Surgical Oral Boards

Esophageal perforation nonoperative management

- Clinically stable w/o signs of sepsis - Instrumental perforation w/ pt being NPO - Perforation contained in the neck or mediastinum w/o extravasation, crepitus, PTX, or pneumoperitoneum. - NPO w/o TPN x 5-7 days then UGI

BIRADS

0 = incomplete. re-evaluate 1 = negative. annual mammo 2 = benign. annual mammo 3 = probably benign (less 2%) 6 m mammo 4 = suspicious. biopsy. (3-94%) 5 = highly suggestive. (greater 95%) 6 = known CA

FNA results

1) Nondiagnostic (10-15%) - < 5% risk of CA - Repeat and if still ND then lobectomy 2) Benign / Colloid (70%) - 0.3-5% risk of CA - No further intervention 3) Atypia of undetermined significance - 5-15% risk of CA - Same as nondiagnostic 4) Suspicious for follicular neoplasm - 15-30% risk of CA - Lobectomy possible total 5) Suspicious for malignancy - 60-75% risk of CA - Lobectomy possible total 6) Malignant (5%) - 97-99% risk of CA - Total thyroid

On-table IVP

1-2 mL/kg of iodine-based contrast such as Isoview intravenously and then obtaining a 10-minute excretion film.

Radioactive iodine

1.) ablate thyroid remnant 2.) eliminate persistent dz 3.) eliminate suspected micrometastases Patients: - Gross residual tumor - Tumors bigger than 4cm - Primary tumors 1-4cm - Cervical LN mets - Distant metastatic dz - High risk histologies - Vascular invasion

Umbilical hernia in a cirrhotic

1.5 - 2 g Na / day diet 500-750mL / day of ascites lost w/o IV depletion Excessive volume losses = hepatorenal synd Spironolactone 50-100mg/day; incr q3d max 400 Lasix 20-40 mg/day; max 160 (avoid IV) 25g albumin to prevent depletion and HRS Primary repair. Close the SQ in multiple layers. Nylon suture in a "locking" fashion. Dermabond on top to prevent leaking.

Hyperkalemia

10 mL of 10% Calcium gluconate over 3 min 10 mL of 10% Calcium chloride over 3 min (3x more) 10 U regular insulin in 500 mL of D20 over 1 hr 1 amp of NaHCO3 (44-88mEq) (decrease 1 mEq/L) - Do not give after calcium Albuterol 10 mg nebulized Kayexalate: - 30 g in 50 mL 20% sorbitol PO - 50 g in 200 mL 20% sorbitol PR enema Lasix Hemodialysis

LCIS

17-27% upgraded to invasive CA / DCIS Core bx > surgical excision. H&P q 6-12 months Annual mammograms Offer bilateral risk reduction mastectomy (RRM) +/- immediate reconstruction - Option but not recommended for most - No LN bx unless cancer on final path - If done then annual exam but not mammo Tamoxifen 20mg qd x 5 years - Must be > 35 years - Reduced risk by 49%

Fibroadenoma

20 - 50 y/o Hormonal-related > 3 cm considered "disease" US: round / oval, well-circumscribed, solid mass, homogeneous, low-level internal echos, intermediate acoustic attenuation. RR of 1.3 - 1.9 for CA (no impact on clinical management)

Carcinoid: surveillance

3-12 mo after and then q6-12 mo - H&P - CT or MRI - Chromogranin A - 5 HIAA (esp. if SB carcinoid) - OctreoScan is not routinely recommended (only if possible recurrence) RECTAL < 1 cm = none 1-2 cm = endoscopy 6-12 months after rsxn APPENDIX < 2 cm = 1 year following or only if clincially indicated STOMACH (Type 1 and 2) If no EMR then H&P q 6-12 mo f/u endo q6-12 mo x 3 yrs then q yr.

Neuroendocrine tumor f/u

3-12 mo after surgery q6-12 mo after that H&P Appropriate tumor markers CT/MRI as indicated OctreoScan and PET not recommended for routine surveillance Re-resect locoregional or oligometastatic recurrence

Radiation Rx after mastectomy

50 Gy in fractions of 1.8-2.0 w/ CT-based plan Ipsilateral: - CW - Loco-regional LN - Supraclavicular LN - Internal mammary LN 4 + positive LN on ALND Strongly consider for 1-3 + LN Tumor > 5 cm and 1-3 + LN Tumor > 5 cm and node negative Margin < 1 mm and node negative Complications: heart & lung

ITP management

50,000 + - No specific treatment 30,000 - 50,000 and asymptomatic - No specific treatment Less than 20,000 - 30,000 or 50,000 w/ sx - Admit to the hospital - Prednisone 1mg/kg/d x 2-3 wks - IV immunoglobulin 1g/kg/d x 2 days for bleeding for prepare for surgery Impairs clearance of IgG-coated platelets by competing for binding to tissue macrophage receptors

Pheochromocytoma

73%-90% are sporadic 10% extra-adrenal (40% of those are functional) - More likely malignant (40%) 50% of MEN 2 cases will have pheo - Younger - More likely bilateral - More aggressive and likely to metastasize 30-50 yr old Fractionated plasma free metanephrines 24-hr urine fractionated metanephrines (> 4 x nml) BMP to r/o aldosterinoma - First stop: APAP, BB, SSRI, MAOI CT or MRI Metaiodobenzylguanidine (MIBG) +/- OctreoScan Genetic testing

Incidentaloma

< 4 cm, homogenous, smooth margin, lipid rich - Repeat CT in 6 - 12 months if no change no further f/u - > 1 cm growth in 1 year = removal 4-6 cm - Repeat CT in 3 - 6 months - If no change repeat in 6 - 12 months

MELD

= log Cr + log bilirubin = log INR 3 month mortality ≤ 9 = 4% 10-19 = 27% 20-29 = 76% 30-39 = 83% >40 = 100% < 24 = status 3 ≥ 30 = status 2a

Thyroid cancer prognosis

A ge (less than 40 M and 50 F) G rade E xtension beyond capsule S ize > 4 cm Metastases Score of < 4 has 20 year mortality < 1% Higher scores with 5 year survival 50%

Distal splenorenal shunt: technique

A line, CVC, Foley PRBC, FFP, platelets available Cell saver Left arm tucked and L sided bump L subcostal incision Aspirate and culture ascites Liver biopsy Opening the gastrocolic ligament to expose the pancreas Take down of the splenic flexure from the spleen. Take down of the splenocolic ligament. Expose the inferior margin of the pancreas. Mobilization of the inferior pancreatic border. Identify and divide the IMV. Mobilize the splenic / SMV confluence. Mobilize the splenic vein off of the pancreas. L renal vein is isolated and mobilized. - To the left of the SMA and anterior to aorta. Division of L adrenal vein. Side-biting clamp onto L renal vein. Divide the splenic / SMV junction. - 2-0 tie on SMV side and metal clip on splenic side. End-to-side anastamosis just anterior to the adrenal vein orifice. 2 stay sutures at the corners. Running posterior. Interrupted anterior to avoid purse string. Ligate L and R gastric vein.

Melanoma exam

A symmetry B order irregularity C olor variegation D iameter > 6 mm E volution

Pulmonary function testing

ABG PaO2 > 60% PaCO2 < 45 mmHg FEV1 postop predicted > 800 mL (60% predicted) DLCO > 50% Quantitative xenon-133 ventilation-perfusion lung scan.

Indications for total thyroidectomy with papillary thyroid CA

Age less 15 years or older 45 years Radiation history Tumor > 4 cm in diameter Bilateral nodularity Extrathyroidal extention Cervical lymph node metastases Unknown distant metastases An aggressive variant -Tall cell variant -Columnar cell variant -Poorly differentiated features

RLQ pain

Appendicitis Cecal diverticulitis Terminal ileitis: infectious vs. inflammatory such as Crohn's Typhlitis (neutropenic enteritis) Nephrolithiasis Ruptured ovarian cyst Ovarian torsion Ovarian tumor Ectopic pregnancy Endometriosis Rectal and pelvic exam. UA, u preg, and vaginal cultures for gonorrhea / chlamydia

ARDS

Atelectasis PNA Pleural effusion Sepsis ARDS PTX MI w/ CHF PE Fat embolus

Lip cancer

BCC most common on upper lip. SCC most common on lower lip. Palpate submucosal extent / fixation. Neuro exam (sensation) mental nerve. Submental and submandibular nodes. - Much higher if > 4-5mm deep tumor Elective neck dissection not typically advocated for lip CA.

Lung lesion DD

BENIGN Infectious -Coccydiomycosis Inflammatory Autoimmune Hamartoma / LN MALIGNANT Small cell Non small cell - AdenoCA - Squamous cell

Nipple discharge

Benign in 95% Physiologic vs. Pathologic vs. Pharmacologic vs. Idiopathic Concerning if: - Age > 60 - Spontaneous - Unilateral - Single duct - Bloody or serous ⊕ Solitary papilloma (60%) ⊕ Ductal hyperplasia (15-20%) ⊕ DCIS (5-20%) ⊕ Invasive CA (rarely) Pregnant, Manual stim, Pituitary adenoma, Primary hypothyroid, Ectopic production, Psych / HTN / GI meds

Childs classification

Bilirubin: Less 2; 2-3; Greater 3 Albumin: Greater 3.5; 2.8-3.5; Less 2.8 PT: 1-3; 4-6; Greater 6 Ascites: None; slight; moderate Encephalopathy: None; 1-2; 3-4 A = 5-6 points B = 7-9 points C = 10-15 points

H. pylori treatment

Bismuth 525mg qid Omeprazole 20mg qd Clarithromycin 500mg bid Amoxicillin 1g bid 7-14 days

BRCA 1

Breast CA risk 50-70% (5-10 x pop risk) Contralateral breast CA risk 40-65% Ovarian CA risk 30-45% Tamoxifen OR = 0.38 OCP may reduce risk of ovarian CA

Fascial dehiscence

Broad-spectrum antibiotics. CTAP with PO and IV contrast. Local wound exploration . Transfer to the OR. Wound cultures. Primary fascial failure vs. intra-abdominal sepsis. #1 or #2 absorbable monofilament in a 4:1 suture : wound length (2 cm x 2 cm) Leave the skin open. Biologic mesh vs. VAC Taylor antibiotics and keep till afebrile w/ normal WBC. (7-10 days)

Insulinoma: evaluation

C peptide Urine sulfonylurea 48-72 hour observed inpatient fast (BG < 40-45) - insulin > 3 mcIU/mL - insulin-to-glucose ratio of > 0.3 CT or MRI (r/o metastatic disease) Best localized by EUS (82%) Imamura-Doppman procedure - inject Ca into selective pancreatic arteries - measure insulin in R (usually) or L hepatic vein - last resort when no other method OctreoScan - only if considering octreotide - only use octreotide if octreoscan is + otherwise hypoglycemia Diet and diazoxide

Insulinoma

C peptide > 2nmol/L Serum insulin > 5 mU/mL during sx hypoglycemia. Blood insulin : BG > 0.4 CT or MRI 50-60% Selective angiogram 90% - intra-arterial injection of Ca into GDA, SMA, RHA, splenic and sample RIA of insulin from RHV

HNPCC

C scope at age 20-25 or 2-5 yr prior to earliest CA Endometrial and ovarian - Prophylactic TAH-BSO - No clear evidence for screening but can offer TVUS and/or CA-125 Gastric - No clear evidence but can offer push EGD and/or capsule q2-3 yr 30-35 yr Urothelial - UA q year at 25-30 CNS: annual P.E. at 25-30 Pancreatic: none

Open AAA repair #1

CVS, Pulm, Renal, Coagulation assessment. CTA to define the anatomy, thrombus, Ca++ Epidural. Prep nipples to the knees. Midline from the xyphoid to the pubis. Omentum and transverse colon cephalad. SB to the patient's right. Incise posterior peritoneum from LOT just to the right of IMV down to the aortic bifurcation. +/- minus mobilization of L renal vein. Avoid circumferential mobilization of iliac arteries. - Possible vein injury. Identification of the ureters as they cross the CIA. Systemic heparinization.

MEN 1: workup

Calcium and PTH 24-hr urinary calcium Sestamibi / US less reliable 24-hr urinary cortisol O.N. dexamethasone suppression MRI of sella turcica BL petrosal vein sampling for CRH stim ACTH ACTH - marked elevation with ectopic Cushings - moderate elevation with Cushing disease - suppressed with Cushings syndrome from adrenal adenoma Serum prolactin MRI of sella turcica

Carcinoid of the lung

Carcinoid syndrome rare. CT = spherical / ovoid w/ bronchial compression 80% express somatostatin but scan rarely used. Hypometabolic on PET so not used. Bronchoscopy and biopsy (r/o bleeding) - Epinephrine - YAG laser Typical vs. Atypical Typical = surgical resection w/ preservation of nml lung tissue (ie. sleeve resection or anatomic segmentectomy) Atypical = lobectomy / pneumonectomy (higher rate of LN mets) Poor surgical candidate = endobronchial resection. XRT only if poor surgical candidate or R1. Chemo = ONLY atypical (double-platinum based)

Therapeutic inguinal lymphadenectomy

Clinically detectable nodes = CTAP Superficial + deep if positive SLN Incision just inferior and parallel to groin crease w/ ext onto abdomen lat or down thigh medially as needed. Superficial nodes in femoral triangle: ⊕ Superior = inguinal ligament ⊕ Lateral = sartorius muscle ⊕ Medial = adductor longus muscle Identify and preserve femoral vessels / nv Cloquet's node = most superior node under inguinal ligament If this + then iliac node dissection. Deep iliac nodes via incision through external oblique and retroperitoneal dissection. ⊕ Infection (30%-50%) ⊕ Seroma (25%) ⊕ Lymphedema (25%)

3 Field Esophagectomy

Confirm vocal cords Supine for double lumen ETT, TLC, and a line LLD position on bean bag and padded THORACIC PHASE 5TH ICS Single lung ventilation Inferior pulmonary ligmant Divide azygous Mobilize the esophagus off of the aorta and trachea - Look for the thoracic duct / clip Harvest LN (R main stem, infra carina, L main) ABDOMINAL Examine the abdomen for metastases Gastrocolic > L crus > phrenoesophageal > gastrohepatic Pyloromytomy

Open AAA repair #2

Cross clamp of aorta and iliacs. Aneurysm is entered. Thrombus evacuated. Lumbar arteries ligated. IMA is inspected for back bleeding. - If + then suture ligate from within or close to wall. End-to-end anastomosis w/ polyproylene suture. If iliacs > 2cm then anastamose to distal CIA. Backbleed and forward bleeding. Hemostasis. Aneurysm sac is closed with running absorbable suture. Closure of the posterior peritoneum w/ running absorbable. ? need for medial visceral rotation. Check the LE pulses.

Incidentaloma

Cushing's - weight gain - weakness - MS changes - hair growth FH of endocrine malignancies Check for: - HTN - Cushing-oid appearance - Thyroid exam CXR (r/o lung ca) Mammogram (r/o breast ca)

Glucagonoma

DM, cachexia, necrolytic skin rash Serum glucagon and glucose CT or MRI +/- OctreoScan Most are malignant and located in tail Distal pancreatectomy + spleen + LN If in head then Whipple Perioperative anticoagulation for high risk DVT

Complications of ruptured AAA

Death: 48% Bleeding: 12-14% MI: 14-24% and dead in 19-66% Cardiac arrest: 20% and dead in 81-100% Colonic ischemia: 38% - Grade I (mucosa) - Grade II (m. propria) + 1 = 26% - Grade III (full thick) = 10% Renal failure / no UOP: 26-42% - Check foley. - Bladder pressure. - Urine electrolytes to r/o ATN. Paraplegia: 2.3% Limb ischemia:

Grave's disease

Definitive anti-thyroid medication - when life expectancy is limited - children and adolescents - opthalmopathy ** Radioactive iodine ** - NOT if opthalmopathy - NOT if pregant (PTU over methimazole) Surgery once euthyroid - amp of calcium chloride - calcium gluconate 500mg QID - Rocaltrol 0.5 mcg/day (vitamin D)

Chronic mesenteric ischemia

Differential diagnosis - Chronic cholecystitis - PUD - Gastric CA - Pancreatic CA - Colon CA Broad differential often r/o first leaving it as a dx of exclusion. (CTAP, EGD, c scope, and cholecystectomy) Mesenteric duplex or CTA test of choice for dx and postop f/u. (q 6 months) Expect MSOF post op. Keep them on TPN till BF returns. Aspirin?

Dieulafoy's lesion

Dilated aberrant submucosal vessel that erodes overlying epithelium in absence of a primary ulcer. No branching so 1-3mm (10x nml size). Proximal stomach, lesser curve near GEJ Etiology unknown Men w/ CV disease, CRI, DM, or ETOH abuse Endoscopy w/ epinephrine, bipolar, heater probe but not banding Should tattoo Re-EGD vs angiogram vs. surgery for wedge.

LLQ pain

Diverticulitis Perforated colon CA Infectious, inflammatory, or ischemic colitis Stercoral ulcer Tubo-ovarian abscess Ovarian cyst / abscess Ectopic pregnancy Pyelonephritis FB perforation Lymphoma

MALT lymphoma: evaluation

EGD and bx - Immunohistochemistry & flow cytometry - H. pylori Physical exam with attention to nongastric sites - Eyes and skin CBC, CMP, LDH Urine pregnancy if indicated CT TAP EUS for staging

Esophageal varices

EGD essential - Bleed is frequently nonvariceal Banding Sclerotherapy - 1.5% sodium tetradecyl sulfate - Ethanolamine - Sodium morrhuate - Absolute alcohol IV somatostatin or octreotide: 25-50 mcg/hr Ceftriaxone 1g IV qd x 7d - reduces SBP in cirrhotic Once stable remaining varices banded in 2 wk intervals Transplant candidate = TIPS NOT a transplant candidate STABLE (angiogram to look at PV/LRV) Good = distal splenorenal shunt (DSRS) Bad = Esophageal transection / portacaval Sugiura procedure - suture ligation with devascularization UNSTABLE Portacaval shunt (side-to-side vs. short PTFE) Propranolol 40mg bid before to prevent or after bleeding stops to decrease recurrence.

Inflammatory breast CA

Erythema & dermal edema > 1/3 breast. Palpable border to the erythema. Automatic IIIB, IIIC, or IV More likely to be HER2+ H&P, BL mammo, US prn, CBC, LFT, bone scan, CT TAP +/- PET Preop anthracycline + taxane +/- trastuzumab Responder: Mastectomy + ALND Nonresponder: Chemotherapy Postmastectomy radiation to CW & regional LN. DFS @ 5 years = 35%

Dysphagia DD

Esophageal diverticulum DES Nutcracker esophagus Scleroderma Achalasia Vascular ring Pulmonary sling Schatzki ring Hiatal hernia GERD / Barrett's Stricture Leiomyoma Carcinoma

Enterocutaneous fistula: evaluation

Evaluate the fistula - Fistulogram at 7-10 days ⊗ Large adjacent abscess ⊗ Intestinal discontinuity ⊗ Stricture / damage bowel ⊗ Distal obstruction ⊗ End fistula Spontaneous closure in 1/3 (4-6 wks) Likely to heal: - Esophageal / duodenal / midjejunal - Biliarly / pancreatic Not likely to heal: - Gastric / ligament of treitz / ileal - High output or short tract F - oreign body (including hernia mesh) R - adiation I - nfection or inflammatory bowel disease E - pithelialization from chronic tract N - eoplasia D - istal obstruction

Sarcoma management

Excision must include bx site Stage I (T1a-2b N0) - Surgery definitive is margin > 1 cm or fascia intact - RT if close margin (< 1 cm) or no intact fascial plane Stage II - III - Surgery with RT +/- chemotherapy - Regional LND for stage III w/ involved nodes - Large (8-10 cm) tumors consider neoadj RT, chemo, or chemoRT If preop RT (50 Gy) then wait 6 weeks for surgery -Higher wound complication rate If leaving a drain should be close to incision in case re-excise

Melanoma

Excisional bx w/ 1-2mm border, CXR, serum LDH In situ = 0.5 cm < 1.0 mm = 1.0 cm 1-2mm = 1 - 2 cm > 2 mm = > 2 cm 450 µ Ci of filtered 99mTc-SC at the excision site with serial lymphoscintigrams obtained starting at 15 minutes postinjection. 0.5 - 1mL of isosulfan blue and massage the area for 5 minutes. + LN = stage III = INF alpha

Claudication

Exercise only or rest? Dependent? PMH: HLD, HTN, DM, tobacco use Past stress test, cardiac cath, carotid duplex Meds: statin, BB, asa, plavix, coumadin Exam: pulses, AAA, hairless, ulcers Noninvasives: ABI and toe pressures Tobacco cessation, WL, Exercise - 30 - 45 min; 3-4 x /wk; 12 weeks + - Walk till pain, short rest, walk again Meds as above Cilostazol (Pletal) PDE III inhibitor = SM relaxation

Atypical ductal hyperplasia

Final path demonstrates: DCIS = 13-20% Invasive cancer = 6% Wire localization and excisional bx Mammogram q yr and tamoxifen (75% reduction)

Nipple discharge evaluation

Fluid for cytology US Mammogram Galactogram vs. ductoscope Excision

Esophageal CA workup

H&P Upper GI EGD and bx CT TAP +/- PET CBC, BMP, LFT EUS w/ FNA Bronchoscopy if tumor at or above carina - Note the vocal cords for RLN injury Laparoscopy optional HER2 if metastatic Neoadjuvant chemoRT if T2 or N+ Colonoscopy and colon prep preop

Rectal cancer

H&P and performance status Assess incontinence and GU function CEA Rigid procto C scope Endorectal US - Tumor depth 86% - LN involvement 67% MRI - Tumor depth 69% - LN involvement 66% CT TAP vs. MRI if unable to have contrast PET is NOT routinely indicated Biopsy Enterostomal therapy c/s

Colon CA f/u

H&P q 3-6 mo x 2 y then q 6 mo for total of 5 years CEA q 3-6 mo x 2 y then q 6 mo for total of 5 years CTAP q year for up to 5 years for high risk of recur C scope q year unless no preop c scope due to obstruction then in 3-6 mo. PET scan not routinely recommended.

DCIS

H&P, BL mammogram, pathology review, and ER determination (not PR / HER2) 25% will have invasive CA on final path. Localized = mastectomy vs. excision (> 2mm) + WBI vs. excision (> 10 mm) + clinical observation [low risk DCIS] Widespread (≥ 2 quadrants) = mastectomy I would remove the mass, orient the specimen for pathology and send it for mammography to confirm that I had obtained the entire specimen. WBI reduces local recurrence by 50% (not survival) and boost to tumor bed. - w/o WBI 8 year recurrence = 0%, 21%, 32% for low, intermediate, high risk DCIS. No ALND Tamoxifen = 3.4% ARR ipsilateral / 3.2% contra f/u H&P q6-12 mo x 5 yrs + mammogram 6 mo after Rx and then annually. Recurrence after WLE = mastectomy.

Invasive ductal carcinoma

H&P, CBC, LFT, BL mammogram, breast US prn, ER, PR, and HER2 determinations. Added only if sx or + LN - Bone scan if bone pain, incr alk phos - CT chest if pulmonary sx - CTAP if increased LFTs, alk phos, pain - PET scan Mastectomy + ALND vs. WLE + ALND + WBI At least 10 LN and level III only if clinically + Prophylactic contralat mastectomy discouraged Chemo followed by tamoxifen. Tamoxifen x 5 years = 39% reduction in annual odds of recurrence. Trastuzumab x 1 year Radiation to the CW, supraclavicular, internal mammary. Annual H&P + mammogram. Additional studies only if symptomatic.

Hematochezia

H/o anticoagulant use. Prior EGD and colonoscopies. I would insert an NG tube and aspirate for blood or bile. I would perform a rectal exam and or a procto Diverticulitis Angiodysplasia Colon CA Inflammatory bowel disease Anorectal disease

Indications for EMR

HGD Carcinoma in situ Well - mod diff lesions of the mucosa (T1a) - no evidence of lymphovascular invasion - no LN involvement Esophagectomy should be reserved for unsuccessful EMR. Nodules should be resected and not ablated.

Burn

Head, R arm, L arm, chest x 2, back x 2, front & back R leg, front & back L leg, groin (1%) 4mL x kg x % burn using LR with 1/2 in first 8 hours STSG are typically harvested at a thickness of 0.010 to 0.012 in. HF burn: calcium gel to hand or IV arterial calcium gluconate Electrical burn: IV sodium bicarbonate (5% continuous infusion) and mannitol (25 g every 6 hours for adults) + monitor distal circulation: escharotomy +/- faschiotomy +/- surgical debridement.

Complications of thyroidectomy

Hemorrhage Infection Ext br. Superior laryngeal nerve Recurrent laryngeal nerve (1-3%) Hypoparathyroidism (2.6%)

Cold foot after aortobifem: late

Heparin gtt Angio better than CTA tPA first Once clot lysed assess for underlying lesion - PTA vs. stent vs. surgery Possible intimal hyperplasia at the distal anastamosis - does not respond well to PTA - expose graft, thrombectomy, patch angioplasty 4 compartment fasciotomy

Diabetic foot

How well controlled is is BG? Have they ever had wound healing cx or prior vascular surgery. Thorough vascular exam, fluctuance, crepitus. BG and manage appropriately. -(BG - 60) x 0.02 u/hr Broad spectrum antibiotic regimen such as vanco, piperacillin & tazobactam. I could get a CT scan to look for gas but my clinical exam tells me that they need to go for surgical debridement. CXR, EKG, and ? beta blockade.

Intussusception

Hydrostatic enema is diagnostic method of choice Rule of 3's - Up to 3 feet above patient - Up to 3 attempts - Each attempt no more than 3 minutes Air reduction - 80 mmHg max for young child - 110-120 mmHg for older child If unsuccessful then short perior of bowel rest, NGT, IVF IV abx preoperatively RLQ incision Find the lead point and milk backwards Resection - Inability to manually reduce - Finding of ischemic bowel - Identification of a lead point If reduced - Examine viability - Incidental appendectomy

Breast mass

I would assess her risk for estrogen exposure. I would perform BILATERAL breast exams checking for tenderness, mobility, peau d'orange, nipple retraction or discharge, and palpate her supraclavicular & axillary LN. ⊕ Macrocyst ⊕ Fibroadenoma ⊕ Prominant area of fibrocystic change ⊕ Fat necrosis ⊕ Carcinoma I would obtain an US and mammogram. I would obtain a stereotactic bx and assess ER, PR, and Her2neu status. I would orient the specimen after excision.

Trauma

I would assist or secure his airway; Listen for breath and heart sounds; Place him on a monitor and check his VS; Insert 2 large bore IVs and start LR; Draw labs including TS; Obtain a CXR, PXR, FAST, & EKG. Obtain a quick PMH if known; Alert the blood bank of massive transfusion; Alert the OR; Reassess his VS; C collar in place and complete 2nd survey; NGT; foley catheter; Start antibiotics and tetanus;

General thoughts

I would examine for stigmata of liver disease. I would obtain LFTs to assess nutritional status. I would obtain a urine pregnancy test. I would obtain amylase and lipase to r/o pancreatitis. I would review the operative note. I would confirm the H&P and review the labs. I would check for past h/o EGD or C scope.

Renal failure / low UOP

I would insert a foley catheter. I would check the positioning of the foley catheter. I would obtain a renal US looking for hydronephrosis or fluid around the kidney.

Sigmoid diverticulitis

I would perform a rectal exam!!! I would perform a procto exam in the OR??? I am concerned that the patient has failed medical managment and will need an operation. I would have the enterostomal therapist see her quickly in the preop holding area to mark her for a stoma. I would have the urologist place a left sided stent. I would place her in lithotomy position and have a C scope in the room in case I needed it.

Ureteral repair

I would spatulate the ends and repair it over a double J stent with a fine chromic or PDS.

Acute mesenteric ischemia: Tx

IVF resuscitation Correction of electrolyte imbalances IV ABX Heparin gtt w/ PTT 2x nml. TLC for CVP to assess resuscitation Avoid pressors (esp pure alpha) - Dopamine 3-8 mcg/kg/min - Epinephine 0.05 - 0.10 mcg/kg/min NOMI ⊕ Angiogram (1) narrowing of origins mult brch of SMA (2) alt dilate and narrow of intestinal branches "string of sausages" (3) spasm of the mesenteric arcades (4) impaired filling of the intramural vessels ⊕ Papaverine gtt 30-60mg/hr

Thyrotoxicosis: management

IVF resuscitation Propranolol or esmolol for HR of 60-70 PTU 200-400 mg q 8 hours Lugol's iodide solution 3-5 gtt TID - decreases gland vascularity Hydrocortisone 100mg q8hrs Frozen b/c 2% of adenomas contain CA

Sarcoma management 2

If the tumor is close to or displaces major vessels or nerves no need to resect if adventitia / perineurium removed and clear. Limb sparing surgery w/ RT has recurrence of 15% - No different than amputation Adjuvant RT - 3 - 8 weeks post op - Close margin (< 1 cm) (10-14 Gy) - Microscopically positive margin on bone, vessel, nerve Postoperative chemo improves RFS but maybe not OS - Anthracycline-based (doxorubicin) Postop RT improves local recurrence (0% vs. 22%) PT/OT and f/u q3-6 mo x 2-3 yr then annual. US vs. MRI of the extremity for locoregional recur Consider (stage I) vs. chest imaging q6 mo (stage II/III) x 2-3 yr then annual.

Heparin induced thrombocytopenia

IgG antibody against platelet factor 4 Stop heparin Direct thrombin inhibitor - Lepirudin - Argatroban IVC filter

Splenectomy

Immunize the patient 2 weeks prior to surgery - Pneumovax - H. flu - Meningococcus IV immunoglobulin 1g/kg IV x 2 days prior to the surgery L subcostal incision 2 finger breaths below the costal margin. Triangular ligament of the liver and retract to the midline. Identify the junction of the R/L gastroepiploic arteries and open the gastrocolic ligament along the greater curve including the short gastrics up to the angle of His. Retract the stomach exposing the lesser sac. Identify the splenic artery at the superior aspect of the pancreas, ligate. Mobilize the lateral and inferior attachments of the spleen and elevate into the air. Dissect away the tail of the pancreas and ligate the vessels at the hilum vs. staple. Drain in the LUQ / splenic fossa.

Pericardial window

Incision from xyphoid to 5-6 cm below Dissect down to the level of the fascia Open the fascia but not the peritoneum Develop that plane cephalad to the diaphragm / pericardium 2 thin Deavers to expose and then palpate for bulging / boggy

Injury to neck: management

Insert foley through tract for balloon occlusion. Vascular consult for endovascular stent. Brachial artery cutdown for retrograde balloon occlusion to obtain proximal control. RIGHT sided injury: - Median sternotomy + clavicular incision - Trapdoor (clavicle + sternum + 4 ICS) LEFT sided injury: - Ant / Lat thoracotomy at the 2nd IC space to gain proximal control of the SCA. - Clavicular incision and resection. - Ligation of the IMA, vertebral, thyrocervical trunk. - Primary repair vs. interposition graft with PTFE vs. IJ or GSV

MEN 1: treatment

Insulinoma - Most often multiple - Distal pancreatectomy or enucleation of tumors in the head. Gastrinoma - 70% of gastrinomas are in the duodenum. - Duodenotomy w/ excision of small (usually multiple) and periduodenal LN dissection. Parathyroid hyperplasia - Subtotal parathyroidecotmy vs. total + autoimplantation - Removal of the BL upper thymus - Blood Ca++ q6 mo then annually Prolactinoma - Dopamine agonist (bromocriptine / pergolide)

Achalasia

LES 6-26mmHg Nifedipine 10-30mg SL 30-45 min before meals Isosorbide dinitrate 5mg SL 10-15 min before meal - Sx relief in pt w/ very early disease (no dilation) - Temporary measure in those waiting definitive - High risk patient or those refusing surgery Botulinum injection - 85% effective - Fades over time and usually gone by 2 yrs - Good for older patients Dilation - Pneumatic better than bougie - Perforation in 1.6% - Better than botox but still for poor surgical pt Myotomy

Barrett's esophagus

LGD = 4% 5-year cumulative incidence of CA HGD = 59% 5-year cumulative incidence of CA Associations with progression: - Age - Male - Long standing GERD - Hiatal hernia size - Length of Barrett's Metaplasia or LGD start PPI No dysplasia on 2 bx in 1 year = EGD q3 yr LGD = EGD within 6 mo and if negative x 2 then q yr HGD = EGD within 3 mo to r/o CA and then q 3 mo - EMR vs. RFA

Recurrent breast CA

Lump + WBI = MRM + ALND if not done MRM + ALND + WBI = WLE MRM + ALND = WLE + WBI Axilla = Resect if possible. WBI if possible. Supraclavicular = WBI if possible. Internal mammary = WBI if possible.

Neck mass

Lymphadenopathy: infectious or malignant (lymphoma vs. metastatic) Thyroglossal duct or branchial cleft cyst Carotid body tumor Salivary gland tumor Thyroid adenoma / carcinoma Parathyroid adenoma / carcinoma

MEN 1: general

MEN1 11q13 producing menin Parathyroid hyperplasia (98%) Pancreas (50%) Pituitary (35%) +/- Carcinoid of lung ZE associated with multiple tumors - Gastrin secreting carcinoid in duodenum (70%) Malignant islet cell tumors and carcinoid tumors are most common cause of death. - 90% of gastrinomas - 10% of insulinomas

Gastrinoma: management

MEN1 will be in duodenum 70% of cases PPI and Octreotide Duodenotomy and intra-operative US DUODENAL - Enucleation or local resection - Periduodenal LN PANCREATIC HEAD - Exophytic or peripheral = enucleation + LN - Deep or main duct = Whipple PANCREATIC TAIL = distal pancreatectomy +/- spleen

Elective AAA repair complications

MI Pulmonary decompensation Bleeding - Backbleeding from lumbar arteries. - Inadvertent injury to the spleen. VTE / PE - Do not need heparin but early and freq ambulation Renal dysfunction Colon ischemia (4.5-11.5%) LE ischemia Spinal cord ischemia

MEN 2: treatment

MTC - Baseline calcitonin and CEA (low calcitonin w/ high CEA = aggressive) - Preoperative neck US of the thyroid and cervical LN RET + w/ nml calcitonin and no masses or LN on US can forgo central node dissection Tumor < 1 cm and unilateral can consider no LN Prophylactic thyroidectomy and BL level VI LN - at diagnosis - MEN 2B = by 1 year of age - MEN 2A = by 5 years of age - familial MTC = by 5 years of age - if level VI + consider II - IV MEN 2A w/ hyperparathyroidism should autotranplant equivalent of 1 nml gland MTC cells do not concentrate RAI and does not respond to conventional cytotoxic chemo Synthroid to keep TSH in normal range H&P, BP, calcitonin, CEA, plasma / urine metanephrines @ 3 months, q 6 mo x 3 years then annual.

Malignant polyp

Malignant polyp - CA invading through m. mucosa into submucosa - Endoscopic resection ONLY if: ⊗ Pedunculated (some sessile) ⊗ Grade 1 or 2 ⊗ No angiolymphatic invasion ⊗ Negative resection margin - Transanal excision ⊗ Sessile lesions ⊗ Grade 3 or 4 ⊗ Angiolymphatic invasion ⊗ Fragmented or margins can't be assess

Paget's disease: management

Mastectomy and ALND = standard of care Mastectomy and SLN bx for IDCa and DCIS (can't do later if final path shows CA) ? Possibility of WLE of N.A.C. as well as enough underlying tissue to negative margin + WLE of associated CA + WBI. - Does not have to be a single specimen. - If DCIS and not IDCa then no SLNB Adjuvant therapy due to high risk of recurrence. If no invasive CA then Tamoxifen for RR.

Trendelenberg procedure

Median sternotomy Cardiopulmonary bypass Tapes around SVC and IVC 2 prolene traction sutures in the mid pulmonary artery Longitudinal incision between the sutures Extraction of the clot w/ forceps, suction, catheters Open the pleural space and compress the lungs to dislodge distal clots. Decannulate and close.

Multinodular goiter

Medical management Serial exams, TFT, US Surgery (total thyroidectomy) if: - Compressive sx - Severe or bothersome cosmetic deformity - Any dominant nodule greater than 4 cm - Any nodule greater than 1 cm w/ FNA results that meet the criteria for removal

Carcinoid: metastatic

Metastases - Local LN - Liver - Bone Resection of primary and limited mets = 50% 10-year survival. Wide metastases = resection of primary only for palliation if symptomatic. Octreotide LAR 20-30 mg IM q 4wks Octreotide 150-250 mg SC TID prn breakthrough Cardiology c/s and TEE (59% w/ TR) Liver disease - Octreotide + RFA vs. arterial embolization etc.

Rectal cancer management 2

Mid to upper rectum = LAR w/ 4-5cm margin and TME. Proximal favorable (T3N0) may not get neoadj CRT - 22% of T3N0 have node + disease on final path Neoadjuvant therapy (ChemoRT x 6 mo) - Stage II (T3 or T4 N0) - Stage III (Node +) - Preop RT w/ slightly better local recurrence Follow up - H&P q3 mo 2 years then 6 mo x 5 yr - CEA q3 mo 2 years then 6 mo x 5 yr - C scope 1 year after unless no preop the 3 yr then 5 yr. - Procto q6 mo x 5 yr if LAR - CT TAP q year x 5 years

ACLS

Monophasic shock 360 J Epinephrine 1mg Vasopressin 40 U Amiodarone 300mg then 150mg Lidocaine 1mg/kg then 0.5mg/kg total 3 doses Magnesium 2g IV r/o hypovolemia, hypoxia, H+, hypoK, hypoGlu, hypotherm r/o toxins, tamponade, tension ptx, thrombosis MI/PE, trauma

Esophagectomy complications

Mortality 0-22% Morbidity 20-80% Respiratory (16-67%) - PNA (Marker for death 20% vs. 3%) - COPD, bronchspasm, ARDS, VDRF Cardiac - MI (1.1 - 3.8%) - CHF - Afib (20% marker for complications) VTE (1.5 - 2.4%) Anastamotic leak (5-18% + 12% death) - Risk factors: ischemia, neoadj, comorbid, THE - EGD / stent + methylene blue vs. insufflate Anastamotic stricture (9-40%) - Before 6 months, bx to r/o CA, dilation Conduit ischemia (9%) Functional conduit disorders - Dumping, postprandial hypoglycemia, emptying, dysphagia, GERD Recurrent laryngeal nerve injury Chylothorax (0-8%)

Breast CA in pregnancy

Most often node-positive, larger, poorly differentiated, ER/PR negative, & 30% HER2 + Mammogram with shielding US of breast and LN Core needle biopsy CXR with shielding, LFT, Cr, CBC Node + = consider liver US & MRI spine. Mastectomy standard of care SLN bx should not be offered under 30 wks 5-FU + doxorubicin + cyclophosphamide (FAC) No chemo in 1st trimester or after 35 wks Risk of birth defects in 2nd / 3rd tri 1.3% Endocrine Rx and radiation contraindicated.

Heller myotomy

Myotomy - Abdominal approach better than thoracic - Length = 4 + 2 cm - Endoscope to check myotomy and leak - Esophageal perforation 7% - 4-0 vicryl oversew + Dor + drain ⊗ Incomplete myotomy (33%) ⊗ Myotomy fibrosis (27%) ⊗ Fundoplication disruption (13%) ⊗ Fundoplication too tight (7%) Failed options - Botox injection - Re-do myotomy - Esophagectomy

Lower GI bleed

NGT lavage DRE and anoscopy / procto Colonoscopy -GoLytely through NGT 1L/hr till clear Tagged RBC (0.5 ml/min) Angio (1 ml/min) - Methylene blue for localization - Coil / gelfoam embolization - Vasopressin injection - 50% rebleed Segmental vs. subtotal colon resection - > 4 units in 24 hrs - Still bleeding after 72 hrs - Re-bleed within 1 week

ABI

NML: 0.97+ Claudication: 0.40 - 0.80 Rest pain: 0.20 - 0.40 Ulceration: 0.10 - 0.40 Acute ischemai: less than 0.10

Head trauma

NS no D5, elevate HOB, CPP = MAP - ICP ICP monitoring: GCS less than 8 and: - Intracranial pathology on CT scan - 40 + yrs old - Any h/o HOTN - Abnormal motor posturing Mannitol: 0.25 g/kg Sedation with propofol Anti-seizure x 7 days

Hematemesis

Nasopharyngeal bleeding Esophagitis Esophageal or gastric varices Erosive gastritis / duodenitis PUD Angiodysplasia Dieulafoy's lesion Mass (polyp or cancer) Mallory-Weiss syndrome

Thyroid nodule

Neck radiation, heat & cold intol, dysphagia, hoarseness, recent URI, & tobacco use. Assess for movement with swallowing and palpate for LN. TFTs and calcitonin. US and 27ga needle for FNA. Presence of capsular or angioinvasion of the follicular cells. 127I or 99Tc scan to see if hot nodule.

Paget's disease: diagnosis

Neoplastic cells in the epidermis of N.A.C. Associated cancer elsewhere in 80-90% - Not necessarily adjacent. - DCIS or invasive ductal CA Full thickness surgical bx including a portion of the N.A.C. Breast MRI to define extent

Carotid disease: management

Neuromonitoring with transcranial doppler or EEG Supine, arms tucked, and shoulder roll. Incision along the SCM. Dissect through the platysma. Dissect the IJ and transect the facial vein. Heparinize the patient. Sodium nitroprusside 0.3 mcg/kg/min max 10 Stat carotid duplex. Immediate re-exploration of the neck. Evacuate the clot and suture the intimal flap with 7-0 prolene.

Facial melanoma

Nodal basins - Parotid - Postauricular - Internal jugular - Occipital If in the parotid LN then superficial parotidectomy Functional neck dissection - Spare the SCM, IJ, and spinal accessory

Hypercalcemic crisis

Normal saline: 200-300 mL/hr to restore euvolemia (UOP 150 mL/hr) Salmon calcitonin: 4 IU/kg IM/SC q6-12hr - Rapid action - Good for the first 48 hr - Not via nasal route Pamidronate: 60 mg IV x 1 - Requires 48hrs to take effect - Do not repeat for 7 days Zoledronic acid: 4 mg IV x 1 - Drug of choice for malignancy related Lasix Hydrocortisone: 200-400 mg/d x 3-5d - hypercalcemia of granulomatous dz Dialysis

Cold foot s/p aortobifem bypass

OUTFLOW OBSTRUCTION ⊕ Kink of the graft passing through tunnel ⊕ Narrowing of the anastamosis ⊕ Poor outflow (extensive fem-pop disease) ⊕ Emboli / thrombosis at anastamosis OTHER ⊕ Shock ⊕ Spasm ⊕ Embolism ⊕ Compartment syndrome Assess level of occlusion (duplex vs. angio) Neuro status of the foot Check 4 Ps Check compartment pressures

Modified Sugiura procedure

One-stage through the abdomen 1.) Splenectomy 2.) Devascularization of 8-10 cm of the esophagus 3.) Transection and end-to-end anastamosis of the lower esophagus 4-5cm proximal to the GEJ. 4.) Devascularization of the lesser and greater curvatures of the stomach 5.) Pyloroplasty

Esophageal perforation

Open the muscle further to expose full extent. 4-0 absorbable running for mucosa. 4-0 nonabsorbable interrupted for muscle. NGT above, insufflate underwater to test. Pleural or IC muscle flap is needed. If achalasia then myotomy on opposite side.

GERD stricture

PPI Guided dilation - dilated esophagus to 13 mm to 15 mm diameter - (40-45 fr) - Serial dilations Rule of 3s - Choose a dilator 1 mm (3 Fr) larger than estimated stricture diameter - Dilate sequentially in 1 mm (3 Fr) - Up to 3x

Gastrinoma: evaluation

PUD + diarrhea Assess family history Gastrin levels - stop PPI 1 week before CTAP or MRI +/- OctreoScan +/- EUS

Chronic pancreatitis

Peustow procedure for duct > 7mm -65-80% successful - Duct opened to within 1cm of duodenum

Ruptured AAA

Place on monitor including EKG. IVF resuscitation with permissive HOTN. Palpate all pulses. Type and cross vs. uncrossmatched (O neg) FAST if available otherwise OR. If possible I would prepare the patient for transfer. Blood bank. OR to 70 degrees, Bair hugger, Cell saver, rapid infuser. Muscle relaxants, narcotics, and sedatives should be avoided until prepped in OR. Neck to knees. A line, NGT, Foley. May lose pressure at anesthesia or opening of abdomen (loss of tamponade). Loss of pulses = supraceliac control - ? L thoracotomy to clamp and cardiac massage - Triangular ligament + liver - Open gastrohepatic, open R crus, and feel for NGT. - Esophagus to the left and finger dissect around aorta. - Move clamp infrarenal ASAP - Kidneys tolerate 30 min Stable = bowel to RUQ, duodenum to the R and lateral to LOT or medialize colon and infra-renal control. Suprarenal extension = 9th IC space extension and medial visceral rotation. Identify the neck and clamp. Oversew any lumbars +/- IMA Tube graft better than bifurcated unless: - Small (3-4 cm) iliac aneurysms at a later date - Large iliac aneurysm - Severely calcified aortic bifurcation - Severe iliac occlusive disease Backbleed the iliacs +/- Fogarty catheter Check colon. Check femoral and pedal pulses. Close the sac.

Aldosterinoma

Plasma aldosterone : renin > 30 Confirmatory study - Saline suppression test - Salt loading test Rarely malignant but suggested if: - CT w/ irregular shape, lipid poor, no washout - > 3 cm - Secretes more than 1 hormone - Open adrenalectomy Adrenal vein sampling for aldosterone - Differentiate btw adenoma and BL hyperplasia - If surgical candidate - Not needed if younger than 40 y/o Adenoma = laparoscopic adrenalectomy BL hyperplasia = spironolactone

Postoperative hypotension

Postoperative bleeding Anesthesia or Narcotic overdose MI, PE, PTX, cardiac tamponade (from CVL) Assist or secure their airway, listen to heart and breath sounds, check that the monitor and pulse ox are working, secure IV access and start resuscitating with LR. STAT ABG and CXR, EKG and troponins, CBC and BMP ICU for monitoring. Possible Swan Ganz catheter is needed. TEE if intraoperative

Rapid sequence intubation

Pre-oxygen with 100% O2 by face mask or BVM w/ cricoid pressure prn for 5 minutes. Yankauer suction, laryngoscope, and ETT. Cricothyroidotomy tray available. Check IVs are functioning Check monitor and pulse ox functioning. Block the "pressor response" (elevated HR / BP w/ laryngeal stimulus): Fentanyl 2-3 mcg/kg Atrophine 0.01 mg/kg for children / adolescents Lidocaine 1.5 mg/kg over 30-60 sec INDUCTION AGENTS Fentanyl: 5-15 mcg/kg Ketamine: 1-2 mg/kg Etomidate: 0.3 mg/kg Propofol: 2 mg/kg Apply cricoid pressure if not already. PARALYZING AGENTS Succinylcholine: 1.5 mg/kg (unless burn / plegia) - Bradycardia - Hyperkalemia - Increased ICP Rocuronium 1.0 mg/kg Vecuronium 0.1 mg/kg Intubate. Inflate cuff, check condensatio, chest rise, BS, capnography. Secure tube. CXR for placement.

SMA bypass

Prep down below the knees. Midline incision. Elevate the omentum and colon. SB packed to the RLQ. Peritoneum opened lateral to the duodenum down over aorta and onto iliac artery. Isolate the proximal SMA distal to the disease and the proximal internal R iliac. 6-8 mm dacron graft or externally re-enforced PTFE unless soilage. Heparinize the patient. ⊕ End-to-end on the SMA and a "lazy C" configuration to origin of R or L CIA for end-to-side ⊕ "lazy C" from distal infra-renal aorta ⊕ Short 8-10 mm retrograde from just below infra-renal aorta to SMA ⊕Supraceliac anterograde - more difficult but less kink - If distal aorta / iliac unclampable - If distal vessels diseased - If distal vessels aneurysmal Omental flap through the transverse mesocolon for coverage of prosthetic.

SMA embolectomy

Prep down below the knees. Midline incision. Elevate the omentum and colon. SB packed to the RLQ. Horizontal incision to open the peritoneum at the base of the mesentary. SMA to the left of the SMV May need to carefully mobilize inferior pancreatic border. Isolate a segment of SMA between MCA and RCA. Systemic heparinization (5,000 u). Transverse incision unless small then vertical and vein patch closure. Bleed clot out proximally. Fogarty 3-4 fr prn. Fogarty 2-3 fr distally. 5-0 prolene to close w/ interrupted vs. GSV patch.

Contraindications to WLE of the breast

Previous CW radiation Pregnancy Diffuse / suspicious microcalcification on MG Widespread disease Pathologically positive margin on re-excision Relative: - Connective tissue disease (scleroderma) - Tumors > 5 cm - Focally positive pathologic margins

Hyperparathyroidism

Primary hyperparathyroidism - Adenoma (80-90%) - Hyperplasia (10-15%) Secondary hyperparathyroidism (renal) Carcinoma ( less than 1%) Thyrotoxicosis (mild hyperCa) Milk alkali syndrome (intake) Hypervitaminosis D Medication (thiazide / lithium) Familial hypocalciuric hypercalcemia Bones, stones, groans, and moans iPTH: increased Urine Ca: increased Chloride : Phosphate > 33 24 hr urinary Ca : Cr Cl < 0.01 CT-Sestamibi scan Selective arteriography with venous sampling of PTH 20 mCi of 99mTc-sestamibi injected 2-4 hr preop and handheld gamma probe Failure = Ca that never normalizes Recurrence = Nml Ca elevated in 6 mo.

Breast CA risk factors

Prior radiation Postmenopausal HRT (RR = 1.24) Complex fibroadenoma (RR=1.5-2) Sclerosing adenosis (RR = 1.5-2) Mild ductal hyperplasia (RR - 1.5-2) 1st degree relative (RR = 2-3) - Higher if premenopausal Atypical ductal hyperplasia (RR = 4-5) Atypical lobular hyperplasia (RR = 4-5) BRCA 1 or 2 (RR 5-10)

FAP

Proctocolectomy or colectomy Ileorectostomy - Endoscopic rectal exam q6-12 mo IPAA - Pouchoscopy q 1-3 years Consider NSAIDS Thyroid: annual exam +/- US Stomach / duodenum: baseline side-viewing EGD Small bowel: SB CT scan Annual exam for CNS, abdominal desmoid, hepatoblastoma, pancreatic CA

MEN 2: general

Proto-oncogene RET = activation of tyrosine kinase receptor RET MTC (98%) - All should be tested for RET (10% risk of genetic) - 1st to 3rd decade of life if familial (25% of MTC) Pheochromocytoma (50%) Hyperparathyroid (25%)

ITP indications for surgery

Refractory severe sx thrombocytopenia - more than 10-20mg / day x 3-6 mo w/ platelet count under 30,000 Requires toxic doses of steroids Relapse of thrombocytopenia after initial steroids

Post thyroidectomy w/ neck mass

Review prior op note and path. r/o other primary: - CXR - Mammogram - Nasolaryngoscopy If negative: - serum TG (can be checked on Synthroid but more sensitive off or w/ rTSH admin) - neck US - RAI scan

Perioperative risk of MI

Revised cardiac index risk: - High risk surgery (intraperitoneal) - h/o ischemic heart disease - h/o CHF - h/o CV disease - DM on insulin - Preop Cr 2.0 or more No factors = 0.4% 1 factor = 1.0% 2 factors = 2.4% 3 or more = 5.4% Drug eluding stent = wait 3-6 months Bare metal = wait 4-6 weeks

Carotid disease: evaluation

S/S of TIA PMH including CV, prior stress test / stents. Meds: Statin, HTN, ASA, plavix. Vascular exam from head to toe and confirm bruit. Palpate for a AAA. Check lipid panel and HgA1C. Carotid duplex - < 50% and asymptomatic = medical management - 50 - 69% = significant benefit from CEA Confirmatory test with CTA or angiogram of the neck if borderline If CVA and recovers then 9% / yr recurrence risk. Combined CEA and CABG CVA or death = 17.7% - statin, B blocker, ASA perioperatively

Acute mesenteric ischemia: Dx

SMA embolus SMA thrombosis SMV thrombosis Nonocclusive mesenteric ischemia h/o afib , CHF, hypercoag or prior embolic events, h/o postprandial pain, food avoid, WL h/o perioperative HOTN or pressors RECTAL exam DD: pancreatitis, cholecystitis, appendicitis, diverticulitis... Amylase / lipase, ABG, Lactate AXR: nothing / ileus / "thumbprinting" / PNA CTA with IV and "negative" PO contrast (ie. water just before). Angiogram: if suspecting NOMI otherwise CTA.

Carcinoid: management

STOMACH Type I (hypergastrin / atrophic) - < 2cm = EMR vs. observation - > 2cm = EMR vs. surgical resection Type II (hypergastrin / Z.E.) - < 2cm = EMR vs. observation vs. octreotide - > 2cm = EMR vs. surgical resection Type III (sporadic) - radical resection + LND (more aggressive) DUODENUM - EMR - Transduodenal local excision +/- LN - Pancreaticoduodenectomy SMALL INTESTINE & COLON - Surgical resection + LND - Examine entire bowel for synchronous - Cholecystectomy APPENDIX ≤ 2 cm confined to appendix = appy 1-2 cm but high grade = colectomy > 2 cm = R hemicolectomy RECTUM < 2 cm = EMR or TAR > 2 cm = LAR or rarely APR

Parathyroid ectopic location

SUPERIOR - At the cricothyroid junction - 1 cm cranial to the juxtaposition of the recurrent laryngeal and inferior thyroid a. INFERIOR - More variable - 50% neighboring the lower pole of thyroid - 28% in thyrothymic ligament or superior mediatinal thymus (migrate into the anterior / superior mediastinum where 1/3 of missing glands are found) Ectopic -Thyrothymic ligament - Tracheoesophageal groove - Retroesophageal space - Carotid sheath - Intrathyroidal

Soft tissue mass DD

Sarcoma Primary or metastatic carcinoma Melanoma Lymphoma Desmoid Lipoma Lymphangioma Leiomyoma Neuroma

Pancreatic tail mass

Serous cystadenoma Cystic mucinous neoplasm -Ovarian struma -CEA level ≥ 192 -10-50% risk of CA Intraductal papillary mucinous neoplasm -Involves main or branch duct -20-50% risk of CA Concerning radiographic features of branch duct IPMN: 1.) A solid component or mural nodule 2.) Septations 3.) Size greater than 3 cm

Cushing's syndrome

Serum cortisol Serum ACTH - High = pituitary vs. ectopic - Low = benign vs. malignant adrenal tumor Dehydroepiandrosterone (DHEA-S) Confirmatory test - Dexamethasone suppression (unless ACTH low) - Repeated MN salivary cortisol or 24 hr urine CT TAP if ACTH low to assess adrenals and r/o mets. If benign appearing then adrenal vein sampling of cortisol to differentiate adenoma from BL hyperplasia. Adenoma = laparoscopic adrenalectomy BL hyperplasia = medical mangement - Ketoconazole 400 - 1200 mg qd - Mitotane - BL adrenalectomy if fails

Insulinoma: management

Sporadic = solitary vs. familial = multiple PANCREATIC HEAD Exophytic / peripheral = enucleation Deep = Whipple PANCREATIC TAIL Exophytic / peripheral = enucleation Deep = splenic preserving distal pancreatectomy

Enterocutanteous fistula: management

Stabilize the patient - Manage dehydration - Electrolytes (UGI = NS, duodenum = + HCO3) - LFTs, prealbumin, albumin, and nutrition - Control the fistula output - Skin and wound care - Drainage of infection H2 / PPI Octreotide Operate in less than 8 days or wait 4-5 months. Should be resected as "repair" is associated with 50% failure rate.

MALT lymphoma: treatment

Stage I/II ⊕ H. pylori testing - Positive = antibiotics - Negative = RT preferred over Rituximab Stage III/IV - Induction chemoimmunoRx vs. RT 3 month restaging and f/u endoscopy after abx - H.P. / MALT neg = observe - H.P. neg / MALT pos Asymptomatic = obs 3 more mo vs. RT Symptomatic = RT - H.P. pos / MALT neg = 2nd line abx - H.P. / MALT pos Stable = 2nd line abx Progression = RT and 2nd line abx If complete response then EGD / staging q3-6mo x 5 yrs then annually

Neoadjuvant chemo for breast CA

Stage IIA (T0N1, T1N1, T2N0) Stage IIB (T2N1, T3N0) Some stage IIIA (T3N1M0) T1 = < 2 cm T2 = > 2 cm but < 5 cm T3 = > 5 cm N1 = ipsilateral level I and II Place clips pre chemo in case of complete pathologic response (CPR). Should do SLN bx before chemo. May increase breast conservation but no improvement in survival. 1.) Taxane + Anthracycline + Cyclophos (TAC) 2.) If HER 2 + then trastuzumab (better CPR) 3.) If postmenopausal and ER + then aromatase > tamoxifen. No post op chemo if completed full course pre.

Pheochromocytoma: management

Surgical resection Preoperatively - Forced hydration - Salt loading (5,000g/d) x 7 days - Phenoxybenzamine 10mg BID to get HR 60-80 bpm and SBP 90-120mmHg +/- alpha-methytyrosine (tyrosine hydroxylase inh) to prevent hypertensive crisis +/- beta blockade f/u w/ BP measurement and metanephrines Sodium nitroprusside 0.5mcg/kg/min for HTN crisis Avoid morphine, fentanyl, ketamine, halothane Use propofol and most gases

Fat embolism

Syndrome 24-48 hr after event - Dyspnea - Petechia - Mental confusion Clinical dx with above and fever. No lab is diagnostic. Steroids to prevent is controversial. MV and supportive care.

Sarcoma staging

T1 = 5 cm or less a = Superficial b = Deep T2 = 5 cm or greater N0 = No nodes N1 = Regional LN + Grade 1-3 Stage IA = T1N0M0 (any G1) Stage IB = T2N0M (any G1) Stage IIA = T1N0M0G2-3 Stage IIB = T2N0M0G2 Stage III = T2G3 or any N1

Breast reconstruction

TRAM - No smoking - No diabetes - No need for XRT

Thyrotoxicosis: diagnosis

Technetium 99 scan GRAVES - homogenous uptake - RAI > ATM > surgery TOXIC NODULAR GOITER - heterogenous w/ 2+ enlarged areas of uptake - lobectomy + isthmusectomy SOLITARY TOXIC NODULE - single area of uptake - lobectomy + isthmusectomy

Thyroid CA postop

Thyroxine to keep TSH 0.1 - 0.5mU/L Stop after 2 months x 4-6 wks then: RAI and thyroglobulin to r/o mets.

Rectal cancer management 1

Transanal excision - T1N0 early-stage - Less than 3 cm - Well to moderately differentiated - Within 8 cm of the anal verge - Less than 30% of the rectal circumference Transanal endoscopic microsurgery (TEM) - Same and more proximal lesions - Orient for the pathologist Pathology requiring more radical resection: - Positive margins - LV invasion - Poor differentiation - Invasion of the lower 1/3 of the submucosa Recurrence: 13.2% vs. 2.7% for LAR / APR

Perforated gastric ulcer

Truncal vagotomy (TV) and pyloroplasty is NOT appropriate. Intractable = failure of 12 wks of PPI Type I = hyposecretion (antrectomy only) Type II = hypersecretion (BII + TV) Type III = hypersecretion (BII + TV) Type IV = hyposecretion (Csendes) Type V = NSAIDS (BII + TV) Unstable = ulcer bx & omental patch Stable - H. pylori unknown = ulcer bx & omental patch (unless type III = always BII + TV) - H. pylori or long ulcer hx then definitive procedure.

AAA stable

US screening: males 65-75 years of age with any h/o ever having smoked. Diameter Rupture risk (%/yr) Less 4 0 4-5 0.5-5 5-6 3-15 6-7 10-20 7-8 20-40 More 8 30-50 11% increase in diameter / year Medical management vs. EVAR vs. open AAA - Smoking cessation - Statin - +/- beta blocker or ACEI - Doxycycline 200mg qd for chlamydia - US or CT q 6 months

Mallory-Weiss tear

Usually associated with hiatal hernia. Longitudinal rent with will defined edges. L posterolateral wall of esophagus onto stomach Bleeding from submucosal arteries EGD - Epinephrine (1:10,000 - 20,000) - Bipolar probe @ 15 watts, mild tamponade, 1 sec - Hemoclip IV infusion of vasopressin Esophageal balloon tamponade Angiographic embolization Surgery w/ anterior gastrotomy and oversewing of vessel.

Splenorenal shunt indications

Variceal bleeding refractory to endoscopic and pharmacologic therapy who have well-preserved and stable liver function Portal HTN and normal livers, such as those with portal vein thrombosis, who have refractory bleeding and a patent splenic vein Patients locations, where there is only one chance to control bleeding, and they cannot return for the multiple visits required for management with endoscopy or TIPS NOT a candidate if: Jaundice Ascites Encephalopathy

Injury to the neck: evaluation

Zone 1 clavicle > cricoid Zone 2 cricoid > angle of jaw Zone 3 angle of jaw up Avoid IV to that extremity. Femoral vein? Immediate OR exploration: - Shock - Expanding hematoma - Evolving stroke Also: - Pain on swallowing - Hemoptysis - SQ emphysema - Neuro deficits CXR: missile, aortic knob, pneumomediastinum FAST: pericardium Gastrograffin swallow (if neg) > thin barium (if neg) > flexible esophagoscopy (~100%) Flexible bronchoscopy

Adjuvant chemo for breast CA

docetaxel [taxane], doxorubucin [anthracycline], & cyclophosphamide (TAC) ⊕ Lymph node positive ⊕ Tumor > 1 cm ⊕ 0.6 - 1.0 cm and node negative: low vs. HIGH risk - intramammary angiolymphatic invasion - high nuclear grade - high histologic grade - HER2 + - ER/PR negative ⊗ Tumor ≤ 0.5 cm and node negative: NONE

Sarcoma workup

h/o radiation exposure to the involved area MRI for extremity STS and CT for abdominal (BEFORE biopsy) Core needle bx or incisional bx CT chest to r/o lung mets Angiosarcoma = CTAP and CTH PET to assess response to preoperative chemo - Change in SUV by 35-40% predicts DFS

Pulmonary embolism

⊕ Major vs. massive PE ⊕ Acute MI ⊕ Aortic dissection ⊕ Sepsis ABG: PaO2 50-60 vs. less than 50 mmHg b CXR: Westermark's sign (oligemia) or Fleishner lines (atelectasis) EKG: r/o MI and S1Q3T3 TTE or TEE: R ventricular dilation / leftward septal shift VQ scan CTA / MRA Angiogram Heparin gtt 70 u/kg then 20 u/kg/hr

Refractory ascites

⊕ Therapeutic paracentesis -12.5g 20% albumin q 2 L fluid removed. No real max. Can be complete. - "Z-tract technique" w/ needle to prevent leak ⊕ Transjugular intrahepatic portosystemic shunt - 49% - 79% relief of ascites. - Contraind: biventricular CHF, pulmonary HTN, extensive PV thrombosis, large volume HCC. ⊕ Peritoneovenous shunt (Leveen, Denver) - SQ cath from peritoneum to central vein w/ one-way valve. ⊕ Liver transplantation.

Hurthle cells

"Oncocytes", cells that are derived from follicular cells Appear as large bizarre, polygonal shaped cells with hyperchromatic nuclei. May be present in Hurthle cell adenomas or in Hurthle cell carcinoma.