Surgical Oral Boards

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.

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

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

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

RLQ pain
Cecal diverticulitis
Terminal ileitis: infectious vs. inflammatory such as Crohn’s
Typhlitis (neutropenic enteritis)
Ruptured ovarian cyst
Ovarian torsion
Ovarian tumor
Ectopic pregnancy

Rectal and pelvic exam.
UA, u preg, and vaginal cultures for gonorrhea / chlamydia

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;

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

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.

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

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

Colon CA
Inflammatory bowel disease
Anorectal disease

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.

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.

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

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

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.

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.

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.

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.

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

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.

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

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

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.

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

Head trauma
NS no D5, elevate HOB,
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

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

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

Nipple discharge evaluation
Fluid for cytology
Galactogram vs. ductoscope

20 – 50 y/o
> 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)

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)

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

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

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%

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.
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.

Contraindications to WLE of the breast
Previous CW radiation
Diffuse / suspicious microcalcification on MG
Widespread disease
Pathologically positive margin on re-excision
– Connective tissue disease (scleroderma)
– Tumors > 5 cm
– Focally positive pathologic margins

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.

Radiation Rx after mastectomy
50 Gy in fractions of 1.8-2.0 w/ CT-based plan
– 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

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

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.

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%

Breast reconstruction
– No smoking
– No diabetes
– No need for XRT

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.

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.

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

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%)

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

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.

Succinylcholine: 1.5 mg/kg (unless burn / plegia)
– Bradycardia
– Hyperkalemia
– Increased ICP
Rocuronium 1.0 mg/kg
Vecuronium 0.1 mg/kg

Inflate cuff, check condensatio, chest rise, BS, capnography.
Secure tube.
CXR for placement.

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)

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
– 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

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

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
– 30 g in 50 mL 20% sorbitol PO
– 50 g in 200 mL 20% sorbitol PR enema

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

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.

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

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.

Acute mesenteric ischemia: Tx
IVF resuscitation
Correction of electrolyte imbalances
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

⊕ 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

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.

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.

Complications of thyroidectomy
Ext br. Superior laryngeal nerve
Recurrent laryngeal nerve (1-3%)
Hypoparathyroidism (2.6%)

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

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.

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.

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:

Lower GI bleed
NGT lavage
DRE and anoscopy / procto
-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

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
– H. pylori unknown = ulcer bx & omental patch
(unless type III = always BII + TV)
– H. pylori or long ulcer hx then definitive procedure.

Parathyroid ectopic location
– At the cricothyroid junction
– 1 cm cranial to the juxtaposition of the recurrent laryngeal and inferior thyroid a.

– 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)

-Thyrothymic ligament
– Tracheoesophageal groove
– Retroesophageal space
– Carotid sheath
– Intrathyroidal

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.

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
Hydrocortisone: 200-400 mg/d x 3-5d
– hypercalcemia of granulomatous dz

Dysphagia DD
Esophageal diverticulum
Nutcracker esophagus
Vascular ring
Pulmonary sling
Schatzki ring
Hiatal hernia
GERD / Barrett’s

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
– Pneumatic better than bougie
– Perforation in 1.6%
– Better than botox but still for poor surgical pt

Heller 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

= 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

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

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

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

Indications for EMR
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.

GERD stricture
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

Heparin induced thrombocytopenia
IgG antibody against platelet factor 4
Stop heparin
Direct thrombin inhibitor
– Lepirudin
– Argatroban
IVC filter

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

Heparin gtt 70 u/kg then 20 u/kg/hr

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.

Cold foot s/p aortobifem bypass
⊕ Kink of the graft passing through tunnel
⊕ Narrowing of the anastamosis
⊕ Poor outflow (extensive fem-pop disease)
⊕ Emboli / thrombosis at anastamosis

⊕ Shock
⊕ Spasm
⊕ Embolism
⊕ Compartment syndrome

Assess level of occlusion (duplex vs. angio)
Neuro status of the foot
Check 4 Ps
Check compartment pressures

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

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

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.

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

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)

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

Open AAA repair #1
CVS, Pulm, Renal, Coagulation assessment.
CTA to define the anatomy, thrombus, Ca++
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.

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.
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.

Elective AAA repair complications
Pulmonary decompensation
– Backbleeding from lumbar arteries.
– Inadvertent injury to the spleen.
– Do not need heparin but early and freq ambulation
Renal dysfunction
Colon ischemia (4.5-11.5%)
LE ischemia
Spinal cord ischemia

Esophageal varices
EGD essential
– Bleed is frequently nonvariceal
– 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
Portacaval shunt (side-to-side vs. short PTFE)
Propranolol 40mg bid before to prevent or after bleeding stops to decrease recurrence.

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:

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

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.

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

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

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.

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

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.

Soft tissue mass DD
Primary or metastatic carcinoma

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

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

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

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

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

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.

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

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
– 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.

Esophageal CA workup
Upper GI
EGD and bx
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

3 Field Esophagectomy
Confirm vocal cords
Supine for double lumen ETT, TLC, and a line
LLD position on bean bag and padded
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)

Examine the abdomen for metastases
Gastrocolic > L crus > phrenoesophageal > gastrohepatic

Esophagectomy complications
Mortality 0-22%
Morbidity 20-80%
Respiratory (16-67%)
– PNA (Marker for death 20% vs. 3%)
– COPD, bronchspasm, ARDS, VDRF
– MI (1.1 – 3.8%)
– 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%)

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

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

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

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

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

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

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.

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

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
Operate in less than 8 days or wait 4-5 months.
Should be resected as “repair” is associated with 50% failure rate.

Carcinoid: management
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)

– Transduodenal local excision +/- LN
– Pancreaticoduodenectomy

– Surgical resection + LND
– Examine entire bowel for synchronous
– Cholecystectomy

≤ 2 cm confined to appendix = appy
1-2 cm but high grade = colectomy
> 2 cm = R hemicolectomy

< 2 cm = EMR or TAR > 2 cm = LAR or rarely APR

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)

< 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.

Carcinoid: metastatic
– 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.

Gastrinoma: evaluation
PUD + diarrhea
Assess family history
Gastrin levels
– stop PPI 1 week before
+/- OctreoScan
+/- EUS

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
– only if considering octreotide
– only use octreotide if octreoscan is + otherwise hypoglycemia
Diet and diazoxide

Insulinoma: management
Sporadic = solitary vs. familial = multiple

Exophytic / peripheral = enucleation
Deep = Whipple

Exophytic / peripheral = enucleation
Deep = splenic preserving distal pancreatectomy

Gastrinoma: management
MEN1 will be in duodenum 70% of cases
PPI and Octreotide
Duodenotomy and intra-operative US

– Enucleation or local resection
– Periduodenal LN

– Exophytic or peripheral = enucleation + LN
– Deep or main duct = Whipple

PANCREATIC TAIL = distal pancreatectomy +/- spleen

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

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

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
Metaiodobenzylguanidine (MIBG)
+/- OctreoScan
Genetic testing

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

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

Pheochromocytoma: management
Surgical resection
– 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

< 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

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

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%)

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
– marked elevation with ectopic Cushings
– moderate elevation with Cushing disease
– suppressed with Cushings syndrome from adrenal adenoma

Serum prolactin
MRI of sella turcica

MEN 1: treatment
– Most often multiple
– Distal pancreatectomy or enucleation of tumors in the head.

– 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

– Dopamine agonist (bromocriptine / pergolide)

MEN 2: treatment
– 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.

Thyrotoxicosis: diagnosis
Technetium 99 scan
– homogenous uptake
– RAI > ATM > surgery
– heterogenous w/ 2+ enlarged areas of uptake
– lobectomy + isthmusectomy
– single area of uptake
– lobectomy + isthmusectomy

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)

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

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

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

Pleural effusion
Fat embolus

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

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
– Inability to manually reduce
– Finding of ischemic bowel
– Identification of a lead point
If reduced
– Examine viability
– Incidental appendectomy

MALT lymphoma: evaluation
EGD and bx
– Immunohistochemistry & flow cytometry
– H. pylori
Physical exam with attention to nongastric sites
– Eyes and skin
Urine pregnancy if indicated
EUS for staging

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

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

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

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

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

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
– No clear evidence but can offer push EGD and/or capsule q2-3 yr 30-35 yr
– UA q year at 25-30
CNS: annual P.E. at 25-30
Pancreatic: none

Proctocolectomy or colectomy
– Endoscopic rectal exam q6-12 mo
– 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

Lung lesion DD
Hamartoma / LN

Small cell
Non small cell
– AdenoCA
– Squamous cell

Chronic mesenteric ischemia
Differential diagnosis
– Chronic cholecystitis
– 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.

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.

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