Surgery Review

Chapter 2: Preoperative care of surgical patient Identify risk factors and make risk assessment -Risks: CVA, MI, cardiac disease, stroke, DM, cancer, pulmonary disease, GI conditions, bleeding/clotting issues, blood disorders, anesthesia issues, alcohol/drug use Physical exam should be geared towards uncovering clues Order: HcG, coags, CBC, EKG and CXR ECG = >40 male or >50 female for thoracic procedures CXR = >60yrs or all pts undergoing thoracic procedure Hematocrit = expected >500mL blood loss Pregnancy test = all women of childbearing age GOLDMAN criteria for cardiac risk ->70, MI in 6mos, S3 gallop, valvular stenosis, non-sinus rhythm, PVC, PO250 -pts with an MI within 3mos of surgery will have a 30% chance of having a recurrent one Wait until >6mos timeframe since risk is then 5% DM pts and surgery Take half their dose of insulin prior to surgery of int/long lasting Can hold oral medications Can also have an IV drip of insulin Keep glucose levels between 80-110 Fluid management Avoid K+ infused fluids in kidney failure pts Have normal saline to replace blood loss Blood products FFP and platelets for pts with thrombocytopenia, coagulopathy issues, ITP, Used for pts with >500mL blood loss and 1000 level of gastrin in the blood during a fast -non-beta cell pancreatic tumor 90% of tumors found in between cystic duct, CBD and duodenum/pancreas Pt presents as increased diarrhea, nausea, abdominal pain and wt loss Use of MRI/US for localization are used, CT as well Tx involves use of PPI, H2 blockers and octreotide(decrease gastrin secretion) Must do complete resection of the tumor in order to cure High chance of malignancy Stomach cancer High mortality upon diagnosis in 5yrs (90%) Endemic in Japanese males Diet related – smoked fish/meats, nitrosamines, Hx of atrophic gastritis increases risk Most are adenocarcinomas and pre-pyloric in location Ulcerating/penetrating tumors are most common and mistaken for benign ulcers Pt presents with increased fullness, wt loss, N/V, anorexia, hematemesis, belching, early satiety, discomfort Can lead to S/S of gastric outlet obstruction, PUD(bleeding) May present as firm, nontender mass in abdomen *mets can show up as 1. sister mary-joseph’s node  periumbilical mass 2. virchow’s sentinel node  supraclavicular (right > left) Dx: anemia is present(hypochromic, microcytic with iron deficiency

Occult blood in stool Endoscopy >> barium swallow -due to ability to biopsy and direct visualization Tx: primary tumor resection and lymph node resection Total gastrectomy + Billroth II/Roux-en-Y anastomosis for lesions in the antrum/pre-pyloric region Total gastrectomy for mid/proximal lesions Spleen removal common as well Proximal lesions = worst prognosis Palliative tx Chapter 4 Small intestine Duodenum  jejunum  ileum Digest/absorb nutrients Superior mesenteric artery  Right, middle and ileocecal arteries Mucosa contain plicae circulares Small bowel obstruction Results in proximal accumulation of fluids and gas -Peristalysis still occurs, packing the region of the obstruction leading to increased SB dilatation and abdominal distention -pt will present with N/V, abdominal pain(intermittent), no passage of gas, bilious vomit if proximal, feculent if distal, abdominal distention Most common causes of SBO are adhesions and hernias Adhesions from prior abdominal surgeries Hernias  incarcerated (non-reducible) and strangulated(non-reducible and ischemic) Gall stone can cause obstruction (GS ileus) Mesenteric ischemia  pain out of proportion to PE (pushing on abdomen does not increase pain) DDX Localized tenderness(constant)  think peritonitis/ischemia/gangrene Dx: obstruction series X-ray (air-fluid levels) Dilated SB and colon = paralytic ileus while SBO = dilated SB only x-ray  CT scan to R/O GS ileus, etc Tx: 1. conservative: NPO, IV fluids, NG tube, pain-control, anti-emetics 2. surgical: if perforation, ischemia or necrosis present, failed conservative tx Crohn’s disease Inflammatory disease that affects the terminal ileum Consists of skipped lesions, cobblestoning, rectum sparing, abscesses, fistulas, strictures, anal fissures Ashkenazi jews and US citizens > japan Bowel becomes hypervascular, bowel walls are edematous/fibrotic Pt presents with hx of abdominal pain, diarrhea, fever, wt loss, nausea/anorexia May also present with erythema nodosum, skin tags, fissures, fistulas, ankylosing spondylitis, uveitis Dx: barium contast enteroclysis(SI enema)  colonoscopy for biopsy CT for abscess R/O Complications from crohn’s disease Strictures, fibrosis are common  obstruction(presentation) Kidney stones from ileal bowel involvement = calcium binds oxalate (this doesn’t occur)  stones Increased levels of oxalate since fat in stool binds calcium Adenocarcinoma is risk Tx: metronidazole(ABx and anti-inflammatory process), CS, azathioprine, IV fluids, Meckel’s Diverticulum Most common congenital abnormality of small intestine Rule of 2 -2in in length, 2 feet from ileocecal valve, 2% population, 2% are symptomatic, 2x more in males, occurs before 2yrs old, 2 types of cells (gastric/pancreatic/duodenal/intestinal) Presents as painless bleeding from rectum in an infant (most common cause) Dx using a meckel’s scan Complications  bleeding, intussusception, or volvulus Tx: surgical resection Small bowel tumors Rare 1-5% of tumors Most are benign Villous adenomas, lipomas, leiomyomas, hemangiomas -consider if café-au-lait spots(NF-1), telengectasias(Rendu-Weber-Olser), lip hyperpigmentation(peutzjeghers) Asymptomatic/incidental If symptomatic  obstruction(presentation) then hemorrhage(2nd) Malignant  adenocarcinomas, stromal tumors, carcinoid, lymphoma Present with bleeding/obstruction

90% GI bleeds are between esophagus- duodenum or ileocecal valve to anus Dx: endoscopy with biopsy for proximal; barium swallow for more distal(beyond duodenum) CT scan can be helpful Tc99-labeled RBC studies ordered when GI bleeding occurs to localize the bleed 1. pt must be actively bleeding 2. takes long time (hours) Carcinoid tumors Most common endocrine tumors of GI tract Arise from endochromaffin cells Able to secrete serotonin, histamine, dopamine, peptides, prostaglandins Detectable in urine  5-hydroxyindoleacetic acid (metabolite of serotonin) Serotonin is metabolized by the liver Carcinoid syndrome: flushing, diarrhea, sweating, wheezing havce vasoactive substance secretion from the tumor This suggests mets to the liver 85% of carcinoid tumors found in intestine(ileum has highest mets), 50% in appendix(rarely mets) Can mets to the lungs Pt presents with abdominal pain, upper GI bleeding, rectal bleeding, wt loss, palpable mass DX: elevated levels of plasma serotonin(most commonly secreted hormone by tumor) and 5hydroxyindoleacetic acid(urine excretion metabolized product of serotonin) barium studies useful, colonoscopy for distal tumors, CT not good Tx: surgical resection of primary tumor -If pt has carcinoid syndrome; relief achieved from SQ injections of octreotide (decreases serotonin production) -CAUTION with anesthesia  triggers life threatening carcinoid crisis which results in hypotension, flushing, tachycardia, arrhythmias If 50% have it above age 80 Pt presents with painless rectal bleeding, pain in LLQ Dx: colonoscopy >> barium Tx: usually no treatment if asymptomatic, minimal bleeding Surgical resection if symptomatic(recurrent bleeding) Colonoscopy can allow for Dx and embolization of bleeding site Subtotal colectomy is offered if both embolization and partial resection fail DDx; hemorrhoids(rectal) Diverticulitis Inflammation/infection of the outpouching diverticula Most commonly occurs in the sigmoid colon Will have LLQ pain, tenderness with rebound/guarding Dx: WBC elevated, x-rays will be normal; do CT scan AVOID COLONOSCOPY/BARIUM ENEMA since it will increase risk of perforation with acute episode Complications: stricture, perforation, fistulas

Tx: conservative or surgical hartmann procedure(resection of colon with colostomy created) can be reversed(removal of colostomy) Conservative tx: oral antibiotics ciprofloxacin and Flagyl Metronidazole covers anaerobic, Cipro covers aerobic Colonic neoplasms Adenomatous polyps  malignancy 50% of carcinomas has ras gene mutation, 75% have p53 mutation 2nd most common cause of death in US Risks: high fat, lowe fiber diet, age, FHx 90% of colon cancers are adenocarcinomas Screening begins >50 with sigmoidoscopy every 5yrs Colonoscopy every 10yrs TNM Tumor: 6cm Nodes: 0, 1-3, 4+ Mets: none, mets Pt may present with blood in stool, abdominal mass, wt loss, obstruction, constipation, tenesmus, fatigue Rt colon cancers bleed while left colon cancers obstruct Rectal tumor mass will have mucosal passage in feces 65+ yo with painless bleeding in stool = colon cancer until proven otherwise Dx: Mets is most common to the liver CEA marker shows progress of tumor/treatment; non-diagnostic Marker for recurrence Colonoscopy = dx and biopsy Can perform barium enema (double contrast) Shows “apple core lesion” for colon cancer (adenocarcinoma) PET can show mets Tx: complete surgical resection of cancer and lymph nodes proximally Cecal/ascending colon cancers = right hemi-colectomy Transverse cancers = tranverse colectomy Descending/sigmoid = sigmoidectomy Angiodysplasia Significant source of lower GI bleeding Vascular lesions similar to telangectasias and occur most commonly in the right colon and cecum Pt presents with multiple episodes of lower GI bleeding Dx: ateriography, endoscopy Tx: electrocautery and coagulation Volvulus Rotational closed-loop obstruction of colon that creates ischemia to bowel Prone in bed-ridden, >70yo of total hepatic lobectomy Liver transplant is viable option Liver mets occurs from lung > colon > pancreas > breast > stomach Liver abscesses Frequently due to bacteria, amebas or tapeworm(echinococcus) Bacterial sources include e. coli, klebsiella, enterococci, anaerobes Risks include: HIV, alcohol abuse, foreign travel Echinococcus is common outside of US source of abscesses Pt presents with vague abdominal pain, wt loss, malaise, fever, anorexia Liver may be tender/enlarged, jaundice present Dx: AST/ALT elevated and WBC; U/S is 90% reliable, CT is better Tx: do not aspirate echinococcal infections! Increases the risk of peritoneal infection DO treat with ABx (flagyl) and drain other abscesses Echinococcal abscesses require open procedure Portal hypertension Process of impeded hepatic blood flow Presinusoidal: schistosomiasis, portal vein thrombosis Sinusoidal: cirrhosis(alcohol, Hep B and C) Postsinusoidal: budd-chiari syndrome, pericariditis, right-sided heart failure Complication of PHTN  esophageal varices/rupture Risks: alcoholism, hepatitis, prior variceal injury Pt presents with ascites, jaundice, caput medusae, palmar erythema, red face Tx: beta blockers to reduce portal HTN, band ligation/endoscopy NG tube + IV fluids for bleeding NG tube = upper GI lavage for bleeding Dx Balloon can stop bleeding but cause localized tissue ischemia and perforation Definitive treatment is a shunt Chapter 7: gallbladder RUQ below the liver Involves cystic duct, cystic artery and vein CD + hepatic duct = CBD + pancreatic duct = ampulla of vater/sphincter of odi Bile produced by liver stored in GB Emulsifies fat and vitamins ADEK CCK stimulates contraction of GB Gallbladder disease Cholelithiasis is presence of GS in GB

Choledocholithiasis is stones in CBD Biliary colic = no infection/inflammation – pain when contractions occur with stone obstruction Acute cholecystitis – constant pain; inflammation(+) e. coli, klebsiella, pseudomonas GS pancreatitis = stone in CBD impinging on pancreatic duct GS made up of cholesterol(common), calcium bilirubinate(pigment) Black stones = GB – cirrhosis, sickle cell anemia Brown stones = CBD 10% occurrence in US Most are asymptomatic More common in women, Fat, Fertile, Female, Fatty foods, 40yo, OCP, DM, rapid wt loss Pt presents with RUQ pain worse with inspiration, (+) Murphy’s sign, pain radiates to back, N/V, Pain is worse after eating(contraction of GB), fever/chills present Choledocholithiasis has dark urine, pale stool(clay colored), Common cause of cholangitis Cholangitis – fever, RUQ pain, jaundice – Charcot triad Reynold’s pentad = cholangitis + hypotension + AMS = sepsis Palpable non-tender GB = malignancy (Courvoisier law) Dx: Cholecystitis, WBC elevated, U/S Choledocholithiasis: elevated serum bilirubin + ALP, ERCP HIDA scan differentiates between cholecystitis and choledocholithiasis Cholangitis: WBC + elevated bilirubin + LFT elevation, ERCP GS pancreatitis: elevated lipase/amylase Complications: GS ileus SBO occurs in ileum, LBO in sigmoid colon Perforation from stone Tx: IV fluids, morphine, anti-emetics, laparoscopic cholecystectomy, IV ABx, NPO Percutaneous drainage possible for pts with high risk, comorbidities, inoperable at time Gallbladder cancer Adenocarcinoma is most common malignancy of gallbladder Females 3:1 males RUQ mass, jaundice, wt loss, nausea/anorexia Tx: resection - 55yo, AST >250, Glucose >200, LDH >350, WBC >16k -Pancreatitis can result in a pleural effusion on CXR -Also show sentinel loop of dilated mid/distal duodenum/proximal jejunum located in LUQ CT scan for acute panc, U/S for GS panc CT will show parenchymal edema and inflammation GS pancreatitis  ERCP dx/tx Common bile duct stones (choledocholithiasis) Tx: conservative: NPO, NG tube, IV fluids, morphine, anti-emetics, ABx if infection surgical: removal of necrotic portions from ischemia, enzyme breakdown, inflammation/edema CT scan with IV contrast can determine extent of necrosis Pancreatitis can result in peripancreatic pseudocysts – drain if >6cm and >6weeks

Necrotic pancreas will form abscesses – abx will not touch this Surgical I/D and debridement needed Not perQ! – ineffective Chronic pancreatitis Alcohol is the main cause Persistent inflammation, calcifications may be present Calcifications suggest alcohol abuse Obstructive pancreatitis suggests prior scarring to ducts from trauma or acute pancreatitis, stenosis, tumor Pt presents with exacerbation of chronic condition – abdominal pain, radiates to back, addicted to narcotics Dx: ERCP > CT > US ERCP defines the pathologic changes of the pancreatic ductal system and biliary tree CT/US are R/O of other causes Tx: IV fluids, NPO, opiates, pancreatic enzymes (if malabsorption present), Surgical: only if failed medical tx Does not relieve pain Adenocarcinomas of Pancreas Leading cause of cancer death, men > women Risks: smoking and increasing age Ductal adenocarcinomas are the most common at 80% At head of gland Pt presents with obstructive jaundice, wt loss, constant deep abdominal pain, mass Mass = palpable GB = malignancy Dx: ALP and direct bilirubin will be elevated with obstructive jaundice CT scan and ERCP CT – location/size ERCP – ductal anatomy and obstruction + biopsy Tx: whipple procedure – removal of pancreas and portion of duodenum Low 5yr survival with Dx Other pancreatic neoplasms Cysts are congenital – no tx Serous cystadenoma – women 30-50 and asymptomatic; resection required Mucinous cystic neoplasms – malignancy potential; resection required Insulinoma Most common tumor of pancreatic islet cells Women > men Inc. insulin levels at fasting  hypoglycemic episodes Whipple triad: low fasting glucose levels(1000 dx Association with MEN-I Pt presents with PUD like s/s, ulceration and secretory diarrhea Dx: CT scan, gastrin levels at fasting Tx: Octreotide + PPI + surgical resection Chapter 11: Hernias Defect/weakness in muscle/fascial layer Reducible: can be manipulated back into place Incarcerated: non-reducible but still has blood flow Strangulated: non-reducible with ischemia Most common hernia is indirect(50%), direct(25%) Rarest hernia is obturator Males 5:1 females Femoral hernias more common in women (but 6% overall) Inguinal hernias Indirect hernia: bowel herniates through inguinal canal into the scrotum Seen in younger pts (pediatric) Direct hernia: bowel herniate through inguinal cana

Abdominal wall weakness of transversalis Involves hesselbach’s triangle(rectus sheath, inguinal ligament and inferior epigastric vessels) Seen in older pts Pt presents with complaints of bulge in scrotum or pelvic/groin Non-reducible can result in N/V, pain, fever Dx: hernia check with finger(indirect) or CT scan/PE Tx: can watch them or surgically fix them Use of mesh reduces recurrence by 50-75% Laparoscopic repair has a 10% recurrence while open laparotomy repair has a 4% recurrence Before surgical option: trendelenberg + sedation + manual pressure/placement NEVER REDUCE A NECROTIC STRANGULATED BOWEL; can result in perforation/sepsis Umbilical hernias Pediatric population, most resolve before age 4 Higher chance in AA vs Caucasians Femoral hernias Through the femoral canal Incisional hernias Occur after closure of abdominal surgery Ventral hernias – occur midline Spigelian hernias – between rectus abdominus and lateral hip Pantaloon hernia –combined direct/indirect hernia Richter hernia – knuckle of bowel protrudes but only outer portion of bowel involved with no change in bowel function Results in gangrenous necrosis of outer loop Sliding hernia – esophageal or contains organs Obturator hernia – women and thin with bowel obstruction; can have nerve paresthesias from compression of obturator nerve Littre hernia – groin hernia containing meckel’s diverticulum -Diastasis recti – stretched/weakened linea alba (midline ligament of abdomen) becomes weakened allowing for a ‘hernation’ like appearance when val salva maneuver performed Chapter 12: Thyroid Recurrent laryngeal nerves – control cricophayngeus muscle/vocal cords From vagus nerve Right one lies behind the subclavian artery Thyroid gland maintains metabolism and thyroxine levels Graves disease / toxic nodular goiter These are the most common causes of hyperthyroidism TNG = plummer’s disease Graves – autoimmune overproduction of TH Pt presents with palpitations, wt loss, sweating, rapid HR, anxiety, fatigue, heat intolerance Exopthalamos – classic with grave’s disease Dx: TSH low and T4 high Iodine uptake is high with graves disease and not absorbed with thyroiditis TNG will have diffuse iodine pickup Tx: medical with PTU and methimazole + BB Surgical with thyroidectomy  synthroid Thyroid nodule Common in population (women > men), 90% are benign Risks: radiation to neck/head, FHx, MEN-I, male, 60, voice changes Dx: FNA can tell benign, malignant, or other Light microscopy is gold standard FNA anything >1-1.5cm U/S Presence of follicular of hurthle cells – surgical intervention Goiters Iodine deficiency worldwide United states – hashimotos thyroiditis as the cause Surgical intervention – neck/airway compromise, difficulty swallowing, speaking Thyroid cancer Women > men Most common type is papillary neoplasms Papillary and follicular are more promising outcome Tx: surgical resection with lymph node removal Complications of thyroid surgery Damage to RLN – voice(hoarseness) and airway compromise Hoarseness can be permanent or last 3mos Paralysis can be treated with Teflon or gel foam

Laryngoplasty Damage to superior laryngeal nerve -less high pitch ability with yelling/singing Calcium levels – hypocalcemia with total thyroidectomy Supplement with PTH removal as well Hematoma can result in airway compromise Chapter 13: Parathyroid 4 glands present posterior to thyroid Endocrine organs that regulate calcium and phosphate metabolism PTH released = remove calcium from bones into the blood, raising serum levels Primary PTH: high serum calcium, low phosphate and osteoporosis results Parathyroid adenoma is 80% of primary PTH Secondary PTH: renal disease pts (low reabsorption of calcium from kidneys results in PTH overload to compensate) Tertiary PTH: complication of 2ndary PTH pseudoPTH: malignancy 2 causes of hypercalcemia – hyperparathyroidism or malignancy MEN-I: involves parathyroid, pancreas and pituitary Insulinomas, gastrinomas, etc PTH carcinoma is rare Pt presents with hypercalcemia complaints Groans – N/V, abdominal pain, constipation Stones – kidney or GS Psychiatric – mood swing, anxiety Bones – arthralgias/aches Surgical intervention Serum calcium > 1.0mg/mL, >400mg/d hypercalcuria,