydrocele or indirect inguinal hernia.
10) Sciatic → post pelvis, herniation through greater sciatic foramen; ↑↑↑
strangulation risk.
11) Richter → antimesenteric wall of the intestine protrudes through a defect in the
abdominal wall
12) Littre → RIH (usually) w/ Meckel's diverticulum within the hernia sac.
13) Grynfelt-Lesshaft
a. Through superior lumbar triangle (quadratus lumborum muscle, 12th rib, &
internal oblique).
14) Petit
a. Through the inferior lumbar triangle (external oblique anteriorly, latissiums
posteriorly, iliac crest inferiorly).
15) Maydi
a. 2 adjacent small intestine loops in hernia sac, intervening bowel w/in abd
deprived of its blood supply → becomes necrotic.
16) Cooper → femoral hernia containing 2 hernia sacs.
17) Hesselbach → beneath inguinal ligament, but lateral to femoral vessels.
18) Intraparietal → b/w layers of abd wall containing abd contents (a type of
eventration).

183

Uploaded by MEDBOOKSVN.ORG
 19) Parastomal
a. ↑ in colostomies (50% at 5yrs) vs ileostomies.
b. RFs → fascial opening too large; stoma lateral to rectus sheath, obesity, COPD,
age.
c. Don’t fix unless sig sxs, most are tolerated well (< 10% need fixed).
d. Absolute repair indications → obs, incarceration w/strangulation, severe pain.
e. Relative repair indications → incarceration alone, severe prolapse.
f. Tx → observe unless causing significant Sxs
i) If surgery needed, relocate to rectus (preferred) (SCORE says 1st→local
repair, 2nd→local repair+mesh, 3rd→relocate).
ii) Prolapse → keep stoma at same site, fix hernia w/mesh (Sugarbaker
technique, see ostomy cx in Small Bowel Ch) ± fix mesentery (if ostomy in
rectus & fascia intact, but bowel prolapsing through).
20) Ventral
i) See incisional & epigastric.
B. Rectus Sheath Hematoma Painful abd wall mass. MC s/p trauma
1) MC source if inf to umbilicus → epigastric vessel injury.
2) Fothergill sign → More prominent & painful w/rectus flexion.
3) Carnett sign → point of max TTP same spot when sitting or supine.
4) Types
1 → small, w/in rectus. Doesn’t cross midline or fascia.
2 → w/in rectus. Either crosses midline or dissects into transversalis
fascia.
3 → below arculate, large, bleeding into peritoneum &/or space of
Retzius.
5) Usually just need rest, analgesia, & transfusion PRN (90% success). Correct
coagulopathy if risk > benefit (ie no mech Ao valve).
Worsens → angio emb. (OR rarely needed).
C. Desmoid Tumors F, typically painless, benign, locally invasive, ↑↑↑ recurrence,
asso w/Gardner’s syndrome. Fibrotic, Øcalcs, highly cellular.
1) Tx
a. Abdominal wall 1st → OR, 2nd → XRT (or if not op candidate).
b. Intra-Abdominal 1st → medical, 2nd → OR ± XRT.
c. WLE if possible; if involves sig mesentery → don’t excise (often can’t resect
completely) → Med Tx (sulindac & tamoxifen).

184
D. Mesenteric Masses Most 1° tumors are cystic.
Benign → MC peripheral. Malignant → MC near mesentery root.
1) Malignant → liposarcoma (#1), leiomyosarcoma.
2) Dx → abdominal CT.
3) Tx → resection ± resect associated bowel PRN (if unsafe/too much bowel →
marsupialize).
4) Sclerosing Mesenteritis → well-circumscribed, fatty, near mesentery root, needs Bx
to r/o CA.
E. Omental Masses
1) Cysts → usually no sxs, but can torse.
2) Tumors MC solid tumor→mets(Tx→omentectomy for CAs [eg ovarian]). 1° solid
tumors → rare (⅓ malignant).
a. No Bx 2/2 ↑ bleeding. Tx → resection.
3) Torsion → omentum twists around long axis w/vessels → mimics intra-abd perf →
usually dx'd in OR, MC on right.
a. 1° → no known path/prior surgery. 2° → MC vs 1°. 2/2 tumor, inflammation,
adhesions, or herniae. 30s-40s, obese kids.
b. Tx → resection.
i) Serosanguinous fluid MC. If purulent → look for other etiology.
F. Epiploic Appendigits Tx → NSAIDs, OR only if abscess/peritonitis (in which case
question the dx).
G. Radiation
1) CT Aorta > contrast vs cardiac cath, CT abd/pelvis, & KUB.
2) C-Arm positioning → x-ray source under table as far as possible (↓skin dose), image
intensifier above & close (sharper image) → ↓scatter → ↓total radiation.
H. Stitch / European Hernia Society Guidelines → 5/5mm bites/apart > 1/1cm (p <0.05),
4:1 suture:wound, running>interrupted.
1) Slowly abs monofilament (ie. PDS).
2) Ppx mesh for open AAA repair → ↓hernia.
I. Peritoneal Dialysis Catheter OK to fix umbilical hernia at the same time.
1) Placement → Prox cuff in preperitoneum, tunnel a few cm away, distal cuff in
subQ, & flush w/NS.

185

Uploaded by MEDBOOKSVN.ORG
 a. Laparoscopic → Simple, quick, immediate usage, ↓migration vs open (3 vs 18%),
& 1yr cath survival (94 vs 75%).
b. Open → Precise & ↓perf risk.
c. If outflow obstruction → omentectomy.
2) CI(s) → Only absolute is lacking functional peritoneum.
a. Relative CIs → scar/adh, can’t self-dialyze, homeless, anura & obesity (lg vol),
active inflam/CA, ostomy (do presternal cath), lg unrepairable abd herniae, & VP
shunt.
3) Types
a. Continuous ambulatory PD (CAPD)
b. Automated PD (APD)
c. Continuous cycles PD (CCPD)
d. Nightly intermittent PD (NIPD)
e. Tidal PD (TPD)
f. Intermittent PD (IPD)
4) Infection
a. MCC → coag neg staph (S. epidermidis). Dx → Abd pain, cloudy
peritoneal fluid, & peritoneal WBC >100/mm3.
b. Tx → intraperitoneal abx x2 weeks. not 2/2 S. epi → less likely to clear → d/c PD
cath, insert temp HD cath, cont abx.
J. Pseudomyxoma Peritonei / Peritoneal Carcinomatosis
1) Semisolid mucous plastering peritoneum w/lg loculated cysts & scalloping.
2) MC in F, 50s-70s.
3) Disseminated Peritoneal AdenoMucinois (DPAM)
a. Histologically benign, MCC → ruptured appy (60%) w/mucinous
adenoma/adenoCA.
4) Peritoneal Mucinous CArcinomatosis (PMCA)
a. Well-dif appendiceal/intestinal mucinous adenoCA. Up to 76% recur.
b. Usually no sxs. MC 1st sx → ↑abd girth.
c. Tx → cytoreduction of 1° & 2° implants, peritonectomy, omentectomy & HIPEC if
ECOG ≤ 2, PCI < 14, & no extra-abd mets or RP dz.
d. MI for HIPEC prognosis → complete cytoreduction.
5) Malignant ascites + SBO → predict incomplete resection & ↓ survival
6) Clear appy origin → right colectomy. Clear ovary origin → TAH+BSO.
K. Malignant Bowel Obstruction
1) Med Tx for sxs → glucocorticoids, antiemetics (typically Haldol, not metoclopramide
or 5HT3 receptor antagonists → constipation), octreotide, antiAChs, analgesia, ± GI
decompression.
2) Absolute CIs to surgery → recurrent ascites s/p paracentesis, diffuse palpable
masses, multiple areas of obs, technically impossible, diffuse mets, or prox stomach
involved.
3) Relative CIs → mult. intraabd tumors, ↓Alb., prev abd XRT, poor nutrition,
liver/extraabd mets, or hepatic/renal failure.
186
 a. SBO w/o peritonitis 2/2 Stage IV CRCa (or ovarian) CA w/diffuse carcinomatosis
w/implants throughout mesentery & omentum involving sig portion of bowel
→ palliative G-tube.
b. Carcinomatosis, SBO w/o transition point, PEG in place, best next tx → opioids +
ondansetron.
c. W/ transition point & candidate → bypass.
L. Tuberculous Peritonitis Best test → quantaferon gold.
1) Wet type → abundant ↑density ascites (20-45 HU), smooth & thickened
peritoneum & omental smudging. Thick strands of clumped mesenteric vessels.
2) Fixed fibrotic → omental mass w/matted bowel + nodular mesentery/bowel
thickening, & occasional loculated ascites.
A great mimicker of peritoneal carcinomatosis.
3) Dry/Plastic → fibrous rxn in peritoneum → adhesions & caseous LNs.
M. Pearls
1) Immediate pain s/p lap inguinal herniorrhaphy → back to OR.
a. MC nerve in lap IHR → femoral br of gentiofemoral (medial thigh) or lateral
femoral cutaneous (lateral thigh).
2) Pediatric IHR →open, high-ligation (floor/ring isn’t weak like adults).
3) MCC s/p herniorrhaphy → urinary retention.
4) Herniorrhaphy complication rates: overall ~10%, SSI-1-2%.
5) Fascial dehiscence → copious salmon-colored fluid from wound.
a. Tx → OR to close fascia.

187

Uploaded by MEDBOOKSVN.ORG
33. Urology

A. Anatomy
1) Contents renal hilum ant to post → Vein, Artery, renal Pelvis (VAP).
a. Right renal artery crosses post to IVC.
b. Left renal vein crosses ant to aorta (usually).
2) Ureters cross over iliac vessels.
3) Left renal vein can be ligated from IVC 2/2 collaterals on left (left adrenal vein, left
gonadal vein, left ascending lumbar vein). None on right.
a. MCC of venous bleeding when dissecting L renal v if adrenal & gonadal tied off →
ML avulsed inf phrenic vs lumbar vein 2/2 excess traction.
4) Right renal vein → NO collaterals → cannot be safely ligated.
5) Seminal vesicles → connected to vas deferens.
6) Erection (Point)→ Parasymp (pelvic splanchnic nerves).
7) Ejaculation (Shoot) → Symp (pudendal nerve).
8) Epididymis → saccular structure on top of testes.
9) Seminal vesicle → makes 95% of ejaculatory volume.
10) Sperm travels (“SEVEn UP”) Seminiferous tubules → Epididymis → Vas →
Ejaculatory ducts → nothing → Urethra → Penis.
B. Nephrolithiasis
1) Sxs → severe colicky pain, restlessness.
2) Dx → U/A w/blood, KUB w/stones, CT → stones, hydronephrosis. 90% opaque.
3) Stone Types:
a. Calcium oxalate (radio-opaque) → MC type (75%). ↑’d s/p TI resection 2/2
reabsorbed oxalate in colon.
b. Mg++ ammonium phos (radio-opaque)/Struvite stones → asso w/urease
organisms (eg. Proteus). Cause staghorn calculi.
188
 c. Uric acid (radio-lucent). RFs → gout, ileostomies, short gut. Ileostomy →
↓alkaline fluid → ↓ urine pH/vol → stones.
d. Cysteine stones (either) → asso w/congenital d/o cysteine met. Prevent
w/tiopronin (↓ cysteine solidification).
4) ESWL indications (best Tx) → intractable pain/infection, ↑obs/renal damage, 1
kidney, > 6 mm (can’t pass).
C. Hematuria + smoker → c/f bladder CA. +flank pain → c/f RCCa
+ trauma → c/f collecting system inj.
D. Hydrocele → PAINLESS. Transilluminates (peritoneal fluid). Most idiopathic. If non-
communicating → most resolve by 1yo.
1) Does NOT affect fertility. If acute → suspect tumor (eg. Pelvic or abd).
2) Tx: Jabonlay bottleneck repair → scrotal incision, remove excess sac, evert edge, &
sew edge behind cord. Use inguinal approach if c/f CA.
3) MCCx is scrotal hematoma.
E. Varicocele → Engorgement of veins → NO transillumination. Does affect fertility.
1) Dx → CT abd (r/o RCCa). CA obs left renal vein → obs left testicular vein → left
varicocele.
a. This is why you can divide left renal vein near IVC b/c kidney still drains via
gonadal & adrenal vein. Not true on the right!
F. Spermatocele → MC scrotal cyst (sup & separate from testis). U/S → hyperechoic
w/o transillumination.
1) Tx → remove if sxs. Does NOT affect fertility
G. Ureteropelvic Junction Obstruction Tx → pyeloplasty (relieves obs).
H. Vesicoureteral Reflux 1st→CT/IVP, then retrograde pyelo PRN. Tx→re-implant
ureter into bladder w/tunnel → ↓reflux.
I. Ureteral Duplication MC urinary malformation. Tx → re-implantation in bladder if
obs. Not a CI to kidney donation for TXP.
J. Hypospadias → Ventral Tx → repair at 6mns w/penile skin.
K. Epispadias → Dorsal Tx → surgery.
L. Horseshoe Kidney → usually inf poles. Cxs → UTI, urolithiasis,
hydronephrosis. Tx → may need pyeloplasty if obs.
M. Bilateral Absence of Vas Deferens→sweat chloride test (cystic fibrosis).
N. Persistent Urachus → b/w umbilicus & bladder. 10% have bladder outlet obs.
1) Dx → voiding cystourethrogram (for obs).
2) Tx →resect sinus & cyst, close bladder, & relieve any obs.
O. Epididymitis 2/2 inflam/infection (MC→Chlamydia). MCC acute scrotal pain in men
(MC <20yo → torsion).
1) Non-infectious 2/2 abd straining/heavy lifting. Sxs → sudden scrotal pain (r/o
torsion 1st). U/S → ↑epididymal blood flow.
P. Neurogenic Bladder Spastic. Accidental/copious voids. MC 2/2 spine injury above
T12. Tx → surgery to ↑ bladder resistance.

189

Uploaded by MEDBOOKSVN.ORG
Q. Neurogenic Obstructive Uropathy
1) Flaccid, incomplete emptying, frequency. 2/2 nerve/spine injury below T12 (eg.
w/APR). Tx → intermittent catheterization.
R. Pneumaturia → MCC → colovesicalur fistula 2/2 diverticulitis.
1) Dx → cystoscopy.
S. Phimosis Can’t replace foreskin back over glans. Tx → dorsal slit
T. Priapism RFs → sickle cell, hypercoag, trauma, intracorporeal injections for
impotence, sildenafil.
1) Tx → corpus cavernosum asp + dilute epi. May need I&D via glans to relieve.
U. Peyronie’s Disease 2/2 tunica albuginea plaques → penile curvature
1) Tx → conservative Tx for 1yr (eg. Colchicine & Vit E). If fails → Nesbit operation
(shorten side opposite of plaque).
V. Testicular Torsion U/S → No blood flow (If equivocal but c/f torsion, still go to OR.)
1) Clinical dx→high, red testicle w/o cremaster reflex.
2) Tx→Detorse like opening book, pexy testicle + contralateral side also.
W. Bladder Cancer ↑age, smoker, hematuria. Dx → cystoscopy.
MC type → transitional cell. SCCa 2/2 schistosomiasis.
1) Tx: T1 (not in muscle) → transurethral resection w/intravesical BCG.
T2+ → needs cystectomy, inguinal LNDx, & CTX-XRT.
X. Renal Cell Carcinoma (Hypernephroma)
1) MC 1° tumor of kidney (MC kidney tumor → breast CA mets).
2) RFs → smoking. Sxs → abd pain, mass, & hematuria (classic).
3) Dx → CT (disrupts renal contour)
4) Path → 90% 1° solid renal masses are RCC (± necrosis/calcs). MC subtype→clear
cell (75%). MC mets→to lung (30% at Dx).
5) Paraneoplastic syndromes:
a. Erythrocytosis 2/2 ↑epo (dx for RCCa). HTN 2/2 ↑renin.
b. Stauffer Syndrome → ↑LFTs; better s/p resection.
6) Wide range of 5ys, related to size & degree of spread: Stage I (< 4 cm) → >95%
5ys. Stage IV (eg. Lungs mets) → 5% 5ys.
7) Tx → radical nephrectomy (kidney, adrenal, fat, Gerota's) w/Regional LNDx.
Isolated lung mets → resect.
a. Partial nephrectomy if nephrectomy would make pt depend on HD (eg tumor
<4cm & Cr >2.5 or bilateral).
b. Penchant to grow into IVC/right atrium (can pull tumor thrombus out).
c. Adj CTX-XRT (doxorubicin based), IFN, IL-2 (all marginal). Renal pelvis transitional
cell CA→radical nephroureterectomy.
8) Von Hippel-Lindau → RCC, CNS tumors, pheos.
Y. Oncocytomas → benign
Z. Angiomyolipomas → hamartomas, 2/2 tuberous sclerosis, benign

190
AA. Congenital Adrenal Hyperplasia + Testicular Mass → Adrenal rest on testes,
confused for CA. Tx → steroids (regress).
BB. Testicular Cancer MCC of CA death in 25-35yo M. Sxs→hard painless mass. Tx→
inguinal orchiectomy (scrotal incision disrupts lymphatics).
1) Most testicle masses → malignant. Dx → U/S. CT CAP (for RP & chest mets). ↑LDH
w/↑tumor. Get β-HCG & AFP levels.
2) 90% → germ cell (seminoma vs nonseminoma). Undescended testicles
(cryptorchidism)→↑testicle CA risk (ML seminoma).
3) Seminoma MC, very radiosensitive.
a. Dx → Nml AFP, 10% have ↑β-HCG.
b. Tx →All get inguinal orchiectomy & RP XRT; CTX for mets.
4) Non-Seminomatous
a. “Non-radiosensitive” From embryonal remnants (choriocarcinoma, teratoma,
yolk sac). Dx → ↑AFP & β-HCG in most.
b. Tx → Inguinal orchiectomy & RP LNDx (Early LN mets. Take cord at internal ring).
Stage II+ → CTX.
CC. Prostate Cancer
1) MC CA in US for M. 2nd MC CA death in M (MC → lung CA)
2) Sxs → none (MC); obs/irritative (eg frequency, dysuria); hematuria; ED.
3) Screening → NO survival benefit (DRE or PSA)
a. PSA → not specific/sensitive; ↑ w/prostatitis, BPH, chronic cath. Nml → < 4.
↑Alk phos → c/f mets/extracapsular dz.
4) Dx → TRUS w/6-12 Bxs (prognosis asso w/histology), CT scan, PSA, Alk phos, &
DEXA.
a. MC site → posterior lobe. MC mets → bone (Osteoblastic. X-ray →
hyperdensity).
5) Stage IA s/p TURP (not palpable, not on imaging). Tx → nothing.
a. TURP can cause hypoNa+.
6) Stage I + II (T1/2 [confined to capsule]), either:
a. 1) Watchful waiting (if >75yo or ↓life expectancy), 2) XRT, or 3)radical
prostatectomy w/pelvic LNDx (lifespan > 10yrs).
7) Stage Ill (through capsule) or Stage IV (invades adj structures/mets) → XRT &
androgen ablation (leuprolide [GnRH analogue, flutamide (anti-androgen, ± bilateral
orchiectomy [most effective]).
8) XRT helps bone pain & ↓local recurrence.
9) Prognosis → ↑PSA, Gleason grade, & age → ↑ mets.

191

Uploaded by MEDBOOKSVN.ORG
34. Gynecology
A. Anatomy
1) Round lig → Anteverts uterus (uterus →through inguinal canal → labia majora).
2) Suspensory/lnfundibular lig → Peritoneal fold from ovary to pelvic wall. Contains
ovarian a, v, & n.
3) Broad lig → Side of uterus to pelvic floor & walls. Contains Cardinal lig.
4) Cardinal lig → Keeps cervix & vagina at base of broad lig. Contains uterine a & v.
B. Ectopic Pregnancy
1) MC ectopic site → fallopian tube ampulla.
2) Sxs → abd/pelvic pain, missed period, vaginal bleeding, + β-HCG, hypoTN (=
ruptured ectopic → go to OR now). U/S → no intra-uterine pregnancy.
3) RFs → previous ectopic/tubal surgery/PID, smoker, ↑age. ⅓ preg s/p tubal surgery
are ectopic.
4) Life-threatening bleed → ligate ant br of internal iliacs/hypogastics.
5) Tx → MTX vs laparoscopy (Not ruptured → salpjngotomy, hemostasis, repair tube.
Ruptured/Not HDS → salpingectomy)
a. MTX CIs Absolute → nursing. Relative → β-HCG >5000, ≥3.5cm + FHTs.
C. Abortions Incomplete → tissue through os.
Threatened → 1st tri bleed + heartbeat. Ectopic → see above.
Missed → 1st tri bleed, closed os, U/S→sac, & NO heartbeat.
D. Endometriosis Sxs→infertility, dyspareunia, dysmenorrhea. Occ. involves
rectum→BRBPR w/menses. Endoscopy→blue mass.
1) MC site → ovaries. Dx lap → allows dx & tx.
2) Tx→OCPs, Danazol, NSAIDs. Refractory & Premenopause→ablate (58% recur).
Post→TAH (18% recur) or TAH-BSO (8% recur)
E. Pelvic Inflammatory Disease 2/2 N gonorrhoea & Chlamydia (infertility d/t fallopian
tube scars). Tx→ceftriaxone+doxy.
F. Mittelschmerz 2/2 Graafian follicle rupture 14d s/p onset of prior menses →
RLQ/LLQ pain (confused w/appy).
G. Tuboovarian Abscess → ascending infection (eg. PID) 2/2 upset cervical mucous
barrier.
a. Tx → HDS/HDN, NOT ruptured, <9cm, responds to abx, & premenopause → Abx
alone (all required for non-op tx).
i) Ruptured or > 9cm → percutaneous drainage (OR if peritonitis or not HDS).
H. Ovarian Torsion Sxs → rapid RLQ/LLQ pain, n/v. Dx → U/S.
1) Tx → de-torse (resect only if necrosis).
I. Ovarian Cysts
1) > 95% benign (follicular, luteal, & thecal).
2) Simple cyst < 10 cm → < 1% CA risk.
3) CA MC post-menopause (↓oophorectomy threshold).
4) Tx → laparoscopy (preferred). Use endocatch bag (spillage upstages ovarian CA).

192
 5) CA RFs → Post-menopause, last >2-3mns, >10cm, complex (septae, ↑vascularity,
solid, papillary projections, thick wall), ↑CA-125.
6) Incidental Finding → Don’t touch! Get transvaginal U/S in 6-12wks.
7) Pre-menopausal Not concerning → transvaginal U/S in 6-12wks. Complex → 1-
2% CA risk. Try to avoid oophorectomy (>95% benign).
a. Tx → dx lap, cyst wall excision/fenestration. If c/f CA (ie. Complex & ↑CA-125)
→ lap oophorectomy w/frozen section.
8) Post-menopausal Complex → 15% CA risk.
a. Complex, lasts >2-3mns, >10cm, or ↑CA-125 → lap oophorectomy w/frozen
section (If +, get intra-op OBGYN consult → will likely convert to open TAH-BSO
w/staging).
b. Not c/f CA → serial U/S until one of above RFs.
J. Incidental Ovarian Mass in OR
1) Simple cyst → leave alone (see above).
2) Incidental mass during elective case + findings c/f CA (eg. peritoneal studding, thick
septae, ascites, solid) → abort.
3) Adnexal mass + _______ = _______.
bleeding = ectopic preg fever + d/c = TOA n/v = torsion
4) Anechoic & unilocular cyst → get CA-125 & TVUS in 3mns.
K. Polycystic Ovarian Disease
1) Sxs → amenorrhea, infertility, hirsutism. Tx → clomiphene.
L. Uterine Leiomyomas (Fibroids) Sxs → bleeding (MC), cyclic w/menses, recurrent
spont abortions, infertility.
1) Med Tx → GnRH analogues (eg leuprolide). If leiomyosarcoma on post-op path
w/neg margins → NO further surgery.
M. Uterine Prolapse Uterus through vagina. RF → multiparity. Tx → ↓wt, D/C smoking
(↓cough), pessary, trans-vag hyst.
N. Pregnancy Issues
1) Fetal loss rates: acute appy (1.5%), open appy (3%), lap (7%), perf (36%).
2) Rad (5mGy max throughout pregnancy), greatest risk in 1st 15wks.
a. No radiation w/MRCP.
b. HIDA is CI (↑radiation).
c. Traumagram OK.
d. CT Head < 0.005mGy.
e. CT abd/pelvis (appy/preg protocol) 2.5mGy.
3) Viable (≥24wks) → Intra-op monitoring.
4) Previable (<24wks) → FHTs pre & post-op.
5) Umbilical hernia → up to 90% of pregnant women. Surgery only if very bad sxs or Cx
(incarceration, strangulation).
a. No/min sxs → elective OR postpartum.
O. Krukenberg Tumor Gastric met to ovary. Signet ring cells → classic.

193

Uploaded by MEDBOOKSVN.ORG
P. Immature Cystic Teratoma
1) Premenopause → ipsilateral slapingo-oopherectomy, paraAo & pelvic LNDx,
omentectomy, peritoneal bxs, & washings.
2) Postmenopause → BSO + above.
Q. Meige’s syndrome Ovarian fibroma→ ascites + hydrothorax.
1) Tx → Excision (curative).
R. Vulvar Cancer Elderly, nulliparous, obese. Often unilateral.
1) MC type → SCCa (to ing LNs 1st). Overall 5ys→75%.
2) Tx → Paget’s, VIN III+, CIS → preCA (Tx → WLE).
<2cm (St I) → WLE w/ipsilateral ing+fem LNDx.
>2cm (St II+)→radical B/L vulvectomy + B/L ing+fem LNDx.
<1cm margin → XRT.
S. Vaginal Cancer MC → CRCa invasion.
MC 1° → SCCa. s/p DES → clear cell CA. Tx → XRT for most.
1) Botryoides → Vaginal rhabdomyosarcoma, young girls.
a. Tx → resect.
T. Cervical Cancer MC → SCCa (to obturator LNs 1st). Asso w/HPV 16 & 18.
1) Tx → CIN I → obs CIN II → LEEP vs. cryo
CIN III/CIS (no BM invasion) → conization
St I/IIa → TAH
St IIb-IV → XRT, radical hysterectomy,
upper ⅓-½ vagina, pelvic LNDx.
2) ML to injure ureter ligating uterine a (at medial area of broad lig.
U. Endometrial Cancer → MC F genital tract CA. Postmenopausal vaginal bleeding →
endometrial CA until proven otherwise.
1) RFs → nulliparity, late 1st preg, obesity, tamoxifen, unopposed estrogen.
2) Uterine polyps → 0.1% CA risk. Serous & papillary → worst.
3) Screening: In general→ none (3% risk).
a. HNPCC (12-54% risk) & Cowden synd (PTEN TSG mut, 13-28% risk)
→ hysteroscopy w/endometrial bxs.
4) Dx → endometrial curettage.
a. Pre-op work-up/imaging → MRI likely most beneficial.
5) Tx
a. Stage I (endometrium) → TAH-BSO.
b. Stage II (myometrium or +LNs) → TAH-BSO w/para-Ao & pelvic LNDX + adj XRT.
i) Serous, clear cell, high grade, myometrium >50%, >2cm → paraAo & pelvic
LNDx.
ii) Serous or clear cell → omentectomy.
V. Ovarian Cancer MC gynecologic c/o death. MC in 60s. Sxs → Abd/pelvic pain, change
stool/urinary habits, vaginal bleeding.
1) ↓ risk → OCPs, bilateral tubal ligation
2) ↑ risk → nulliparity, late menopause, early menarche

194
3) Types → teratoma, granulosa-theca (↑estrogen → precocious puberty); Sertoli–
Leydig (↑androgens → virilizaiton), struma ovarii (thyroidal); choriocarcinoma (↑β-
HCG), mucinous, serous (MC), papillary, & clear cell (worst prognosis).
4) BRCA1 & wants kids → CA125 & TVUS q6m. S/p kids or at 35-40yo → ppx BSO to
↓risk.
5) Staging I → one/both ovaries (MC initial met→ other ovary)
II → pelvis III → throughout abd/+LNs IV → Distant mets
6) Tx → Debulking all deposits > 1cm effective (omentectomy helps CTX- XRT).
a. All stages → TAH-BSO, pelvic & para-Ao LNDx, omentectomy, 4 quadrant
washings, & CTX (cisplatin+paclitaxel).
b. Consider unilateral salpingo-oophorectomy if unilateral St I & pt wants kids.
Neoadj CTX if NOT debulking candidate.

195

Uploaded by MEDBOOKSVN.ORG
35. Neurosurgery
A. Nerve Injury Types
1) Neuropraxia → MC (& mildest, like foot falling asleep)
a. Interrupted conduction impulse → temp ↓func (motor > sense). Will recover.
No axon/myelin sheath injury.
b. Severe blunt trauma →6-8wks to recover.
2) Axonotmesis → Disrupted axon, intact myelin sheath → No sensation + paralysis.
MC 2/2 crush. Regenerates 1mm/d.
a. Wallerian degeneration antegrade toward end plate.
3) Neurotmesis→ Disrupted axon & myelin sheath → Worst.
a. 2/2 stretch, contusion, laceration. OR for chance to recover.
Central nerves do NOT regenerate.
B. Positional Nerve Injury → can occur w/appropriate padding. RF → DM neuropathy. MC
→ ulnar & brachial. Protective → fat.
C. Diabetes Insipidus → ↓ADH→↑UOP, ↓urine specific gravity, ↑serum Na+ & osm.
2/2 ETOH, TBI, lithium (nephrogenic).
1) Tx → DDAVP, free water replacement.
D. SIADH → ↑ADH → ↓UOP, ↑urine conc, ↓ serum Na+ & osm. 2/2 TBI.
Tx → water restriction, then diuresis.
E. Brain Tumors
1) Glioma → MC 1° brain tumor in adults/overall.
2) Medulloblastoma
3) Neuroblastoma
4) Astrocytomas
a. Grade
i) I – Pilocytic, Subepemdymal giant cell, Subependymoma
ii) II – Low-grade fibrillary, Pleomorphic xanthoastrocytoma, Mixed
iii) III – Anaplastic
iv) IV – Glioblastoma multiforme (GBM) MC subtype, uniformly fatal.
F. Spine Tumors
1) Neurofibroma & Paragranglioma
G. Myelomeningocele Neural cord defect w/spinal cord herniation & nerve roots. MC
in lumbar.
1) Tx → If ruptured, surgery to prevent meningitis.
H. Berry Aneurysm If <10mm → obs.

196
36. Orthopaedics
A. Spondylolisthesis → One vertebra subluxes over another. MC in lumbar. MCC
lumbar pain in adolescents (esp. gymnasts).
1) Tx → based on sxs & amount of subluxation (conservative vs fusion).
B. Cervical Stenosis Tx → surgical decompression if sig myelopathy.
C. Lumbar Stenosis Tx → surgical decompression for if refractory.
D. Herniated Lumbar Disc
E. Common Nerve Injuries
1) Bx of posterior cervical mass then shoulder droop & winged scapula → CN IX.
2) Winged scapula alone (no shoulder droop) → long thoracic nerve.
F. Fat Emboli Syndrome → s/p long bone fxs.
1) Bergman’s triad → AMS, petechiae, & dyspnea.
G. Upper Extremity
1) Shoulder Dislocation
a. Ant → Axillary n injury risk (90%).
i) Tx → closed reduction. ORIF if w/displaced humeral fx.
b. Posterior → 2/2 seizures, electrocution. Axillary a injury risk.
i) Tx → closed reduction. ORIF if w/displaced humeral fx.
2) Acromioclavicular separation → Brachial plexus & subclavian injury risk.
a. Tx → sling.
3) Clavicle fracture → Vascular inj risk. Tx → sling (usually).
4) Scapula fracture → sling. + glenoid fossa → internal fixation.
5) Rotator Cuff Tears
6) Humeral fracture
a. Proximal → Axillary n injury risk.
i) Tx → Non-displaced → sling
Displaced/comminuted → ORIF
b. Mid-shaft → radial n injury risk (weak wrist+finger ext)
i) Tx → sling (usually). Failed reduction/neurovascular sxs→OR.
c. Supracondylar → brachial a injury & Volkmann's Contracture/compartment
synd risk.
i) Adult Tx → ORIF
ii) Kids Tx → Non-displaced → closed reduction. Displaced Tx → closed
reduction & internal fixation w/Kirschner wire.
7) Monteggia fracture → Prox ulnar fx & radial head dislocation. Tx → ORIF.
8) Colles’ fracture → fall on outstretched hand, dist radius fx ± dist ulnar dislocation.
MC fx in kids. Tx → closed reduction for most.
9) Nursemaid’s Elbow → radial subluxation at elbow 2/2 pulling on an
extended/pronated arm. Tx → closed reduction.
10) Torus/greenstick fracture → bone cortex buckles (eg dist radius). Kids.
Tx → cast for 3wks.

197

Uploaded by MEDBOOKSVN.ORG
 11) Open fractures Tx → washout, soft tissue coverage, abx, & ex fix until healed.
12) Scaphoid fracture (eg wrist or perilunate wrist fx). MC carpal fx. MC wrist fx.
Sxs → classic snuffbox TTP.
a. Neg initial X-ray → spica cast to elbow still, f/u X-ray in 2wks for occult fx.
b. Non-displaced fx → spica cast to elbow for 6-8wks (lunate or scaphoid).
c. Displaced fx → ORIF (lunate or scaphoid).
d. Avascular necrosis risk w/scaphoid fx. Tx → hip bone graft.
13) Volkmann’s contracture 2/2 supracondylar humerus fx → occludes ant
interosseous a → closed humeral reduction →artery opens → reperfusion
injury/edema → forearm compartment synd (MC flexor compartment).
a. Sxs → tense & weak w/painful passive wrist extension. MC affects median n.
b. Tx → forearm fasciotomies (volar & dorsal compartments).
14) Dupuytren’s contracture Asso w/DM & ETOH. ↑Palmar fascia prolif→contracture
(MC 4th/5th digits)→ can’t extend fingers.
a. Tx → NSAIDs, steroid injections. If sig → fascia excision.
15) Carpal tunnel syndrome Med tx 1st. OR→Total transverse carpal lig release. Avoid
median recurrent br of median n (motor).
16) Tenosynovitis
a. Trigger finger → flexor tendon tenosynovitis → catches at MCP on finger
flex/ex.
i) Tx → mainly steroid injections & splint. If fails → release MCP pulley system.
b. Suppurative → Minor trauma (eg. cat/dog bite) → infection along flexor tendon
sheath → destructive.
i) Sxs → classically are TTP, pain w/passive motion, swelling, partially flexed
digit.
ii) Tx → mid-axial longitudinal I&D, abx (NOT lateral → nerve injury).
17) Flexor tendon injuries < 60% lac → non-op.
≥ 60% lac→ repair w/non-abs (Prolene) w/in 2wks (>2wks → retraction).
18) Hand/Digits → Each finger innervated by 4 nerves (2 palmar & 2 dorsal).
H. Lower Extremity
1) Hip dislocation
a. Anterior → Externally rotated, shortened, & abducted leg. Femoral a & n injury
risk.
i) Tx → closed reduction w/in < 24hrs (avoid avascular necrosis).
b. Posterior → MC type (90%). Internally rotated, shortened, & adducted leg.
Sciatic n injury risk. Tx → closed reduction.
2) Hip fracture (ie femoral head/acetab). Tx → hip replacement. High M&M >65yo
(20% w/in 6 mns).
3) Femoral fracture
a. Neck → Externally rotated, shortened, & abducted leg.
b. Tx → ORIF v hemiarthroplasty. (Delay → avascular necrosis).
c. Shaft/Distal <6yo → spica cast. >6yo → ORIF w/IM rod.

198
 4) Knee
a. Anterior cruciate ligament injury → + ant drawer test. Knee effusion & pain
w/pivoting. Dx → MRI best confirmation.
i) Tx → NO instability → strengthening PT
Instability → reconstruct w/patellar vs hamstring tendon.
b. Posterior cruciate ligament injury → + post drawer test. Knee pain & effusion.
ACL much MC.
i) Tx → initially conservative. OR if med tx fails.
c. Medial (MCL) → 2/2 lat knee trauma. Asso w/meniscus injury.
i) Tx: Small tear → brace Large tear → surgery.
d. Lateral (LCL) → 2/2 med knee trauma. Asso w/meniscus injury.
i) Tx: Small tear → brace Large tear → surgery.
e. Meniscus tears → joint line TTP.
i) Tx → arthroscopic debridement/repair.
f. Dislocation
i) Anterior Tx → closed reduction + angio to r/o popliteal a injury (25% risk).
Pulse deficit → go directly to OR.
ii) Posterior
5) Patellar fracture Tx → long leg cast. Comminuted → ORIF.
6) Tibial plateau fracture →Popliteal a injury/compartment syndrome risk. Tx → ORIF.
a. If open → ex fix until soft tissues heal. Artery injury tx like anterior dislocation.
7) Plantaris muscle rupture → contracted plantaris → painful mass below pop fossa
& ankle ecchymosis(eg. tennis player). Can walk. Tx → non-op.
8) Achilles tendon tear Can’t walk. Tx → repair.
9) Ankle fracture Tx → MC immobilize w/cast. If Bi-/trimalleolar → ORIF.
10) Metatarsal fracture Tx → cast immobilize vs brace x 6wks.
11) Calcaneus fracture → Foot compartment syn risk.
a. Asso w/lumbar/distal forearm fx (5-10%).
b. Tx → Non-displaced → immobilize w/cast. Displaced → ORIF.
12) Talus fracture Tx → closed reduct MC. Severely displaced→ORIF.
13) Foot drop → Common peroneal injury 2/2 leg crossing (temp), long lithotomy
(→compression by stirrups), or fibula head fx.
a. Common peroneal wraps around fibular neck, divides into deep & sup. peroneal.
i) Tx → foot brace.
14) Fat emboli syndrome → s/p long bone fxs.
a. Bergman’s triad → AMS, petichiae, & dyspnea.
I. Infectious Arthritis Swollen, painful, & erythematous joint. MCC → Staph aureus.
MCC w/STI → gonorrhea. Dx → arthrocentesis (WBC >50k).
1) Tx → washout & abx (Empiric vanc + levofloxacin. If gonorrhea → ceftriaxone).
Remove any involved hardware.

199

Uploaded by MEDBOOKSVN.ORG
J. Pediatric Orthopaedics
1) Osteomyelitis Kids → metaphysis (MCC → Staph).
a. Sxs→pain, ↓extremity usage. Dx → MRI, bone bx. Tx → I&D + abx.
2) Idiopathic Adolescent Scoliosis Prepub F, MC → right chest. MC no sxs.
a. 20-45° → brace(↓progression). >45°/progression → fusion.
3) Osgood–Schlatter Disease/Tibial Tubercle Apophysitis
a. 2/2 quads traction inj in 13-15yo. MC → pain ant to knee.
b. X-ray → irregular shape/ tibial tubercle fragmenting.
c. Tx→ Mild sxs→↓activity. Severe→ cast 6wks + ↓activity.
4) Legg–Calvé–Perthes Disease → Femoral head AVN. Kids 2+ yo.
a. Can be 2/2 hypercoag. 10% bilateral.
b. Sxs → painful gait w/limp. X-ray → femoral head flattening.
c. Tx → ROM exercises. OR only if femoral head not covered by acetab.
5) Slipped Capital Femoral Epiphysis
a. 10-13yo M. ↑fem head AVN risk. Sxs → painful gait.
b. X-ray → irregular/wide epiphyseal plate. Tx → surgical pin.
6) Congenital Hip Dislocation MC in F.
a. Tx → Pavlik harness(reduces fem head & abducts legs).
7) Clubfoot Tx → serial casting.
K. Bone tumors
1) Metastatic Breast (MC), prostate (#2 MC)
2) Osteochondroma
3) Chondrosarcoma → can arise from osteochondroma
4) Osteosarcoma → MC 1° malignant bone tumor (35%).
a. MC at knee (50%). MC in youth (80% <20yo). Overall 5ys → 65%.
b. Tx → limb-sparing resection ± doxorubicin-based neoadj CTX-XRT.
5) Ewing’s Sarcoma → MC in adolescents. Sxs → Painful swelling.
a. X-ray → “onion-skin” appearance (classic).
b. MC location → proximal femur.
c. Tx → doxorubicin-based (+ ifosfamide & etoposide) CTX-XRT 2/2 ↑risk of micro-
mets, then limb-sparing resection.

200
37. Pediatric Surgery
A. Resuscitation
1) Trauma bolus → 20 mL/kg x 2 (isotonic → LR or NS); blood 10 mL/kg.
Total blood volume → ~80mL/kg.
2) Get hypothermia quicker vs adults.
3) Tachycardia → best shock indicator in kids.
a. Neonate >150 ETT size =
b. Age 0-1 year >120 (4 + age in yrs) / 4
c. > 1year >100
4) Initial IVF resus for dehydration (eg. 2/2 pyloric stenosis) → NS 20 mL/kg bolus.
5) Neonates & infants → UOP 2-3 mL/kg/hr.
6) Toddlers & school age → UOP 1 mL/kg/hr.
7) 6mo → 25% GFR capacity vs adults 2/2 poor concentration. Need less K+. ML to get
hypocalcemia w/massive transfusion.
8) Maintenance IVF → 4 mL/kg/hr - 1st 10kg
nd
2 mL/kg/hr - 2 10kg 1 mL/kg/hr - after 1st 20kg.
a. Exp → 27 kg girl mIVF → 67 mL/hr (40 mL/hr - 1st 10kg, 20 mL/hr - 2nd 10kg, 7
mL/hr - last 7 kg).
9) mIVF for sick kids → ½ NS w/5% dextrose ± K+ (↓hypoNa+ risk).
10) Avoid ¼ NS (previously rec’d in toddlers)
11) Neonates → avoid K+.
12) Infants & toddlers → avoid K+ until good UOP.
B. Choanal Atresia → Obs choana (nasal passage) by bone or mucous membrane. Most
are unilateral.
1) Sxs → occasional resp distress & poor feeding. Tx → repair.
C. Branchial Cleft Cyst → cysts, sinuses, & fistulae.
1) 1st branchial cleft cyst → near mandibular angle w/poss external auditory canal/CN
VII involvement.
2) 2nd branchial cleft cyst (MC) → ant/mid-SCM through carotid bifurcation into
tonsillar pillar.
3) 3rd branchial cleft cyst → inf neck, med/through inf SCM.
4) Tx (all types) → resection.
D. Thyroglossal Duct Cyst → along thyroid descent through foramen cecum through
hyoid. Poss. pt’s only thyroid tissue.
1) Upward mvmt w/swallowing.
2) Sxs → dysphagia, midline cervical mass (b/w hyoid & thyroid).
3) Infection risk. CA risk → 1% (MC papillary thyroid CA).
4) Tx → Sistrunk procedure → excise cyst, tract, & central hyoid via lat neck incision.

201

Uploaded by MEDBOOKSVN.ORG
E. TracheoEsophageal Fistulae asso w/VACTERL (Vertebra, Anal, Cardiac, TE fistula,
Renal, Limb).

1) Type A – Atresia, no TEF → gasless abdomen.

2) Type B - Atresia w/proximal TEF → gasless abdomen.
3) Type C - MC. Atresia w/distal TEF → distended stomach.
4) Type D - Atresia w/proximal & distal TEF → distended stomach.
5) Type E - No atresia w/TEF (“H”) → distended stomach.
6) Tx → right thoracotomy (extra-pleural), tie off & divide fistula/resect atretic seg,
tension-free 1° anastomosis (mobilize prox, not distal, esophagus), & place G-tube.
a. Often must divide azygos vein → TEF often underneath.
b. Prox esophagus → better blood supply (inf thyroid) vs distal (intercostal).
c. Delayed repair → premature infants, <2,500 g, or sick (eg PNA, severe cardiac
anomaly). 1st Tx → Replogle, G-tube (decompress + feed), & delayed TEF repair.
7) MC Cx s/p repair → GERD (others → leak, stricture, fistula).
8) Survival linked to birth wt & asso anomalies (MI → cardiac).
F. Aerodigestic Foreign Bodies PA & lat x-ray will ID most & direct Tx.
1) “Double contour” sign (round opacity w/opaque 2nd outer ring) → battery. All
batteries must be removed immediately to prevent liquefactive necrosis if battery
spills.
2) Esophageal → rigid EGD (flexible “OK”).
Pharyngel/proximal trachea → direct laryngoscopy w/McGill forceps.
Tracheal/bronchial → rigid bronchoscopy.
3) Stomach/intestines → if not battery, allow to pass PR (KUB in 2wks).
G. Cystic Hygroma (lymphangioma, benign) → Post neck triangle (post/lat to SCM).
Also axilla & groin.
1) Macrocytic lymphatic malformation → fluctuant & multi-loculated → forms sinuses
→ get infected (MC staph & strep).
2) Tx → resect (No margins. Preserve other important structures).
H. Hemangioma
1) Kasabach–Merritt Syndrome → consumptive coag w/↓PLTs & heart failure 2/2 A-V
shunt. Tx → embolization + steroids.

202
I. Laryngeal Papillomatosis → MC pediatric larynx tumor. Most involute s/p puberty.
Poss 2/2 maternal HPV.
1) Tx → endoscopic removal vs laser (recur frequently).
J. Congenital Laryngomalacia → MCC of infant airway obs. 2/2 immature epiglottic
cartilage w/collapse of epiglottis. Most outgrow by 12mns.
1) Sxs → sporadic resp distress & stridor worse when supine.
2) Tx → Usually supportive. Tracheostomy rarely needed.
K. Congenital Tracheomalacia → Tracheal rings fragmented & elliptical not C-shaped
→ collapses ant/post. RFs → TEF/EA.
1) Sxs → exp. wheezing, “dying spell” w/feed. Improves by 1-2yo.
2) Dx →narrow trachea on lat CXR.
3) Tx→Usually non-op. OR if → “dying spell”(MC), repeated infection, vent wean fails
→ aortopexy to sternum→opens trachea.
L. Congenital Lung Anomalies
1) Bronchogenic Cyst → extra-pulmonary (most) 2/2 abnml lung (parenchyma &
cartilage). No airway communication.
a. MC mediastinal cyst. MC post. carina to right. MC affects newborns.
b. Sxs → compress airways → resp distress, infection.
c. Milky fluid. Risk of malignant degen. Tx → resect.
2) Congenital Cystic Adenomatoid Malformations (CCAM) → intra-pulmonary (most)
bronchiole overgrowth.
a. Sxs → Newborns - resp distress. Older children – infection. Rapid decomp w/vent
→ emergent decompression/excision.
b. MC in lower lobe. Air-trapping. Connected to bronchus. Risk of malignant degen.
c. Tx → lobectomy.
3) Congenital Lobar Emphysema → hyperinflation. Sxs→resp distress/hypoTN 2/2
hyperexpansion of lobe(s) (like tension PTX). MC location → LUL.
a. Dx: CXR → hyperinflation of a lobe (hyper-lucent area); compression of other
structures (eg other lung lobe, mediastinum)
b. Failure of bronchial cartilage development → air trapping on expiration. Nml
vasc supply Tx → lobectomy.
4) Pulmonary Sequestration Abnml artery off Aorta/abd Aorta.
Venous drainage = P I E S; Pulmonary  Intra, Extra → Systemic)
a. Intralobar w/in nml pleura. Pulm venous drainage. Dx → CTA (to define
vasculature).
b. Extralobar in separate pleura. Systemic drainage (usually azygous). Dx → CTA (to
define vasculature).
5) Pulmonary AVM
M. Pectus
1) Carinatum → “Pigeon chest”. Surgery doesn’t ↑ pulm dynamics (if still growing
brace → success 65-80%).

203

Uploaded by MEDBOOKSVN.ORG
 2) Excavatum → caved in. Haller index → distance b/w (lat-most ribs) / (ant vertebra
to sternum). Nml → ≤ 2.5.
a. Tx → if resp/emotional sxs, sternal osteotomy w/strut placement vs Nuss (strut
w/out osteotomy).
i) Poss ↑ pulm dynamics. MI step → passing bar across ant mediastinum. 2nd
MI step → stabilizing bar.
N. Herniae
1) Inguinal Spontaneously reducing inguinal bulge in asymptomatic infant →
elective repair. If reduces w/exam → repair prior to d/c. If it doesn’t reduce → OR
now.
a. Open → high ligation.
b. Lap → suture closure of internal ring w/sac (avoid vessels & vas).
2) Umbilical Linea alba fails to close (usually by 3yo). Incarceration rare.
a. ↑ in African Americans & premature infants.
b. Tx → persists >5yo, incarcerated, or needs VP shunt. 1° suture repair (NO mesh).
3) Diaphragmatic
a. Bochdalek’s “Back-to-the-left.”MC Post Left. MC type. Usually NO sac.
b. Morgagni’s → rare; MC right/ant (retrosternal).
i) MC in adults 2/2 ↑inta-abd pressure. Has a sac. Incarceration risk.
ii) Tx → repair w/PTFE patch.
c. Eventration → diaphragm fails to fuse.
O. Choledochal Cysts (see Biliary)
P. Biliary Atresia → >2 wk old, acholic stools, ↑ direct bili. Dx → U/S, HIDA (not
useful w/severe jaundice), MRCP (best to dx), & liver Bx (PRN).
1) Intra-hepatic → liver TXP.
2) Extra-hepatic → Kasai (ReY hepatic portoenterostomy) before 2 mn old (usually
w/in 45d → prevent irreversible liver damage). ⅓ die, ⅓→txp soon after, ⅓ → txp
eventually. Give ursodiol, TMP-SMX, vit ADEK, & prednisone (tapered over 6wks)
post-op.
a. MC Cxs s/p Kasai → Cholangitis (30-60% w/in 1-2wks), cirrhosis, nut def (→ fxs).
Q. Duodenal Atresia 2/2 failure of recanalization → projectile, bilious emesis 1st 1-3
wks.
1) MC obs in newborns. MC form of intestinal atresia. MC dist to ampulla.
2) “Double-bubble”.
3) Also seen w/annular pancreas, trisomy 21, polyhydramnios. IVF resus before any
OR.
4) Tx → DD or DJ, resect duo webs via longitudinal duodenostomy.
R. Intestinal Atresia Other than duo, 2/2 intrauterine vascular accidents.
1) Bilious emesis, distension, can’t pass meconium, polyhydramnios.
2) AXR → distension w/dist decomp. Often multiple. IVF resus before OR.
3) Get barium enema prior to OR (r/o colon involved → suggests Hirschsprung’s.)
4) “High”/prox jejunal atresia → may need duo derotation for end-to-end
anastomosis.
204
 5) Types
a. I → mucosal/membranous w/intact wall & mesentery.
b. II → blind ends divided by fibrous cord.
c. IIIa → blind ends divided by V-shaped mesenteric defect.
d. IIIb → “apple-peal” atresia.
e. IV → multiple (↑incidence of SES in IIIb & IV → place g-tube intra-op).
6) Tx → Resection w/primary anastomosis ± ostomy (extensive damage).
S. Pyloric Stenosis → Projectile, non-bilious emesis w/olive mass on exam; usually 3-12
wk old 1st born M
1) Dx → hypochloremic, hypokalemic, metabolic alkalosis w/paradoxical aciduria. U/S
→ pylorus ≥4mm thick & ≥14mm long.
2) IVF resus before OR (20mL/kg NS, then D5 ½ NS + 20KCl @ mIVF rate). Preop resus
goals → HCO3- < 30 mEq/dL, normovolemic.
3) Tx → Pyloromyotomy (RUQ inc, divide vein of Mayo, extend prox to gastric circular
mm).
a. Ramstedt pyloromyotomy → retract liver, deliver pylorus, open serosa sharply,
divide muscle fibers bluntly, expose submucosa just prox to hypertrophied muscle
to prox to pyloric vein, & leak check.
b. Lumen entry→close w/fine abs suture + omental patch. If need to close defect →
rotate pylorus 180° & do posterior myotomy.
T. Intussusception (see Small Bowel)
U. Malrotation 2/2 failure of counterclockwise 270° rotation. MC duo obs in kids (90%
<1yo) except newborns (→ duo atresia).
1) Sxs → sudden billous emesis (Ladd's bands → duo obs, in right RP). Bilious emesis &
<2yo → STAT UGI to r/o malro.
2) Ladd's bands → fibrous peritoneal stalk from RUQ to sup/med displaced cecum →
can compress duo → obs → bilious emesis.
3) Midgut volvulus (clockwise around SMA) can happen w/malro.
4) Dx → UGI (best) 1Duo doesn’t cross midline, 2DJ jxn displaced right, & 3DJ below the
level of the pylorus.
5) Tx → IVF resus + Ladd's procedure
a. Rotate bowel counterclockwise until mesentery is widened & assess viability.
“Turn back the hands of time.”
b. Completely mobilize/straighten duo & place in RUQ.
c. Divide band(s) between cecum & abdominal wall.
d. Place small bowel on left, colon on right.
e. Appendectomy (prevents future confounding dx).
6) Persistent SBO s/p Ladd’s → 2/2 duo webs (Tx → resect via longitudinal
duodenostomy). Look for this at initial surgery.
V. Gastroschisis → 2/2 intrauterine umbilical vein rupture. NO peritoneal sac. Right of
midline.
1) ↓ most congenital anomalies vs omphalocele (only 10%), except ↑malro &
intestinal atresia.
205

Uploaded by MEDBOOKSVN.ORG
 2) Tx → saline gauze over bowel & IVF resus, TPN, NPO. Repair when stable (place
bowel back in abd ± Vicryl mesh silo).
a. Bowel stiff bowel 2/2 amniotic fluid exposure. 1° closure later if silo.
W. Omphalocele 2/2 failure of embryonal development. Midline. Peritoneal sac (usually
bowel ± liver/spleen) w/attached cord.
1) ↑ congenital anomalies (50%) → worse prognosis vs gastroschisis.
2) Cantrell Pentalogy
a. (1) Cardiac, (2) Pericardial-usually at diaphragm, (3) Sternal cleft/absence inf
sternum, (4) Absent septum transversum-diaphragm, (5) Omphalocele
3) Tx → saline gauze over sac & IVF resus, TPN, NPO. Repair when stable (place bowel
back in abd ± Vicryl mesh silo). 1° closure later if silo.
X. Meckel’s Diverticulum (see Small Bowel)
Y. Meconium Ileus Thick meconium (ie 1st stool) doesn’t pass → distal ileal obs.
1) Meconium pseudocyst (cyst w/air-fluid lvls & egg-shell calcs) → In utero perforation
2/2 meconium.
a. Tx → ex lap (esp. if ischemia or peritonitis), ostomy if able. NOT able → leave
drains & come back in 4-8wks.
2) Sxs → NO meconium passage, abd distention, bilious vomiting, & strictures (late,
2/2 ischemia).
3) Sweat chloride vs PCR for Cl- channel defect (95% have cystic fibrosis).
a. Cystic fibrosis → 2/2 loss of transmembrane conductance regulator (CFTR) → ↓
panc enzymes → thick meconium.
4) AXR → dilated small bowel loops w/o air 2/2 meconium too thick, ground
glass/soap suds appearance; decompressed colon.
5) Tx → IVF resus important (osmotic load w/gastrografin enema will draw-in fluid →
hypoTN), empiric abx & NGT.
a. Fluoroscopic gastrografin or N-acetylcysteine enema (best test & best Tx) →
treats problem 80%.
b. Surgery if → enema fails, perf/necrosis, gets sicker. → milk out meconium via
enterotomy, place enterostomy tube for antegrade N-acetvlcysteine enemas.
Z. Cystic Intestinal Duplication/ Mesenteric Cysts
1) MC mesenteric border ileum. Tx → resect.
AA. Necrotizing Enterocolitis 10% mortality.
1) Sxs → BRBPR + abd distension s/p 1st meal in premie, feeding intolerance, lethargy,
emesis.
2) Probiotics in 1st 2wks ↓NEC, but may ↑ sepsis so NOT widely used.
3) MC in jejunum, then near ICV.
4) RFs → premie, hypoxia, sepsis. Poss 2/2 ischemia-reperfusion.
5) Pneumatosis alone is NOT an indication for surgery.
6) AXR → pneumatosis (pathognomonic; cystic [foamy] → submucosal, linear →
muscularis), free air on lat decub, or portal air.

206
 7) Initial Tx → IVF resus, NPO, antibiotics, TPN, OG decomp, serial exams+AXR (Q 6
hours) for 1st 2wks.
8) Surgical indications → free air (MC), peritonitis, persistent metabolic acidosis or
↓PLTs (<100 s/p transfusion), worse clinically, abd wall erythema/edema (→ dead
bowel), or feces on paracentesis.
9) Resect dead bowel & do a 2nd look. NOT able to resect perf(s) → create ostomies
& place silo. Can’t ex lap → place drains in NICU.
10) Get UGI w/SBFT & barium enema prior to feeds or ostomy takedown to r/o
obs/stenosis.
11) Short bowel syndrome later in 25% (esp w/sig resection). 70-80% of strictures are
colonic.

NEC
Stage Clinical Exam/Lab Radiographic Medical Tx Surgical Tx
Suspected NEC,
Distension,
A ↑/↓ temp, ± Dilation
FOBT+
I ↓HR, emesis
Grossly bloody Abx (Vanc + /
B Suspected, SAA SAA
stools gent /
Definite NEC, Dilation, ceftriaxone),
A SAA
SAA, ± TTP pneumatosis NPO,
II decompression,
Definite, SAA, ± Metabolic Relative indications
B SAA + ascites IVF resus,
cellulitis acidosis, ↓PLTs → failure to
parenteral progress,
Advanced NEC, Apnea, ↓WBC,
A SAA nutrition compartment synd,
SAA, ↓BP DIC
abd wall erythema,
AND portal venous gas,
fixed loops.
q6-8h exams,
III
Advanced, Pneumo- CBC, & 2-view x- 1° drain for VLBW
B Peritonitis
perforated peritoneum ray. infants. Resect
dead bowel, divert
if focal/2nd look if
multifocal.
BB. Hirschsprung’s disease → MCC infant colon obs. MC M (4:1).
1) MC sx → fail to pass meconium w/in 1st 24hrs.
2) Others → distension, constipation, emesis, explosive diarrhea upon DRE, colitis,
chronic constipation (2-3yo).
3) AXR → dilated prox colon/small bowel (ganglion cells) w/distal decomp (NO
ganglion cells).
4) Dx → rectal biopsy (Suction cup. Mucosa & submucosa. Best test) → NO ganglion
cells in Auerbach's myenteric plexus.
5) 2/2 caudad neural crest ganglion cells progression failure → starts in rectum, moves
prox → functional obs.
a. Rectum only (short seg) → 75%. Entire colon (long seg)→ 5%.
6) Tx → resect until ganglion cells appear (intra-op path). May need ostomy.
Eventually connect to anus (Pull-through → Soave or Duhamel).
a. Soave → submucosal endorectal dissection.
b. Duhamel → aganglionic rectal stump anterior, nml ganglion colon posterior →
staple & divide together.

207

Uploaded by MEDBOOKSVN.ORG
 7) Hirschsprung's Colitis - can rapidly progress. MCC of death in Hirschsprung's. Sxs →
TTP, foul diarrhea, sepsis, lethargy.
a. Tx → rectal irrigation, poss emergent colectomy.
CC. Imperforate Anus → Rectal blind pouch. Often w/ perineum or GU fistula (M →
urethra, bladder, scrotum; F → vagina).
1) Asso w/VACTERL (60% have an anomaly; see TE Fistula above; MC - urinary tract
anomaly)
2) Do not typically present with bowel obstruction; low lesions can present with
defecation problems
3) High lesions (above levator ani). If high, MC in M (>50%).
a. M → meconium in urine (MC fistula to prostatic urethra).
b. F → meconium in upper vagina (poss cloaca).
c. Tx → colostomy (soon, but NOT emerget) & delayed reconstruction w/post
sagittal anoplasty
4) Low lesions (below levator ani). Fistula to perineal skin/median raphe or scrotum vs
lower vagina. MC in F (90%).
a. Tx → post sagittal anoplasty (NO colostomy). Post-op dilation (prone to
stricture/constipation).
DD. Undescended Testicle/Cryptorchidism
1) MC location → 90% inguinal canal (Can’t feel testis in inguinal canal → MRI to
confirm presence.) Hernia common.
2) Can be anywhere in RP, ectopic, or “vanished.”
a. Bilateral (30% → get gene studies). Dx → physical exam & U/S.
3) Risks → Torsion, Infertility (improves s/p correction), Testicular CA (unilateral → 5x,
bilateral → 10x, persists s/p correction).
MC → seminoma.
4) Medical Tx → β-HCG (questionable success).
5) Surgery Wait 4-6mns to see if descend by themselves. Needs to be
done prior to 2yo.
a. Inguinal orchiopexy → attach testis to scrotum → high ligation (like hernia).
b. Can’t get testicles down → divide spermatic/testicular vessels laparoscopically
(vas artery collateralizes to testicles).
6) Adult cryptorchidism → orchiectomy (are non-functional).
7) Prune Belly Syndrome → cryptorchidism, absent/hypoplastic abd wall, pulm
hypoplasia, urinary & skeletal anomalies.
EE. Teratoma (Dermoid Cyst) Cystic, solid, or mixed. Malignant degen risk (↑ AFP or β-
HCG). Tx → excise.
1) Neonates (embryonal) along midline.
2) MC & MC overall → sacrococcygeal.
3) Adolescents (germ cell) → ovaries (MC), testicles (rare).
4) Sacrococcygeal Teratomas MC in F; usually at birth (if on pre-natal U/S → very
poor prognosis. 90% benign at birth).
a. Exophytic (most). Can be entirely internal (pre-sacral, poss rectal/bladder
involvement) & dx later in life.
b. ↑ malignant degen → adenoCA.
c. <2mn → usually benign. >2mn → usually malignant.
208
 d. Get CT scan to assess extent/depth.
e. Tx → coccygectomy w/tumor excision & long-term f/u if CA (AFP → good
recurrence marker).
FF. Ovarian Masses <9yo → 80% malignant → unilateral salpingo-oophorectomy.
Hemoperitoneum NOT a CI to laparoscopy.
1) Cystic & simple (NO septations or calcs) → likely benign → U/S in 4-8wks (~50%
resolve w/in 3mn.).
GG. Neuroblastoma → Diarrhea, HTN, raccoon eyes (= orbital mets), unsteady gait (=
opsoclonus-myoclonus-ataxia syndrome).
1) Dx → calcs on CT, +MIBG, ↑n-myc (poor prognosis), ↑NSE (mets likely), asso w/NF
type 1. ↑age→↓prognosis.
2) Tx → Resect adrenal & kidney. Intermediate/high risk → neoadj CTX. Adjuvant XRT
if residual dz.
HH. Wilms Tumor (Nephroblastoma) → HTN, hematuria, & hemihypertrophy.
1) Renal vein/IVC involved → can still resect (extract like for RCCa). Rupture → ↑local
recurrence & upstages. All get CTX. Pulm mets → whole lung XRT.
2) Neoadj CTX→b/l(St V, 10%)or attempting nephron-sparing surgery (NSS).
3) Beckwith-Wiedemann Syndrome → Macroglossia, macrosomia (birth wt >90%tile),
abd wall defects, ear creases, neonatal hypoglycemia. Asso w/Wilm’s tumor &
hepatoblastoma.
4) WAGR → Wilm’s, Aniridia, GU anomalies, mental Retardation.
5) Denys-Dash→ Wilm’s, nephropathy, gonadal dysgenesis.
II. Hepatoblastoma → Abd mass w/↑AFP (r/o teratoma), fxs, precocious puberty.
1) Tx → resect + cisplatin CTX. . + margin→adj XRT
2) Most are unresectable → neoadj/definitive CTX.
3) Liver TXP for → (1) multifocal at dx, (2) progresses on neoadj CTX, (3) R 1 or 2
resection, (4) intrahepatic recurrence, or
(5) tumor near portal vein bifurcation, 3 major hepatic veins, or IVC.
JJ. Patent Urachus → connection b/w umbilicus & bladder → wet umbilicus.
1) Tx → resect.
KK. Patent Omphalomesenteric Duct (Vitelline Duct) → connection b/w ileum &
umbilicus → succus from umbilicus.
1) If seals only at umbilicus → Meckel's diverticulum.
2) Sxs → pain, obs. Tx → resect.
LL. Umbilical Granuloma
1) Tx → Silver nitrate (± topical steroids if chronic or c/f polyp or cyst).
MM. Persistent Omphalomesenteric Vessels (Vitelline Vessels)
1) Presents w/bowel torsion (MC) ± strangulation/necrosis.
2) Sometimes asso w/Meckel's.
3) 2 Arteries → umbilicus to aorta (1 artery → c/f abnml chromosomes).
4) 1 Vein → umbilicus to portal vein.
5) Tx → detorse bowel (dead → resec) & ligate persistent vessels.
NN. Omphalitis → Umbilical stump infection, can → portal vein thrombosis → ↑LFTs ±
bleeding varices.
1) Tx → abx for infection, heparin gtt for acute portal vein thrombosis.

209

Uploaded by MEDBOOKSVN.ORG
38. Statistics & Pt Safety
A. Types of Data
1) Internal/Continuous
a. Normal/Parametric Central tendency → Mean (SD)
i) 2 groups
A) Student’s T-test → different groups
B) Paired T-test → same pt, but before & after tx. (Best test to analyze
before/after BPs w/a new vasopressor.)
ii) >2groups
A) ANOVA
2) Categorical/Discrete/Qualitative
a. Types
i) Nominal → no order (eg. hair color).
A) Binary/Dichotomous is a subtype (eg. Yes or No).
B) Central tendency → proportion.
1. Group comparison → Chi2.
ii) Ordinal → ordered (eg. tumor stage, pt satisfaction).
A) Non-normal/Non-parametric (includes bimodal distributions)
1. Central tendency → Median (IQR)
2. 2 group comparison → Wilcoxon/Mann-U-Whitney.
3. >2 group comparison → Kruskal Wallis
3) Kaplan-Meier → survival estimate.
B. Measures
1) Sensitivity → TP / TP+FN
2) Specificity → TN / TN+FP
3) Incidence → # new cases in an area over a set time.
4) Prevalence → ↓prevalence will dec PPV & inc NPV.
5) PPV → TP / TP+FP
6) NPV → TN / TN+FN
7) OR → odds an outcome will occur given a particular exposure. MC used in case-
control.
8) RR → probability an outcome in an exposed group to the probability of an outcome
in an unexposed group. MC in cohort.
9) RRR → (CG% - TG%)/CG%
10) ARR → difference in risk (CG% - TG%)
11) NNT → 1/ARR
12) Error
a. Type I / α → FP “Jumps the gun” “α = aggressive”
Type II / β → FN “stuββorn” (↓ by ↑ sample size. Power = 1-β).
C. Types of studies
1) Case-control → Pts w/dz compared to pts w/o dz. Uses OR. Can be retrospective
or prospective.

210
 2) Cohort → exp vs unexp. Calculate prevelance & RR. Prospective→ can only use
starting RFs → ↑cost & wait time for results.
3) Meta-analysis → Combines different studies on specific dz or tx (eg multiple studies
examining risk of stroke after CABG).
4) Systematic review → qualitative evidence.
5) Survival analysis → time to death b/w groups.
6) Linear regression → compares multiple continuous variables associated
w/continuous outcomes.
7) Cox Proportional Hazard → regression for most survival analysis.
8) Confounders, can use → multivariate regression, propensity score, or instrumental
variable analysis.
D. CEBM Levels of evidence
1) 1a → Systematic Reivew (homogeneous) of RCTs
2) 1b → Individual RCTs
3) 1c → all or none
4) 2a → Systematic Reivew (homogeneous) of Cohort
5) 2b → Individual Cohort & low-quality RCTs
6) 3a → Systematic Reivew (homogeneous) of Case-Control
7) 3b → Individual Case-Control
8) 4 → Case series
9) 5 → Expert opinion
E. Medical decision making
1) Ethical principles
a. Beneficene – Do good for the pt.
b. Non-maleficence – Do no harm.
c. Justice – Equitable treatment.
d. Autonomy – Let the pt decide.
2) Always 1admit & 2apologize for mistakes, 3build relationships, 4explain
implications, & 5document discussion.
3) Informed Consent → always obtain unless emergency & pt unable. Involves detailed
discussion of procedure, it’s risks, benefits, & alternatives.
4) Hierarchy → Competent pt (or capacity per judge) > Power of Attorney > Spouse >
Adult child > Either parent > Adult sibling.
5) Pt w/ (insert bad surgical problem) consents to all medical therapy but says “I
would rather die than have surgery.” Next day pt in shock & intubated. Spouse
now wants surgery. Tx → max medical tx.
6) Pt injured, has advanced directives indicating desire to be an organ donor. Pt’s
siblings refuse. What to do? → Honor pt’s wishes (Also, consult ethics.)
7) Elderly pt w/“mild confusion” has early stage CA, but refuses tx. Family wants
aggressive tx. What do you do? → Honor pt’s wishes if they have capacity.
Encourage pt to communicate with family.
8) Diffuse CA w/multiple SBOs, what do you do → Bypass for sxs.

211

Uploaded by MEDBOOKSVN.ORG
 9) Nursing home pt w/explicit advance directives against advanced life-prolonging
measures brought to ED & develops resp distress & now unconscious. No family,
WTD? → Supportive care to improve resp status.
10) Decision to amputate a mangled, entrapped leg at POI in unconscious, unstable pt
best based upon → substitutive decision-making (NOT consensus of all HCPs at
scene).
11) Elderly pt w/devastating injury → CPR unlikely to benefit.
F. Wrong site surgery prevention → sign in pre-op hold area.
G. Quality of Life Surveys → best if performed by pt.
H. Clinical practice guidelines → "Statements that include recommendations, intended
to optimize patient care, that are informed by a systematic review of evidence & an
assessment of the benefits & harms of alternative care options" per Institute of
Medicine.
I. Substance abuse → Social consequences of usage.
J. Substance dependence → Physiological & behavioral sxs of usage.
K. MC reasons for readmission in general post-op → #1 SSI (20%), #2 ileus (10%).
1) If for abdominal (specifically bariatric) surgery only → #1 ileus (25%).
L. Surgeons w/blood-borne infections
1) Pt has right to know risks & benefits of intervention. Recent data indicates
transmission is exceedingly low, particularly w/ double gloving & low counts. No
current law requiring surgeon to inform pt, though likely has a moral obligation to
inform pt. However, in court may be accused of knowingly endangering pt &
negligent vs poss assault) if pt contracts the dz & can prove that it was transmitted
by surgeon.
M. Reporting drunk attending → non-malefecence.
N. If minor needs emergent intervention to save life, but parents don’t consent → do it
anyway (best interest standard), consult ethics/court order if time.
O. MCC of adverse event/medical lawsuit → poor communication.
P. ACS NSQIP → gathers data on outcomes to measure & ↑surgical quality in the US.
Q. GAP protection → checklist & structured pt handoffs/transfer of care.
R. Sentinel event (JCAHO) → unexpected serious injury/death (or risk thereof) for which a
hospital performs a Root Cause Analysis.
S. Time out (JCAHO) → prior to cut, check pt, position, site, side, poss implants, & special
requirements.
T. SCIP (Surgical Care Improvement Project) Goal → ↓ post-operative/hospital
acquired complications.

212
39. MIS
A. Initial entry/port location
1) Veress entry
a. ↑peak pressures & bradycardia w/pneumoperitoneum, 1st step → Remove
trocars & desulflate.
b. ↑ insufflation pressures → tip not intraperitoneal (or tubing kinked or pt not
relaxed).
2) 1 port in lap RLQ VHR → LUQ.
st

3) Most consistent method to prevent trocar-associated injuries → “Macrobracing”

w/non-dominant hand.
4) Safest entry method→Hasson (↓ bowel & vascular inj vs Veress/optical).
5) ML to be injured during laparoscopic access → small intestines.
6) Insufflation
a. CO2 used b/c easily absorbed & exchanged.
b. Bradycardia on insufflation → 2/2 vagal response to peritoneal distension.
c. Pressure set at 15, pressure reading of 20 2/2 inadequate anesthesia.
d. Pneumoperitoneum → ↓preload & UOP, ↑ afterload & SVR.
7) Air embolus (eg. during CVC exchange) → ↓EtCO2 → trendelenburg w/left side
down to get CO2 bubble to RV apex.
8) CI to lap → pt not HDS stable.
B. Robotics
1) Outcomes vs lap → no diff in mortality, Cxs, & length of stay, but ↑$$$.
C. Surgical energy devices CI w/pacemaker → Monopolar/Bovie. (Harmonic
would be better than bipolar here).
1) “Advanced” bipolar/LigaSure → vessels ≤7mm w/min thermal spread.
D. EGD → deflect UP & rotate CLOCKWISE to intubate duo.
E. CSP Best way to see small polyps → ≥ 6min withdraw time.
1) Best way to reduce sigmoid loop → LLQ pressure.
F. Enhanced recovery after surgery (ERAS) protocol.
1) Carb load (clear liquid day prior & up to 2hrs before) → ↓ preop thirst/
hunger/anxiety; ↓ postop insulin resistance; ↓nitrogen & protein loss, preserves
skeletal muscle, early bowel function, ↓ LOS & overall Cxs.
2) Entereg (alvmopan) → opiod antagonist. Periop use → ↑return of bowel function
by 15-24hrs.

213

Uploaded by MEDBOOKSVN.ORG
40. Abbreviations
Ab = antibody MI = most important/myocardial infarction
Abx = antibiotics Min = minute
AD = autosomal dominant mIVF = maintenance intravenous fluids
Adj = adjuvant ML = most likely
Ag = antigen Mn = month
AKI = acute kidney injury MPD = myeloproliferative disorder
Alb = albumin Nml = normal
Ant = anterior NOAC = novel oral anticoagulant
APAP = tylenol NPO = nil per os
ASA = aspirin NSQIP = national surgical quality improvement program
AT-III = anti-thrombin-III Nut = nutrition
Avg = average OCP = oral contraceptive pill
BP = blood pressure OD = overdose
c/f = concern for PCI = percutaneous intervention
Ca++ = calcium PCN = penicillin
CA = cancer PD cath = peritoneal dialysis catheter
Cath = catheter PF3 = platelet factor 3
CI = contraindicated PICC = peripherally inserted central catheter
CKD = chronic kidney disease PLT = platelets
Coag = coagulation/coagulopathy PNA = pneumonia
Conc = concentration PO = per os
CRCa = colorectal cancer Post = posterior
CTX = chemotherapy ppx = prophylaxis
Cx = complication pRBC = packed red blood cell
D = day Prev = previous
D/o = disorder Pt = patient
Def = deficiency PTC= percutaneous transhepatic cholecystostomy
Dep = dependent Pulm = pulmonary
DLI = diverting loop ileostomy RCRI = revised cardiac risk index
DOAC = direct oral anticoagulant RDA = recommended dietary allowance
Dx = diagnosis RF = risk factor
DVT = deep vein thrombosis Rxn = reaction
Dz = disease S/p = status-post
e/o = evidence of Sat = saturation
EF = ejection fraction SCIP = surgical care improvement project
f = factor SE = side effect
FFP= fresh frozen plasma SCFA = short chain fatty acid
FSP = fibrin split product Sig = significant
FXN = function Spont = spontaneous
GOO = gastric outlet obstruction Sx = symptom
Gtt = drip TAC = total abdominal colectomy
Hb / Hgb = hemoglobin TPN = total parenteral nutrition
HD = hemodialysis Tx = treatment
HR = heart rate TXF = transfusion
IBD = inflammatory bowel disease TXP = transplant
ICH = intracranial hemorrhage Umb = umbilical
Infxn = infection UFH = unfractionated heparin
Inh = inhibit Vit = vitamin
INH = inhaled VTE = venothromboembolus
IPAA = ileal pouch anal anastomosis vWB = von Willebrand factor/disease
IV = intravenous W/ = with
LBW = low birth weight W/o = without/washout
LD = loading dose W/u = work-up
LE / UE = lower / upper extremity WB = whole blood
LMWH = low molecular weight heparin (= LVX) Wk = week
Lvl = level XRT = x-ray therapy (aka radiation)
LVX = Lovenox Y/o = year-old
MACE = major adverse cardiac event Yr = year
MC = most common YS = year survival
MCC = most common cause
MCFA = medium chain fatty acid
Mech = mechanical
214