Advanced Surgical Recall 4e

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ADVANCED SURGICAL RECALL Fourth Edition “‘SCUT’............ Forgive me for this; I HATE this word. Ward work is patient care. It’s the work of Angels and Saints. It is a privilege to do. It’s fun. It is necessary to the care of patients. If you call this patient care scut, you (and your protégés) won’t do it. If you call an admission a ‘hit,’ you won’t take care of them. Your language defines your feelings. Your feelings determine what you have energy for. I get energy from getting a patient a cup of coffee, drawing their blood well, and closing their skin in a nice manner ............ as much energy as I get from transplanting their hearts and lungs, and bypassing their vessels. I can’t do what I don’t have energy for.” —Curt Tribble, M.D.

ADVANCED SURGICAL RECALL Fourth Edition Recall Series Editor and Senior Editor Lorne H. Blackbourne, M.D., F.A.C.S. Acute Care Surgery, Trauma, Burn, Surgical Critical Care San Antonio, Texas

Advisor Curtis G. Tribble, M.D. Chief, Division of Cardiothoracic Surgery Vice Chair, Department of Surgery Medical Director of Transplantation University of Mississippi

Acquisitions Editor: Tari Broderick Product Manager: Lauren Pecarich Marketing Manager: Joy Fisher Williams Manufacturing Manager: Margie Orzech Design Coordinator: Terry Mallon Art Director: Jennifer Clements Compositor: Aptara, Inc. Fourth Edition Copyright © 2015 Wolters Kluwer Copyright © 2015, 2008, 2004, 1997 Lippincott Williams & Wilkins, a Wolters Kluwer business. Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA

351 West Camden Street Baltimore, MD 21201

Printed in China All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via email at [email protected], or via website at lww.com (products and services). 987654321 Library of Congress Cataloging-in-Publication Data ISBN: 978-1-4511-1653-3 Available upon request

DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.

Dedication This book is dedicated to my father, Dr. Brian D. Blackbourne, M.D.

Editors and Contributors Contributors Will Cauthen, M.D. Chief Resident General Surgery University of Mississippi Medical Center Contributors to Previous Editions Gina Adrales, M.D. Joshua B. Alley, M.D. Stephen Bayne, M.D. Gauri Bedi, M.D. Robert Benjamin, M.D. Kyrie Bernstein, M.D. Oliver A.R. Binns, M.D. Shawn A. Birchenough, M.D. Joshua Bleier, M.D. Carol Bognar, M.D. Lee Butterfield, M.D. Sung W. Choi, M.D. Vernon L. Christenson, M.D. Jeffery Cope, M.D. Sagar Damle, M.D. Jennifer Deblasi, B.S. Soffer Dror, M.D. Matthew Edwards, M.D. Brian Ferris, M.D. Anne C. Fischer, M.D. Kirk J. Fleischer, M.D. Charity Forstmann, M.D. Cynthia Gingalewski, M.D. Thomas Gleason, M.D. Penelope A. Goode, M.D. Sharon Goyal, M.D. David D. Graham, M.D. Tobi Greene, M.D. Fahim Habib, M.D. Huntington Hapworth, M.D. Sean P. Hedican, M.D.

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Stanley “Duke” Herrel, M.D. Teofilo R. Lama, M.D. Jason Lamb, M.D. Scott London, M.D. Tananchai A. Lucktong, M.D. Jana B.A. MacLeod, M.D., M.S.C. F.R.C.S. (C) Peter Mattei, M.D. Addison May, M.D. Joseph R. McShannic, M.D. Nancy E. Morefield, M.D. Paul Mosca, M.D. Mark Mossey, M.D. David Musante, M.D. Mark J. Pidala, M.D. John Pilcher, M.D. Philip Pollice, M.D. Cherie D. Quesenberry, M.D. Naveen Reddy, M.D. Brian Romaneschi, M.D. Janice Ryu, M.D. Moises Salama, M.D. Robert E. Schmieg, Jr., M.D. Donald B. Schmit, M.D. Carl Schulman, M.D. Paul Shin, B.A. Kimberly Sinclair, M.S. John Sperling, M.D. Akin Tekin, M.D. Pierre Theodore, M.D. Steven D. Theis, M.D. Michael Tjarksen, M.D. Stephanie VanDuzer, M.D. Jeffry Watson, M.D. Mark Watts, M.D. Joseph Wells, M.D. David White, M.D. Kate Willcutts, M.D.

Editors and Contributors vii

Jonathan Winograd, M.D. Jim Soo Yoo, M.D. Stephen Yung, M.D. Amer Ziauddin, M.D.

Sara S. Kim Resident Department of Surgery University of North Carolina

Developmental Contributor Patricia Blackbourne Kingsbury, Texas

Tad Kim, M.D. Resident Division of Cardiothoracic Surgery University of Mississippi Medical Center Peter Vezeridis, M.D. Orthopedic surgery Boston, MA

Editor Jon D. Simmons, M.D. Assistant Professor Associate Residency Director Department of Surgery Division of Trauma, Acute Care Surgery, Burn, & Surgical Critical Care University of South Alabama Editors, Previous Editions Oliver A.R. Binns, M.D. Anikar Chhabra, M.D. Kirk J. Fleischer, M.D. Tananchai A. Lucktong, M.D. Damle Sagar Joseph Wells, M.D. Associate Editors Louis R. Pizano MD MBA FACS Associate Professor of Surgery and Anesthesia Chief, division of Burns Director, Trauma/ Surgical Critical Care Fellowship Program University of Miami Brian J. Eastridge MD FACS Trauma Surgery University of Texas San Antonio, Texas

Associate Editors, Previous Editions Fouad M. Abbas, M.D. Tekin Akin, M.D. Robert Benjamin, M.D. Kyle D. Bickel, M.D. Duke E. Cameron, M.D. H. Ballantine Carter, M.D. Bruce Crookes, M.D. Martin A. Goins, III, M.D. David D. Graham, M.D. Tobi Greene, M.D. Fahim Habib, M.D. Richard F. Heitmiller, M.D. David Holt, M.D. Billy Johnson, M.D. Brian Jones, M.D. Scott Langenburg, M.D Teofilo Lama, M.D. Jana Macleod, M.D. John Minasi, M.D. Stanley L. Minken, M.D. Michael A. Mont, M.D. Marcia Moore, M.D. Paul J. Mosca, M.D., Ph.D Charles N. Paidas, M.D. John Pilcher, M.D. Moises Salama, M.D.

viii Editors and Contributors

Donald Schmit, M.D. Carl Schulman, M.D. Dror Soffer, M.D. R. Scott Stuart, M.D. Rafael Tamargo, M.D. Curtis G. Tribble, M.D. Reid Tribble, M.D. Craig A. Vander Kolk, M.D. Kate Willcutts, M.D. Leslie Wong, M.D. Jeffrey Young, M.D.

International Editor Gwinyai Masukume, MB ChB(UZ), Dip Obst(SA) Department of Obstetrics and Gynaecology Mpilo Central Hospital Bulawayo Zimbabwe

Foreword Advanced Surgical Recall is a study aid for students and residents who have progressed past their introductory experiences in the discipline of surgery. In actuality, this group includes surgical residents, senior medical students, and even junior medical students who have progressed past the usual introductory materials. This book should also serve as a source of questions for teachers of surgery, particularly for the venerable activity of teaching rounds. The best teachers usually are those individuals who have thought the most about how they themselves learned. The editors of Advanced Surgical Recall clearly are teachers who have given an enormous amount of thought to learning and teaching. They have used the principles of the Socratic method and of their own self-education techniques to develop this collection of questions. These editors have a special knack for writing and editing these types of questions and study aids; through their impressive medical and surgical educational trajectories, they have won teaching awards and created a plethora of study aids. This collection of questions and answers is useful to students of surgery, not only because it will help them learn the answers they need to know, but also because it will help them remember the questions. Knowing the right questions is, in my opinion, more important than knowing the answers, at least in real life. After all, the answers will change over time. The questions are timeless. Curtis G. Tribble, M.D. Chief, Division of Cardiothoracic Surgery Vice Chair, Department of Surgery Medical Director of Transplantation University of Mississippi

ix

Preface ADVANCED SURGICAL RECALL Fourth ed. is written as the natural extension of SURGICAL RECALL. It is intended primarily for surgical residents, but advanced students will also find it can give them an extra competitive edge. In addition to the previous features, this new edition includes a Rapid Fire Review for the ABSITE. Lorne H. Blackbourne, M.D., F.A.C.S. Acute Care Surgery, Trauma, Burn and Surgical Critical Care San Antonio, Texas

x

Contents Editors and Contributors .................................................................................................. vi Foreword ............................................................................................................................... ix Preface .................................................................................................................................... x

SECTION I OVERVIEW AND BACKGROUND SURGICAL INFORMATION 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

Introduction .................................................................................................. 1 Review of Surgical Acronyms and Memory Aids ...................................14 Surgical Syndromes .....................................................................................26 Surgical Most Commons.............................................................................27 Surgical Percentages ...................................................................................30 Surgical History ............................................................................................32 Surgical Instruments ...................................................................................36 Sutures and Stitching..................................................................................53 Surgical Knot Tying......................................................................................61 Incisions .........................................................................................................64 Surgical Positions .........................................................................................66 Surgical Speak ..............................................................................................69 Preoperative 201 ..........................................................................................70 Advanced Procedures .................................................................................72 Surgical Operations You Should Know ....................................................85 Cell Biology and Cytokines ..................................................................... 108 Wounds ....................................................................................................... 115 Drains and Tubes....................................................................................... 118 Surgical Anatomy...................................................................................... 123 Surgical Respiratory Care ........................................................................ 138 Renal Facts.................................................................................................. 144 Fluids and Electrolytes ............................................................................. 154 Surgery by the Numbers and Surgical Formulae ............................... 157 Blood and Blood Products ...................................................................... 162 Surgical Hemostasis ................................................................................. 173 Surgical Medications ................................................................................ 175 Complications ............................................................................................ 180 Common On-Call Pages ........................................................................... 192 Surgical Nutrition...................................................................................... 198 Shock ........................................................................................................... 201 Surgical Infection ...................................................................................... 204 xi

xii Contents

32. 33. 34. 35. 36. 37.

Fever ............................................................................................................ 212 Surgical Prophylaxis ................................................................................. 213 Surgical Radiology .................................................................................... 215 Anesthesia .................................................................................................. 223 Surgical Ulcers ........................................................................................... 235 Surgical Oncology..................................................................................... 237

SECTION II GENERAL SURGERY 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67.

GI Hormones and Physiology ................................................................. 243 Acute Abdomen and Referred Pain....................................................... 251 Hernias ........................................................................................................ 256 Laparoscopy ............................................................................................... 259 Trauma ........................................................................................................ 262 Burns ........................................................................................................... 287 Upper GI Bleeding .................................................................................... 297 The Stomach .............................................................................................. 299 Bariatric Surgery ....................................................................................... 304 Ostomies ..................................................................................................... 306 Small Intestine ........................................................................................... 310 The Appendix ............................................................................................ 316 Carcinoid Tumors ...................................................................................... 319 Fistulas ........................................................................................................ 323 Colon and Rectum .................................................................................... 324 The Anus ..................................................................................................... 330 Lower GI Bleeding..................................................................................... 333 Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis ....................................................................................... 335 Liver ............................................................................................................. 338 Portal Hypertension ................................................................................. 345 Biliary Tract................................................................................................. 350 Pancreas ...................................................................................................... 364 The Breast ................................................................................................... 370 Endocrine ................................................................................................... 379 Thyroid Gland ............................................................................................ 390 Parathyroid................................................................................................. 399 Spleen.......................................................................................................... 402 Surgically Correctable Hypertension .................................................... 406 Soft Tissue Sarcomas and Lymphomas ................................................ 409 Skin Lesions................................................................................................ 416

Contents xiii

68. Melanoma................................................................................................... 417 69. Surgical Intensive Care ............................................................................ 420

SECTION III SUBSPECIALTY SURGERY 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82.

Vascular Surgery ....................................................................................... 437 Pediatric Surgery....................................................................................... 469 Plastic Surgery ........................................................................................... 490 Hand Surgery ............................................................................................. 504 Otolaryngology Head and Neck Surgery ............................................. 528 Thoracic Surgery ....................................................................................... 548 Cardiovascular Surgery............................................................................ 582 Transplant Surgery ................................................................................... 640 Orthopedic Surgery.................................................................................. 649 Neurosurgery ............................................................................................. 699 Urology ....................................................................................................... 722 Ophthalmology ......................................................................................... 764 Obstetrics and Gynecology..................................................................... 775

SECTION IV RAPID FIRE POWER REVIEW 83. Rapid Fire Review for the American Board of Surgery In-Training Examination (ABSITE).......................................................... 789 Index .................................................................................................................................. 815

SECTION I Overview and Background Surgical Information

Chapter 1 Introduction HOW ADULTS LEARN Learning is accomplished through motivation, repetition, and association. Motivation must come from within; most medical students and residents are obviously motivated to learn. Repetition is obtained by reading, rereading, and studying information until it is mastered. Association is obtained by connecting information that has already been mastered to some new knowledge, such as remembering the anatomic order of the trauma neck zones 3, 2, and 1 in conjunction with the Le Fort fractures 3, 2, and 1.

HOW TO STUDY Always read about your patient’s disease as you are taking care of him or her. This habit serves two purposes: You will associate the information with that patient for life, and your increased knowledge will improve that patient’s quality of care.

USING THIS BOOK After completing the surgical basics in Surgical Recall, focus your attention on this book. Review the answers on the right until mastered. This book is designed to foster the acquisition of surgical information and will not help you gain experience in test taking; this skill can be learned from other books.

NURSES Treat nurses with respect and professional courtesy at all times; they often know more than you in any given situation. If your relationship is based on mutual respect, it is also less likely that they will call you at 3 AM asking for Tylenol.

SLEEP DEPRIVATION The best offense to combat sleep deprivation is to be in good physical shape and to be motivated. Staying up for 48 hr is no different than participating in an ultramarathon. Many residents find benefit from caffeine, orange juice, hot showers, brushing their teeth, doing push-ups, running steps, yelling, changing their socks, or listening to loud music. Try not to sit down, because sitting is conducive to falling asleep quickly. Studies have shown that in sleep deprivation physical abilities remain intact until extreme deprivation of sleep occurs. Tell yourself, “I am hardcore and I need no sleep!” 1

2 Section I / Overview and Background Surgical Information

INTERNSHIP The Perfect Intern Says only “Yes sir,” “No sir,” or “My fault, sir” and “Yes ma’am,” “No ma’am,” or “My fault, ma’am” Is always honest Is a team player Has a “can do” attitude Always brushes teeth before rounds Is the first to arrive and the last to leave clinic Is always clean Always makes the upper-level residents look good Teaches the students Does not scut the students too much Knows more about the patients than anyone else Is a physician, and not merely a scribe Is never late Never complains Is never hungry, thirsty, or tired Is always enthusiastic Follows the chain of command Some thoughts for interns to live by: “They can hurt you but they can’t stop the clock.” Internship only lasts for 12 months. “Never trust your brain.” Write everything down, do not trust anything to memory, and check off your chores when completed. “Load the boat.” Inform your superiors when a patient is not doing well or if you have any questions. That way, if your patient’s condition worsens (the proverbial sinking ship), you have loaded the ship with your superiors and they will go down with you. “Bad news does not age well.” Call right away (see above). “Never lie.” Honesty is the best policy.

LIVING WITH MISTAKES You will make mistakes, and many times these mistakes will harm your patients. Mistakes are forgivable if you are doing your absolute best. Do not make mistakes that result from laziness. There is a saying in surgery: “You cannot hurt yourself by getting out of bed.” After a mistake is made and you have determined that you were doing your absolute best, you must then forgive and remember. That is, forgive yourself for the mistake, but always remember the mistake and be sure to learn something from it.

Chapter 1 / Introduction 3

Recovery Room Protocol Several things need to be done before you can take time to eat some food, so the acronym F.O.O.D.D. is helpful: Family: Talk to the patient’s family. Operative note: Write in the chart. Orders: Write postop orders. Dictate the procedure. Doctor: Call the primary/referring doctor.

DEALING WITH ACHES AND PAINS IN THE OR Many residents find that taking NSAIDs before and after long cases helps decrease muscle strains. Others do sit-ups to strengthen abdominal muscles and reduce backache, or use the OSHA back support belts. Support hose can lessen foot edema and the pain associated with venous lower extremity incompetence associated with long periods of standing.

AVOIDING MALPRACTICE Do the right thing. Talk to your patients and their families (never say “no comment” or “I can’t talk about it”). Be nice to your patients and their families. Honesty is the best policy. Document everything! Seek advice from mentor, colleagues, and lawyer. What should you do if you write the wrong word in a chart?

Put a line through the word, but make sure it is still legible, and then initial. Never blot out—it will look as though you are trying to hide something.

HIERARCHY AMONG SURGICAL RESIDENTS Suggestions and ideas regarding patient care should flow freely among all surgical residents (including interns), but the decisions follow a concrete chain of command.

ABBREVIATIONS AKA

Above the knee amputation

ALI

Acute lung injury

AMA

Against medical advice


AMF YOYO

Adios my friend; you’re on your own

ARF

Acute renal failure

ASIS

Anterior superior iliac spine

ATFQ

Answer the first question

AVN

Avascular necrosis

BAL

Bronchoalveolar lavage

BAM

Bilateral augmentation mammoplasty

BCC

Basal cell carcinoma

BMI

Body mass index

BSO

Bilateral salpingo-oophorectomy

Bx

Biopsy

CMV

Cytomegalovirus

CRF

Chronic renal failure

CRNA

Certified Registered Nurse Anesthetist

DJD

Degenerative joint disease

DOE

Dyspnea on exertion

ELAP

Exploratory laparotomy

ER

Estrogen receptor

ESRD

End-stage renal disease

ETT

Endotracheal tube (a.k.a. ET)

FDP

Fibrin degradation product

FEV1

Forced expiratory volume in 1 sec


FIDO

Forget it; drive on

FOS

Full of stool

FROM

Full range of motion

G1P1

Gravida (# of pregnancies), Para (# of children)

GI

Gastrointestinal

GIST

Gastrointestinal stromal tumor

GSW

Gunshot wound

hCG

Human chorionic gonadotropin

HNP

Herniated nucleus pulposus

HOB

Head of bed

HODAD

Hands of death and destruction

ICH

Intracranial hemorrhage

ICU

Intensive care unit

IDDM

Insulin-dependent diabetes mellitus

IM

Intramuscular

INR

International normalized ratio

IOC

Intraoperative cholangiogram

IVC

Inferior vena cava

KISS

Keep it simple, stupid

KVO

Keep vein open

LMD

Local medical doctor

LOS

Length of stay


MAFAT

Mandatory anesthesia fooling around time

MAP

Mean arterial pressure

MCC

Motorcycle collision/crash

ME

Medical examiner

MODS

Multiple organ dysfunction syndrome

MOF

Multiple organ failure

MRA

Magnetic resonance angiography

MRCP

Magnetic resonance cholangiopancreatography

MRI

Magnetic resonance imaging

MRSA

Methicillin-resistant Staphylococcus aureus

MRSE

Methicillin-resistant Staphylococcus epidermidis

MVC

Motor vehicle collision/crash

PEA

Pulseless electrical activity

PFO

Patent foramen ovale

PFTs

Pulmonary function tests

pRBCs

Packed red blood cells

PSV

Pressure support ventilation

PVR

Pulmonary vascular resistance

QD

Once a day

RHIP

Rank has its privileges

RT

Respiratory therapist


RTC

Return to clinic

SCIWORA

Spinal cord injury without radiographic abnormality

SDH

Subdural hematoma

SIMV

Synchronized intermittent mandatory ventilation

SIRS

Systemic inflammatory response syndrome

SVC

Superior vena cava

SVR

Systemic vascular resistance

SVT

Supraventricular tachycardia

TAH

Total abdominal hysterectomy

TAPP

Transabdominal preperitoneal (groin hernia repair)

TEPA

Totally extraperitoneal approach (groin hernia repair)

THE

Transhiatal esophagectomy

TLC

Triple lumen catheter

TPN

Total parenteral nutrition

TURB

Transurethral resection of bladder

Ucx

Urine culture

UNOS

United Network for Organ Sharing

VAP

Ventilatory-associated pneumonia

VRE

Vancomycin-resistant Enterococcus

WBAT

Weight bearing as tolerated


WWDWWC

“Wound was dry when we closed”

y

Psychiatric (Greek letter psi)

mg

Microgram

ADVANCED GLOSSARY Antecolic

In front of the colon (anterior)

Bezoar

Undigested mass (“hair ball”)

Colloid

IV fluid with large molecules (e.g., albumin)

Colonized

Bacteria residing in the anatomic area but not causing infection, inflammation, signs, or symptoms

Demarcation

Line defining borders between two anatomically distinct entities (e.g., between viable and dead tissue)

Eschar

Thick dead skin seen after third-degree burns

Granulation

Wound with a surface made of “proud flesh” consisting of collagen/fibroblasts and without an epithelial cover

Montgomery straps

Straps affixed to a patient’s abdomen with tape; cloth straps are laced and tied after repeated wound changes, to avoid repeated taping of dressings

Pulsus paradoxus

Seen with cardiac tamponade; >10 mm Hg decrease in systolic blood pressure on inspiration

Pyrosis

Heartburn

Retrocolic

Behind the colon (posterior)

Seldinger technique

Placement of a tube over a previously placed wire (e.g., central line placement)


Sterile

All microorganisms are killed

Sterile field

The prepped area of the patient, the drapes, and the instrument table: All items touching this area must be sterile

Strike through

Wound drainage penetrating (“striking through”) all layers of a wound dressing

Thrill

Palpable vibration of arterial turbulent flow

ADVANCED SIGNS Aaron’s sign

Pushing on McBurney’s point in patient with acute appendicitis results in epigastric pain!

Chandelier’s sign

Severe pain upon manual manipulation of the cervix on pelvic exam (patient “jumps for the chandelier”)

Claybrook’s sign

Pneumoperitoneum (ruptured hollow viscus) results in transmission of breath and heart sounds when abdomen is auscultated

Deep sulcus sign

Deep costophrenic angle in supine chest radiograph in patients with a pneumothorax


Dunphy’s sign

Abdominal pain with coughing; sign of peritonitis

Jiffy Pop sign

Colostomy bag full of air!

Mannkopf ’s sign

Increase in heart rate upon pushing on a point of maximal abdominal tenderness (seen with real pain, not in malingering)

Ring sign

CSF and blood form rings when dropped on filter paper (or cloth), seen in CSF otorrhea and rhinorrhea

Soap bubble sign

Retroperitoneal air seen in severe pancreatitis

Ten horns sign

Pronounced tenderness upon manual tension applied to right spermatic cord, seen in acute appendicitis (think ten horns will make you go ten hut!)

MEDICAL STATS YOU NEED TO KNOW Define the following terms: Mean

The average value of all data points (e.g., 5, 10, 5, 20; 40/4 = 10 is the mean)

Mode

The most common numeric value of a set (e.g., in the set 2, 3, 4, 4, 4, 5, 6, 7; 4 is the mode)

Median

The middle value within the ordered set (e.g., 4, 4, 5, 6, 6; 5 is the median)

False-positive

A data point that is reported as positive but is really negative

False-negative

A data point that is reported as negative but is really positive

Distribution

A description of how the data look graphically (i.e., their shape)


Describe some examples of common distributions. Normal distribution

A bell-shaped curve that is symmetrical around the middle

Skewed distribution

Not symmetrical, but slanted to the right or left

Bimodal distribution

Two graphical peaks of the distribution (i.e., two modes)

Define the following terms: Sensitivity

True-positives True-positives + false-negatives

Specificity

True-negatives True-negatives + false-positives

Blind study

The patient is blind to the clinical intervention

Double-blind study

The patient and the care providers are blind to the clinical intervention; (NOT two orthopods trying to read an ECG!)


What is the Hawthorne effect?

Improved outcomes in the control group due to increased medical staff vigilance during research

In statistical tests, what is the null hypothesis?

It is the hypothesis that states that there is no difference between the population value and the hypothesized value, or no difference among the groups being tested; the null hypothesis is often denoted H0

What is a type I error?

Rejecting the null hypothesis when it is true

What is a type II error?

Failing to reject the null hypothesis when it is not true

How is a paired t-test performed?

For each subject or pair of subjects, the difference is calculated for the two variables (e.g., weight before diet minus weight after diet); the difference is then analyzed using a one-sample t-test to determine whether or not the differences are equal to zero

When is the analysis of variance (ANOVA) method used?

When there are more than two groups to compare

Is it unusual to observe an effect with a placebo?

No, people often show an improvement with a placebo if they are blinded to the treatment

How is the incidence of a disease defined?

It is the number of new cases that occur during a specified amount of time divided by the number of people at risk of developing the disease at the beginning of the time interval

How is the prevalence of a disease defined?

It is the number of cases existing in a given population at a specific period of time (period prevalence) or at a particular moment in time (point prevalence)

What is the relative risk of a disease?

It is a measure of the relative amount of disease occurring in different populations


How do you calculate relative risk?

Relative risk equals (incidence of disease in exposed group) divided by (incidence of disease in the unexposed group)

MEDICAL SPANISH Translate the following words and phrases: Hello

Hola (o la)

Good-bye

Adios

Please

Por favor

Sir

Senõr

Ma’am

Señora

You

Usted (respectful); Tu (familiar)

Speak

Hablas

English

Inglés

Where

Donde (dohn-day)

Is

Es; esta

Pain

Dolor (dough-lore)

Worse

Peor

Better

Mejor (mehor)

Nauseas

Mareado or náuseas

Where is the pain?

Donde esta el dolor?

Is the pain worse?

Es peor el dolor?

Is the pain better?

Es mejor el dolor?

Breathe deeply

Respiro profundo


Cough

Tocé (toe say)

Does it hurt to breathe?

Le duele al respiro? (duele = doo-el-ay)

Does it hurt if I push here?

Le duele cuando aprieto aquí?

Where does it hurt?

Donde le duele?

Tetanus shot

Inyección de tétano

X-ray

Radiografía

Were you knocked out?

Estuvo inconsciente?

Neck

Cuello

Abdomen

Abdomen

Arm

Brazo

Rectum

Recto

Chest

Pecho

Head

Cabeza

Need an operation

Necesita una operación

Chapter 2 Review of Surgical Acronyms and Memory Aids Memory aid for sodium seen with SIADH?

SIADH = “Sodium Is Always Down Here” = Hyponatremia

Cause of SIADH?

Syndrome of Inappropriate AntiDiuretic Hormone (Think: Inappropriately Increased ADH)

Chapter 2 / Review of Surgical Acronyms and Memory Aids 15

Goodsall’s rule?

Think of a dog with an anterior straight nose and posterior curved tail

Grey Turner’s sign?

Think: TURNer’s = TURN side to site = flank

Symptoms triad for pheochromocytoma?

PHE ochromocytoma: Palpitations Headache Episodic diaphoresis

Leriche’s syndrome?

CIA = Claudication of buttocks, Impotence, Atrophy of buttocks

Gardner syndrome?

SOD = Sebaceous cysts, Osteomas, Desmoid tumors (Think: A “Gardner” plants SOD)

Diabetes insipidus (DI)?

DI = DECREASED ADH


Symptoms/signs and cells of carcinoid syndrome?

B FDR in a COOL CAR: Bronchospasm Flushing Diarrhea Right-sided heart failure KULchitsky cells CARcinoid

Colon polyp with the highest rate of malignancy?

Villous Adenoma (Think: VILLous = VILLain) 40% malignant

Radiolucent kidney stones?

Uric = Unseen

Kidney stone due to UTI?

Struvite = Sepsis

Most radiosensitive testicular cancer?

Seminoma = Sensitive

Billroth I vs. Billroth II?

Billroth I has 1 limb and Billroth II has 2 limbs coming off the stomach

Orientation of nerve and vessels below a rib?

VAN = Vein, Artery, Nerve under the rib

Order of femoral vessels?

Right side lateral to medial = NAVEL: Navel Artery Vein Extralymphatic material Lymphatics (Thus, the vein is medial to the pulse)

What is the strongest layer of the small bowel?

SUbmucosa = SUperior (not serosa!!!!)

Jejunum vs. ileum?

Ileum is Inferior in thickness and arcade length and has smaller plicae circulares


What is the treatment of hyperkalemia?

“CB DIAL K”: Calcium Bicarbonate Dialysis Insulin/glucose Albuterol Lasix Kayexalate

Differential for hypercalcemia?

“CHIMPANZEES”: Calcium overdose Hyperparathyroidism (1°/2°/3°) Hyperthyroidism/Hypocalciuric Hypercalcemia (familiar) Immobility/Iatrogenic (thiazide diuretics) Metastasis/Milk–alkali syndrome (rare) Paget disease (bone) Addison disease/Acromegaly Neoplasm (colon, lung, breast, prostate, multiple myeloma) Zollinger–Ellison syndrome Excessive vitamin D Excessive vitamin A Sarcoid

Clotting factor in hemophilia A?

Think: “EIGHT” sounds like “A”

Clotting factors deficient with hemophilia A and hemophilia B?

Think alphabetically and chronologically: A before B—8 before 9 Hemophilia A = factor VIII Hemophilia B = factor IX


Fat-soluble vitamins?

K, A, D, E (“KADE”)

Causes of postoperative fever?

W’s Wind – atelectasis Water – UTI Wound – wound infection Walking – DVT/Thrombophlebitis Wonder drugs – drug fever

Curling’s ulcer?

Curling iron burn = ulcer due to burn injury stress

Cushing’s ulcer?

Ulcer due to brain injury; Think: Dr. Cushing = NeuroSurgeon = CNS

Product of chief gastric cells?

“PEPpy chief ” = PEPsinogen

GCS eye-opening score?

4 = 4 eyes

GCS motor score?

6 = 6-cylinder motor

GCS verbal score?

5 = Jackson 5

Treatment of myoglobinuria?

HAM: Hydration with IV fluid Alkalize urine with bicarbonate IV Mannitol IV diuresis (1 g/kg)

Effect of food intake on symptoms of duodenal ulcers?

Duodenum = Decrease in pain (thus, many patients with duodenal ulcers gain weight!!)

Indications for surgery with duodenal ulcers?

I HOP: Intractability Hemorrhage Obstruction Perforation

Indications for operation with gastric ulcers?

I CHOP: Intractability Cancer or cancer rule out Hemorrhage Obstruction Perforation


Product of G cells in stomach?

G cells = Gastrin

Causes of small-bowel obstruction (SBO)?

ABC = Adhesions, Bulges (hernias), Cancer

Conditions that keep an enterocutaneous fistula open?

HIS FRIEND: High output Intestinal destruction (>50% circumference) Short segment (<2.5 cm) Foreign body (e.g., 6-tube) Radiation Infection Epithelialization (e.g., colostomy) Neoplasm Distal obstruction

Major risk factor for hepatocellular adenoma?

ABC = Adenoma Birth Control; thus, birth control pills

Risk factors for gallstones?

4 Fs = Fat, Forty, Female, Fertile (has children)

Causes of pancreatitis?

I G.E.T. S.M.A.S.H.E.D.: Idiopathic Gallstones Ethanol Trauma Scorpion bite Mumps Autoimmune Steroids Hyperlipidemia/Hypercalcemia ERCP Drugs

Ranson criteria <24 hr?

Georgia law = GA LAW: Glucose >200 Age >55 LDH >350 AST >250 WBC >16,000


Ranson criteria 24–48 hr?

C HOBBS (Think: Calvin and HOBBes) Calcium <8 mg/dL HCT drop >10% Oxygen <60 Base deficit >4 BUN >5 increase Sequestration of >6 L

Historical risk factors for breast cancer?

NAACP: Nulliparity Age at menarche (<13) Age at menopause (>55 yr) Cancer in breast (in self or family) Pregnancy with first child (>30 yr)

Anatomic risk factors for breast cancer?

CHAFED LIPS: Cancer in past Hyperplasia Atypical hyperplasia Female Elderly DCIS LCIS Inherited genes (BRCA I and II) Papilloma Sclerosing adenitis

Tumors of MEN-I?

Think: type 1 = Primary, Primary, Primary = PPP = Parathyroid, Pancreas, Pituitary

Tumors of MEN-IIa?

MPH = Medullary thyroid cancer, Pheochromocytoma, Hyperparathyroidism

MEN-IIb?

Think: 3 M plastics = MMM P: Marfanoid body habitus Medullary cancer Mucosal neuromas Pheochromocytoma


Symptoms of acute arterial occlusion?

The “6 P’s”: Pulseless Polar (cold) Paresthesia Pain Paralysis Pallor

P’s of papillary thyroid cancer?

The “7 P’s” of Papillary cancer: Popular (most common) Psammoma bodies Palpable lymph nodes (spreads most commonly by lymphatics, seen in ≈33% of patients) Positive 131I uptake Positive prognosis Postoperative 131I scan to diagnose/treat metastases Pulmonary metastases

4 F’s of follicular thyroid cancer?

Follicular cancer: Far away metastasis (spreads hematogenously) Female (3:1 ratio) FNA … NOT (cannot diagnose cancer with FNA) Favorable prognosis

4 M’s of medullary cancer?

Medullary cancer: M II aMyloid Median lymph node dissection Modified neck dissection (if lateral nodes positive)

Cause of ACUTE and SUBACUTE thyroiditis?

Alphabetically: A before S, B before V (i.e., Acute before Subacute and Bacterial before Viral, and thus: Acute = Bacterial and Subacute = Viral)

I’s of ITP?

Immune etiology I = Immunosuppressive drugs (steroids) Immunoglobulins Improvement with splenectomy


Formula for pressure?

Pressure = flow × resistance or P = F × R (Think: Power FoRward)

Risk factors for sarcomas?

“RALES” Radiation AIDS Lymphedema (chronic) Exposure to chemicals Syndromes (e.g., Gardner)

Malignancy potential of actinic keratosis?

Asset Kicker = Actinic Keratosis = premalignant

Most common sites of melanoma?

SEA: Skin #1 Eyes #2 Anus #3

Most common type of melanoma?

SUPERior = SUPERficial spreading

Define ARDS:

CXR: Capillary wedge pressure <18 X-ray of chest with bilateral infiltrates Ratio of PaO2 to FiO2 <200 (P:F ratio)

Ratio for ARDS diagnosis?

Think P:F ratio or “PUFF” ratio

Medications that can be delivered by an endotracheal tube?

Think: “NAVEL”: Narcan Atropine Vasopressin Epinephrine Lidocaine

Conservative treatment for claudication?

Remember: “PACE”: Pentoxifylline Aspirin Cessation of smoking Exercise

Differential diagnosis of mediastinal tumor/mass?

Classic four T’s: 1. Thyroid tumor (neurogenic tumor, ganglioneuromas, neurofibromas) 2. Teratoma 3. Terrible lymphoma 4. Thymoma


Clinical findings associated with Brown-Séquard syndrome of spine?

Think: CAPTAIN Brown-Séquard = “CPT” Contralateral Pain Temperature loss

Liver clotting factors?

Factors II, VII, IX, and X; Think: 2 + 7 = 9, and then 10

Formula for FENa?

“YOU NEED PEE” = UNP (UNa+ × Pcr/PNa+ × Ucr) × 100

Modified Childs criteria?

Think: “A BEAR”: Ascites Bilirubin Encephalopathy Albumin Prothrombin time (PT)

O2 Sats and FiO2?

Think of the 40, 50, 60…, 70, 80, 90 Rule: PaO2 of 40, 50, 60 corresponds roughly to an O2 sat of 70, 80, 90 respectively

Position of hemorrhoidal cushions?

Think: TROL: “Two on the Right, One on the Left”

Orientation of incision of pericardium and the phrenic nerve?

A-P: Anterior-Posterior: “Anterior to Phrenic”

Breast location of cancer in patient with ductal carcinoma in situ (DCIS)?

Think: DCIS = Directly in same breast

Breast location of cancer in lobular carcinoma in situ (LCIS)?

Think: LCIS = Liberally in either breast

Felty’s syndrome?

Think: “FELT a SURGE”: SRG = Splenomegaly, Rheumatoid arthritis, Granulocytopenia

Three histological layers of the adrenal cortex?

1. Zona glomerulosa (think “salt”) 2. Zona fasciculata (think “sugar”) 3. Zona reticularis (think “sex”) (Think: GFR = salt, sugar, sex)


Signs of impending bowel necrosis with small SBO?

Think: FATAL: Fever, Acidosis, Tachycardia, Abdominal pain, Leukocytosis

Gastric ulcers: Type II?

II = 2 ulcers—one in stomach and one in duodenum

Type III?

III = 3 = PREpyloric

Type IV?

IV = 4 = “by the door”

Treatment of most extremity injuries?

RICE = Rest, Ice, Compression, Elevation

“Signs” of life after blunt trauma cardiac arrest?

PERM = Pupillary reaction, EKG activity, Respirations, Movement

Findings with central spinal cord syndrome?

CAM = Central = Arm Motor Loss or “CAMeL”

Findings with anterior spinal cord syndrome?

A.M. P.T. (“morning physical therapy” = AM PT) = Anterior = Motor, Pain, Temperature Loss

Side effect of bleomycin?

Think: BLEomycin = BLEw with lungs and thus = pulmonary fibrosis

Functions of the two pneumocyte types?

Type 2 = 2 jobs = 1. surfactant; 2. convert into type 1 Type 1 = 1 job = to line the alveoli

How can you remember that addisonian crisis is adrenal insufficiency?

Think: ADDisonian = ADrenal Down

Treatment options for anaphylactic shock?

Think: “BASE”: Benadryl Aminophylline Steroids Epinephrine


Memory aid for Ewing’s sarcoma?

Think: TKO: Twenty or less (<20 yr old) Knee joint (distal femur or proximal tibia) “Onion skinning”

How can you remember where to place skin incisions for a four-compartment fasciotomy?

“FATP” FA = Fibula anterior TP = Tibia posterior

How can you remember the laboratory test for carcinoid?

“5 HIgh CAR pile up” = 5-HIaa CARcinoid test

What is the major nutrient of the colon?

BUTyrate = BUTT = Think “BUTT is near the colon!”

What is a memory aid for the surgical differential for eosinophilia?

Think: A MAD PA: Addison’s disease Malignancy Atheroembolism Drugs Parasites Asthma

What are the categories for all causes of a surgical acute abdomen that you need to consider in your diagnosis?

I BOP: Inflammation/Ischemia

How can you remember the tumor, hormone, and stimulation tests for Zollinger– Ellison syndrome?

Think: Secret ZE Gas = Secretin = ZE = Gastrinoma and gastrin

How can you remember Mackler’s triad for Boerhaave’s syndrome?

Think: BOER PEE: Pain (lower chest) Emesis Emphysema (subcutaneous)

Bleeding (ulcers, etc.) Obstruction Perforation


Chapter 3 Surgical Syndromes Define the following the syndromes: Blue toe syndrome

Painful, blue discoloration of the toes caused by microcirculatory blockage due to microemboli from aortic plaque

Bouveret’s syndrome

Gallstone causing obstruction of duodenum

DiGeorge’s syndrome

Congenital absence of parathyroid glands and thymus

Li-Fraumeni syndrome

p53 gene defect = tumors

Meigs’ syndrome

Pleural effusion, ascites associated with an ovarian mass

Münchausen syndrome

Multiple hospitalizations for acute medical condition although no disease process is found

Nonketotic hyperosmolar syndrome

Severe hyperglycemia without ketoacidosis

Paget–von Schröetter syndrome

Axillary vein thrombosis (a.k.a. effort vein thrombosis)

Plummer–Vinson syndrome

Syndrome of: 1. Esophageal web 2. Iron deficiency anemia 3. Dysphagia 4. Spoon-shaped nails 5. Atrophy of tongue and oral mucosa

Sick euthyroid syndrome

Change in thyroid hormone regulation resulting from severe illness, trauma, or stress. Patient has normal thyroidstimulating hormone (TSH) but has decreased ↓ T4, ↓ T3

Chapter 4 / Surgical Most Commons 27

Turcot syndrome

Central nervous system (CNS) malignant tumor and colon polyps

Verner–Morrison syndrome

Vipoma

von Hippel–Lindau syndrome

CAP: Cystic cerebellar hemangioblastoma Angiomatous malformation of the retina Pheochromocytoma

Waterhouse–Friderichsen syndrome

Adrenal insufficiency caused by bilateral adrenal hemorrhage, classically caused by meningococcal infection

Wernicke–Korsakoff syndrome

Chronic alcohol abuse: Cranial nerve VI palsy (bilateral) Ataxia Delirium Strabismus Nystagmus Diplopia

What is a CN VI palsy?

CN VI = abducens nerve; palsy results in diplopia and inability to look laterally

Chapter 4 Surgical Most Commons What is the most common: Cause of traumatic death in adults?

Brain injury

Tumor causing an adrenal incidentaloma?

Cortical adenoma (nonfunctioning)

Cause of chronic pancreatitis?

Alcohol abuse

Cause of Budd–Chiari syndrome in Western countries?

Prothrombotic state


Benign breast mass in women 18–36 yr of age?

Fibroadenoma

Nosocomial infection in surgical patients?

Urinary tract infection (UTI)

Side with a traumatic diaphragmatic rupture?

Left (liver protects the right)

Site of GI tract lymphoma?

Stomach

Cause of death in adults <44 yr of age?

Trauma

Cause of liver bacterial abscess?

Biliary tract obstruction or disease (used to be appendicitis)

Cause of intraperitoneal fungal infection?

Severe pancreatitis

Injured vascular structure in the neck?

Internal jugular

Injured portion of the duodenum?

Second portion

Leg with a DVT?

Left leg

Gram-negative bacteria causing a wound infection?

Escherichia coli

Anaerobic bacteria causing a wound infection?

Bacteroides fragilis

Cause of ARDS?

Sepsis

Cause of postoperative renal failure?

Hypotension (ATN)

Gastric sarcoma?

Leiomyosarcoma

Gastric site of a gastric carcinoma?

Lesser curve

Chapter 4 / Surgical Most Commons 29

Small-bowel benign tumor?

GIST (GastroIntestinal Stromal Tumor)

Small-bowel malignant tumor?

Adenocarcinoma

Site of small-bowel adenoma?

Duodenum

Endocrine surgical operation?

Thyroid resection

Cause of spinal cord injury?

MVC’s

Cause of a false-positive aortogram for aortic injury in trauma?

Ductus diverticulum

Cause of hypotension?

Hypovolemia

Cranial nerve injured in blunt trauma?

Cranial nerve I (olfactory); easily missed initially!

Benign tumor of the esophagus?

Leiomyoma

Cause of a visceral arterial aneurysm?

Splenic aneurysm

Congenital bleeding disorder?

von Willebrand’s disease

Cause of postoperative premature labor?

Hypovolemia

Cause of viral transmission with blood transfusions?

Cytomegalovirus

Cause of death of children >4 yr of age?

Trauma

Cause of traumatic death in children?

Brain injury


Chapter 5 Surgical Percentages What percentage of spinal cord injuries occur in the cervical spine?

50%

What percentage of clean wounds become infected?

1.5%

What percentage of patients with resolution of mild gallstone pancreatitis will have a common duct stone on intraoperative cholangiogram?

≈5% (i.e., 95% of stones pass)

What percentage of gastrinomas are found in the “gastrinoma triangle”?

80%

What percentage of patients with Crohn’s disease will need a laparotomy within 20 yr?

75%

What percentage of postop myocardial infarctions are silent (asymptomatic)?

75%

What percentage of patients with antibiotic-associated colitis have pseudomembranous colitis?

50%

What percentage of patients with pseudomembranous colitis have a positive assay for Clostridium difficile toxin?

95%

What percentage of patients with antibiotic-associated colitis without pseudomembranes have a positive assay for C. difficile toxin?

≈66%

Chapter 5 / Surgical Percentages 31

What percentage of patients who WILL resolve their partial small-bowel obstruction (SBO) with conservative treatment do so in 48 hr?

80%

What percentage of patients who have SBO (regardless of treatment) will have a subsequent bout of SBO?

≈33%

In what percentage of cases does a thoracic aortogram to rule out a torn thoracic aorta after blunt trauma yield a positive study?

≈10%

What percentage of patients undergoing laparotomy develop a postoperative SBO at some later time?

≈5%

What percentage of colonic villous adenomas contain cancer?

≈40% (Think: VILLous = VILLain)

Mets with VIPOMA at time of diagnosis?

50%

Gallbladder cancer with porcelain gallbladder?

50%

Percentage of penetrating injury to the chest treated with a chest tube?

85%

Percentage of patients with anal melanoma who will have metastasis on diagnosis?

40%


Chapter 6 Surgical History How are physicians and surgeons in England addressed?

The tradition of addressing physicians as “Doctor” and surgeons as “Mister” persists; it stems from the Medieval era’s disdain for surgeons

Who is widely considered to be the father of experimental surgery?

Hunter (1728–1793), born in Scotland

Who was Dominique Jean Larrey?

Napoleon’s surgeon; responsible for the first ambulance and Larrey’s point (subxiphoid)

Who was William Beaumont?

A U.S. Army doctor; studied the gastric physiology of his patient, Alexis St. Martin, who formed a gastrocutaneous fistula from a musket wound in 1822

Who is responsible for the “germ theory”?

Louis Pasteur (1822–1895)

Who is considered the “father of aseptic surgery”?

Joseph Lister (1827–1912)

With what did Lister “disinfect” wounds, hands, and instruments?

Carbolic acid

Who performed the first successful gastrectomy?

Billroth (1829–1894); he also developed the Billroth I and II

Who performed the first successful end-to-end vascular anastomosis?

Alexis Carrel (1873–1944), a Frenchman; his technique made transplantation a technical possibility

Who is credited with the first cholecystectomy?

Carl Langenbuch, in 1882; the patient endured 5 d of preliminary enemas, but smoked a cigar the day after surgery, got up on the twelfth day, and went home 6 wk later

Chapter 6 / Surgical History 33

When and at what hospital did McBurney describe the point named after him?

In 1889, at the Roosevelt Hospital in New York City

Who is credited with starting the routine use of sterile surgical gloves during operations?

William Stewart Halsted, in 1890; his head nurse, Caroline Hampton, complained about dermatitis caused by surgical chemicals; his solution “won her hand,” literally!

What role in surgery did Goodyear Rubber Company play?

It manufactured the first thin rubber gloves with gauntlets for Halsted

On whom did Halsted perform his first gallbladder operation?

His mother, in 1882; he was a pioneer in gallbladder disease research and the first professor of surgery at Johns Hopkins

What disease did Trousseau, of Trousseau syndrome, die of?

Pancreatic cancer; his syndrome was a deep vein thrombosis (DVT) associated with an abdominal malignancy

Why was Kocher’s (1841–1917) surgical career marked by tragedy as well as triumph?

He perfected the total thyroidectomy by 1898, reducing operative mortality from 13% to 0.5%, but to his horror, produced scores of cretinous and myxedematous patients; he swore thereafter never to remove a complete thyroid again

Who was Harvey Cushing?

A neurosurgeon who trained at Johns Hopkins; Cushing (1869–1939) was responsible for advances in neurosurgery (Cushing’s ulcer), pituitary disease, and intracranial pressure (Cushing’s triad)

Why did Cushing insist upon complete silence in the OR?

To minimize droplet infection of wounds; this theory gained increasing acceptance because of the work by Flugge circa 1897, proving that although masks protected the patient against wound infection, they offered little protection if the surgeon was bearded

Who is considered the “father of the modern residency system” in surgery?

A German named von Langenbeck (1810–1887), who trained Billroth


Who established the first surgical residency program in America?

Halsted, at Johns Hopkins Hospital

With what eponym is Le Fort associated?

The Le Fort fractures were named for him, for experiments he conducted in 1900 in which he dropped cannonballs onto cadaver skulls, resulting in 1 of 3 fracture patterns

Who set the standard of requiring complete physical examinations of all patients, and started the first of many large clinics staffed with experts from various fields?

The Mayo Brothers; they built their famous clinic in Rochester, Minnesota, in 1910

Who was Sister Mary Joseph?

The Mayos’ nurse; she noticed the paraumbilical adenopathy associated with advanced gastric cancer

Was Bovie an MD?

No, he was a PhD in physics; he developed the electrocautery in Boston in the 1920s

Who discovered penicillin?

Fleming, a surgeon, in 1928

Which surgeon performed the first human cardiac catheterization?

Forssmann (1904–1979), in 1929 in Berlin, passed a tube through an arm vein into his own heart while watching it on a fluoroscope screen!

Who is credited with developing the heart–lung machine (extracorporeal circulation)?

Gibbon (1903–1973) first used his device in 1953

Who performed the first heart–lung transplantation?

Reitz, in 1982

Who performed the first successful human pancreas transplantation?

Lillehei and Najarian, in 1966 at the University of Minnesota

Who performed the first human laparoscopic cholecystectomy?

Mouret in Lyon, France, in 1987

Chapter 6 / Surgical History 35

Where and when was the first clinical use of general anesthesia?

Massachusetts General Hospital using ether on October 16, 1846 (by a dentist, William Morton)

Who performed the first appendectomy?

Claudius Amyand, in 1735

Who designed the ileoanal pull-through?

Sabiston and Ravitch, in 1947

Why was this unusual?

Sabiston was a cardiovascular surgeon

On whom did Boerhaave first describe the syndrome named after him?

Baron van Wassenaer, admiral of the Dutch fleet

Who was the first to surgically correct Boerhaave’s syndrome?

Barrett, of Barrett’s esophagus

Which father of American academic surgery used cocaine and opium throughout his career?

Halsted

Which battle was the Battle sign named after?

William Battle (1855–1936) named it; (Trick question!)

Who developed the first chest tube?

Crosswell Hewett, in 1876

What was the first chest tube?

A rubber catheter

Who developed the Swan–Ganz catheter?

Dr. Swan got the idea of placing a balloon at the end of a catheter and letting it sail to the pulmonary artery after watching sailboats at the beach!


Chapter 7 Surgical Instruments Identify the proper technique: “Palming” an instrument when you are not using it

Chapter 7 / Surgical Instruments 37

Removing a clamp with your left hand

How do you put a blade on a scalpel?

Define the instrument: Adson–Brown tissue forceps

Never with your hands; always use a clamp


Angled DeBakey vascular clamp

Balfour retractor


Bandage scissors

Bayonet forceps

Used to cut bandages


Bone-cutting forceps

Bookwalter retractor


Bulldog clamp

Castroviejo needle holder


DeBakey aortic clamp

Bowel clamp

Doyen bowel clamp


Doyen rib stripper

Periosteal rib elevator

Duval clamp forceps

Used as a lung clamp (a.k.a. Pennington clamp)


Ferris-Smith tissue forceps

For fascia (often called Ferris Buellers!)

Finochietto rib spreader

Fish retainer

A sheet of rubber that protects the bowel during laparotomy closure


Frazier suction

Gelpi retractor

Designed initially for neurosurgery


Gigli saw

Gomez retractor

Hegar dilator


Jamieson scissors

Keuttner

Kidney pedicle clamp

Pronounced “kitner” or “peanut” by most; basically, a small cloth dressing held by clamp


Lahey thyroid clamp

Lebske knife

Used for manual sternotomy with a mallet


Lone Star retractor

Used to expose anal/rectal mucosa

Loupes

Maryland dissecting forceps

Used for blunt laparoscopic dissection


Poole sucker

Used for suctioning fluid (often irrigation) from peritoneal cavity

Pratt rectal speculum

Rectal speculum


Rat-toothed forceps

Rongeur


Russian forceps

Used for fascia

Satinsky

Vascular clamp

Chapter 8 / Sutures and Stitching 53

# 12 Scalpel blade

Vein retractor

Chapter 8 Sutures and Stitching Should the subcutaneous fat be closed with sutures?

No, because fat will not hold sutures, which then become a foreign body, increasing the rate of infection


SUTURE TECHNIQUES What is a slipknot?

It slips to tighten, but does not hold in place for long

How is a suture removed?

Simply cut one side of the knot and then pull the knot out!

What is a Lembert stitch?

It is a second layer in bowel anastomoses


What is a Connell’s stitch?

The first mucosa-to-mucosa layer in an anastomoses; basically a running U stitch

How can one remember the order of the Connell’s stitch?

“Into the bar—have a drink then go out of the bar—cross the street and go into the bar—have a drink—go out of the bar—cross the street . . . .”

What is a Gambee stitch?

A one-layer anastomosis


What is a Halsted stitch?

An interrupted horizontal mattress stitch

What is the Cushing stitch?

A running horizontal mattress stitch used to approximate two adjacent surfaces

What is a locking stitch?

A stitch used for hemostasis


What is a retention suture bridge?

A bridge used to slowly tighten the retention suture as edema resolves

What is a taper needle?

A needle used in easily penetrated tissues (e.g., bowel)

What is a cutting needle?

A needle for getting through tough material (e.g., skin); the edge is on top of the needle


What is a “reverse” cutting needle?

A cutting needle with the edge on the bottom

What is a “Keith” needle?

A straight needle

SUTURE TECHNIQUE How do you pass a suture on a “passer” around a clamped bleeding vessel?

Smead–Jones stitch?

“Tip to tip”


How do you repair a hole in the heart near a coronary artery?

Large U stitch under the coronary artery

Best way to suture an intercostal artery and avoid painful postop nerve injury?

U stitch that does not wrap around the rib


SUTURE MATERIALS How long do plain and chromic gut sutures retain their tensile strength?

Plain gut: 7–10 d Chromic gut: 10–12 d

How many throws are needed in a Prolene knot?

At least five (most use >6)

What are the following absorbable sutures made of: Vicryl?

Polyglactic acid

PDS?

Polydioxane

Maxon?

Polyglyconate

Dexon?

Polyglycolic acid

Why can PDS or Maxon be used for closing abdominal fascia?

Keeps its strength for >42 d

Why should silk be avoided in contaminated wounds?

Nonabsorbable, and its pores can harbor bacteria

Why do “train tracks” occur with sutures?

Because the suture track epithelializes after 7 d

What type of suture is used to repair the biliary tract or GU system?

Absorbable suture; otherwise, the suture material acts as a nidus for stone formation

Suture material for diaphragm repair?

Nonabsorbable (e.g., Prolene)

Suture material for an umbilical hernia?

Nonabsorbable

Chapter 9 / Surgical Knot Tying 61

In the following anatomical sites, identify the sutures as ABSORBABLE or NONABSORBABLE: Bile duct?

Absorbable

Ureter?

Absorbable

Bladder mucosa?

Absorbable

Diaphragm?

Nonabsorbable

Heart?

Nonabsorbable

Blood vessels?

Nonabsorbable

Chapter 9 Surgical Knot Tying After mastering the instrument knot and two-handed knot tying, now it is time to consider mastering the one-handed knot: Describe the first throw of the one-hand tie (the “OK” throw):

Grab the suture forming the “OK” sign (A,B); place the suture between the index finger and the middle finger (C); use your middle finger to sweep the suture (D–F)


Describe the second half of the one-hand tie (the “snap your finger” throw):

Hold your fingers and the suture like you would snap your fingers (A,B); put the suture between the index finger and thumb (C); use the index finger to sweep the suture (D–G)

Chapter 9 / Surgical Knot Tying 63


Chapter 10 Incisions What is it called if the McBurney or Rocky-Davis incision is extended medially?

Weir extension

What is a Lanz incision?

Right lower quadrant (RLQ) incision following Langer’s lines in the RLQ

2/3 1/3

What is a thyroid incision also known as?

The “collar incision”

McBurney’s point

Chapter 10 / Incisions 65

What is a transverse abdominal incision?

Used mainly in infants and children (or for hemicolectomy in adults)

What is a paramedian incision?

Incision that is longitudinal, but lateral to the linea alba (rarely used)

What is a double Kocher incision?


What is the incision for brachial artery repair?

What is the incision for popliteal artery repair or bypass?

How large should the fascial incision be for a colostomy?

2 fingers

Chapter 11 Surgical Positions Describe the following surgical positions: Sims’

“Semiprone”: patient lies prone with right knee drawn up

Chapter 11 / Surgical Positions 67

Kidney

Flexed lateral decubitus position; used for nephrectomy and other procedures involving the urinary tract

Jack-knife prone

Patient lies prone, with legs lowered and hips raised; used for anorectal procedures

Fowler

Patient lies supine with main body (back) at a 45-degree incline, with knees flexed and elevated

Position that allows both abdominal and thoracic incisions in trauma patients with thoracoabdominal injuries?

Elevate left side of body, then move table to allow for abdominal incision; then do chest incision with table down to right

A


B

Durant

Left lateral decubitus with head down; use for patients with air/CO2 embolus to capture air in the right ventricle/ atrium and keep it out of the pulmonary vasculature

How do you prevent a brachial plexus injury with arms extended in the supine position?

Arm should never extend more than 90 degrees from the body

Chapter 12 / Surgical Speak 69

Chapter 12 Surgical Speak Define the following terms: Dehiscence

“Splitting open” (e.g., wound dehiscence = skin open, fascial dehiscence = fascia splits open)

Eructation

Belch

Pyrosis

Heartburn

Define the following prefixes: “Acro-”

Extremity

“Entero-”

Small intestine

“Odyno-”

Painful (e.g., odynophagia is painful swallowing)

Define the following suffixes: “-dynia”

Pain

“-itis”

Inflammation (e.g., appendicitis is inflammation of the appendix)

“-pexy”

Fixation (e.g., gastropexy is surgical fixation of the stomach to the abdominal wall)

Define these types of surgery: Enteroenterostomy

Surgical anastomosis between two loops of small bowel

Hepaticojejunostomy

Surgical anastomosis of the hepatic duct(s) (but not the common bile duct) to the jejunum

Pancreaticoduodenectomy

Whipple procedure: surgical removal of pancreas (head) and duodenum

Ureteroneocystostomy

Surgical anastomosis between ureter and bladder (at “new” site = neo)


Chapter 13 Preoperative 201 What should be done before elective surgery for a patient taking a monoamine oxidase inhibitor (MAOI)?

Stop taking the MAOI 2 wk before the procedure (coordinate with primary care physician)

Why is postoperative MI so feared?

66% mortality!

What is the rate of postoperative MI in the following conditions: Previous MI <3 mo?

38%

Previous MI >6 mo?

4%

No previous MI?

0.13%

What is the only medication shown to reduce the incidence of postoperative MI?

β-blocker

What are the 10 Goldman criteria for cardiac risk in patients undergoing noncardiac surgery?

Aortic stenosis, MI within 6 mo, jugular venous distention (JVD), S3 gallop, ectopy, poor medical condition, emergency surgery, thoracic or intraperitoneal procedure, age >70 yr, nonsinus rhythm

Give the points by Goldman criteria for each of the following factors (more points = more risk): S3 gallop or JVD

11

MI within 6 mo

10

Ectopy or nonsinus rhythm

7

Chapter 13 / Preoperative 201 71

More than five premature ventricular contractions (PVCs)

7

Age >70 yr

5

Emergency surgery

4

Aortic stenosis

3

Intraperitoneal or thoracic surgery

3

Poor medical condition

3

Define poor medical condition:

Bedridden, abnormal blood gas (PO2 < 60; PCO2 >50), abnormal electrolytes (K+ <3.0; HCO <20), renal dysfunction (BUN >50; creatinine >3.0), chronic liver disease

What is the mortality rate for patients who have less than 5 points according to the Goldman criteria?

0.2%

What is the mortality rate for patients who have more than 26 points according to the Goldman criteria?

50%

What are the two major risk factors for perioperative MI?

CHF and recent MI (3 mo)

What heart valvular disease is associated with the highest risk for postoperative cardiac complications? Why?

Aortic stenosis, because the heart responds poorly to fluid shifts

What are the signs and symptoms of aortic stenosis?

Systolic ejection murmur, angina, syncope, CHF (think; Aortic Stenosis Complications = Angina, Syncope, Congestive heart failure)


Which two kinds of noncardiac surgeries are associated with the highest rates of perioperative cardiac complications?

Operations on the aorta, followed by operations on the peripheral vascular system (because of associated CAD)

Is spinal or epidural anesthesia safer than inhalational anesthetics in patients with CAD?

No; although counterintuitive, the loss of vascular resistance associated with spinal or epidural anesthesia does not result in significantly lower rates of perioperative cardiac events

Which inhalational anesthetic has the highest degree of cardiac depression?

Halothane

What is the mechanism of cardiac depression with halothane?

Can lead to direct cardiac depression coupled with peripheral vascular dilatation, without the normal compensatory tachycardia

What are the two contraindications for epidural and spinal anesthesia?

1. Hypertrophic obstructive cardiomyopathy 2. Cyanotic congenital heart disease (because of loss of vascular tone and increased venous capacitance)

Chapter 14 Advanced Procedures CRICOTHYROIDOTOMY Indications?

Failure to obtain airway by endotracheal oral intubation

Landmarks?

Feel thyroid cartilage and then right below it is the depression between the cricoid and the thyroid cartilage; that is where the tube goes

Chapter 14 / Advanced Procedures 73

Cricoid cartilage

Incision?

Longitudinal skin incision—then transversely through cricothyroid membrane; (Note: If you make the skin incision transversely and you are in the wrong spot you are going to make a second incision! Landmarks can be hard to find in obese persons or those with hematoma)

How to maintain the route into the trachea before the tube is placed?

Place an instrument (Kelly works well) into the lumen to maintain the tract

Thyroid cartilage Cricoid cartilage


Insert tube?

Insert trach tube or endotracheal tube after placing instrument into airway to maintain access into trachea

What is a perc trach?

A percutaneous tracheostomy placed by Seldinger technique


VENOUS CUTDOWN Indications?

Inability to get standard percutaneous intravenous access

Incision?

Transversely over saphenous vein above the medial malleolus

Procedure?

Ligate distal vein with 3-0 silk, place tie proximal (do not tie), then make transverse cut in vein with a 15 blade; place catheter and then tie proximal silk around the catheter


CENTRAL LINE Landmarks: Subclavian?

Curve of the clavicle aim for the sternal notch

Suprasternal notch Subclavian vein

Clavicle First rib

Superior vena cava

Internal jugular (IJ)?

Apex of sternal triangle: Aim for ipsilateral nipple at 45 degrees with small “seeker” needle first, followed by a larger needle after successful venous cannulation

Sternocleidomastoid muscle Internal jugular vein Suprasternal notch

Clavicle


Femoral?

Think NAVEL (Nerve, Artery, VEin, Lymphatics) on right (medial to femoral arterial pulse) 45 degrees

Femoral artery Femoral nerve

Femoral vein Saphenous vein

What is the sequence of events for placing the central line?

Seldinger technique: Cannulate vein, then place wire in vein, cut skin at wire entrance site after removing needle, dilate, then advance catheter over wire; (The wire must always have free movement within the catheter while advancing)

Rule concerning handling of wire?

Never, ever lose contact with the wire; always have finger contact with the wire at all times

What must you get before using an IJ or subclavian central line?

Chest x-ray to confirm position and rule out pneumothorax

If you have a chest tube in the patient, in which side do you put the IJ or subclavian central line?

Same side as chest tube (You have already treated for a pneumothorax!)


SWAN–GANZ Indications?

Confusion regarding a patient’s fluid status/hypotension, pulmonary edema, poor cardiac output, and need to maximize inotropic/pressor support

Are there any prospective, double-blind studies showing a clear benefit from Swan–Ganz catheters?

No

Relative contraindications?

Left bundle branch block (must float Swan with a pacer or external pacer as the patient may go into complete heart block; severe acidosis/hypoxia as this may lead to v tach with floating)

With LBBB, what is the risk of complete heart block when you float the Swan?

≈5%

How do you get the swan–Ganz catheter into the heart?

Central venous access via the subclavian or IJ approach: Place a large “introducer” catheter; (The Swan is placed through this catheter and is introduced into the central venous system)

How does the Swan–Ganz catheter give you volume status?

The catheter wedges in the pulmonary artery and then all flow ceases; since there are no valves in the pulmonary arterial system, the back pressure the catheter tip records is the pressure in the pulmonary capillaries, which is then an indirect measure of the left atrial pressure

What is the ultimate pressure for determining volume status?

Left ventricle diastolic pressure (next best left atrial mean pressure)

When do you inflate the Swan–Ganz balloon?

Only when advancing; start at ≈20 cm


What is the average distance to the right ventricle tracing?

20–25 cm

What is the average distance until you “wedge”?

50 ± 5 cm

As you “float” the Swan balloon, what tracings should you get for the following positions: 1. Right atrium

2. Right ventricle

3. Pulmonary artery


Dicrotic Good trace

Notice dicrotic notch 4. Pulmonary capillary wedge pressure (a.k.a. “wedge pressure”)?

What does the overall tracing from the superior vena cava to the pulmonary wedge pressure look like?

What is an “overwedged” pressure tracing?

CVP Right atrium

Right ventricle

Pulmonary artery

Wedge

Wedge pressure that increases to a very high-pressure tracing; it may be due to balloon obstructing distal pressure port

Overwedged trace Balloon inflation


What is the wedge tracing with bad mitral regurgitation?

V waves (looks almost like a PA tracing and not a wedge tracing!) V wave

Balloon inflation

When withdrawing the Swan–Ganz catheter, should the balloon be inflated or deflated?

Always deflated!

How should the balloon be inflated when in the pulmonary artery?

Very slowly; if there is any resistance, stop inflation

What is a dreaded complication of inflating the balloon for a wedge pressure?

Pulmonary artery rupture

Other complications?

Arrhythmias, tying a knot with the catheter in the ventricle, pulmonary infarction; (Always deflate the balloon after getting a wedge pressure!)

Classic Swan–Ganz findings with cardiac tamponade?

Equalization of pressures: mean RA pressure, diastolic RV pressure, diastolic pulmonary pressure, and wedge pressures all about the same

Classic Swan–Ganz findings with a pulmonary embolus?

Rise in CVP, RA, RV, and pulmonary pressures but no change in the wedge pressure


ER THORACOTOMY Incision?

Below left nipple to the “table”

Where do you put the crank handle on the Finochietto chest retractor?

Key point: Handle and “t” must be on the patient’s left so you can go across the sternum and clamshell if you need to; otherwise, the retractor will block you! See arrow:

First move to mobilize the lung?

Cut the inferior pulmonary ligament

Inferior pulmonary ligament


Where should you cut the pericardial sac?

Above the phrenic nerve (think A-P = Anterior to Phrenic nerve)

How should you clamp the thoracic aorta?

First open the pleura!

DIAGNOSTIC PERITONEAL LAVAGE Incision?

Safest to do “open” DPL incision: Vertical incision above the umbilicus if any possibility of a pelvic hematoma

Dissection?

Incise skin and subcutaneous fat, and then fascia in midline to reveal peritoneum and then into peritoneal cavity


Tube placement?

Place tube down into the pelvis gently (i.e., do not puncture the bowel!)

How do you get the fluid in?

Hang and let flow in by gravity

How much fluid?

1 L LR or NS

How do you drain fluid out?

Place the bag on floor and the fluid will drain out

Chapter 15 / Surgical Operations You Should Know 85

Chapter 15 Surgical Operations You Should Know BACKGROUND How should an area be prepped for operation?

Scrub skin with povidone-iodine (Betadine) in an enlarging circular motion from the center spiraling out to the periphery

How should you glove yourself?

Never allow the outside of the gloves to touch your skin: 1. Turn gloves upside down on forearm of opposite arm 2. Grasp back of cuff and turn over other hand 3. Draw cuff back to wrist


Which drapes do you place first: top and bottom, or sides? Why?

Sides first, because 1. Your gown might touch the sides during placement of towels 2. If placed last, the side drapes will fall down due to gravity after placement of towel clips (whereas the top and bottom towels will keep the side towels in place)

What is the correct height of the OR table?

Operative field is elbow height

SURGICAL MANEUVERS What is the Pringle maneuver?

Occlusion of the porta hepatis; decreases blood flow to the liver to slow bleeding during repair of a traumatic liver injury


What is the double Pringle maneuver?

Used to isolate the porta hepatis in portal vein injury

What is the Grey-Turner maneuver?

Incising the left hepatic attachments to retract the left lobe of the liver to the right

What is the Kocher maneuver?

Dissection of the lateral peritoneal attachments of the duodenum; allows inspection of the duodenum, pancreas, and other retroperitoneal structures


What is the Cattel maneuver?

Mobilization of the ascending colon to the midline; if combined with a Kocher maneuver, exposes the vena cava; (Think: Cattel = Kocher = right sided)

What is the Blaisdell maneuver?

Medial rotation of left-sided viscera but leaving left kidney in situ

What is the Mattox maneuver?

Mobilization of the descending colon to the midline; exposes the abdominal aorta


What is the Utley maneuver?

Used in tracheoinnominate fistula hemorrhage; placement of finger into tracheostomy or between innominate and trachea; this provides hemostasis with digital pressure, compressing the innominate artery hole against the sternum

OPERATIVE PROCEDURES Define or describe the following operative procedures: Kraske? Beger procedure?

Transcoccygeal rectal biopsy/resection Subtotal excision “duodenal preserving” of the head of the pancreas and anastomosed to a Roux-en-Y limb Stomach Common bile duct Pancreatic duct Pancreatic remnant

Cimino?

Radial artery to cephalic vein AV fistula for hemodialysis

Cephalic vein Radial artery


Frey procedure?

What is a “functional end-to-end small-bowel anastomosis”?

Roux-en-Y limb to filleted opened dilated pancreatic duct

A side-to-side anastomosis that “functions” like an end-to-end anastomosis (EEA)


How can you get control of a bleeding injured IVC?

Via two sponge sticks proximal and distal to injury

How can you get at a hemostasis with a throughand-through liver GSW?

Balloon tamponade (Penrose around a red rubber catheter)


How should you reanastomose an SMA injury with a pancreatic injury?

Anastomose to distal aorta (away from the pancreas!)

What is a pulmonary “tractomy”?

For fixing a bleeding hole in the lung: fillet open with a GIA, then oversew all bleeding points


Csendes?

Gastric resection with long gastrojejunostomy

Braun?

Enteroenterostomy between the limbs of a Billroth II


Right hemicolectomy?

Extended right hemicolectomy?


Transverse colectomy?

Left hemicolectomy?


Sigmoid colectomy?

Retrocolic Roux-en-Y?

Limb of Roux-en-Y placed behind transverse colon


Witzel?

Wrapping bowel wall around catheter; used in jejunostomies

Bogota bag?

Abdominal wall closure using plastic sheet (e.g., urologic irrigation bag)

Urologic irrigation bag


Splenorrhaphy?

Surgical repair of the spleen

Ripstein?

Rectopexy with mesh (think: Ripstein = “rip” a piece of mesh for repair)


Grillo?

Pleural flap for buttressing an esophageal repair

Plug and patch inguinal hernia repair?

Plug


Patch

Choledochojejunostomy?

Anastomosis of common bile duct to jejunum

Common bile duct

Jejunum

Truncal vagotomy?

Transection of vagal nerves (Note: while in the OR, get frozen section to confirm that you actually resected the nerve)

Truncal vagotomy


Jaboulay pyloroplasty?

PEG?

Percutaneous Endoscopic Gastrostomy

Guidewire

Snare

Tube


Finney pyloroplasty?

Stamm gastrostomy?

Open gastrostomy with purse-string suture

Stomach sutured to abdominal wall

Hasson?

Purse-string suture

Cut down under direct vision and placement of trocar for laparoscopy


OPERATIVE PEARLS As a last resort, how do you obtain exposure of the iliac vein during trauma surgery?

Transect the iliac artery!

What is the smart operation to perform if you find extensive spread of cholangiocarcinoma at laparotomy?

Cholecystectomy—stents often block the cystic duct, causing cholecystitis!

How do you find the segment III hepatic duct?

Follow the falciform ligament into the umbilical fissure

How do you advance a dilator when placing a large IV catheter?

Always under fluoroscopic guidance, so the dilator does not have to follow a flimsy guidewire!

What intraperitoneal pressure is needed to release an abdomen to avoid abdominal compartment syndrome?

>25 mm Hg with compromise (think: “release >25—keeps the patient alive”)

Which is closed first: the top or bottom of a laparotomy fascial incision?

Bottom—get the guts in first! (Liver is up top)

What must be in place before doing a diagnostic peritoneal lavage (DPL) for trauma?

1. Foley catheter 2. Nasogastric tube (NGT) or orogastric tube (OGT)

How do you mark a specimen for orientation?

Short suture = Superior Long suture = Lateral

When should you biopsy an esophageal leiomyoma?

Never

When do you mark varicose veins?

Preoperatively, while the patient is standing; use nonpermanent ink; otherwise you might tattoo the skin!


Should you ever use a Bovie during a tracheostomy?

Never on the trachea—100% oxygen can result in a fire!

When is the best time to cut the peritoneum?

During expiration, because the bowel falls away

Should you close the small bowel longitudinally or transversely?

Transversely—better to shorten than to stricture!

Where must the catheter be placed for a DPL with a pelvic fracture?

Supraumbilical position (pelvic hematoma tracks up the medial umbilical ligaments); even with a supraumbilical approach, there is up to a 20% false-positive rate!

What are the seven pearls for successfully placing a subclavian central line?

1. Place towels below scapulae transversely or between the scapulae 2. Place patient in the Trendelenburg position (think: headdownenburg) 3. Keep the needle flat 4. Go for the left subclavian, if all things are equal 5. Always have one hand on the wire at all times and never let go 6. Always go on the side of a chest tube (chest tube treats pneumothorax) 7. Always get a chest x-ray after the procedure, before moving the patient, or before trying the other side

What are the four pearls for easy placement of an NGT?

1. Flex the head (chin to chest) 2. Apply mild topical anesthetic (e.g., Cetacaine spray) 3. Apply lubrication 4. Have the patient drink water

How many rings on the stapler do you need after a successful EEA with a stapler?

Two


What will help open the pylorus and stop the contractions of the stomach/ duodenum during an esophagogastroduodenoscopy (EGD)?

IV glucagon

What will help retain contrast dye during a biliary cholangiogram?

IV morphine

Can the suprarenal IVC ever be ligated?

No; a mortality rate of ≈100% is associated with such attempts

How can you tell if a body fluid is pus or tube feeding?

Check the glucose; tube feedings have a high glucose level

Can the infrarenal IVC be ligated?

Yes, but with a morbidity rate of ≈50%

How should a through-andthrough penetrating injury to the IVC be fixed?

Enlarge the anterior defect, fix the posterior defect, and then close the anterior defect

Which three veins must be ligated during a Warren distal splenorenal shunt for esophageal varices?

1. Coronary vein (left gastric vein) 2. Right epiploic vein 3. Left gonadal vein

If a 12-French Foley catheter cannot be inserted into the bladder, what should be tried next?

1. Larger Foley catheter 2. Lidocaine jelly to anesthetize the urethra 3. Coude catheter

During an inguinal hernia repair, the suture needle goes through the femoral vein or artery. What should be done?

Remove the suture and hold pressure; do not tie the suture down!

How should an anal fistula that goes above the anal sphincters be treated?

Seton suture, which will allow subsequent tightening and scarring down of the sphincter muscles


What test should be performed after a tracheostomy?

Chest x-ray

After the mesoappendix is stapled off during a lap appy, the appendiceal artery continues to pump blood. What should be done?

A metallic clip (as used for lap chole) can be applied or a suture must be placed

How should the skin be closed after a grossly contaminated abdominal case?

It should be left open, and closed by secondary intention or delayed primary closure

How should a vas injury be repaired during a procedure to correct an inguinal hernia?

A urologist should be called in to perform an end-to-end repair (unless the patient is elderly)

How should an ilioinguinal nerve transection be repaired during a procedure to correct an inguinal hernia?

A metallic clip should be applied to prevent neuroma formation

What can help identify the ureters during a difficult pelvic dissection (e.g., postradiation)?

Preoperative ureteral stents placed by a urologist

What can help identify an occult ureteral injury?

IV indigo carmine (collects in urine and most likely will be seen in operative field with ureteral injury)

Why do some surgeons “bowel prep” for gastric cancer surgery?

In case of the unexpected gastrocolonic fistula

Prior to prepping a patient, what mental checklist should be reviewed?

Position? Antibiotics? Clip hair? Sequential decompression device (SCD) boots? NGT? Foley? Special equipment ready and available? Fluoroscopy needed?

What are the five intraoperative signs of Crohn’s disease?

1. 2. 3. 4. 5.

Creeping mesenteric fat Thickened mesentery Thickened bowel wall Serositis Abscesses/fistulae/strictures


Should a frozen section be taken to rule out microscopic disease at the margins before an anastomosis after a smallbowel resection for Crohn’s disease?

No; microscopic disease at an anastomosis does not have any effect on the rate of anastomotic healing (1 cm of grossly normal bowel is needed for margins with Crohn’s disease)

A stable patient has a chestpenetrating wound in the box formed by the clavicles, nipples, and costal margins. How should this patient be evaluated for cardiac injury?

Subxiphoid pericardial window or echocardiogram if no hemothorax

What is the strongest layer of bowel for an anastomosis?

The submucosa (not the serosa; think SUbmucosa = SUperior strength)

Should you mobilize and dissect out the ureter?

No; dissecting out the ureter will devascularize it

How can you shrink a prolapsed rectum or colostomy?

Put sugar on it!

What condition contraindicates a hemorrhoidectomy?

Crohn’s disease

LAPAROSCOPIC PEARLS What must you do when you use the argon laser during laparoscopy?

Open a trocar vent; otherwise, intraabdominal pressure will build up and may result in CO2 embolus

What is the appropriate treatment for bladder Veress needle puncture?

Postoperative Foley drainage

What is the appropriate treatment for trocar bladder injury?

Closing by suture and placement of Foley drainage

How can placement of a trocar through an epigastric vessel be avoided?

Transilluminate the abdominal wall and identify the vessels


Name the four options for repair of a bleeding trocar site:

1. Insert a Keith needle into the peritoneal cavity, out the abdomen, under the vessel, and tie over a bolster 2. Cut down and tie off the vessel 3. Insert a Foley catheter through the trocar site; pressure should be held with outward traction 4. Carter Thomason port closure system ligation

Chapter 16 Cell Biology and Cytokines List the major characteristics of prokaryotic cells:

Simplest cells Few organelles Lack nuclear membranes (All bacteria are prokaryotes)

List the major characteristics of eucaryotic cells:

Sophisticated cells Specialized organelles Distinct nucleus (All animal cells are eucaryotes)

Describe the following phases of the mammalian cell cycle: G1

Slow biosynthesis (ploidy = 2n)

S

DNA synthesis (Think: S = Synthesis)

G2

Lag phase between DNA synthesis and mitosis (ploidy = 4n)

M

Mitosis (Think: M = Mitosis) Shortest phase Cell division (two daughter cells, each 2n)

Describe the following organisms: Gram-positive

Thick cell wall; single-layer plasma membrane; lacks mitochondria and a nuclear membrane

Chapter 16 / Cell Biology and Cytokines 109

Gram-negative

Thin cell wall; plasma membrane with inner and outer layers (outer = endotoxin); lacks mitochondria and a nuclear membrane

Fungus

Cell wall is structurally different than that of bacteria; has mitochondria and a nuclear membrane

Describe the function of the organelles listed as follows: Smooth endoplasmic reticulum

Steroid and lipoprotein synthesis, detoxification, fatty acid desaturation

Rough endoplasmic reticulum

Synthesis of proteins for export from cells

Free ribosomes

Synthesis of proteins for use within cells

Golgi apparatus

Protein modification prior to export

Lysosome

Proteolysis of cellular debris and exhausted organelles

Peroxisome

Enzymatic hydrolysis of fatty acids and amino acids; by-product is toxic H2O2, which is reduced by catalase

Nucleus

Contains most of the cell’s genetic material

Nucleolus

Also known as the nuclear organizing region; synthesizes ribosomal RNA (rRNA) for export to cytoplasm

Messenger RNA (mRNA)

Reads nuclear DNA to form the mRNA template; the template then moves to the cytoplasm for translation during protein synthesis

rRNA

Site of mRNA interpretation during protein synthesis


Transfer RNA (tRNA)

Reads mRNA at the ribosome and delivers the appropriate amino acid for protein synthesis

Mitochondria

Site of cellular respiration and ATP production

What important biochemical reaction occurs in the mitochondrial matrix?

Krebs cycle (citric acid cycle) generates NADH and FADH2 to power the electron transport chain

What is the electron transport chain?

A series of closely linked oxidative phosphorylation reactions at the mitochondrial membrane that drives ATP production

What conditions inhibit the Krebs cycle (and therefore inhibit cellular respiration and ATP synthesis)?

Acidosis and excess pyruvate

What conditions inhibit the electron transport chain?

Hypoxia and cyanide poisoning; the clinical result is lactic acidosis

Describe the workings of the following second-messenger systems: cAMP

Generated by adenyl cyclase, it acts as an intracellular messenger by activating protein kinase A, which then activates target proteins

Phosphatidylinositol phosphate (PIP)

Receptor activation leads to phosphorylase C cleavage of PIP to IP3 and DAG, both of which act as intracellular messengers

Calcium (Ca2+)

Rapid increases in intracellular Ca2+ activate calmodulin, an intracellular protein that activates other cytoplasmic proteins


Describe the location and/or function of the following cell types: Gastrointestinal parietal cells

Fundus/body of stomach; produce HCl and intrinsic factor

Chief cells

Fundus/body of stomach; produce pepsinogen

Mucous neck cells

Fundus/body of stomach; produce mucus and HCO3– to form a protective layer at the gastric mucosa

G cells

Antrum of stomach; produce gastrin in response to antral distention, vagal stimulation, and peptides; inhibited by pH <2

S cells

Duodenum/jejunum; produce secretin in response to duodenal acidification

Kulchitsky cells

Gl crypts/bronchial epithelium; progenitors of neuroendocrine tumors

Pulmonary: Type I pneumocytes

Alveolar epithelial cells responsible for gas exchange

Type II pneumocytes

Granular alveolar cell responsible for producing surfactant and new type I cells

Pulmonary capillary endothelial cells

Convert angiotensin I to angiotensin II and degrade bradykinin

Endocrine: α cells

β cells

Pancreas; produce glucagon; located at the periphery of the acinus; comprise 20% of the islet cell population Pancreas; produce insulin; located at the center of the acinus; comprise 70% of the islet cell population


δ cells

Pancreas; produce somatostatin; located at the periphery of the acinus; comprise 5% of the islet cell population

PP-secreting cells

Pancreas; produce pancreatic polypeptide; located at the periphery of the acinus; comprise 5% of the islet cell population

Follicular cells

Thyroid; iodine uptake and T3/T4 production

C cells

Thyroid, also known as parafollicular cells; produce calcitonin and are progenitors of medullary carcinoma of the thyroid

Immune system: B cells

Lymphocytes responsible for humoral immunity (antibodies)

Plasma cells

Activated B cells that produce antigenspecific immunoglobulins

T cells

Lymphocytes responsible for cell-mediated immunity

Helper T cells (TH)

Marked by the presence of CD4 antigen; regulate all T-cell activity; produce IL-2 and IL-4; moderate interactions with other immune cells

Suppressor T cells (Ts) < cm

Marked by the presence of CD4 antigen; downregulate T-cell activity and antibody production

Cytotoxic T cells (Tc)

CD8+; lysis of foreign cells and neoplastic cells

NK cells

Lysis of neoplastic cells; become LAK cells in the presence of lymphokines

Macrophages

Antigen processing and presentation; produce IL-1, which stimulates TH


Kupffer cells

Growth and healing: Osteoblasts

Liver sinusoids; largest collection of macrophages in the body; responsible for clearance of antigens from the gut

Produce bony matrix

Osteoclasts

Responsible for bone resorption and remodeling

Fibroblasts

Collagen-producing cell line important in wound healing and remodeling

Myofibroblasts

Specialized cell responsible for wound contraction; displays characteristics of both fibroblasts and smooth muscles

Vascular endothelial cells

Intimal cells; produce nitric oxide from L-arginine to mediate vasodilation

Cytokine associated with PMN mobilization and activation?

TNF and IL-1

Cytokine causing cachexia with tumors?

TNF

What are the acute phase reactants?

α1-antitrypsin, ceruloplasmin, C-reactive protein, haptoglobin, α-antichymotrypsin, amyloid, fibrinogen, complement C3

Cytokines that increase acute phase reactants?

IL-1, IL-6, and TNF

First major cytokine to rise after endotoxin?

TNF (then falls after ≈2 hr)

Cytokine that rises in the bloodstream second and rises for ª8 hr after endotoxin infusion?

IL-6


Which cytokine levels in meningococcemia correlate with mortality?

TNF and IL-6

Cytokines that are major pyrogens?

IL-1 and IL-6 cause fever

Cytokines with a procoagulant effect?

TNF and IL-1

Cytokines used to treat systemic melanoma?

IL-2 and interferon (γ)

Cytokine that converts lymphocytes to lymphocyteactivated killer (LAK) cells?

IL-2

Cytokine thought to be involved with fever from atelectasis?

Alveolar macrophages are thought to release IL-1

Cytokine released by lymphocytes by virus infection to inhibit viruses?

Interferon

Cytokine that reproduces septic shock in animal studies?

TNF (and IL-2 in high doses)

Cytokine that increases B cells?

IL-6

Cytokine that increases antibody production from B cells?

Interferon

Chapter 17 / Wounds 115

Chapter 17 Wounds How do you get rid of “dog ears” (extra tissue on one side of a wound being closed primarily)?

Pull extra skin out at the end of the incision and cut it off

How long before you can débride a brown recluse spider bite?

Area of necrosis may not be demarcated for weeks

Until the necrotic area is defined, how is a brown recluse spider bite treated?

With dapsone (check for glucose-6phosphate dehydrogenase [G-6-PD] deficiency)

DECUBITUS ULCERS What are decubitus ulcers?

Describe the stages of decubitus ulcers: Stage I

Pressure ulcers due to skin or muscle breakdown and necrosis resulting from prolonged pressure on a bony prominence (e.g., ischial tuberosity, sacrum, occiput)

Erythema

Stage II

Partial skin thickness loss

Stage III

Full-thickness skin loss


Stage IV

Full-thickness skin loss and injury to underlying tissues

WOUND CLOSURE AND HEALING Should you suture the subcutaneous fat closed?

No

How do you treat a large wound with a large subQ space and likely fluid collection?

Insert a drain

When do you remove drains?

Optimally, when drainage is <30 mL/day; however, the longer a drain is left in, the higher the infection rate; remove axillary drains by 2 wk

What is a Wound Vac and what is its purpose?

A sponge placed into a wound and covered by an airtight plastic sheet with suction applied; it is used to help contract and close chronic wounds

What does a “scab” contain?

Fibrin and blood

Do abrasion wounds heal slower or faster with a scab?

Slower!

Does silver sulfadiazine (Silvadene) slow or speed up abrasion wound healing compared to a dry dressing?

Speeds it up due to moisture and a decreased bacterial wound count

If a skin wound that was sutured closed opens up, when can you reclose it primarily?

If possible to do so in <8 hr after dehiscence, the wound usually can be reclosed (but, of course, with an increased risk of infection)

What is an ABD?

Abdominal Battle Dressing—thick dressing with a lot of absorptive ability

What is Aquacell?

Hydrophilic dressing that will not stick to wound; great for exposed bowel

Chapter 17 / Wounds 117

What is Duoderm?

Thick dressing that is great for protecting at-risk skin from forming a decubitus ulcer, and around ostomies

WOUND INFECTIONS What would the Gram stain of a clostridial wound infection show?

Gram-positive rods

What does streptococcal or staphylococcal wound infection show on Gram stain?

Gram-positive cocci

What are first and second most common bacterial cause of infection in clean wounds?

1. Staphylococcus aureus 2. Streptococcal organisms

When and what antibiotics are used for a clean wound infection?

After opening the wound, if cellulitis or signs of systemic reaction are present, then use antistaph/antistrep IV antibiotics: Cefazolin sodium (Ancef) Oxacillin

What is the usual bacterial count necessary for a wound infection?

>105

What are the causes of wound infection after perineal or bowel surgery?

Many are mixed infections

In a nonimmunocompromised patient, when would you treat a wound for a Candida infection?

1. Positive culture 2. Antibacterial treatment fails 3. Any coronary artery bypass graft (CABG) patient with a sternal wound infection and culture positive for Candida

What is the relationship between risk of wound infection and operation duration?

Infection risk doubles every hour!


Chapter 18 Drains and Tubes DRAINS AND TUBES What is a Cantor tube?

A long intestinal tube with a mercury-filled balloon tip; sometimes used in partial bowel obstruction

How is a Cantor tube removed?

Very slowly—pull out 1 ft every 2 hr

What is a Miller–Abbott tube?

A long intestinal tube

Who invented the Dobbhoff tube?

Not Dr. Dobbhoff; it was actually two individuals: Dobbie and Hoffmeister

What are some tricks for getting the Dobbhoff tube past the pylorus?

Slack, right lateral decubitus and metoclopramide (Reglan)

What should be given during a T-tube cholangiogram?

IV antibiotics

Is it possible to drain the free peritoneal cavity?

No

Should a drain ever be brought out of the body through a suture line?

No; it should be brought out through a separate incision

What is the maximum recommended rate of pleural effusion drainage?

Not to exceed 1 L over the first 30 min of drainage; a faster rate could result in acute pulmonary edema caused by rapid lung re-expansion (rare)

Have prophylactic oral antibiotics been shown to help prevent drain tract infections after mastectomies?

Yes; although controversial, antibiotics may help prevent closed-drain tract infections after mastectomy, according to research by Touran and Frost (1990)

What are the two indications for intraperitoneal drains?

1. Well-formed abscess cavity 2. To control a fistula

Chapter 18 / Drains and Tubes 119

How long after placement are peritoneal drains completely surrounded by omentum?

48 hr

Is a drain needed after a routine appendectomy?

No

Are drains usually needed after a ruptured appendix?

No, unless there is an abscess pocket (remember: the free peritoneal cavity cannot be drained)

Should a closed drain be placed after removal of a large sarcoma?

Yes; always place the drain exit hole close to the incision, for easy postoperative re-excision in case of recurrence

Is a drain needed after a cholecystectomy?

No

Is a drain needed after an acute rectal perforation?

Yes; presacral drains (Jackson-Pratt) are necessary, along with a diverting colostomy, if the perforation is intraperitoneal then closure

What is “marsupialization” for a pancreatic abscess?

The practice of packing the wound open with Kerlex or other gauze pads, creating a wound “pouch,” following débridement of the pancreas

Are perineal drains indicated after closure of the perineum following an abdominoperineal resection (APR)?

Yes; closed drainage of the perineum is indicated after primary closure

Does a drain after splenectomy decrease or increase the intraabdominal infection rate after a concomitant GI tract injury?

Increases the risk (especially after a colon injury); thus, concomitant GI tract injury is a relative contraindication for postsplenectomy drainage

For what purpose was the Jackson-Pratt drain initially developed?

For postoperative SDH drainage


What percentage of all pulmonary injuries can be treated definitively with a chest tube?

≈85%

How quickly will a small, stable pneumothorax absorb?

≈1% a day; therefore, 10% by volume will absorb in ≈10 d

Does it matter if the chest tube is removed during maximal expiration or inspiration?

No

What treatment is indicated for an extraperitoneal bladder injury?

Drainage of the bladder (with a Foley catheter), in most cases

Currently, which method of draining intraperitoneal abscesses is used most often?

Percutaneous catheter placement, under the guidance of CT or ultrasound

What are six relative contraindications for percutaneous drainage of an intraperitoneal abscess?

1. 2. 3. 4. 5. 6.

What is a Hemovac?

A drain with spring suction

No safe route to the abscess Multiple septations Multiple small abscesses Phlegmon undefined collection Contrast allergy (for CT guidance) Coagulopathy

Detachable trocar for getting drain through skin

Chapter 18 / Drains and Tubes 121

What is a Davol drain?

What is the purpose of a catheter contrast study before removing a percutaneous catheter placed for abscess drainage? How often is percutaneous transhepatic cholangiography (PTC) successful: With dilated biliary ducts? With nondilated biliary ducts? What is a Portacath?

To rule out an enteric abscess cavity fistula to bowel

≈90% successful 75% successful

A central line with a subQ port for injection over a long period Catheter

Reservoir and catheter


What is a Schrock shunt?

A shunt to bypass the IVC retrohepatic for repair of retrohepatic vena caval injury running from atrium to IVC

What is a Malencott tube?

When can a biliary T-tube be removed?

Usually after 3 wk; if bilirubin level does not increase, no signs or symptoms of cholangitis are seen after clamping, and after obtaining normal T-tube cholangiogram

CATHETERS What is a pigtail catheter?

A small tube with a curved end (pigtail) placed into pleural cavity to drain fluid by gravity

How long should a peripheral IV be left in place before replacement?

72–96 hr unless obviously infected, at which time they should be removed immediately

How often should IV administration tubing be changed?

Every 96 hr unless TPN infused, then more frequently

Which IV site has the lowest rate of IV phlebitis?

The hand

Which site has the highest rate of IV phlebitis?

The lower extremity

Chapter 19 / Surgical Anatomy 123

Which central line site has the highest infection rate?

The internal jugular (higher than the femoral vein!)

When inserting a central line, does it help to wear a sterile gown and full-length sterile drape?

Yes—lower central line infection rate if gown, cap, and large sterile drape used

How often should the transparent plastic (polyurethane) central line dressings be changed?

Every 7 d (every 2 d for gauze bandages)

Should you rotate ports of a central line for hyperal (TPN)?

No—use only one port exclusively for TPN

Do antiseptic-coated central lines lower the central line infection rate

Ye; chlorhexidine/silver sulfadiazinecoated catheters lower the infection rate

What is the most common bacterial cause of central line infection?

Coagulase-negative staphylococci

Chapter 19 Surgical Anatomy THYROID Which nerve travels with the superior thyroid artery ª15% of the time?

The superior laryngeal nerve

During a thyroidectomy, should the inferior thyroid artery be transected as close to its origin as possible?

No; the parathyroids receive their blood supply from the inferior thyroid arteries; thus, the inferior thyroid artery should be transected as close to the thyroid as possible


What are neck delphian nodes?

The delphian nodes are located just cephalad to the isthmus over the cricothyroid membrane

Cricothyroid muscle Cricoid cartilage Thyroid

What is the Zuckerkandl’s tubercle?

Pyramidal lobe Delphian lymph nodes

Most posterior lateral extension of the thyroid gland

NECK Which structure separates the anterior from the posterior neck triangle?

The posterior border of the sternocleidomastoid muscle

Where is Erb’s point?

Point in posterior cervical triangle where spinal accessory nerve exits

Which muscle is between the subclavian vein and subclavian artery?

The anterior scalene muscle

Which nerve runs along the anterior border of the anterior scalene muscle?

The phrenic nerve (transection of this nerve paralyzes the diaphragm)

What muscle is between the subclavian artery and the subclavian vein?

Anterior scalene


What nerve lies on top of the anterior scalene muscle?

Phrenic nerve!

What are the four branches of the thyrocervical trunk?

1. Inferior thyroid artery 2. Ascending cervical artery (off the inferior thyroid artery) 3. Transverse cervical artery 4. Suprascapular artery

How can you remember the branches of the thyrocervical trunk?

Think: “STAT”: Suprascapular artery Transverse cervical artery Ascending cervical artery Thyroid artery (inferior)

Which artery does the vertebral artery branch off from?

The subclavian artery, bilaterally

Which artery does the internal mammary artery branch off from?

The subclavian artery, bilaterally

What are the branches of the extracranial internal carotid artery?

None

Where is the thoracic duct located?

It empties into the left subclavian vein

What is Irish’s node?

A node in the left axilla (associated with gastric cancer)

Which muscles lose innervation if the radial nerve is cut at the forearm?

None; only sensory innervation to the dorsum of the hand is lost


What is a Langer’s arch found in the axilla?

An accessory slip of the latissimus dorsi muscle traversing the axilla; it is a congenital variant

Where does the subclavian artery turn into the axillary artery?

At the lateral border of the first rib

Where does the axillary artery become the brachial artery?

At the inferior border of the teres major muscle

What are the clinical signs of a cut long thoracic nerve during an axillary dissection?

Loss of innervation to the serratus anterior muscle, resulting in a winged scapula

What is the usual distance from the skin at the right internal jugular vein to the pulmonary artery wedge?

50 ± 5 cm

What is the usual distance from the skin at the right subclavian vein to the pulmonary artery wedge?

45 ± 5 cm

What is the usual distance from the skin at the left subclavian vein to the pulmonary artery wedge?

55 ± 5 cm


If you blindly push an endotracheal tube into the lung, which tracheal mainstem will it go down?

The right mainstem due to less of an angle

Trachea

Small angle

Large angle

Right mainstem

Left mainstem

ABDOMEN What phrase helps you remember the direction of the external oblique fibers?

“Hands in the pockets”

What phrase helps you remember the direction of the internal oblique fibers?

“Hand over heart”

What are the boundaries of Petit’s triangle (inferior lumbar triangle)? (See Chapter 40)

Think: Petit Lie Posterior boundary: Latissimus dorsi Inferior boundary: Iliac crest Anterior boundary: External oblique (Floor: Internal oblique and transversus abdominis muscle)


What are the boundaries of Grynfeltt–Lesshaft’s triangle (superior lumbar triangle)? (See Chapter 40)

Superior: Twelfth rib Anterior: Internal oblique Floor: Quadratus lumborum

What are the layers of the bowel?

Where is Larrey’s point located?

Subxiphoid

What is the criminal nerve of Grassi?

The small posterior branches of the vagus nerve occasionally missed during a truncal vagotomy

What are the veins of Sappey?

The diaphragm veins that drain into the liver

What is Sappey’s line?

A line drawn around the abdomen at approximately L2; it is thought that lymph drainage above Sappey’s line goes to the axilla and below the line to the groin nodes

What is the node of Lund?

The cystic node found in the triangle of Calot (also known as Calot’s node)


What is the Hartmann’s pouch?

The gallbladder infundibulum

What is another name for the supreme artery of Kirk?

The dorsal pancreatic artery

What three structures constitute the hepatocystic triangle?

1. Cystic duct/gallbladder 2. Common hepatic duct 3. Lower edge of the liver

Identify the segments of the liver (French system):

What is the rationale behind the segmental anatomy?

1. Most local and distant metastases to the liver follow the portal venous system 2. The segmental anatomy is based on the portal and venous systems of the liver

How many segments are there?

8

What is segment 1?

The caudate lobe (remember, the caudate lobe is caudal to the quadrate lobe)


What is the overall arrangement of the segments in the liver?

Clockwise, starting at segment 1

What is segment 4?

Quadrate (named so because it has 4 sides, thus quad = 4)

Which segment is long and often subdivided into parts A and B?

Segment 4

Which segments are divided by the falciform ligament?

It divides segments 2 and 3 from segment 4

What is Cantlie’s line?

An imaginary line drawn from the left of the IVC through the liver, just left of the gallbladder fossa (separates the left and right lobes of the liver)

Which segment is located between Cantlie’s line and the falciform ligament?

Segment 4

Which segment is located above the gallbladder?

Segment 5

Which structure lies within Cantlie’s line?

The middle hepatic vein

Which segments are separated by Cantlie’s line?

Segment 4 is separated from segments 5 and 8

Which segments are resected in the following operative procedures: Right hepatic lobectomy?

5, 6, 7, 8

Left hepatic lobectomy?

2, 3, 4 (classically, segment 1 is not removed)


Right trisegmentectomy?

1, 4, 5, 6, 7, 8

Left lateral segmentectomy?

2, 3

What is the vein of Mayo?

The vein often seen during a pyloromyotomy for pyloric stenosis over the pylorus

What is the angle of His?

The gastroesophageal angle

What are the boundaries of the gastrinoma triangle?

1. Third portion of the duodenum 2. Porta hepatis 3. Neck of pancreas

What is the meandering artery of Gonzalez?

A proximal collateral arterial arcade of the colon that shadows, and is proximal and medial to, the marginal artery Meandering artery

SMA

IMA

What are two advantages of a midline abdominal incision?

1. Wide exposure of peritoneal cavity 2. No major vessel, nerve, or muscle is cut


What is the significance of an arcuate line in the abdominal closure of a midline incision?

Below the arcuate line, all three abdominal wall muscles fasciae form the anterior rectus sheath fascia (i.e., there is no posterior fascia); above the line, the transversus and half of the internal oblique fascia form a posterior rectus sheath fascia

Where is the white line of Hilton located?

Between the external and internal anal sphincters

What is the space of Riolan?

The avascular area in the mesentery to the left of the middle colic artery

What are Jackson’s veils?

Peritoneal folds across the ascending colon, from the cecum to the right flexure

What are Treves’ folds?

Avascular ileocecal peritoneal folds (Treves was also the benefactor of the “Elephant Man”)

How long is the average colon?

≈1.5 m

How long is the average length of the adult small bowel?

≈6 m

How long on average is the: Anus? Rectum? Define the amount of peritoneal covering of the rectum by thirds: Proximal third

3–3.5 cm ≈12 cm

Total peritoneal covering

Middle third

Anterior surface covered by peritoneum

Distal third

No peritoneal covering


What is the most common location of an anal fissure and Why?

Posterior due to watershed area of low blood supply

How many anal hemorrhoidal cushions are there?

Three—TROL: Two on the Right One on the Left

What is Griffith’s point?

The watershed area between the midgut and the hindgut blood supply to the colon—the area between the proximal two-thirds and the distal third of the transverse colon

What is Sudeck’s point?

The watershed between the superior hemorrhoidal artery and the middle hemorrhoidal artery

How do you remember the correct proximal/distal orientation of Sudeck’s and Griffith’s points?

Just think General Surgery: GS = Griffith’s first, Sudeck’s second!

What do you call a gallbladder that hangs off the liver and folds in half?

Phrygian cap

Identify the zones of the retroperitoneum:


What is the space of Retzius?

The preperitoneal space between the pubis bone and bladder

How much third-space fluid would it take to increase the entire peritoneum by 1 mm in thickness?

18 L

What is the node of Rosenmüller?

Node over the greater saphenous vein/ femoral vein junction

What is Denonvilliers’ fascia?

The fascia between the rectum and the vagina or prostate

What is in Alcock’s canal?

1. Internal pudendal artery and vein 2. Pudendal nerve branch (penile or clitoral branch)

What are the boundaries of the femoral triangle?

Think: “PSA”: 1. Poupart’s ligament 2. Sartorius 3. Adductor longus

Where does the external iliac artery become the femoral artery?

At the inguinal ligament (Poupart’s ligament)

Where does the superficial femoral artery become the popliteal artery?

At the adductor hiatus, where the superior femoral artery leaves the adductor canal and turns into the popliteal fossa

What is another name for the adductor canal?

Hunter’s canal

What is the node of Cloquet?

A node in the femoral triangle

LOWER EXTREMITY What are the four compartments of the lower leg?

Anterior, lateral, deep posterior, and superficial posterior


Identify the bones and compartments of the lower leg: 1. 2. 3. 4. 5. 6.

Anterior compartment Tibia Deep posterior compartment Lateral compartment Superficial posterior compartment Fibula

How do you find the approximate location of the femoral artery in a patient without a femoral pulse?

Two fingers lateral to the pubic tubercle

How do you remember where to make the skin incisions for a four-compartment lower leg fasciotomy?

FATP: Fibula = Anterior Tibia = Posterior

What is Waldeyer’s fascia?

Presacral fascia

What nerve can be injured during lateral lower leg fasciotomy?

The superficial peroneal nerve, which runs in the anterior aspect of the lateral compartment


What does the resulting injury cause?

An inverted foot and loss of sensation of the dorsum of the foot and toes

Why might a patient with CAD go into coronary arrest after clamping the left subclavian?

The patient has an internal mammary artery coronary bypass!

Do only actors have thebesian veins?

No; these are the veins that drain directly into the heart!

Why can one tie off the left renal vein without consequences, but not the right renal vein?

The left renal vein can drain through the left gonadal (testicular/ovarian) vein (the right gonadal vein drains into the IVC)

What is the venous drainage of the adrenal glands?

Usually one central vein: Right = IVC Left = left renal vein (± accessory vein draining into the inferior phrenic vein)

What is the arterial supply to the adrenal arteries?

Three arteries: 1. Superior adrenal artery (branch of the inferior phrenic artery) 2. Middle adrenal artery (branch of the aorta) 3. Inferior adrenal artery (branch of the renal artery)

GI EMBRYOLOGY What are the most common sites for heterotopic pancreatic tissue?

The stomach, small intestine, and Meckel’s diverticulum

How much does the stomach rotate during development?

90-degree clockwise; thus, the left vagus is anterior

How much does the midgut rotate during development?

270-degree counterclockwise around the superior mesenteric artery, when viewed anteroposteriorly


What is the embryonic origin of a Meckel’s diverticulum?

The vitelline duct

To which adult organs does the foregut give rise?

The lungs, esophagus, stomach, and duodenum (up to the ampulla of Vater); the pancreas, liver, bile ducts, and gallbladder are formed from outbuds of the duodenum

To which adult organs does the midgut give rise?

The duodenum (distal to the ampulla of Vater), small bowel, and large colon (to the distal third of the transverse colon)

To which adult organs does the hindgut give rise?

The distal third of the transverse colon to the anal canal

Which pancreatic bud is connected to the bile duct?

The ventral pancreatic bud

Which pancreatic bud migrates to fuse with another bud?

The ventral bud migrates posteriorly to the left to fuse with the dorsal bud

What does the ventral pancreatic bud form in the adult pancreas?

The uncinate process and the inferior aspect of the pancreatic head

What does the dorsal pancreatic bud form?

The superior aspect of the pancreatic head, and the body and tail of the pancreas

The small accessory pancreatic duct of Santorini forms from which pancreatic bud?

From the dorsal bud; the main duct of Wirsung forms from the entire ventral pancreatic duct, then fuses with the distal pancreatic duct of the dorsal bud

What abnormality arises if the ventral pancreatic bud migrates posteriorly and anteriorly to fuse with the dorsal pancreatic bud?

Annular pancreas


Chapter 20 Surgical Respiratory Care Atelectasis

What is absorption atelectasis?

Elevated inhaled oxygen replaces the nitrogen in the alveoli resulting in collapse of the air sac (atelectasis); nitrogen keeps alveoli open by “stenting” it

What is incentive spirometry?

The patient can document tidal volume and will have an “incentive” to increase it

What is oxygen-induced hypoventilation?

Some patients with COPD have low oxygen as the main stimulus for the respiratory drive; if given supplemental oxygen, they will have a decreased respiratory drive and hypoventilation

Why give supplemental oxygen to a patient with a pneumothorax?

Pneumothorax is almost completely nitrogen—thus increasing the oxygen in the alveoli increases the nitrogen gradient and results in faster absorption of the pneumothorax!

What is a nonrebreather mask?

100% oxygen with a reservoir bag

hrf '04

What is the most common cause of fever in the first 48 hr postop?

Chapter 20 / Surgical Respiratory Care 139

Exhalation valve opens Valve closes

Reservoir bag expands fully

Why do nonrebreather masks have a “reservoir” bag?

Inhalation flow will exceed the delivery rate of the tubing and the bag allows for extra oxygen

What is the maximum oxygen FiO2 delivered by a nonrebreather mask?

≈80%–90%

How do you figure out the PaO2 from an O2 sat?

PaO2 of 40, 50, 60 roughly equals 70, 80, 90 in sats

What is an oxygen nasal cannula?

Oxygen delivered via tubing with prongs into nares


How much do you increase the FiO2 by each liter added to the nasal cannula?

≈3%

What is the maximum flow for a nasal cannula?

6L

What is a CPAP mask?

Continuous Positive Air Pressure mask— noninvasive mask that gives positive pressure for an entire respiratory cycle

Inflow

Outflow

What is a nasal BiPAP?

Bilevel Positive Airway Pressure mask— nasal mask with basically pressure support and PEEP


What is the normal I:E ratio (time for inspiration: time for expiration)?

1:2–1:3

What is “auto peep”?

Incomplete exhalation results in increased pressure in the alveoli after expiration

What infectious complication is seen with nasal endotracheal intubation?

1. Sinusitis 2. VAP (Ventilator-Associated Pneumonia)

How can you check for laryngeal edema in the intubated patient?

Deflate EET balloon and momentarily occlude ETT and see if air moves around the ETT

What is a “double-lumen” endotracheal tube?

It allows for a single lung to be ventilated

Trachea Tracheal balloon Tracheal lumen

Endobronchial balloon Endobronchial lumen

Left bronchus

TRACHEOSTOMY Does early placement in a trauma patient result in early wean off the ventilator?

No studies have shown a clear benefit with early tracheostomy placement

What is done if a tracheostomy falls out before a mature tract is formed?

Oral endotracheal tube placement


What is a fenestrated trach tube?

Trach tube that allows for speaking

Cricoid cartilage

Thyroid cartilage

MECHANICAL VENTILATION What are the two main types of mechanical ventilation?

Volume cycled and pressure cycled

What is the difference between volume and pressure cycled mechanical ventilation?

Volume cycled delivers a breath until a prescribed volume is reached; pressure cycled delivers a breath until the prescribed pressure is reached

What are the common types of volume cycled mechanical ventilation?

Volume Control/Assist Control (VC/AC) and Synchronized Intermittent Mechanical Ventilation (SIMV)

What is the difference between AC and SIMV?

Both give a breath at the prescribed rate; the main difference is when the patient initiates a breath; in AC, the breath is fully supported with the prescribed tidal volume; in SIMV, the ventilator does not support the breath unless you add pressure support to patient initiated breaths (SIMV/PS)


What does synchronized mean in SIMV?

If the patient initiates a breath immediately prior to the ventilator giving a breath, the ventilation with provide the full tidal volume and not “stack” breaths

What is “breath stacking?”

When the ventilator gives a breath before the patient completely exhales the previous breath; this is the feared complication of AC

What is the difference between AC and SIMV in a paralyzed or nonbreathing patient?

None

What are the common modes of pressure cycled mechanical ventilation?

Pressure Control Ventilation (PCV) and PS ventilation

What is PCV?

The ventilator gives a breath until the prescribed pressure is reached. The tidal volumes will vary according to lung compliance with each breath

What is pressure support (PS) ventilation?

After the patient initiates a breath, the ventilator will ASSIST each initiated breath with additional pressure

What happens if the patient does not initiate a spontaneous breath while on PS?

No breaths will be given; the ventilator will only assist spontaneous breaths from the patient in PS

What is the major concern with PS?

The minute ventilation can vary greatly

What is the rough formula for the amount of PS needed?

(PIP – peep) × ½

What is pressure regulated volume control (PRVC)?

PRVC is a volume cycled mode that adjusts the inspiratory flow with each breath to achieve the prescribed volume without high airway pressures


When is PRVC used?

ARDS (Acute Respiratory Distress Syndrome)

What is proportional assist ventilation (PAV)?

The ventilator will match a percentage of the effort provided by the patient with each breath; basically, a fancy form of PS

What is airway pressure release ventilation (APRV)?

APRV is two levels of CPAP—Peephigh and Peeplow. The patient breaths spontaneously during both periods

What are the advantages of APRV?

Decreased dyssynchrony, increased oxygenation, increased cardiac output; all due to the effects of spontaneous breathing

What is APRV in a patient who is not spontaneously breathing?

Analogous to inverse ratio pressure control ventilation

Chapter 21 Renal Facts What is the anatomic nutcracker and what is its clinical significance?

Origin of the superior mesenteric artery (SMA) courses over the left renal vein and third portion of the duodenum; compression of the vein may cause abdominal pain and hematuria

What is the anatomic relationship between the renal artery, renal vein, and renal pelvis?

Anterior to posterior: vein, artery, and pelvis

Name the five basic regions of the nephron and at what location the classic diuretics work

1. Bowman’s capsule 2. Proximal tubule 3. Loop of Henle—thin descending/thick ascending limbs 4. Distal tubule 5. Collecting duct

Chapter 21 / Renal Facts 145

What structures form the glomerular filter?

Composed of three layers: capillary endothelium, basement membrane, and podocyte foot processes

Name three factors of a molecule that decrease its ability to be filtered at the glomerular basement membrane (GBM)

1. Increased size (molecular weight in kilodaltons) 2. Negative charge 3. Binding to plasma proteins (albumin is not filtered)

What size molecule is freely filtered?

<7,000 kDa

Can hemoglobin pass through the normal GBM?

Yes, it can after intravascular hemolysis (68,000 kDa) which may cause tubular dysfunction

What size molecule is virtually impenetrable through the GBM?

70,000 kDa


Why is albumin not filtered across the GBM?

Albumin is negatively charged with a molecular weight of 67,000 kDa; this combination prevents it from being filtered

How much of the cardiac output does the kidney receive?

25%

What is the approximate glomerular filtration rate (GFR) of the normal kidney?

120 mL/min in men and 100 mL/min in women

What is the most practical way to measure GFR?

Creatinine Clearance =

What GFR is needed to prevent dialysis?

Above 15 mL/min

Why does Creatinine Clearance overestimate GFR?

Creatinine is both filtered and secreted

Why does Urea Clearance underestimate GFR?

Urea is filtered and reabsorbed

What is a more accurate way to estimate GFR than Cr Clearance?

Average of the Urea and Creatinine Clearance

Compare the Urea clearance with creatinine clearance

Urea Clearance is approximately two-thirds the creatinine clearance; therefore, BUN levels rise before Cr and fall after Cr during the onset and resolution of acute kidney injury (AKI)

What determines the GFR?

Constriction/dilation of afferent and efferent arterioles

What measurement defines the upper limit of normal for daily urine protein excretion?

150 mg/24 hr; it takes >300 mg/24 hr to be detected by standard dipstick

Renal vein obstruction can cause which type of urine abnormality?

Massive proteinuria

Ucr × UOP (mL/min) Pcr


What is the approximate specific gravity (sg) at which the kidney does the least amount of work?

1.010 sg; this corresponds to ≈280 mOsm/L (same as plasma)

What is the maximum urine sg in the adult?

1.035 sg

Which ketone is detected with standard dipsticks?

Acetoacetate; not β-hydroxybutyrate

What is the normal range of urine pH?

5–8

Where does secretion of ammonia and K+, and acidification of urine occur?

Distal tubule

What medications alter the afferent arteriole?

Dopamine and Fenoldopam cause vasodilation of the afferent arteriole to increase GFR

Does Dopamine improve survival in acute kidney injury?

No, it should not be used to improve urine production

What is the mechanism of Fenoldopam?

Potent dopamine agonist (6-fold increase in afferent vasodilation compared to dopamine)

Define the following: Azotemia

Oliguria

Identify the urine output (UOP) for: Anuria

Excess of urea and other nitrogenous waste in the blood Urine excretion <0.5 mL/kg/hr, or ≈500 mL/24 hr; generally the level below which the daily osmolar load cannot be excreted

<100 cc/24 hr

Oliguria

<400 cc/24 hr

Nonoliguric AKI

>400 cc/24 hr (increase in creatinine with normal UOP)


What is the new and correct terminology for acute renal failure?

AKI

What does the term “AKI” indicate about UOP?

Nothing; it is possible to have oliguric or nonoliguric AKI

What is believed to be the cause of nonoliguric AKI?

Preservation of some GFR in the presence of tubular dysfunction (this has a better prognosis than oliguric AKI!)

What is the percentage of ICU patients with AKI?

≈6%

Why is AKI so important in the ICU?

Mortality is 60%—higher than ARDS!

What are the three classic classifications of AKI?

Think PIP Prerenal Intrarenal Postrenal

What are the common causes of AKI in the ICU?

Acute tubular necrosis (ATN) (45%) Prerenal (20%) Acute on chronic renal failure (13%) Vasculitis (4%) Acute interstitial nephritis (AIN) (2%) Atheroemboli (1%)

What are some good diagnostic and laboratory tests to differentiate the causes of AKI?

Response to fluid bolus Urine Na+ and FENa+ Urine volume (UOP) BUN/creatinine ratio Urinalysis and urine sediment microscopy Renal ultrasound

How much would the creatinine rise in the first 24 hr after removal of both kidneys?

1–2

How can ultrasound be helpful in the differentiation of the above?

It can rule out postrenal obstruction or other structural abnormalities

Chapter 21 / Renal Facts 149 +

How is urine Na useful in the work-up of AKI?

Prerenal azotemia: Na+ generally <20 mEq/L Renal azotemia: Na+, generally >30 mEq/L because of the tubular dysfunction and ensuing inability to reabsorb Na+

What is one drawback of this method?

Urine Na+ levels are affected by diuretic use

What is the single best test for differentiating prerenal from intrarenal AKI?

Un Pn FENa = Pn × Un

What is the value of FENa for prerenal AKI?

<0.01 (<1%)

What is the value of FENa for intrarenal AKI?

>0.02 (>2%)

What other urine component is useful on AKI?

Urea, the level of which is unaffected by diuretics (high urine urea—prerenal azotemia)

What are the possible nonrenal causes of elevated serum BUN?

Dehydration, catabolic states, high protein diet, reabsorption of GI bleed, and ureterocolic anastomosis

How is urine osmolarity helpful in AKI?

Prerenal: >400 mOsm/L Renal: <400 mOsm/L, because of tubular inability to concentrate urine

What are the four common laboratory values consistent with prerenal azotemia?

1. 2. 3. 4.

What is the most common cause of intrarenal AKI postoperatively?

ATN due to intraop hypotension

How can microscopic examination of urine sediment be helpful to diagnose ATN?

Granular casts are pathonumonic for ATN

FENa <0.01 Urine Na <20 Urine osmol >400 BUN/creatinine ratio >20


How is ATN diagnosed?

First, by exclusion of prerenal and postrenal causes, followed by differentiation from other intrinsic renal causes (AIN or glomerulonephritis/ vasculitis)

What are the causes of ATN?

Ischemia, nephrotoxins, sepsis, and myoglobin

What forms granular casts?

Tubular epithelial cells from ATN

Are hyaline casts pathological?

No, they are normal urinary constituents which are increased in fever and other administration of loop diuretics

What is the significance of RBC casts?

Most often caused by glomerular nephritis, but can also be present in AIN, diabetic nephropathy, renal embolism, and renal vein thrombosis

What is the significance of WBC casts?

Often caused by pyelonephritis or AIN

What classic urine abnormality is present in AIN?

Eosinophilia (present in only 15% of cases)

What are the most commonly encountered nephrotoxins?

Antibiotics (aminoglycosides, β-lactams, amphotericin B), NSAIDs, ACE inhibitors, radiocontrast dyes

Will dialysis help prevent renal injury after administration of IV contrast?

NO; the damage is already done

Which IV contrast material has a lower rate of renal injury?

Visipaque (nonionic iso-osmolar, not low osmolar)

What is the optimal treatment of myoglobinuria?

1. IV hydration is the most important 2. Alkalinize the urine with bicarbonate IV 3. Diuresis with Mannitol


What is the goal of the above treatments for myoglobinuria?

To increase urine flow (UOP)

When do you stop treating myoglobinuria?

When CK <5,000 and urine is clear

What is the general rule of thumb for determining the location of hematuria?

Dysmorphic RBCs: glomerular process Isomorphic RBCs: nonglomerular process

What is the most common postrenal cause of renal failure?

Mechanical obstruction (large prostate or stones)

Does glomerular filtration stop on the affected side in unilateral obstruction?

No, a small amount of flitration continues, but is completely reabsorbed by tubules

What are the most common emergent problems encountered in AKI?

Hyperkalemia, severe uremia, severe acidosis, coagulation defects, respiratory failure, severe hypertension

What is the emergent treatment of hyperkalemia?

1. Intravenous calcium 2. 50 mL of D50 W with 10 units of insulin 3. Loop diuretic (i.e., Furosemide) 4. Saline bolus

How does the above treatment work?

Causes an intracellular shift of K+

What is the downside to the above treatment?

Potassium will shift back to the extracellular compartment in 3–4 hr; this gives you time to set up dialysis!

What are the indications for dialysis?

Think: AEIOU Acidosis Electrolytes (↑K+) Inflammation (uremic pericarditis) Overload/Overdose (fluid/drug) Uremic encephalopathy


What are the three dialysis modalities?

1. Hemodialysis (HD) 2. Peritoneal dialysis 3. Continuous veno–veno hemofiltration with or without HD

What are the three principles of HD?

1. Diffusion 2. Ultrafiltration 3. Convection

Describe the following: Diffusion Ultrafiltration Convection

What is the pore size of the dialysis membrane?

Solute movement from higher to lower concentration Solute movement from higher to lower pressure (hydrostatic) Solutes are dragged across the membrane (oncotic) Large enough to allow molecules up to 1,500–5,000 Da to pass easily


What is the advantage of CVVHD vs. standard HD?

CVVHD can be used in patients with hypotension

What is the disadvantage of CVVHD vs. standard HD?

Takes much longer to obtain the same clearance

How do you increase the solute clearance in CVVHD?

Increase the dialysate flow rate

What is the difference between CVVHD and CVVUF?

HD refers to the removal of solute; ultrafiltrate (UF) refers to the removal of water; CVVH can use either or both simultaneously


Chapter 22 Fluids and Electrolytes What is the classic electrolyte abnormality with a TURP?

Hyponatremia

What electrolyte abnormality occurs with SIADH?

Hyponatremia

Name the causes of hyponatremia: Hypovolemic hyponatremia?

GI losses, third spacing, renal loss, skin loss

Hypervolemic hyponatremia?

Cirrhosis, TURP, CHF

Isovolemic hyponatremia?

SIADH, polydipsia

How do you calculate the Na+ deficit in hyponatremia?

(140 – measured Na+) × (0.60 × IBW); IBW = Ideal Body Weight

What is the danger in rapid correction of hyponatremia?

Central pontine myelinolysis (irreversible)

What is pseudohyponatremia?

Low Na+ value during severe hyperglycemia; add 2 mEq to Na+ level for elevated glucose levels in increments of 100 above normal.

What is the most common etiology of hypernatremia?

Loss of free water—usually not excess sodium

Classic example of isovolemic hypernatremia?

Diabetes insipidus—lack of ADH

Define diabetes

Basically, polyuria

Define insipidus

Insipid means “tasteless” in contrast with the “sweet” urine of diabetes mellitus!

What medication is known to cause nephrogenic diabetes insipidus?

Amphotericin B

Chapter 22 / Fluids and Electrolytes 155

How do you replace the free water deficit in hypernatremia (in liters)?

[(Patients NA+/140) – 1] × (IBW × 0.60)

Why use D5W instead of H2O to replace free water deficits?

H2O is too hypotonic and will result in major hemolysis!

What is the danger in rapid correction of hypernatremia?

Cerebral edema causing seizures and permanent brain damage

What is the primary intracellular cation?

Potassium (K+) at about 150 mEq (Na+ is only 10 mEq!)

What is a rough estimate for K+ replacement?

Serum K+ increases 0.25 with each 100 mEq of KCl

What are two surgically correctable causes of hypokalemia?

Conn’s disease and colonic polyp secreting mucus high in K+

Why is the potassium level important in patients who take digoxin?

Potassium and digoxin compete for the same receptors; thus, if K+ is low, the patient is vulnerable to digoxin toxicity

Which is more dangerous: hyperkalemia or hypokalemia?

Hyperkalemia!

What is the effect of hypothermia on K+?

Hypokalemia

What is the formula for estimating the “true” calcium level with low albumin?

Add 0.8 mg to calcium level for every 1 g deficit in albumin

What are the signs of hypocalcemia?

Chvostek’s sign (tapping facial nerve produces twitching), hyperreflexia, perioral tingling/numbness, Trousseau’s sign (carpopedal spasm after inflating a BP cuff)

Should hypocalcemia be treated in rhabdomyolysis?

No; doing so may increase calcium deposition in injured muscles and exacerbate the rhabdomyolysis


What is the distribution of magnesium?

45% bone 45% intracellular 10% extracellular

Which two electrolyte deficiencies are a sign of a third electrolyte deficiency?

Hypokalemia (refractory to repletion) and hypocalcemia are signs of hypomagnesemia

Name the causes of hypophosphatemia

Iatrogenic (phosphate binders, diuretics), renal loss (ATN recovery, dieresis), burn patients, refeeding syndrome, respiratory alkalosis, vitamin D deficiency

Signs of severe hypophosphatemia?

Muscle weakness leading to respiratory failure and flaccid paralysis

Treatment of hypophosphatemia?

Potassium phosphate or sodium phosphate IV, depending on Na+ and K+ levels

Causes of hyperphosphatemia?

Renal failure, acidosis, hypoparathyroidism (postop parathyroidectomy)

Signs of hyperphosphatemia?

Tetany from hypocalcemia

Rx hyperphosphatemia?

Hydration and dieresis (acetazolamide is the classic diuretic); PO phosphate binders (aluminum hydroxide PO); low phosphate diet; Dialysis if severe and refractory

What is the content of the following intravenous fluids: Normal saline?

Na+ 154, Cl− 154, Lactate 0, pH 4.5, Osmolarity 308

Lactate Ringers (LR)?


D5W?

Na+ 0, Cl− 0, Lactate 0, pH 5, Osmolarity 252

D5W½ NS?


What is the normal osmolarity of serum?

285–295

Chapter 23 / Surgery by the Numbers and Surgical Formulae 157

What other electrolytes are in LR?

K+ 4 mEq and Ca++ 3 mEq (per liter)

How much Na+ is in 1 ampule of sodium bicarbonate?

50 mEq/ampule (1 ampule = 50 mL)

Which electrolyte abnormalities are associated with the following conditions: Conn’s disease?

↓K+ ↑Na+

Addisonian crisis?

↑K+ ↓Na+

Vipoma?

↓K+

Diabetes insipidus?

↑Na+

SIADH?

↓Na+

Chapter 23 Surgery by the Numbers and Surgical Formulae What are the numbers for the following: Maximum GCS verbal?

5

Maximum GCS motor?

6

Maximum GCS eyes?

4

GCS coma?

<8

Minimal BMI for gastric bypass with weight-related medical problems?

35

Minimal BMI for gastric bypass without weightrelated medical problems?

40


Size of appendix carcinoid treated by appendectomy?

<1.5 cm

Size of appendix carcinoid treated by right Hemicolectomy?

>1.5 cm

Minimal T. bili for jaundice?

>2.5

Blood for massive hemoptysis?

>600 cc

Urine output (UO) for oliguria?

<400 cc/24 hr

UO for Anuria?

<100 cc/24 hr

With what FeV1 should you get a perfusion–ventilation scan before performing lung resectional surgery?

FeV1 <2 L

Minimal UO for adults?

>30 cc/h

RBC count for positive DPL?

>100,000/mm3

WBC count for positive DPL?

>500/mm3

Indication for thoracotomy blood in cc’s after initial placement of a chest tube for a traumatic hemothorax?

>1,500 cc

Indication for thoracotomy by hourly blood output after chest tube for traumatic hemothorax?

>200 cc/h for 4 hr

Heart rate for tachycardia?

>100 beats/min

Calorie content of fat?

9

Calorie content of carbohydrates?

4


Calorie content of protein?

4

Prerenal FENa value?

<1

Renal cause of renal failure FENa value?

>1

Vitamin K–dependent clotting factors?

2, 7, 9, 10

Hemophilia A clotting factor deficiency?

8

Hemophilia B clotting factor deficiency?

9

AAA diameter for surgical repair?

>5 cm

Surgical margin for melanoma <1 mm?

1 cm

Surgical margin for melanoma >1 mm?

2 cm

CCs of blood for melena?

>50

How many days after a laparotomy can you see “free” air on AXR?

>7

How many days post-op should you wait before a CT looking for a peritoneal abscess?

>7

Sodium (in mEq) in normal saline?

154

Sodium (in mEq) in LR?

130

Chloride (mEq) in normal saline?

154


Maximum blood loss into a closed femur fracture?

1,500 cc

Affinity of hemoglobin to CO2 vs. O2?

CO2 is 249 × the affinity of O2

Length of rectum?

12–15 cm

Maximum blood loss in a closed humerus fracture?

750 cc

Minimal projected post-op FeV1 for lung resection?

>800 cc

How to convert nitrogen to protein?

Multiply nitrogen by 6.25 to get protein

Percentage of cardiac output to each kidney?

12.5% to each kidney (or 25% to both)

Cardiac output to the liver (hepatic artery only)?

10% (but remember 2/3 of blood flow to liver is from the portal vein, so combined portal and arterial blood flow = 25% of cardiac output)

Cardiac output to brain?

15%

Cardiac output to spleen?

Only 5%!

Percentage of pancreas that can be resected without endocrine or exocrine dysfunction?

Up to 80%

How to approximately convert % TBSA burn into centimeter squared body surface?

Multiply % TBSA by 200

Length of a cyst-enteric anastomosis for a pancreatic pseudocyst?

>3 cm


SURGICAL FORMULAE Cardiac output?

HR × stroke volume

Mean blood pressure?

MAP: DBP + 1/3 SBP − DBP

Cerebral perfusion pressure?

MAP − ICP

Laplace’s law?

Wall tension = radius × pressure

SVR?

MAP − CVP/CO × 80

PVR?

PAP(mean) − PCWP/CO × 80

BMI?

Wt in kg/Ht in meter squared

Parkland formula?

= 4 × kg × % burn (for burn fluid resuscitation)

FENa?

U Need Pee = Urine Na+ × plasma Cr × 100 urine Cr × plasma Na+

Correction of calcium level with low albumin?

(4 − measured albumin) × 0.8 add to measured calcium level

Maintanance fluid rate?

4 − 2 − 1 (4 × first 10 kg, then 2 × the next 10 kg, then 1 × the remaining kgs)

Anion gap?

Na+ − (Cl + HCO3–)

Pressure?

Pressure = flow × resistance

Oxygen delivery?

CO × (HgB × O2 Sats)

pH and CO2?

Every increase in CO2 by 10 = 0.08 decrease in pH

Unstable pediatric resuscitation?

20 − 20 − 10 = LR 20 cc/kg, then 20 cc/kg LR, then 10 cc/kg blood


SURGICAL RATIOS Respiratory quotient (R/Q) for pure fat?

0.7

R/Q for pure carbohydrate?

1

R/Q for pure protein?

0.8

Extubation by Tobin rapid shallow breathing index?

<105 (rr/vt)

P:F ratio with ARDS?

<300

P:F ratio with mild ARDS (acute lung injury)?

200–300

Normal I:E (inspiration: expiration) ratio?

1:2

Number to divide into a French to get diameter?

Pi or 3.14

For “mild ARDs”

200–300

PaO2 to FiO2 ratio for ARDS?

<300

Chapter 24 Blood and Blood Products Which blood component is the most common source of bacterial infection in a transfusion?

Platelets, because they are stored at room temperature and staphylococci or streptococci from the donor’s skin may be incubated

What percentage of a unit of packed RBCs can be hemolyzed in the first 24 hr after transfusion?

Up to 25%!

How much will the platelet count increase with 1 unit of platelets?

≈5,000

Chapter 24 / Blood and Blood Products 163

How many units of platelets are usually transfused?

6 or 10 (6 or 10 “pack”)

What is the risk of receiving a unit of blood infected with hepatitis C?

≈1 in 100,000

Briefly describe hemostasis in a cut vessel:

First, vasoconstriction occurs; platelets adhere and form a “white thrombus”; then one of the coagulation pathways adds fibrin

Describe the extrinsic coagulation pathway:

7 → 10 → thrombin (from prothrombin) to fibrin (from fibrinogen)—think 7, 10, T, F (test the extrinsic pathway with prothrombin time [PT])

Describe the intrinsic coagulation pathway:

12 → 11 → 9 → 8 → 10 → thrombin (from prothrombin) to fibrin (from fibrinogen)— think 8–12, T, F (test the intrinsic pathway with partial thromboplastin time [PTT])

From Ewald GS, McKezie CR, eds. Manual of Medical Therapeutics, 28th ed. Boston: Little, Brown, 1995, with permission.


Which molecules are responsible for platelet aggregation?

Adenosine diphosphate (ADP), thromboxane, and serotonin

Which enzyme is responsible for thromboxane formation?

Cyclooxygenase

What are the two main products of arachidonic acid?

1. Thromboxane 2. Prostacyclin (PGI2)

Which enzymes are responsible for: Thromboxane?

Prostacyclin?

1. Cyclooxygenase 2. Thromboxane synthetase 1. Cyclooxygenase 2. Prostacyclin synthetase

What is the major source of thromboxane?

Platelets

What is the major source of prostacyclin?

Endothelial cells

Is thromboxane vasodilator or vasoconstrictor?

Vasoconstrictor

Is prostacyclin vasodilator or vasoconstrictor?

Vasodilator

What is the effect of prostacyclin on platelet function?

Inhibits platelet aggregation

How can you remember the function of thromboxane compared with that of prostacyclin?

Thromboxane = thrombosis, thus causes vasoconstriction and platelet aggregation Prostacyclin = cycling of platelets, thus causes platelet cycling by inhibiting thrombosis through vasodilation and inhibition of platelet aggregation

What is the function of platelet-derived growth factor?

It is released from platelets and causes growth and migration of fibroblasts and smooth muscle cells


What effect does nitric oxide have on platelets?

Inhibits platelet aggregation

What do fibroblasts make?

Collagen

How does von Willebrand factor (vWF) work?

It binds the platelet to subendothelial collagen

What is the role of DDAVP on coagulation?

Causes release of vWF and procoagulant factor VIII:C from tissue stores

When should IV calcium be administered following a massive blood transfusion?

Most experts believe that calcium should be infused after 10 units of packed RBCs because of the citrate (a calcium binder)

Do packed RBCs have any clotting factors?

No

What percentage of patients receiving IV heparin develop antiplatelet antibodies?

Up to 10%!

What does the abbreviation “HIT” stand for?

Heparin-Induced Thrombocytopenia

How should HIT be treated?

By stopping the administration of heparin (always monitor platelet counts in patients receiving heparin)

Can heparin prolong PT, as well as partial thromboplastin time (PTT)?

At very high doses, PT can also be prolonged with heparin

How does heparin work?

It activates antithrombin III

What side effect is associated with prolonged (>2 mo) heparin infusion?

Osteoporosis

What disorder may inhibit heparin anticoagulation?

Antithrombin III deficiency

What factors can cause the oxyhemoglobin dissociation curve to shift to the right?

Acidosis, elevated 2,3-diphosphoglycerate (2,3-DPG), fever, elevated PCO2


Give the normal life span for polymorphonuclear neutrophil (PMN) leukocytes:

1d

Which test—PT or PTT— measures the extrinsic clotting system?

PT (think: pet = extrinsic)

Which test—PT or PTT— measures the effect of heparin on the clotting system?

PTT (often reported by the lab as “heparin PTT”)

What substance binds platelets to each other?

Fibrinogen

What binds platelets to collagen?

vWF

What substance binds platelets to vWF?

Platelet glycoprotein Ib (GpIb) [think; GpIb = Grab platelet]

What is Bernard–Soulier syndrome?

A bleeding disorder caused by decreased levels of GpIb, factor V, and factor IX

What is Glanzmann thrombasthenia?

A defect in platelet aggregation caused by the absence of GpIIb and GpIIIa, which bind platelets to fibrinogen and thus to each other

What lab findings are associated with hemolysis?

Increased indirect bilirubin, normal direct bilirubin, decreased hematocrit, decreased haptoglobin

What disorder (other than hemolysis) can cause decreased haptoglobin levels?

Liver disease; haptoglobin, which is synthesized by the liver, is increased in inflammatory reactions (i.e., acute phase reactant)

What is the function of haptoglobin?

Binds hemoglobin and then is cleared by macrophages

Which enzyme causes fibrinolysis?

Plasmin


What substance activates plasmin?

Tissue plasminogen activator (tPA) activates plasmin from plasminogen

How does ε-aminocaproic acid (εACA) work?

εACA is an antifibrinolytic that inhibits plasminogen-to-plasmin conversion, thereby inhibiting fibrinolysis by plasmin

How does aprotinin work?

1. Inhibits fibrinolysis by inhibiting plasmin and kallikrein 2. Promotes platelet adhesion receptors

What does the abbreviation ACT stand for?

Activated Clotting Time

What is ACT?

A widely used measure to assess heparin anticoagulation in the OR

What is an abnormal ACT?

>120 sec

Which medications increase the breakdown of warfarin?

Those which increase cytochrome P-450 liver microsomal enzyme metabolism (e.g., barbiturates, carbamazepine)

What is Christmas disease?

Hemophilia B

What is hemophilia C?

A deficiency of factor XI

Which type of hemophilia is more common in the United States?

Hemophilia A is four times more common than other types

Which blood product, cryoprecipitate or fresh frozen plasma (FFP), has the highest concentration of vWF?

Cryoprecipitate

What is the “universal donor” for FFP?

AB

What is factor VIIa?

Recombinant clotting factor VII; used in hemophiliacs and in exsanguinating patients (e.g., trauma damage-control patient)


What is recombinant factor VIIa?

Genetically engineered factor VIIa used in massive hemorrhage

What is the goal of factors in a preoperative hemophilia A patient?

≥80% factor VIII levels

When do you give cryoprecipitate?

Fibrinogen <100

Blood cell associated with parasites?

Eosinophils

Acronym for diagnosis of eosinophilia?

A MAD PA: Addison’s DZ Malignancy Atheroembolism Drugs Parasites Asthma

Immunoglobulin associated with anaphylaxis?

IgE

What is lupus anticoagulant?

An antibody associated with systemic lupus erythematosus (SLE), procainamide, phenothiazine, hydralazine, quinidine, and HIV infection; it can prolong PTT in vitro, but does not inhibit hemostasis in vivo, and can actually cause thrombotic problems

What effect does uremia have on platelets?

Inhibits platelet function

How should uremic platelet dysfunction be treated?

With dialysis or DDAVP, or both

What can cause a coagulopathy in brain-injured patients?

Brain thromboplastin


What are the three main inhibitors in coagulation regulation?

1. Antithrombin 2. protein C 3. protein S

What does antithrombin do?

Binds factors (heparin accelerates this process)

What does protein C do?

1. Inhibits factors V and VIII 2. Possibly releases tPA

What does protein S do?

Stimulates and enhances the effects of protein C (think protein S = Stimulates protein C)

How should protein C deficiency be treated in the acute thrombotic setting?

Although counterintuitive, FFP is the best source of protein C and heparin, and should be supplemented with antithrombin III, as needed; (Consult a hematologist)

If a patient has a deficiency in protein C, S, or antithrombin III, what is the effect on the coagulation system?

A hypercoagulable state

Which renal disease is associated with a hypercoagulable state?

Nephrotic syndrome with the wasting of proteins, including proteins C and S

What is the effect of hypothermia on clotting?

Inhibits clotting factors and platelet function

Does double gloving lower the incidence of finger blood soilage in the OR?

Yes (so do it!)

On average, how many HIV particles are transmitted on a solid bloody needle: Through one glove? Through two gloves? Which antibiotic can have the side effect of anticoagulation?

10 HIV particles per puncture 1 HIV particle per puncture! Cefotetan


How does ticlopidine work?

Inhibits platelet aggregation by disrupting ADP–induced fibrinogen binding to platelet membrane; ticlopidine is an aspirin substitute, but it has side effects: neutropenia and agranulocytosis

What is posttransfusion purpura?

Thrombocytopenia and purpura due to antiplatelet antibodies after a platelet transfusion (patient has had a previous transfusion)

Who can receive O+ blood as a universal donor?

Males

What is the risk of death from a blood transfusion?

1 in ≈650,000

What is the risk of HIV from a blood transfusion?

1 in 500,000

What is the risk of nonfatal hemolytic transfusion reaction?

1 in 6,000

TRALI What does TRALI (“trolley”) stand for?

Transfusion-Related Acute Lung Injury

What is it?

Lung injury due to blood and/or blood product transfusion (platelets, FFP, PRBC, whole blood, cryoprecipitate)

What are the signs?

Similar to ARDS: patchy infiltrates on chest x-ray (pulmonary edema); difficult to oxygenate with PaO2:FiO2 ratio <300; PCWP <18 or no signs of overload; rapid onset of dyspnea; fever and increased respiratory rate (tachypnea); ± hypotension

Claim to infamy?

Most common cause of death from transfusion

Mortality rate?

5% (5%–25% reported)


Difference between ARDS and TRALI?

TRALI is temporally and mechanistically related to blood or blood product infusion; onset <6 hr posttransfusion

Most common blood products that causes TRALI?

Platelets (whole blood–derived that also has plasma) and FFP

Cause of TRALI?

Most likely multifactorial; probably involves antibodies that activate PMNs/leukocytes

Treatment?

Supportive, and of course then limit all blood and blood product transfusions

Prognosis?

Most patients recover by 72 hr

THROMBOELASTOGRAPHY (TEG) What is TEG?

Thromboelastography, a.k.a. TEG

What does it do?

Measures the combination of all of the clotting factors and platelets and how efficiently they form a clot

How does it work?

Small cup of blood rotates around a sensor rod; as the blood clots, there is more resistance in the system, which is graphed in real time

What are the four parameters in a TEG graph?


Define what the following TEG parameters represent: R time?

R time is the time until clot formation

K time?

K time is the time from the beginning of clot formation (R time) until 20 mm, and represents clot formation speed

Alpha angle?

Represents the tangent of the clot formation and represents clot formation speed

MA?

Maximum Altitude; represents the maximum clot strength

What does fibrinolysis look like on TEG?

Lysis of clot results in decreased MA

What does the TEG look like with decreased platelets or with platelet dysfunction?

Decreased MA and normal R time (normal alpha angle and prolonged K time)

What does the TEG look like with decreased clotting factors or on heparin?

Decreased MA and prolonged R time (Alpha angle decreased and K time prolonged as well)

What is ROTEM?

Rotational thromboelastometry

Chapter 25 / Surgical Hemostasis 173

Chapter 25 Surgical Hemostasis What is the motto of Bovie hemostasis?

“Charcoal doesn’t bleed”

What is bipolar electrocautery?

Coagulation between two electrocauter electrodes

What two factors need to be in place before bipolar coagulation will work?

1. Gap between the metallic electrodes 2. Electrolyte-containing fluid between electrodes

Does bipolar coagulation require a grounding pad?

No

What antibiotic is associated with causing a coagulopathy?

Cefotetan; a side chain (methylthiotetrazole, if you must know) increases partial thromboplastin time (PTT)


What IV colloid fluid is associated with a coagulopathy?

Hespan (if >1,500 mL infused)

Define the following:

Avitene

Collagen powder or sheets; acts as a matrix for clotting factors/platelets

Argon beam coagulator

Argon gas coagulator for topical hemostasis by heat; excellent for liver oozing

CUSA

Cavitron Ultrasonic Surgical Aspirator: Acoustic vibrator breaks up tissue and then aspirates the debris; it is used to dissect liver parenchyma while sparing vessels that are then coagulated

Surgicel

Sheets of cellulose matrix which enhance clotting. There are two common types: Original and Fibrillar; the Fibrillar form is more like cotton

Ultrasonic coagulators

Creates protein denaturing from ultrasonic vibrations rather than direct heat which correlates to less heat transfer to surrounding tissues

Chapter 26 / Surgical Medications 175

Chapter 26 Surgical Medications Define the mechanism of action for each of the following medications: Quinolones

Inhibit DNA gyrase

Promethazine

Antinausea agent; affects medullary chemoreceptor trigger zone

Haloperidol

Competitive blocker of postsynaptic dopamine receptors in the brain (contraindicated in patients with Parkinson’s disease)

Misoprostol

Prostaglandin analog for gastric cytoprotection

Cyclosporine

Inhibits interleukin (IL)-2

FK-506

Inhibits secretion of IL-2 and blocks IL-2 receptors

Bacitracin

Inhibits bacterial cell walls, mostly gram-positive coverage; used for peritoneal irrigation and topically only because it causes severe nephrotoxicity if given systemically

Digoxin

Inhibits the Na+-K+-ATPase, which leads to an increase in intracellular Ca+ (positive inotrope and negative chromotrope)

Streptozocin

Selective uptake and death of pancreatic β cells

Sulfasalazine

Cleaved into two compounds: 5-aminosalicylate (5-ASA) and sulfapyridine (which is absorbed); the 5-ASA stays in the gut and most likely wreaks havoc with the arachidonic pathways


Acetazolamide (Diamox)

Carbonic anhydrase inhibitor that results in urinary excretion of bicarbonate; use for metabolic alkalosis

Aminocaproic acid (Amicar)

Inhibits plasminogen activators and plasmin; clot stabilization

Argatroban

Inhibits thrombin; causes anticoagulation in HITT (There is no antidote)

Bumetanide (Bumex)

Diuretic; works on ascending loop of Henle; results in excretion of K+, Na+, Cl−, and H2O

Dalteparin (Fragmin)

Anticoagulant that binds AT-III and increases inactivation of thrombin (IIa), Xa, IXa, XIa, and XIIa; used for DVT prophylaxis

Lepirudin (Refldan)

Anticoagulant from leeches (Hirudin) that causes direct thrombin inhibition; used in HITT

Dexamethasone (Decadron)

Has 30 times the potency of hydrocortisone

Fenoldepam (Corlopam)

Dopamine-1 receptor agonist; results in increased renal blood flow; may lower blood pressure

Glycopyrrolate (Robinul)

Antisialagogue (decreases saliva); used in anesthesia

Milrinone (Primacor)

Phosphodiesterase inhibitor; positive inotrope, vasodilator

Metoprolol (Lopressor)

β-1 adrenergic blockade (β-1 selective blocker)

Ondansetron hydrochloride (Zofran)

Serotonin antagonist (5-HT3 receptor); used for perioperative nausea and vomiting

Phenoxybenzamine (Dibenzyline)

α-adrenergic antagonist; used for preoperative pheochromocytoma patients (think PHEochromocytoma = PHEnoxybenzamine)


Phenylephrine (Neo-Synephrine)

α-adrenergic agonist; used by anesthesia for hypotension

Neostigmine (Prostigmin)

Anticholinesterase; used for Ogilvie colon pseudoobstruction and paralytic reversal

Propranolol (Inderal)

Nonselective β-blocker

ENDOCRINE MEDICATIONS What is the most common cause of adrenal insufficiency in surgical patients?

Suppression of the hypothalamicpituitary-adrenal axis by therapeutic steroid administration

How long after the discontinuation of chronic steroid use is a patient at risk for adrenal insufficiency?

Up to 1 yr

What is the treatment of choice for acute adrenal insufficiency?

100 mg of hydrocortisone, every 8 hr

What are the medical options in the treatment of diabetes insipidus?

Free access to water DDAVP (10–40 μg via nasal spray, qd) Pitressin (IM administration of 5–10 U every 24–48 hr)

What is the major difference between DDAVP and pitressin?

DDVAP has no vasoconstriction effect! (Pitressin does)

MISCELLANEOUS AGENTS How long would it take to replenish depleted stores of iron with typical Fe therapy (200– 400 mg/d of elemental Fe)?

3–6 mo

Which nebulized medication is contraindicated in patients allergic to sulfa?

Acetylcysteine, which contains sulfa

Who should not receive cephalosporins?

Patients with a history of anaphylaxis, swelling/edema, or hives after receiving penicillin, because cross-reactivity occurs in ≈8% of cases


Give the relative antiinflammatory potency of the following substances, with cortisol as 1: Hydrocortisone

1

Prednisone

4

Prednisolone

4

Methylprednisolone

5

Dexamethasone

30 (Think: Dex = 10 ≥ 10 × potency)

Which drug is used to treat refractory hiccups?

Thorazine

Does acetaminophen affect platelet function?

No

Which medications increase the metabolism of warfarin?

Any drugs that increase the cytochrome P-450 microsomal enzyme system in the liver (e.g., barbiturates)

Classically, what two types of patients should avoid β-blockers?

Patients with asthma or reactive airway disease, because β-blockers can cause bronchospasm (albuterol is a β-agonist) Patients taking a calcium channel blocker IV

What is the major side effect of imipenem?

Seizures

Which electrolyte will cause muscles/skin necrosis if infused subcutaneously (i.e., IV infiltration)?

Calcium

When a patient does not respond to a dose of furosemide, should the dose be repeated? Increased? Decreased?

Double the dose if the patient does not respond to the initial dose


Why can shortness of breath be alleviated more quickly than diuresis in patients with CHF who are being treated with furosemide?

Because furosemide is a venodilator and thus increases the venous capacitance faster than the diuresis

Which medication is used to treat promethazine-induced dystonia?

IV administration of diphenhydramine hydrochloride

How is theophylline administered intravenously?

It is not; there is no IV form of theophylline; give IV aminophylline instead

What is the antidote for acetaminophen overdose?

Acetylcysteine

What drug is used to treat malignant hyperthermia?

Dantrolene

What drug is used to treat a brown recluse spider bite?

Dapsone

What must be ruled out before starting dapsone?

Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency

What antibiotic can be an anticoagulant?

Cefotetan


What is the treatment for β-blocker overdose?

Glucagon (Yes, glucagon!)

Which vitamin deficiency is often seen with long-term antibiotic use?

Vitamin K

What is the dose of epinephrine 1:1,000?

1 g in 1 L, or 1 mg/mL

What is the dose of epinephrine 1:10,000?

1 g in 10 L, or 100 μg/mL (1 mg per 10 mL)

How should most patients (not older persons) be dosed for gentamicin these days?

Once daily

Why the change in gentamicin dosing?

Same efficacy, but less nephrotoxicity in younger persons

What is the usual dose for once daily or “extended-interval dosing” for gentamicin?

5–7 mg/kg; then check blood levels and adjust by nomogram

Side effect of etomidate?

Adrenal insufficiency

What drug is used to treat “phantom limb” pain?

Neurontin

Chapter 27 Complications ATELECTASIS Why would high levels of inspired oxygen cause atelectasis?

High levels of oxygen eliminate the nitrogen in the normal alveoli that help keep them open

PULMONARY EDEMA What are the symptoms of pulmonary edema?

Dyspnea, cough productive of frothy sputum, tachypnea, rales, and cyanosis

Chapter 27 / Complications 181

What are Kerley B lines?

On chest radiograph, straight lines (not curly!) from fluid thickening of the lung interstitium (B lines horizontal)

What is cephalization on a chest radiograph?

Increased pulmonary vascular markings superiorly (toward the head) resulting from increased pulmonary venous pressure

What is the appropriate treatment?

1. Oxygen 2. Furosemide (diuresis) 3. If ventilated, continuous positive airway pressure/positive end-expiratory pressure (CPAP/PEEP) 4. Vasodilators and dobutamine as needed (prn) 5. Treatment of the underlying cause

In chronic heart failure, why does furosemide begin to work before the resulting diuresis?

It also causes systemic venous dilation and a subsequent decrease in preload

THYROID STORM What is thyroid storm?

Severe hyperthyroidism

What is the risk factor?

Hyperthyroidism

What events trigger this condition?

Infection, acute abdomen, surgery, trauma, any severe stressor in an already thyrotoxic patient

What are the signs and symptoms?

Fever, tachycardia, psychosis, delirium/ confusion, abdominal pain, nausea/ vomiting, diaphoresis, CHF, pulmonary edema, tremors, hypertension, fever


1. Supportive therapy (oxygen, fluids, fever reduction) 2. Propranolol 3. Propylthiouracil, iodide 4. Hydrocortisone

What is the mortality rate?

10%–20%


FAT EMBOLI SYNDROME What is fat emboli syndrome?

Embolization of fat particles

What are the risk factors?

Fractures of the long bones, trauma

What are the signs?

Bergman’s triad (mental status changes, petechiae, and dyspnea); chest radiograph picture similar to acute respiratory distress syndrome (ARDS) because fat particles cause pneumonitis

What are the complications?

Respiratory failure, disseminated intravascular coagulation (DIC)

What is the treatment?

Ventilator/support with PEEP as necessary, ± steroids, and treatment of DIG (if it develops)

GASTROINTESTINAL COMPLICATIONS Blind Loop Syndrome What are the differential diagnoses of blind loop syndrome?

Stricture of the intestine, Crohn’s disease, postvagotomy syndromes, scleroderma, small-bowel diverticula, decreased gastric acid secretion, incompetent ileocecal valve

What are the signs/symptoms?

Diarrhea, steatorrhea, malnutrition, abdominal pain, hypocalcemia, megaloblastic anemia, vitamin B12 deficiency, iron deficiency


Surgical correction of the underlying disorder causing the stasis, if feasible; otherwise, antibiotics to inhibit bacterial overgrowth

Pouchitis What is pouchitis?

Inflammation of the pouch of an ileoanal pull-through anastomosis/usually after a colectomy for ulcerative colitis


Fever, abdominal cramping, increased frequency of liquid stools



Metronidazole PO

Postgastrectomy Complications What is a postgastrectomy syndrome?

A syndrome of complications following gastrectomies

Name the eight types of postgastrectomy syndromes:

1. 2. 3. 4. 5. 6. 7. 8.

Afferent loop syndrome Efferent loop syndrome Postvagotomy diarrhea Dumping syndrome Roux stasis syndrome Alkaline (bile) reflux gastritis Chronic gastric atony Small gastric remnant syndrome

AFFERENT LOOP SYNDROME What is afferent loop syndrome?

Obstruction of the afferent loop of a Billroth II (afferent loop is the proximal duodenum/jejunum loop draining bile toward the gastrojejunostomy) Site of obstruction with afferent loop syndrome

Afferent loop

Efferent loop

What is the efferent loop?

The distal loop draining away from the stomach (think: efferent = egress)


What is the incidence?

Less than 1%

What are the causes?

Kinking, intussusception, adhesions, volvulus, hernias of the afferent loop

What are the associated risks?

Long afferent loop Antecolic anastomosis Anastomosis to a lesser curvature of the stomach

What are the signs/symptoms of acute onset?

Abdominal pain, epigastric mass, nonbilious (usually in first wk), vomiting, nausea, fever

What are the signs/symptoms of chronic disease?

Abdominal pain relieved by pure bile emesis (from decompression of the obstructed afferent loop)

What is the dreaded complication?

Duodenal stump blowout

What mortality rate is associated with acute onset?

Approximately a third! (surgical emergency)

How is the diagnosis of acute disease confirmed?

Fluid-filled epigastric mass on ultrasound or CT

How is the diagnosis of chronic disease confirmed?

Esophagogastroduodenoscopy (EGD; to rule out alkaline reflux gastritis)


Convert Billroth II to a Roux-en-Y of the afferent loop 40–50 cm from the gastrojejunostomy on the efferent limb

EFFERENT LOOP SYNDROME What is efferent loop syndrome?

Obstruction of the efferent loop, or at the anastomosis of the gastric remnant to the efferent loop

What causes it?

Adhesions, volvulus, hernia, omental wrap with fibrosis of the omentum, tight mesocolon tunnel, anastomotic stricture

How is the diagnosis confirmed?

Upper GI barium series, EGD



Surgical correction of the obstruction or balloon dilatation of stricture

POSTVAGOTOMY DIARRHEA What is postvagotomy diarrhea?

Diarrhea after a truncal vagotomy

What causes it?

It is thought that after truncal vagotomy, rapid transport of unconjugated bile salts to the colon causes osmotic inhibition of water absorption in the colon, resulting in diarrhea


Approximately one-third of patients will have diarrhea after a truncal vagotomy, but only ≈1% will have severe diarrhea Lying down after eating Octreotide Ingestion of carbohydrates to raise blood glucose (for late dumping syndrome)

What percentage of patients with dumping syndrome resolve with medical treatment?

≈75% in <1 yr

If medical therapy fails, what is the appropriate surgical treatment?

1. Roux-en-Y 2. Henley jejunal interposition 3. Billroth II converted to a Billroth I

ROUX STASIS SYNDROME What is Roux stasis syndrome?

Stasis of chyme in the gastric remnant

What causes it?

Loss of normal gastric motility (loss of migration of the normal pacemaker motor waves)

What are the associated signs/symptoms?

Abdominal pain, nonbilious vomiting, nausea postprandially


Endoscopy (rule out outlet obstruction/ ulcer) Emptying study


What is the appropriate medical treatment?

Metoclopramide (Reglan), erythromycin

What is the appropriate surgical treatment?

Subtotal gastrectomy with >75% stomach removed

ALKALINE (BILE) REFLUX GASTRITIS What is alkaline reflux gastritis?

Reflux of bile into the stomach after a Billroth I, Billroth II, or pyloroplasty


Epigastric burning, abdominal pain, nausea, weight loss, anemia, bilious vomiting

How do the symptoms compare with those of afferent loop syndrome?

With reflux gastritis, the bilious vomiting does not relieve the symptoms as it does in chronic afferent loop syndrome


Diarrhea


Cholestyramine (binds bile salts), Lomotil (after ruling out Clostridium difficile)


Reversed interposition jejunal segment or Roux-en-Y for refractory cases

What is a reversed interposition jejunal loop?

10 cm


DUMPING SYNDROME What is dumping syndrome?

Delivery of hyperosmotic chyme to the small intestine (normally the stomach will decrease the osmolality of the chyme prior to its emptying); late dumping is thought to be caused by hypoglycemia

With what conditions is it associated?

Any procedure that bypasses the pylorus or compromises its function (i.e., gastroenterostomies or pyloroplasty), thus “dumping” of chyme into the small intestine


Postprandial diaphoresis, tachycardia, abdominal pain/distention, emesis, increased flatus, dizziness, weakness, weight loss, mental status changes


Small, multiple, low-fat, low-carbohydrate, high-protein meals Avoidance of liquids with meals to slow gastric emptying

What is the major risk factor for alkaline reflux gastritis?

Billroth II


EGD reveals gastritis/bile Biliary scan (pooling in stomach remnant)


H2 blockers, cholestyramine, metoclopramide, sucralfate


1. Conversion to Roux-en-Y 2. Braun enteroenterostomy 3. Henley jejunal interposition

CHRONIC GASTRIC ATONY What is chronic gastric atony?

Delayed gastric remnant emptying following vagotomy

What are the associated risk factors?

Diabetes, smoking, alcohol, Roux-en-Y


What are the associated signs/ symptoms?

Epigastric pain, nausea, early satiety, weight loss, anemia, postprandial exacerbation


EGD (to rule out ulcer/obstruction) Gastric emptying study


Small meals, cessation of smoking and/or alcohol, metoclopramide


Near total gastrectomy with Roux-en-Y (Roux-en-Y without gastric resection is disastrous)

SMALL GASTRIC REMNANT SYNDROME What is small gastric remnant syndrome?

Loss of gastric reservoir and vagalmediated receptive gastric relaxation in patients with >80% gastric resection and vagotomy


Early satiety, epigastric pain, weight loss, anemia, malnutrition


EGD (to rule out obstruction, ulcer, bezoar, cancer)


Small meals, liquid supplements


Jejunal pouch reconstruction

ADRENAL INSUFFICIENCY Signs of adrenal insufficiency in ICU patients?

Hypotension refractory to pressors or requiring very high doses of pressors, abdominal pain

Induction agent associated with adrenal insufficiency?

Etomidate

Best time of day to check a random cortisol on a sick ICU patient?

There is no best time; sick ICU patients have no diurnal cortisol variation


Random cortisol value associated with adrenal insufficiency in a sick ICU patient?

<15

ACTH stimulation test value associated with adrenal insufficiency in sick ICU patients?

Increase in serum cortisol of <9

Medication for adrenal insufficiency in a sick ICU patient

Hydrocortisone 50–100 mg IV Q 8

IV steroid that will not affect serum cortisol measurements?

IV dexamethasone

HEPARIN-INDUCED THROMBOCYTOPENIA What is HIT?

Heparin-induced thrombocytopenia

Bedside sign of HIT?

Skin necrosis at sites of subcutaneous heparin injection

Timing of HIT?

If the patient has had previous exposure to heparin, the onset may be within hours; classically, however, it takes 5 d of exposure for HIT to develop and it is seen most commonly 5–14 d after initiating heparin

Classic lab findings?

Platelet count decreases 30%–50% below baseline 5–14 d after starting heparin

Incidence of antibody-mediated HIT?

3%–5% in IV unfractionated heparin infusions but lower with low-molecularweight heparin (LMWH) and lower doses of unfractionated heparin (e.g., prophylaxis)

What is HITT?

Heparin-induced thrombocytopenic thrombosis (thrombocytopenia and clot formation)

Lab test for diagnosing antibody-induced HIT?

Dropping platelet count; check for heparin PF4 antibodies


What is PF4?

Platelet factor 4 released from α granules of platelets

What causes HITT?

Heparin binds with PF4 and then an antibody forms to the heparin-PF4 complexes; heparin-PF4 antibody causes aggregation of the platelets Heparin Formation of PF4-heparin complexes

PF4

IgC antibody Formation of immune complexes (PF4-heparin-IgC)

Fc receptor Platelet

Platelet activation*

Microparticle release

Where do clots form in HITT?

Any artery or vein, but commonly affects the iliac and femoral arteries and distal aorta (form “white clot”)

Tests to help confirm HITT?

Heparin-PF4 antibody (ELISA), heparin platelet serotonin release assay, and platelet aggregometry


Treatment of HITT?

Stop all heparin and heparin coatings; if an anticoagulant is needed, consider hirudin (Lepirudin) or Argatroban

How are these anticoagulants given and monitored?

IV infusion and check aPTT

How are they cleared by the body?

Think alphabetically: Argatroban = Hepatic clearance Lepirudin = Renal (thus give Argatroban in renal failure)

Can you use LMWH (Lovenox) with HITT?

No

Can you use warfarin alone to treat HITT?

No; warfarin decreases protein C and can worsen HITT; always use an anticoagulant with the initiation of Coumadin

Mortality of HITT?

Up to 25%

MISCELLANEOUS What nutritional problems can follow gastrectomy?

Deficiencies of vitamin B12 (by loss of intrinsic factor), folate, iron, and calcium; weight loss caused by poor food intake; bacterial overgrowth; steatorrhea because of loss of pancreatic enzymes (loss of vagal stimulation)

What is the incidence of gastric cancer following a partial gastrectomy?

Probably slightly increased, usually after 20 yr

What is the incidence of cholelithiasis after truncal vagotomy?

Increased, most likely because of decreased emptying of the gallbladder and decreased opening of the sphincter of Oddi; higher incidence after truncal vagotomy with total gastrectomy

Complications of giving neostigmine for nonobstructive colonic distention (Ogilvie syndrome)?

1. Bradycardia (Have atropine in the room!) 2. Colonic perforation


Classic complication after removal of lymph node in the posterior neck triangle?

Spinal accessory nerve injury

Complication from an undrained ear pinna hematoma?

Cauliflower ear

Complication of an undrained nasal septal hematoma?

Septal necrosis

Complication if you shave the eyebrows?

Sometimes they do not grow back!

Complication of hurricane spray?

Methemoglobinemia

Complication of using a Bovie electrocautery to open the trachea during a tracheostomy?

Airway combustion!

Complication from long-term heparin use?

Osteopenia (osteoclast activation)

What skin complication is associated with warfarin?

Skin necrosis (due to vein thrombosis due to decreased protein C deficiency)

Which anticoagulant should be prescribed for pregnant patients?

Heparin (Never use warfarin, which may cause birth defects!)

Chapter 28 Common On-Call Pages TRACHEOSTOMY COMPLICATIONS Describe the mechanism of tracheoesophageal fistula formation:

Pressure necrosis by tracheostomy tube in apposition to nasogastric tube (NGT)

Chapter 28 / Common On-Call Pages 193

What are the symptoms?

1. Marked increase in tracheal secretions 2. Gastric distention 3. Hypoxia

What diagnostic test is indicated?

Bronchoscopy


Surgical repair

Describe the mechanism of tracheoinnominate artery fistula formation:

Pressure necrosis by tracheostomy tube against the innominate artery

What symptom is associated with the disorder?

Tracheal bleeding—ranging from minor (known as a “herald” bleed) to exsanguinating

What diagnostic test is indicated with minor bleeding?

Bronchoscopy

What is the Utley maneuver?

Direct digital innominate artery pressure through the tracheostomy stoma (with finger in or anterior to trachea), to control massive tracheostomy bleeding

What else can be tried to control bleeding?

Hyperinflation of the tracheal cuff


Surgical repair

ENDOCRINE EMERGENCIES Diabetic Ketoacidosis Who is at risk for diabetic ketoacidosis (DKA)?

Patients with type I diabetes mellitus, following cessation of insulin therapy or stress that renders an insulin dose inadequate

What are the possible precipitants?

Infection, traumatic injury, MI, surgery


What is the pathogenesis?

The ratios of glucagon, growth hormone, catecholamines, and cortisol to insulin increase, causing unrestrained glycogenolysis, gluconegogenesis, and ketogenesis


Vomiting, polyuria, thirst, weakness, altered mental status, abdominal pain, orthostasis, and hyperventilation

What diagnostic laboratory results are typical?

1. 2. 3. 4. 5.


1. Administer insulin and glucose to maintain serum glucose levels between 200 and 300 mg/dL 2. Administer isotonic saline until hypovolemia is corrected, then one-half normal saline 3. Administer potassium when levels are <4.5 mEq/L 4. Administer phosphorus, as needed 5. Administer bicarbonate when DKA is accompanied by shock, when pH is <7.1, or with severe hyperkalemia

What are the possible complications?

1. Shock caused by hypovolemia or acidosis 2. Vascular thrombosis 3. Cerebral edema 4. Hypokalemia 5. Hypophosphatemia

Hyperglycemia Ketoacidosis Pseudohyponatremia Elevated serum potassium Urine ketones

NEUROLOGIC COMPLICATIONS Seizures What is status epilepticus?

Continuous seizure activity beyond 5 min, or at least two sequential seizures without full recovery of consciousness


What initial actions should be taken when a patient experiences a seizure?

Use the ABCs of life support: 1. Administer oxygen by nasal cannula or mask 2. Position head for optimal airway patency; intubate if necessary 3. Monitor ECG 4. Establish IV access and order appropriate laboratory tests 5. NGT to decompress the stomach and decrease the chance of massive aspiration

What laboratory tests should be ordered immediately?

Electrolytes, antiepileptic drug levels (if applicable), arterial blood gases, hemogram, urinalysis, bicarbonate (low levels associated with seizures secondary to local areas of anaerobic metabolism)

What is the initial treatment?

Benzodiazepines and phenytoin (Dilantin) (in different IVs)

What is secondary treatment if refractory?

1. Propofol 2. Phenobarbital

What are the five most common precipitants of status epilepticus in adults?

1. Cerebrovascular phenomena (cerebrovascular accident, tumor, subarachnoid hemorrhage, etc.) 2. Medications (e.g., imipenem) 3. Anoxia 4. Alcohol or drug withdrawal 5. Metabolic/electrolyte imbalances

Digoxin Toxicity What are the symptoms?

1. Fatigue, visual disturbances, anorexia 2. Bradyarrhythmias (second- or thirddegree atrioventricular block) 3. Tachyarrhythmias (VT or VF) 4. Hypokalemia

What is the frequency?

2%–5% of hospitalized patients on digoxin

What is the emergent treatment for life-threatening toxicity?

Digoxin-specific antibody fragments


Alcohol Withdrawal What are the symptoms of alcohol withdrawal at the following intervals: After 6–8 hr?

Tremulousness and irritability

At 8–12 hr?

Hallucinosis (usually auditory)

At 12–24 hr?

Generalized withdrawal seizures

At 3–4 d?

Delirium tremens: confusion, delusions, hallucinations, tremor, agitation, autonomic overactivity (dilated pupils, fever, tachycardia, diaphoresis)

How is it treated?

1. Supportive therapy: fluids, thiamine, and folate 2. Benzodiazepines (e.g., chlordiazepoxide, lorazepam [Ativan]) 3. ± Clonidine

Delirium Describe delirium:

A patient is disoriented to person, place, or time with fluctuating levels of consciousness; hallucinations, usually visual, may also occur

What is the usual perioperative timing of onset?

Onset occures at approximately the third postoperative day, although it can obviously occur at any time, depending on the patient and the circumstances

What is the treatment approach?

1. Check electrolytes, obtain complete blood cell count (CBC), urinalysis, and oxygen saturation to assure that mental status changes do not have a simple organic cause 2. If the patient is not frankly psychotic or agitated, reassurance may be all that is needed 3. If restlessness continues, sedate the patient with haloperidol (Haldol)


With what ECG finding is haloperidol contraindicated?

Prolonged QT interval

When is a CT scan indicated?

If the condition persists with no identifiable systemic cause, or with focal findings of any type

ANAPHYLAXIS What is anaphylaxis?

An acute allergic response mediated by immunoglobulin (Ig) E-stimulating release of histamine, leukotrienes, kinins, and prostaglandins from mast cells and basophils

What are the precipitants?

1. 2. 3. 4. 5. 6.


Pruritus, urticaria, angioedema, laryngeal edema, laryngeal spasm, bronchospasm, and vascular collapse


1. Airway control 2. Epinephrine 0.5 mg (5 mL of 1:10,000 solution) IV, repeat as needed 3. Oxygen 4. Fluids to maintain blood pressure 5. Diphenhydramine 6. Steroids

How much epinephrine is in 1 mL of: Epi 1:100,000? Epi 1:10,000?

Drugs Transfusions Contrast agents Insect stings Foods Latex

100 μg (1 g/10 L = 100 mg/1 L) 1 mg (1 g/l L = 1 mg/1 mL)

EPISTAXIS What is the most common site of epistaxis?

In the inferior portion of the nasal septum in Kiesselbach triangle (90% of bleeds occur here)


Define the Kiesselbach triangle:

A plexus of vessels in the anteroinferior part of the septum

What is the appropriate treatment of bleeds at this site?

Simple pressure and a topical vasoconstrictor

What is the appropriate treatment for a patient bleeding from the posterior nasal cavity?

1. Patients can swallow a great deal of blood while bleeding from this site; first assess their overall volume status to assure that they are not in shock 2. Obstruct the bleed with an inflated Foley balloon, or with a nasal pack of gauze and 2-0 silk; give prophylactic antibiotics to prevent sinusitis and otitis media. Obtain ENT consult

What is the usual relationship between hypertension and epistaxis?

When they occur together, hypertension is often the result of patient anxiety; rarely is it the cause of the bleed, but an ongoing bleed may persist until pressure is lowered

Chapter 29 Surgical Nutrition ASSESSMENT What is the Harris–Benedict equation?

An equation for calculating basal energy expenditure (BEE) in kcal/d

What is the Harris–Benedict equation for men?

66 + (13.7 × wt/kg) + (5 × ht/cm) − (6.8 × age)

What is the Harris–Benedict equation for women?

65 + (9.6 × wt/kg) + (1.7 × ht/cm) − (4.7 × age)

What is the formula for respiratory quotient (RQ)?

RQ = V.CO2/V.O2

What does an RQ 0.7 indicate?

Starvation or underfeeding (ketosis)

What does an RQ of 0.7 indicate?

The majority of substrate oxidized is fat

Chapter 29 / Surgical Nutrition 199

What does an RQ of 0.8–0.85 indicate?

A balanced mixture of substrates are oxidized

What does an RQ of 1 indicate?

The majority of substrate oxidized is carbohydrate

What does an RQ >1 indicate?

Lipogenesis or overfeeding

What is nitrogen balance?

The difference between the amount of nitrogen ingested and the amount excreted

What is the formula for nitrogen balance?

Nitrogen in (dietary protein divided by 6.25) − Nitrogen out (urinary nitrogen + GI nitrogen loss + skin nitrogen loss)

What is average daily GI nitrogen loss?

2–4 g

What is the average daily skin nitrogen loss?

1–4 g

What does a positive nitrogen balance indicate?

More protein ingested than excreted, indicating net anabolism

What does a negative nitrogen balance indicate?

More protein excreted than ingested, indicating net catabolism

What is the nitrogen balance goal?

In critical illness, equilibrium is the goal; positive nitrogen balance is more likely during recovery

MISCELLANEOUS When does refeeding syndrome manifest?

Within 2 d after starting parenteral nutrition, and ≈5–7 d after starting enteral nutrition

What conditions or (nonnutritional) treatments can increase serum prealbumin?

Renal failure; corticosteroid use

What is “immunonutrition”?

Nutrition fortified with nucleotides, arginine, omega-3 fatty acids, and glutamine to augment immune function (efficacy under study)


What is Kwashiorkor syndrome?

Protein deficiency

What is marasmus?

Semistarvation (calories and protein deficiency)

With a normal gut mucosa, is there any advantage to using elemental tube feeding?

No, except elemental tube feeding has a lower incidence of tube clogging!

What feeding route has been shown to hasten the closure of an enterocutaneous fistula?

TPN

What are the best amino acids for patients with liver failure?

Controversial: Branched-chain amino acids (aromatic amino acids are thought to convert to false neurotransmitters)

What is the formula for estimating daily caloric need?

Oxygen consumption (V.O2) × 7

Amino acid precursor for nitric oxide (EDRF)?

L-arginine

Side effects of copper deficiency?

Pancytopenia

Primary nutrient for cancer cells?

Glutamine

How and where is lactate metabolized to glucose?

In the liver: lactate to pyruvate to glucose

Memory aid for colon major nutrient?

Butyrate (think the butt [butyrate] is close to the colon)

Side effect of vitamin E deficiency?

Neuropathy

Side effect of vitamin D deficiency?

Osteomalacia (rickets)

At what residual level do you hold tube feedings?

>200 cc

Chapter 30 / Shock 201

Chapter 30 Shock What is the classic Dr. Gross quote on shock? Define the following: Gastric tonometry

Shock is the “rude unhinging of the machinery of life.” (Samuel Gross, 1872)

Evaluation of shock by monitoring gastric intramucosal pH via a modified nasogastric tube

Inflammatory shock

Shock caused by release of inflammatory factors (e.g., septic shock, reperfusion injury, trauma)

Tissue oximetry

Measures tissue oxygen levels directly from peripheral tissue bed (e.g., muscle) by percutaneously placed probe

Washout phenomenon

Increased lactic acid levels with improved perfusion due to “washout” of lactic acid from previously underperfused tissue beds (conflicting laboratory vs. clinical pictures)

SIRS

Systemic Inflammatory Response Syndrome; manifested by fever, leukocytosis, increased heart rate, increased respiratory rate

Sepsis

SIRS plus documented infection

Septic shock

Sepsis with hypotension refractory to fluid resuscitation

Can a patient be both hypertensive and hypovolemic?

Yes, with increased vascular tone from increased sympathetic release

Can a patient have normal blood pressure and be in shock?

Yes, especially if the patient is normally hypertensive

What is the most common cause of hypotension in patients with closed-head injury?

Hypovolemic shock; NEVER assume that hypotension is due to head injury


At what pH would most give bicarbonate IV for acidosis?

7.2 (especially when CO2 pulmonary elimination is not impaired)

What is the lethal triad in hemorrhagical shock?

ACH: Acidosis, Coagulopathy, Hypothermia

What are the basic moves to rewarm a patient?

Warmed IV fluids/blood, warm room (hot lights, thermostat), warmed gases in ventilator, Baer hugger

What is a Baer hugger?

A plastic blanket with hot air circulating inside

What is the mortality of septic shock?

50%

What is the cause of gram-negative septic shock?

Endotoxin = lipopolysaccharide (LPS), which then causes release of inflammatory factors and subsequent decrease in vascular tone

In septic shock, what is the classic cardiac output?

Elevated due to increased heart rate, but with decreased contractility

What pressors are used for septic shock?

Norepinephrine, dopamine

Is a lower body temperature (<35.5°C) a good sign in septic shock?

No; it is associated with higher mortality rate

What pressors are used in refractory neurogenic shock?

Phenylephrine, norepinephrine (always only after fluid administration)

LACTIC ACID What are the laboratory “end points” of resuscitation?

Lactic acid and base deficit are most commonly used

What base deficit is associated with a 25% mortality in trauma patients?

−12 mmol/L

Chapter 30 / Shock 203

What base deficit is associated with a 50% mortality in trauma patients? In trauma patients, what is the associated mortality until normalization of lactic acid for the following times postinjury: <24 hr?

−15 mmol/L

≈0% mortality

24–48 hr?

22% mortality

>48 hr?

86% mortality

In anaerobic metabolism (glycolysis) how many adenosine triphosphates (ATPs) are produced?

Two ATPs

In aerobic metabolism (glycolysis) how many ATPs are produced?

36 ATPs

What is lactate produced from?

Glycolysis of glucose during anaerobic glycolysis (glucose → 1 lactate + 2 ATP + H2O)

In what organs are lactate and lactic acid metabolized?

Liver and kidney mostly, but lactic acid is metabolized in all cells except RBCs

How is lactic acid metabolized?

Back to glucose or CO2 + and H2O (lactate → pyruvate → glucose)

How is lactate cleared from the bloodstream?

50% liver, 25% renal

Other than hemorrhagic shock, what else can cause an increase in lactic acid?

Thiamine deficiency, seizure, malignancy, liver failure

If given perioperatively, what can cause an increase in lactate?

Glucophage, metformin


Chapter 31 Surgical Infection BACKGROUND AND GENERAL INFORMATION What is the most common: Nosocomial infection?

Urinary tract infection (UTI)

Cause of death from a nosocomial infection?

Pneumonia

Bacteria causing upper respiratory tract infection (URTI)/pneumonia <5 d in the intensive care unit (ICU)?

Gram-positive

Bacteria causing pneumonia in the ICU >5 d?

Gram-negative

Cause of UTI in surgical patients?

Escherichia coli (second: Pseudomonas)

Cause of pneumonia in surgical patients?

Pseudomonas aeruginosa (second: Staphylococcus aureus)

Cause of wound infections?

S. aureus (second most common: tie between E. coli and Enterococcus)

Cause of bacteremia in surgical patients?

Coagulase-negative Staphylococcus (second: S. aureus)

Cause of intra-abdominal Candida infections?

Severe pancreatitis

Device associated with nosocomial bacteremia?

Intravascular catheters in >75% of cases!

When should you systemically treat a fungal wound infection?

1. Positive Candida blood culture 2. Failure of antibacterial agents to clear the wound of infection 3. All sternal wound infections with positive Candida cultures

Chapter 31 / Surgical Infection 205

ANTIBIOTICS What are prophylactic antibiotics?

Antibiotics used to prevent infection

What are empiric antibiotics?

Antibiotics used to treat an infection without identifying the specific bacteria based on previous experience (culture results and sensitivity)

What if you start empiric antibiotics and the bacteria causing the infection is not susceptible?

Mortality rate increases for VentilatorAssociated Pneumonia (VAP) and bacteremia

What are the indications for antibiotics with wound infections?

First, always open the incision; antibiotics are indicated if cellulitis/induration are present around the open wound

What antibiotic is commonly used for wound infection after clean operation?

Cefazolin (Ancef)

What is the common IV antibiotic for wound infections after bowel surgery?

Cefoxitin or cefotetan

What new antibiotic is used for vancomycin-resistant enterococcal (VRE) infection?

Linezolid (Zyvox)

Generally, how long should antibiotics be administered for surgical infections?

General principle: Until the patient demonstrates obvious clinical improvement with a normal temperature for at least 48 hr

How do β-lactam antibiotics work?

They bind to one of the several penicillinbinding proteins (PBP) and inhibit bacterial cell-wall synthesis

What are the two potentially serious side effects of carbenicillin and ticarcillin?

1. High sodium load 2. Inhibition of platelet aggregation


What is the only β-lactam antibiotic that does not crossreact in patients who are allergic to penicillins or cephalosporins?

Aztreonam

What class of antibiotics is aztreonam in?

It is a monobactam

What type of bacteria is aztreonam effective against?

Gram-negative

What is the representative drug of the carbapenem class of β-lactams?

Imipenem

With what other drug is imipenem always combined, and why?

Cilastatin (enzyme inhibitor), because it prevents hydrolysis of the active form of the drug in the kidneys

What side effect of imipenem is important to remember?

It is associated with a significantly higher incidence of seizures

Compared with first-generation cephalosporins, what type of spectrum do second-generation cephalosporins have?

Expanded gram-negative activity

Can second-generation cephalosporins be used for empiric treatment of hospital-acquired gramnegative rod infection?

No; they are generally effective against community-acquired gram-negative rod infections with known susceptibility patterns

Which cephalosporins have good anaerobic activity?

Second-generation cephalosporins: cefoxitin and cefotetan

Which has a longer half-life, cefoxitin or cefotetan?

Cefotetan

What is the potentially serious side effect unique to cefotetan?

Prolonged clotting time

What antibiotic is associated with gallbladder sludge and cholestatic jaundice?

Ceftriaxone


Which bacteria do thirdgeneration cephalosporins have increased activity against?

Gram-negative rods

Which third-generation cephalosporins have increased activity against Pseudomonas, Acinetobacter, and Serratia?

Cefoperazone and ceftazidime

What is the mechanism of action of trimethoprim– sulfamethoxazole?

Trimethoprim is a structural analog of folic acid and competes with dihydrofolic acid for the binding site of dihydrofolate reductase; sulfamethoxazole is an analog of para-aminobenzoic acid (PABA), which is required for the synthesis of folic acid

What is the mechanism of action of quinolones?

They inhibit DNA gyrase, thus inhibiting DNA replication

What type of antibiotic is vancomycin?

A glycopeptide

What is the mechanism of action of vancomycin?

Cell-wall inhibitor; inhibits the transfer of subunits to peptidoglycan by binding to D-alanine residues of pentapeptide moiety

What is the mechanism of action of amphotericin B?

Complexes with fungal sterols (predominantly ergosterol) in plasma membrane, alters membrane permeability

What are the adverse effects of amphotericin B?

Nephrogenic diabetes insipidus Dose-dependent nephrotoxicity (in up to 80% of patients) Fever, hypotension, chills Anemia Hypokalemia

What is the dosage range and dosing interval of amphotericin B?

IV administration of 0.25–1 mg/kg daily, depending on the type of infection and renal function

What electrolyte problem is associated with amphotericin B administration?

Hypokalemia


SPECIFIC MICROORGANISMS What are common bacterial causes of infection after a clean operation?

S. aureus Streptococcal species Or both staph and strep

What are the common bacterial causes of superficial wound infections after bowel surgery/groin surgery?

Mixed: aerobic and anaerobic

In most cases, how long is it before responsible bacteria and their sensitivities are known?

Bacteria: at least 24 hr Sensitivities: 48–72 hr

How are enterococcal infections usually treated?

Although no single antibiotic reliably eradicates enterococcal infections or bacteremia, the most effective antibiotic combination is gentamicin combined with either a penicillin or with vancomycin

What antibiotic combination is used to kill Enterococcus?

1. Penicillin or vancomycin and 2. An aminoglycoside

What broad class of bacteria are the most numerous inhabitants of the GI tract, including the mouth?

Anaerobes

What is the most common anaerobic isolate from surgical infections?

Bacteroides fragilis

What would a Gram stain of clostridia recovered from a soft tissue infection look like?

Gram-positive rods

True or false: Candida organisms recovered from open wounds usually represent true invasion and infection?

False; usually only contamination (but treat all sternal wounds positive for fungus)


Which types of Candida are not treated by fluconazole?

Candida glabrata and Candida kruzeii (think “Glad to Cruise” = glab kruz)

What is the most common cause of breast abscess?

S. aureus; often in nursing mothers

What is lymphangitis and how does it present?

Inflammation of lymphatic channels in subcutaneous tissues Visible red streaks; may lead to lymphadenitis (inflammation of lymph nodes)

What bacteria can cause splenic abscess in patients with sickle cell anemia?

Salmonella

Infection with which microorganism commonly mimics acute appendicitis?

Yersinia enterocolitica

What are the three most common pathogens in suppurative thyroiditis?

1. S. aureus 2. Streptococcus pyogenes 3. Streptococcus pneumoniae

What is the treatment for pelvic inflammatory disease (PID)?

Ceftriaxone 250 mg IM (antigonococcal) and doxycycline 100 mg po bid for 7 d (antichlamydial); treat both

What is a common cause of upper GI bleeding in HIV-infected individuals?

Kaposi sarcoma lesions

What is the most common cause of stomach/duodenal perforation in patients with HIV?

Local CMV infection

What is the most common infectious agent causing colon lesions in patients with HIV?

CMV

How is CMV small-bowel perforation treated in patients with HIV?

1. Resect area of perforation 2. Small-bowel stomas—no anastomosis!


Do asymptomatic HIV-infected patients undergoing elective surgical procedures exhibit significantly more problems with wound healing and infection than their uninfected counterparts?

No

TOXIC SHOCK SYNDROME What is toxic shock syndrome?

A syndrome of fever, hypotension, skin rash, and multiple organ failure (MOF); other symptoms include diarrhea and headache

What causes it?

Exotoxin from S. aureus

What are the associated risk factors?

Tampons, pelvic infection, and sinusitis (nasal packing)

VAP What is “VAP”?

Ventilator-associated pneumonia

How do you diagnose VAP?

Bronchoalveolar lavage (BAL) with 104 colony-forming units (CFUs), infiltrate on chest x-ray, fever

Risk factors for VAP?

Ventilator use (surprise), chronic obstructive pulmonary disease (COPD), burn injury, neurosurgical patients, aspiration, acute respiratory distress syndrome (ARDS), reintubation, enteral feeds

Which carries a higher risk of VAP—oral or nasal intubation?

Nasal has a higher rate, probably due to increased incidence of sinusitis

Does changing the ventilator circuit tubing decrease the risk of VAP?

No, but change for each new patient

Do “subglottic suction” endotracheal tubes decrease incidence of VAP?

Yes


What are the major preventive measures?

Keep head of bed elevated >30 degrees, wash hands, patient oral hygiene, avoid gastric overdistention

Treatment for VAP?

Broad-spectrum empiric antibiotics until cultures return (48–72 hr), then narrow the antibiotics based on sensitivities (de-escalate)

What is the result if you choose empiric antibiotics that are resistant?

Mortality rate goes up!

MISCELLANEOUS What is the most common organism causing osteomyelitis of the foot after a nail puncture through a shoe?

Pseudomonas

Which bacteria are associated with infections after dog or cat bites?

Pasteurella multocida

Which bacteria are associated with infections after a human bite?

Eikenella

How often are central lines changed in burn patients?

Every 3 d

What is the generally accepted number of contaminating bacteria that must be present to establish a clinical infection in a nonimmunocompromised host?

105

How do fluid collections and edema increase the likelihood of infection?

They act as culture media and inhibit phagocytosis and white blood cell (WBC) migration (“WBC can’t swim”)


By what percentage does hair removal by shaving increase the infection rate when compared with removal by clippers or no removal at all?

100%

What is the classic history of an epidural abscess?

Status postoperative; epidural/spinal anesthetic with fever and back pain

What is BAL?

BronchoAlveolar Lavage (irrigate and aspirate the alveolus by a bronchoscope or sterile tubing through the ETT)

What CFU number do you need for a positive BAL?

>10,000 CFUs

Why treat Pseudomonas infections with two antibiotics?

The theory holds that using only one antibiotic will rapidly result in antibiotic resistance

What is the best diagnostic test for sinusitis?

Sinus CT scan

What serologic marker is positive after successful immunization against hepatitis B?

Anti-hepatitis B surface antigen (HBsAg)

Is hand washing able to stop the spread of Clostridium difficile?

No; hibiclens and gloves are needed

Chapter 32 Fever What regulates body temperature?

Anterior hypothalamus

Do all patients with postoperative infections develop fever?

No; only ≈50% develop a significant fever

After GI surgery, what can cause tachycardia and fever specific to the type of surgery?

Anastomotic leak

Chapter 33 / Surgical Prophylaxis 213

What acid–base abnormality is associated with malignant hyperthermia (MH)?

Acidosis

What electrolyte abnormality is associated with MH?

Hyperkalemia

What medications are used to treat MH?

Dantrolene, sodium bicarbonate

What should you do if in the middle of a procedure a patient develops MH?

Halt until hyperthermia is corrected; change to different anesthetic, and then when stable and afebrile, continue with procedure

What are two common endocrine causes of fever?

Pheochromocytoma, thyroid storm

What is the risk of surface cooling in a patient with fever?

May cause vasoconstriction and shivering (which will make more heat)

What is the cause of postoperative fever within 48 hr due to Staphylococcus aureus?

Toxic shock syndrome

Chapter 33 Surgical Prophylaxis What preop measures may help patients with asthma and chronic obstructive pulmonary disease (COPD)?

1. Stop smoking 4 wk before operation 2. Administer bronchodilator (e.g., albuterol) preoperatively

What treatment lowers renal failure before, during, and after IV radiocontrast dye?

1. IV fluid alone (dopamine, diuretics are no help) 2. Acetylcysteine (Mucomyst) PO

What medication provides protection against seizures in patients with brain injury?

Phenytoin (Dilantin) × 1 wk


What antibiotic provides protection against pancreatic abscess in cases of pancreatic necrosis?

Imipenem IV

What IV antibiotic provides protection from endocarditis in patients with vascular graft and heart valves?

Cephazolin (Ancef)

What IV antibiotic should be used if patients are allergic to penicillin?

Vancomycin

What antibiotic provides protection from infection: During colon surgery?

Cefoxitin

In patients with abdominal trauma?

Cefoxitin; cefotetan; ampicillin and sulbactam (Unasyn); (or clindamycin/ gentamicin if patient is allergic to penicillin)

In patients with acute appendicitis?

Cefoxitin or cefotetan

What antibiotic provides protection from endocarditis in endoscopy, incision and drainage, or bronchoscopy (rigid) in patients at risk for endocarditis?

Amoxicillin 2 g PO, or ampicillin IV

What hand scrub is the best?

Chlorhexidine (povidone–iodine hand scrub results in systemic absorption of iodine!)

What risk is associated with overly hard scrubbing?

Dermatitis, which harbors bacteria!

How may an upper extremity (arm) sequential compression device (SCD) provide some prophylaxis against lower extremity DVT?

SCD activates tissue plasminogen activator (tPA)—but this is an urban legend and there are no adequate data to support it

Chapter 34 / Surgical Radiology 215

What measures provide protection against urinary tract infection (UTI)?

Remove catheters ASAP Never open catheter drainage system (i.e., never disconnect tubing system, because doing so doubles the UTI rate) Take all urine samples with a needle

Chapter 34 Surgical Radiology GENERAL What are the risks of IV contrast?

Contrast-induced nephrotoxicity (3%–7% risk) Anaphylaxis: Urticaria, hypotension, facial or laryngeal edema, bronchospasm

How do you figure out the orientation of the arteries below the knee on an angiogram?

LAMP: Lateral = Anterior tibial Medial = Posterior tibial

ABDOMEN What is the “parrot’s beak” or “bird’s beak” sign?

Evidence of sigmoid volvulus on barium enema (BE) Evidence of achalasia on barium swallow

What are the differential diagnoses of retroperitoneal calcification?

Pancreatitis, abdominal aortic aneurysm (AAA), generalized aortic calcification, kidney stone, renal cell carcinoma, renal artery aneurysm (phleboliths, if seen in the pelvis)

What is meant by a “cut-off sign”?

Seen in obstruction, bowel distention and air–fluid level are “cut off ” from the normal bowel

What are sentinel loops?

Distention and/or air–fluid levels near a site of abdominal inflammation (e.g., in the right lower quadrant with appendicitis)


What is pneumatosis intestinalis?

Air in the bowel wall

What 5 signs of small-bowel obstruction (SBO) are visible on abdominal x-ray (AXR)?

1. 2. 3. 4.

What is the “step-ladder” appearance on AXR associated with small-bowel obstruction?

Dilated small-bowel loops lining up on top of each other from the right lower to the left upper quadrant

What is the “string of beads” on AXR?

Seen with small-bowel obstruction; small air bubbles (beads) trapped and separated by the plicae circulares, giving the appearance of a string of beads

What are the best studies to further evaluate small-bowel obstruction after AXR?

Abdominal CT scan, contrast studies (Small-Bowel Follow Through—SBFT)

What AXR finding is associated with a diffuse ileus?

Distended loops throughout, with gas in the small bowel and colon

What is a “string” sign?

Contrast GI study that reveals a stricture; contrast appears as a “string” outlining the narrowing

What is the most common cause of calcifications above the kidney?

Adrenal calcifications (make sure they are not pancreatic calcifications)

What is the best x-ray for diagnosing an AAA?

Cross-table lateral; reveals AAA in more than two-thirds of cases by eggshell calcifications

Can there be free air after a successful percutaneous endoscopic gastrostomy (PEG) procedure?

Yes

Distended loops of the bowel Air–fluid levels String of beads Step-ladder appearance of distended small bowel 5. Paucity of gas in the colon


What is a “lead pipe” on BE?

Seen with chronic ulcerative colitis owing to haustral obliteration and smooth narrowing of the colon; the contrast looks like a smooth lead pipe

What are “collar button” ulcers on BE?

Asymptomatic deep ulcers associated with Crohn’s disease

What is an “apple core” lesion on air contrast BE?

A circumferential lesion of the colon (the vast majority owing to colon cancer)

What do aphthous ulcers look like on BE?

Punctate ulcers with a “lucent halo” of surrounding edema

What is the “double bubble” sign?

Seen on AXR with duodenal obstruction, a duodenal bubble in addition to the gastric bubble

What is a “Meckel’s scan”?

A nuclear medicine scan for ectopic Meckel’s gastric mucosa

What is the falciform ligament sign?

Free air outlines the falciform ligament

On ultrasound (US) of the liver, what is the “double barrel shotgun” sign?

Dilated intrahepatic duct with the paired portal vein branch; looks like a “double barrel” shotgun (due to distal biliary duct obstruction)

What is the “double duct” sign?

Dilated pancreatic and biliary ducts caused by obstruction of the distal common bile duct/ampulla

What test is used for localizing a pheochromocytoma?

A MetaIodoBenzylGuanidine (MIBG) scan (a norepinephrine analog)

What diagnostic study is used to evaluate rectal cancer invasion preoperatively?

Transrectal US

What diagnostic studies are used to localize the parathyroid glands with hyperparathyroidism?

1. US 2. MRI 3. Sestamibi scintigraphy (CT and thallium–technetium scans are losing favor)


Which five radiologic studies should be considered for a patient in the ICU with a fever of unknown origin?

1. Chest x-ray (CXR; to rule out pneumonia) 2. Sinus films/CT (to rule out sinusitis) 3. Lower extremity US, Doppler, venogram (to rule out DVT) 4. Abdominal CT (to rule out abscess) 5. Gallbladder US (to check for acalculous cholecystitis)

Where does peritoneal fluid accumulate in the upright position?

The pouch of Douglas: the space anterior to the rectum and posterior to the uterus (women) or bladder (men)

What is the Mickey Mouse sign?

Orientation of common bile duct (right ear), portal vein (head), and hepatic artery (left ear) looks like a Mickey Mouse head and ears

TRAUMA RADIOLOGY What can be missed on an anteroposterior CXR in trauma?

Anterior pneumothorax

What is a FAST exam?

Focused Assessment Sonogram for Trauma

What four areas are examined?

Pericardial sac, bladder, Morison’s pouch, and spleen


In a trauma patient, what is the significance of fracture of the three lower ribs?

Increased risk of liver or splenic injury

How long should it take for a 10% pneumothorax to reabsorb without a chest tube?

A pneumothorax reabsorbs ≈1% of its measured percentage volume per day; therefore, a 10% pneumothorax should reabsorb in 10 d

How long after a laparotomy can free air be seen on AXR?

≈1 wk

What is the study of choice to evaluate for head trauma?

Unenhanced head CT (blood “lights up”)

What are the four CT scan signs of increased intracranial pressure?

1. 2. 3. 4.

What is DAI?

Diffuse Axonal Injury, or brain shear injury

What is the best test for DAI?

MRI

What is the falx sign?

Seen with subarachnoid hemorrhage as blood tracts along the falx, it results in a “thickened” falx on unenhanced head CT

Effacement of the ventricles Flattening of the brain sulci Loss of the gray-white matter interface Loss of cisterns

CERVICAL SPINE What three x-ray views must be taken to evaluate the bony cervical spine (c-spine) in trauma?

1. Anteroposterior 2. Lateral 3. Odontoid

What should you look at when evaluating a c-spine film?

1. 2. 3. 4. 5. 6.

What does an adequate c-spine film include?

All of C1–C7 and at least the top of T1

Adequacy of film The four parallel lines Soft tissue thickness Atlantodental interval Disc spaces Bones


What are the four parallel lines to check?

Think SPAT: 1. Spinolaminar line 2. Posterior vertebral line 3. Anterior vertebral line 4. Tips of spinous processes

Odontoid

Retropharyngeal space

Retrotracheal space

Anterior vertebral line Posterior vertebral line Spinolaminar line Posterior spinous line

From Gay SB, Woodcook Jr. RJ: Radiology Recall. Philadelphia: Lippincott Williams & Wilkins, 2000, p. 301.

What are the typical prevertebral soft tissue measurements for normal c-spines?

<5 mm from Cl–C3 and <20 mm at C4–C7 (easy way to remember basic measurements: <6 mm at C2 and <22 mm at C6, or “6 at 2 and 22 at 6”)

What is the atlantodental interval?

The distance between the arch of C1 and the odontoid process of C2 (normal adult: <3 mm)

What injury may cause an increased atlantodental interval?

Transverse ligament tear

What x-rays are used to evaluate for ligamentous c-spine injuries in awake patients?

Lateral flexion and extension c-spine films


CHEST What is the “deep sulcus” sign?

Deep costophrenic angle sulcus on anterior CXR due to hidden pneumothorax

What is the “fuzzy border” sign?

On CXR, a bullet in the heart has a fuzzy border because the heart is always in motion

What can cause a cold leg after a thoracic GSW?

Bullet embolus from the heart to the femoral artery!

How many lung lobes are on the right?

Three

How many lung lobes are on the left?

Two

The lingula is part of which lobe?

The left upper lobe

What is the normal heart size?

The transverse heart diameter is normally less than half of the transverse diameter of the chest

What are the five signs of fluid overload on CXR?

1. Large heart 2. Cephalization (distended large vessels in upper lung fields) 3. Pulmonary edema 4. Kerley B lines 5. Pleural effusion

What are Kerley B lines?

Horizontal lines <2 cm long that are found at the lung bases, usually signifying pulmonary edema (B lines = Bases)

What is an air bronchogram?

The outline of an airway made visible by fluid or inflammatory exudates filling the surrounding alveoli

How do you recognize a tension pneumothorax?

Clinically, but on CXR: pneumothorax with mediastinal shift away from the affected side and a small heart

What x-ray indicates whether a pleural effusion is free or loculated?

An ipsilateral lateral decubitus CXR; free fluid will “layer out”


If an endotracheal tube (ETT) is placed too far down, which bronchus will it most likely penetrate? What is the ideal position for a: Swan–Ganz catheter?

The right mainstem bronchus

Tip in the right or left pulmonary artery, usually no more than 1 cm lateral to the mediastinal margin

Central venous catheter?

Tip in the SVC, below the brachiocephalic veins and above the right atrium

ETT?

Tip at or below the clavicles and at least 2 cm above the carina

What x-ray must be taken after a tracheostomy is performed?

CXR (to rule out pneumothorax)

What x-ray should be obtained after a central line placement?

CXR to confirm placement and rule out pneumothorax

What x-ray must be taken after a bronchoscopy?

CXR (to rule out pneumothorax, collapsed lobe)

What x-ray indicates whether a pleural effusion is free or loculated?

Lateral decubitus x-ray shows “layering out”

Chapter 35 / Anesthesia 223

Chapter 35 Anesthesia What is the American Society of Anesthesiologists (ASA) Physical Status Classification? What is its purpose?

Describe the following ASA Physical Status categories: ASA I

It is a status rating (I–VI) assigned to each patient prior to receiving anesthesia; it allows for assessment of anesthetic outcome, but is not meant to predict anesthetic risk and is independent of the surgery planned

Healthy patient

ASA II

Patient with mild-to-moderate systemic disease without significant impairment of activity

ASA III

Patient with moderate-to-severe systemic disease that limits activity

ASA IV

Patient with severe, life-threatening illness

ASA V

Patient who is critically ill and is not expected to live more than 24 hr

ASA VI

A transplant donor

What does the suffix “E” denote in ASA Physical Status rating?

Patients undergoing emergency surgery, regardless of the type of operation or their ASA classification (e.g., emergency appendectomy on an otherwise healthy, young patient: ASA IE)

What is the classification for tongue to mouth size used to assess “airway adequacy”?

Mallampati classification


According to the Mallampati classification, what is: Class I?

Can see soft palate, anterior and posterior tonsillar pillars, and uvula

Class I

Class II?

Cannot see tonsillar pillars

Class II


Class III?

Only uvula base can be seen

Class III

Class IV?

Cannot see uvula at all

Class IV


What is an LMA?

Laryngeal Mask Airway (LMA)

What is a Miller blade?

Straight laryngoscope used for intubation (Think: Miller = 2 letter l’s that are straight)

What is a Macintosh blade?

Curved laryngoscope blade used for intubation (Think: curved, like the “c” in Macintosh)


How do you intubate with a Miller blade?

Blade is used to hold up the epiglottis (posterior to the epiglottis)

Epiglottis

How do you intubate with a Macintosh blade?

Blade is used anterior to the epiglottis

Epiglottis

MUSCLE RELAXANTS What are the sedative or analgesic properties of neuromuscular blockers (NMBs)?

None; patients are unable to move, but they can be fully aware of their surroundings!

What are the two classes of NMBs?

1. Depolarizing 2. Nondepolarizing (a.k.a. competitive)


What is the class, onset, and duration of succinylcholine (Sch)?

Depolarizing, onset <1 min, duration 5–10 min

What is the primary indication for Sch?

Rapid muscle relaxation for endotracheal intubation or treatment of laryngospasm

What are the potential side effects of Sch?

1. 2. 3. 4. 5. 6.

Which patients are at greatest risk for Sch-induced hyperkalemia (and for whom is the use of Sch contraindicated)?

Patients with: 1. Burns 2. Massive soft tissue trauma 3. Spinal cord injury 4. Neurologic/neuromuscular disorders 5. Intraperitoneal sepsis 6. Renal failure (relative contraindication)

Is there a safe period for the use of Sch in patients with acute spinal cord injury?

Yes, in the first 24 hr

What is the primary drug for treating MH?

Dantrolene

Name two long-acting nondepolarizing muscle relaxants (NDMRs):

1. Pancuronium 2. Metocurine

Name three intermediate-acting NDMRs:

1. Atracurium 2. Vecuronium 3. Rocuronium

Hypertension Cardiac arrhythmias Tachycardia Bradycardia Increased intracranial pressure Hyperkalemia (usually a 0.5–1 mEq/L increase) 7. Prolonged paralysis (in patients with atypical plasma cholinesterase) 8. Malignant hyperthermia (MH) 9. Increased intraocular pressure


Name one (relatively) short-acting NDMR:

Mivacurium

Which NDMRs cause histamine release?

1. Curare 2. Metocurine 3. Atracurium

What is the principal hemodynamic effect of histamine release?

Decreased blood pressure (and reflex tachycardia)

Which NDMR causes sympathetic nervous system stimulation?

Pancuronium

How is it manifested?

A 10%–15% increase in heart rate and blood pressure

What is the advantage of rocuronium?

Rapid onset gives adequate muscle relaxation for rapid sequence intubation in patients with a contraindication to Sch

What drugs are used to reverse NDMR?

Anticholinesterase drugs (neostigmine or edrophonium), which inhibit the breakdown of acetylcholine

What drugs must be combined with these reversal agents (and why)?

Anticholinergic drugs (glycopyrrolate or atropine) are used to counteract systemic cholinergic effects of the anticholinesterases

What are the systemic cholinergic effects of anticholinesterases?

Vagotonic effects can cause severe bradycardia, as well as crampy abdominal pain and vomiting

What paralytic is removed by “Hoffman degradation”?

Cisatracurium

What is the last muscle to be paralyzed (and first to recover) by paralytics?

Diaphragm


INTRAVENOUS ANESTHETICS What is TIVA?

Total IntraVenous Anesthesia

Which 3 agents are most commonly used for induction?

Thiopental (Pentothal), propofol (Diprivan), and etomidate

Which 3 agents are less commonly used for induction?

Methohexital, ketamine, and midazolam

What are some advantages and disadvantages of thiopental?

Inexpensive and predictable, but causes dose-dependent blood pressure drops which can be especially dangerous in hypovolemic patients and in the elderly

What is the advantage attributed to etomidate?

Produces little hemodynamic change and may be well suited for hemodynamically unstable patients (trauma, hypovolemic, frail, elderly patients; patients with CAD)

What are the advantages of propofol (Diprivan) compared with benzodiazepines or barbiturates when used for sedation?

High lipid solubility allows for: 1. Rapid changes in the level of sedation (when administered by continuous infusion) by simply changing infusion rate 2. Rapid recovery (usually within 10–15 min) after a bolus dose or after infusion is stopped 3. Physical dependence does not seem to occur 4. Antiemetic properties (suggested by some studies) 5. Bronchodilation

What is the nutritional value of Diprivan?

It is suspended in a carrier of 10% intralipid, providing 1.1 kcal per mL (as fat)

What are the CNS effects of ketamine?

Produces a state of “dissociative anesthesia,” that is accompanied by amnesia and analgesia; patients who receive large doses of ketamine can have hallucinations and unpleasant dreams

What are the respiratory effects of ketamine?

Respiratory drive is largely preserved and laryngeal protective reflexes remain intact


INHALATION ANESTHETICS What does “minimum alveolar concentration” (MAC) mean?

The concentration of an inhalation agent (at 1 atm) at which 50% of patients do not move in response to surgical stimulation (similar to the ED50)

What are the five most widely used inhalation anesthetics?

1. 2. 3. 4. 5.

What is the principal intraoperative risk of nitrous oxide?

Diffusion of nitrous oxide into closed gas spaces can cause complications related to the anatomic area involved; the doubling time of the volume of gas in closed or obstructed loops of bowel is about 3–4 hr, whereas the doubling time for gas volume in a pneumothorax can be as little as 10 min

What does “diffusion hypoxia” mean?

At the cessation of nitrous oxide therapy, the nitrous oxide diffuses rapidly from blood into the alveolar space and can dilute the concentration of inspired oxygen, particularly if the patient is placed on room air; placing the patient on 100% oxygen for 3–5 min can prevent this hypoxia

Which of the volatile inhalation agents is commonly used for mask (or inhalation) induction, and why?

Halothane, because it has the least pungent odor of the volatile agents and tends to be the least irritating to the respiratory tree

Which of the volatile inhalation agents is most commonly associated with cardiac dysrhythmias, and why?

Halothane, because it sensitizes the myocardium to endogenous (and exogenous) catecholamines

Which inhalation anesthetic may cause seizures?

Enflurane (Do not use in neurosurgery!)

Nitrous oxide (gas) Halothane Sevoflurane Isoflurane Desflurane


REGIONAL ANESTHESIA What are the four types of regional anesthesia?

Local (infiltration) or topical Peripheral nerve blocks (including ganglionic and plexus blocks) Epidural Spinal

What are the two most commonly used regional anesthetic agents?

Lidocaine and bupivacaine; other less commonly used agents include tetracaine, mepivacaine, procaine, 2-chloroprocaine, prilocaine, etidocaine, and ropivacaine

What are the signs of systemic toxicity from the injection of local anesthetics (in ascending order of toxicity)?

1. Lingual numbness (tongue numbness), metallic taste 2. Visual and hearing disturbances 3. Sedation 4. Unconsciousness 5. Seizures 6. Respiratory depression 7. Cardiac arrhythmias 8. Cardiovascular collapse

What is the most common cause of toxic plasma levels of local anesthetics?

Inadvertent intravascular injection

Which local anesthetic is the most cardiotoxic?

Bupivacaine is ≈16 times more cardiotoxic than lidocaine

How does the addition of epinephrine alter the peak plasma levels of absorbed local anesthetics?

It decreases the peak level, presumably by causing local vasoconstriction and thus slowing absorption

How does the addition of epinephrine affect the duration of local anesthetics?

It increases the duration, also presumably by local vasoconstriction and decreasing the blood to washout the anesthetic

In what cases is the addition of epinephrine to local anesthetics discouraged?

1. 2. 3. 4.

Uncontrolled hypertension Cardiac arrhythmias Unstable angina Uteroplacental insufficiency


5. Local infiltration into tissues with poor or absent collateral blood flow (digits, ears, tip of nose, penis) 6. Regionally IV anesthesia What is a Bier block?

Regional anesthesia of an extremity by placing a tourniquet and then infusing local anesthetic into a vein

Why are infected tissues difficult to anesthetize with the infiltration of local anesthetics?

Local tissue acidosis present in infected tissues tends to ionize the local anesthetics, preventing their spread and penetration into nerve sheaths

SPINAL AND EPIDURAL ANESTHESIA What dermatomes innervate the peritoneal cavity?

T6–T12

What is a “high spinal”?

An excessively high level of spinal anesthesia resulting in respiratory depression; symptoms range from difficulty breathing to apnea

What are the risk factors for spinal headache/postdural puncture headache (PDPH)?

1. Younger patients (<50 yr) 2. Gender (women > men, especially parturients) 3. Use of larger needles (22 ga vs. 25 ga)

What are the characteristics of a PDPH?

Severe frontal or occipital headache that worsens with sitting up; with increasing severity, the headache becomes circumferential and can result in visual, auditory, or vestibular disturbances

What are the differential diagnoses of severe headache after epidural or spinal anesthesia?

1. 2. 3. 4. 5. 6.

PDPH Caffeine withdrawal Migraine headache Meningitis Cortical vein thrombosis Intracranial hematoma


What is the appropriate treatment of PDPH?

1. 2. 3. 4. 5.

Bed rest Adequate hydration Caffeine (IV) Analgesics Epidural blood patch (usually for headaches lasting longer than 24 hr)

What is an epidural blood patch?

Blood is injected into the epidural space to form a “patch” over the dural puncture

What is a “saddle block”?

A low spinal anesthetic affecting primarily the perineum (i.e., the parts that would touch a saddle); performed using hyperbaric (heavier than CSF) anesthetic solutions with the patient sitting up to facilitate caudal spread of the anesthetic

What is a caudal block?

An epidural block obtained by accessing the epidural space via the sacral hiatus; the epidural space can be cannulated, or a single dose of anesthetic can be delivered through the needle

MISCELLANEOUS ANESTHETIC FACTS Which induction agent is associated with adrenal insufficiency?

Etomidate

What is the differential diagnosis of an intraoperative decrease in end-tidal CO2?

ET tube dislodgement/disconnect, asystole, profound hypotension, pulmonary edema, tension pneumothorax

What are the advantages of propofol?

Bronchodilator, low nausea, quick “on and off ”

Why not use pancuronium in trauma patients?

May cause tachycardia, confusing the hemodynamic status of the patient

Chapter 36 / Surgical Ulcers 235

What is a common error when providing conscious sedation?

Not waiting at least 2 min between sedative doses (can lead to oversedation = unconscious sedation!)

What is EMLA cream?

A topical cream of lidocaine and prilocaine that causes skin anesthesia, but may take 2 hr to work

What is the Sellick’s maneuver?

The use of cricoid pressure during rapid sequence intubation

Chapter 36 Surgical Ulcers What is a “crack ulcer”?

Define the different types of gastric ulcers: Type I

Small punctate gastric ulcer seen in crack cocaine users

An ulcer in the body of the stomach proximal to the incisura and not near the gastroesophageal junction; most are on a lesser curvature


Type II

A type I ulcer and a duodenal ulcer in the body of the stomach (think: type II = 2 ulcers)

Type III

An ulcer in the pyloric or prepyloric area (think: type III = prepyloric, or 3 = pre)

Type IV

An ulcer near the gastroesophageal junction (think: 4 near the “door” to the stomach)

Chapter 37 / Surgical Oncology 237

Chapter 37 Surgical Oncology Define the following terms: IORT

IntraOperative Radiation Therapy

Aneuploidy

Abnormal amount of DNA/chromosomes

Malignant potential

The ability of a tumor to invade and metastasize

Hyperplasia

Increased number of cells

Atypical hyperplasia

Increased number of abnormal cells

Metaplasia

Change in cell type from one type to another

On average, how many cell doublings must take place for a cell to become a tumor of 1 cm3 in volume?

≈30

What is flow cytometry?

Stained DNA passed through a laser beam to identify abnormal DNA of tumor cells

What is the duration of the cell cycle of tumors?

2–5 d

Name the tumors associated with the following oncogenes: C-myc

Breast and lung cancer

N-myc

Neuroblastoma (think: N-myc = Neuroblastoma)

L-myc

Lung cancer (think: L-myc = Lung)

Erb B-2

Breast and ovarian cancer

K-ras

Pancreatic and colon cancer


How does radiation therapy work?

1. Causes breaks in DNA 2. Forms free radicals that damage DNA and intracellular components

TUMOR MARKERS Name the tumors often associated with the following tumor markers: Carcinoembryonic antigen (CEA)

Colon cancer

α-fetoprotein (AFP)

Hepatoma (hepatocellular carcinoma)

CA 19–9

Pancreatic cancer

CA 125

Ovarian cancer

Human chorionic gonadotropin (β-HCG)

Testicular cancer

PSA

Prostate cancer

CA 50

Pancreatic cancer

Neuron-specific enolase

Small cell lung cancer

CA 15–3

Breast cancer

Ferritin

Hepatoma

MISCELLANEOUS TUMOR FACTS Has the monitoring of postoperative CEA levels proved to prolong survival in colon cancer patients after resection?

No

What is the most common primary site with metastatic axillary lymph nodes in women?

Breast cancer


What is the most common malignant cause of axillary adenopathy?

Lymphoma

What is the most common site of sarcoma metastasis?

Lungs (via blood)

What is the most important factor in the prognosis of sarcomas?

Tumor grade

What are the Lynch tumors?

Familial colon cancer syndromes not associated with polyposis

How many types of Lynch syndrome have been identified?

Two

What is Lynch syndrome I?

Autosomal-dominant inheritance Early onset of colon cancer Location of tumor in proximal colon (think: Lynch 1 = 1 cancer)

What is Lynch syndrome II?

Colon cancer and Stomach cancer and/or Ovarian cancer and/or Endometrial cancer

Memory aid for Lynch syndrome II?

Lynch II = Lynch 2 = L.O.S.E. L = Large-bowel cancer O = Ovarian cancer S = Stomach cancer E = Endometrial cancer

Lynch syndrome colon cancers account for what percentage of all colon cancer?

≈7%

In addition to prostate cancer, what other type of cancer must be ruled out in men with elevated PSA levels?

Breast cancer


Which bacteremia is associated with colon cancer?

Clostridium septicum

Which tumors are associated with left supraclavicular adenopathy?

GI tumors (the thoracic duct is right there!)

Why is meperidine contraindicated for long-term pain control in cancer patients?

Because of the buildup of normeperidine, a toxic metabolite that causes seizures and myoclonic movements

What infamous toxicity is associated with bleomycin?

Pulmonary fibrosis (dose related; 1% of patients treated with bleomycin will die from this complication)

CHEMOTHERAPY Methotrexate What is its mechanism of action?

A folic acid analog that inhibits dihydrofolate reductase (DHFR), an enzyme that reduces dihydrofolate (FH2) to tetrahydrofolate (FH4); FH4 is necessary for the 1-carbon transfers that occur in the synthesis of purines, glycine, methionine, and thymidylate. Without it, DNA, RNA, and protein synthesis is impaired; the most important and lethal effect is the inhibition of thymidylate synthesis

What is leucovorin “rescue”?

Leucovorin is folinic acid; it bypasses the need for FH4, thus alleviating the lethal inhibitory effects of MTX; normal cells with intact transport systems take up the leucovorin and are rescued Resistant tumor cells with decreased active transport do not take up leucovorin, and die. (Kills bad cells, saves good cells!)


Mercaptopurine (6-MP) and Thioguanine (6-TG) Describe their mechanism of action:

Purine analogs that are converted to nucleotides; they inhibit both de novo purine synthesis and interconversion of precursor molecules into dATP and dGTP, thus decreasing synthesis of DNA, RNA, and proteins

Fluorouracil (5-FU) Describe its mechanism of action:

A fluorinated analog of the pyrimidine precursor uracil; its active form, F-dUMP, forms a covalent complex with FH4 and thymidylate synthetase (TS), inhibiting TS and decreasing DNA synthesis

What type of cancer is interleukin-2 (IL-2) approved to treat?

Renal cell cancer metastases

Identify the unique toxicities: Bleomycin

Pulmonary fibrosis (Bleo = BLEW = lung fibrosis)

6-MP

Cholestasis

MTX

GI bleeding and GI perforation

Cisplatin

Hearing loss

Cyclophosphamide

Cystitis (remember cy = cystitis)

SECTION II General Surgery

Chapter 38 GI Hormones and Physiology GLUCAGON What is its general role?

Energy utilization

What is its source?

α-islet cells of the pancreas—pancreatic glucagon Stomach—gastric glucagon Intestines—enteroglucagon

What stimulates its release?

Hypoglycemia Elevated serum amino acids (alanine, arginine) Cholinergic (neural stimulation; β-adrenergic; stimulate weakly) Gastric-Inhibiting Peptide (GIP; only in vitro, not in vivo) Gastrin-Releasing Peptide (GRP)

What inhibits its release?

Hyperglycemia Insulin Somatostatin α-adrenergic (neural stimulation) Glucagon-like peptide 1 (GLP-1; feedback control)

What does it target?

Liver adipose tissue

How does it act?

Increases hepatic glycogenolysis and gluconeogenesis (i.e., mobilizes glucose into the bloodstream) Increases lipolysis and ketogenesis

What other actions is it associated with?

Inhibits gastric acid secretion Causes relaxation and dilatation of stomach and duodenum

243

244 Section II / General Surgery

Increases intestinal motility and transit time Inhibits pancreatic secretion of water and bicarbonate What are its clinical uses?

Decreases motility of stomach and duodenum for endoscopy and radiography

GASTRIC INHIBITORY PEPTIDE (GIP) What is its source?

K cells of the duodenal glands, jejunum, terminal ileum


Duodenal amino acids Glucose Long-chain fatty acids Hyperglycemia


Pancreas islet cells Stomach

How does it act?

Enhances insulin release Inhibits gastric acid secretion

VASOACTIVE INTESTINAL POLYPEPTIDE What is its source?

Diffuse pattern of cells throughout the gut and pancreas Peripheral nerve fibers


Intragastric fat Vagal input

What are its effects?

Vasodilation Smooth muscle cell relaxation General increase of water and electrolyte secretion by gut mucosal cells Inhibits gastric acid secretion Inhibits gallbladder contraction

Chapter 38 / GI Hormones and Physiology 245

PANCREATIC POLYPEPTIDE What is its source?

Islet cells of the pancreas and of other tissues of the pancreas


Food, vagal input, hypoglycemia, and other GI hormones (e.g., cholecystokinin)

How does it act?

Inhibits pancreatic water and bicarbonate secretion in postprandial state Inhibits gallbladder contraction May help regulate intestinal motility Causes a change from fasting to digestive patterns

What is its clinical significance?

Tumor marker for pancreatic apudoma tumors

PEPTIDE YY What is its source?

Cells in the distal ileum, colon, and rectum


Intraluminal fat in the intestine


Stomach

How does it act?

Inhibits gastric emptying Inhibits gastrin-stimulated acid secretion Inhibits pancreatic exocrine secretion stimulated by cholecystokinin May mediate the “ileal brake”

NEUROTENSIN What is its source?

N cells in distal small intestine (ileal mucosa)


Intraluminal fat

How does it act?

Inhibits gastric acid secretion Inhibits intestinal motility Stimulates pancreatic secretion of water and bicarbonate Triggers mesenteric vasodilation Has trophic effects for small- or large-bowel mucosa


MOTILIN What is its source?

Cells throughout the gut (highest concentration is in the duodenum and jejunum)


Duodenal acid and food Vagal tone Gastrin-releasing peptide

What inhibits its release?

Somatostatin Secretin Pancreatic polypeptide Duodenal fat or mixed meal

How does erythromycin work?

It is a motilin agonist

How does motilin act?

Increases interdigestive gut motility (think; Motilin = Motility = MMC) Initiates MMCs

What is an MMC?

Migrating Myoelectrical Complex

What is its clinical significance?

Erythromycin and other macrolides may stimulate gastric motility as motilin receptor agonists

GASTROINTESTINAL PHYSIOLOGY What are the histological layers of the gastrointestinal tract?

Mucosa (epithelium, lamina propria, muscularis mucosae), Submucosa Muscularis externa (inner circular, outer longitudinal), Serosa

What is the strongest structural layer?

Submucosa (Strongest = Submucosa)

Where are the intramural neural plexi located?

Meissner’s—submucosal Auerbach’s—myenteric (between the circular and longitudinal layers)

Which neurotransmitters are associated with external innervation to the gut?

Acetylcholine (parasympathetic) Norepinephrine (sympathetic)


What structures are associated with sympathetic innervation of the gut?

Cell bodies of postganglionic adrenergic neurons located in the prevertebral and paravertebral plexi (celiac, superior mesenteric, inferior mesenteric, hypogastric plexi)

What is the effect of sympathetic stimulation of the gut?

Inhibits motility Causes vasoconstriction Stimulates contraction of sphincters

What is the effect of parasympathetic stimulation of the gut?

Stimulates motility, secretion, and digestion

What are the major dietary sources of carbohydrates?

Starches from plants (e.g., amylose and amylopectin) Lactose from milk Fructose from fruits

What are the steps in carbohydrate digestion?

Mouth—salivary amylase Stomach—amylase inactivated by acid Intestines—pancreatic amylase Intestinal brush border— oligosaccharidases (e.g., sucrase, lactase, maltase)

What are the products of starch digestion by amylase?

Amylase hydrolyzes the α-1,4-glycosidic linkages, and basically results in maltose (gluc-gluc) and maltotriose (gluc-gluc-gluc)

DIGESTION What are the essential fatty acids?

Linoleic (18-carbon) Linolenic (20-carbon) (Think: Life = Linoleic and Linolenic)

What is the first enzyme to hydrolyze fat?

Lingual lipase; hydrolyzes dietary triglycerides and is stable at pH 2.2–6

Describe the digestion of lipids:

Start as fat droplets Emulsification by bile salts and phosphatidylcholine to form micelles occurs in the duodenum


Lipids in micelles are hydrolyzed by pancreatic lipase, cholesterol esterase, and phospholipase A2 Lipids in micelles diffuse across the luminal membrane of enterocytes What are the types of lipoproteins and what function is each responsible for?

VLDL (Very Low-Density Lipoprotein)— transport of triglycerides from liver IDL (Intermediate-Density Lipoprotein)— formed in plasma by degradation of VLDL LDL (Low-Density Lipoprotein)—formed in plasma from IDL; transports cholesterol esters to body tissues HDL (High-Density Lipoprotein)— transports cholesterol to liver

Where are most lipids absorbed?

In the proximal 2/3 of the jejunum

What are the essential amino acids?

Histidine Isoleucine Leucine Lysine Methionine Phenylalanine Threonine Tryptophan Valine (Think: HIS ISOlated Lover Lied; Mike Pushed THen TRipped VALerie)

Describe the digestion of proteins:

Stomach—denatured by acid; hydrolyzed by pepsin Pancreas—secretes multiple endopeptidases and carboxypeptidases into the intestine; trypsin, chymotrypsin, and carboxypeptidase hydrolyze protein to small peptides and amino acids Approximately half of protein digestion and absorption is completed in the duodenal intestinal brush border


Dipeptides, tripeptides, and free amino acids are formed by the action of aminopeptidases and dipeptidases Describe the absorption of protein digestion products:

Enterocytes absorb dipeptides, tripeptides, and free amino acids Dipeptidases and tripeptides are digested to free amino acids by cytosolic enzymes Protein digestion and absorption are completed by the midjejunum

What are the characteristics of pepsin?

Stored as inactive proenzyme (pepsinogen) in chief cells as zymogen granules Secreted from chief cells by exocytosis at apical surface Secretion stimulated by gastric acid and by stimulators of gastric acid secretion Acts upon ≈20% of intragastric proteins Requires acidic environment for enzymatic action Permanently inactivated in neutral duodenal environment

What are the characteristics of enterolinase?

Secreted by duodenal mucosa Activates trypsinogen, chymotrypsinogen, and procarboxypeptidase

What are the characteristics of trypsin?

Secreted by pancreatic acinar cells Activates proenzyme trypsinogen In turn activates chymotrypsin, elastase, and carboxypeptidases

What are the characteristics of chymotrypsin?

Secreted by pancreatic acinar cells Inactivates proenzyme chymotrypsinogen Activated by trypsin Hydrolyzes proteins to free amino acids

What are the characteristics of carboxypeptidase?

Secreted by pancreatic acinar cells Inactivates proenzyme procarboxypeptidase Activated by trypsin Hydrolyzes proteins to free amino acids


GASTRIC ACID SECRETION What three main agonists act on parietal cells to secrete acid?

1. Acetylcholine at muscarinic cholinergic receptors 2. Histamine at H2 receptors 3. Gastrin at gastrin receptors

What are the phases of gastric acid secretion?

Cephalic Gastric Intestinal

What stimulates the cephalic phase?

Thought, smell, taste, or presence of food in the mouth (classic Pavlov experiments)

What are the two pathways of the cephalic phase of acid secretion?

1. Telencephalon nucleus tractus solitarius → dorsal motor nucleus → vagal muscarinic cholinergic efferent fibers → parietal cell (cholinergic receptors) → secrete acid 2. Vagus nerve to G cells → secrete gastrin → to parietal cells (gastrin receptors) → secrete acid (chief cells also increase secretion of pepsinogen in cephalic phase)

What stimulates the gastric phase?

Gastric distention

What are the pathways of the gastric phase of acid secretion?

Local and vagovagal reflexes → G cells → gastrin → parietal cells (gastrin receptors) → secrete acid Local and vagovagal reflexes → parietal cells (cholinergic receptors) → secrete acid Gastric mast cells → histamine → parietal cells (histamine-2 receptors) → secrete acid

What inhibits the gastric phase?

Antral acidification

How is gastric secretion measured?

Basal acid output (BAO)—4–6 mEq/h Maximal acid output (MAO)— 30–40 mEq/h

Chapter 39 / Acute Abdomen and Referred Pain 251

COLON Through what networks is the colon innervated?

Two intramural plexi: 1. Submucosal (Meissner’s) plexus; innermost between the muscularis mucosa and the circular muscularis propria 2. Myenteric (Auerbach’s) plexus; outermost between the circular and the outer longitudinal muscle layers

What are the major types of colon motility and how do they function?

Ring contractions: Mix contents Move contents (either antegrade or retrograde) Enhance surface contact with contents Left colon—sustained giant migrating contractions: Propel stool toward rectum Empty colon of luminal contents

What stimulates colonic motility?

Fatty acids, bile acids, undigested food particles, luminal distention, cholinergic stimulation

What is the function of the bacterial load of the colon?

Breakdown of carbohydrates to short-chain fatty acids, which can then be absorbed

Chapter 39 Acute Abdomen and Referred Pain “The general rule can be laid down that the majority of severe abdominal pains which ensue in patients who have been previously fairly well, and which last as long as 6 hours, are caused by conditions of surgical import.” Sir Zachary Cope (1881–1974)


What are some possible causes of diffuse abdominal pain?

Uremia, porphyria, diffuse peritonitis, gastroenteritis, inflammatory bowel disease (IBD), diabetic ketoacidosis (DKA), early appendicitis, small-bowel obstruction (SBO), sickle cell crisis, ischemic mesenteric disease, aortic aneurysm, lead poisoning, black widow spider bite, pancreatitis, perforated viscus, testicular torsion

Of patients <50 yr of age, what are the three most common causes of surgical abdominal pain?

1. Acute appendicitis 2. Cholecystitis 3. SBO

Of patients >50 yr of age, what are the three most common causes of surgical abdominal pain?

1. Cholecystitis 2. Acute appendicitis 3. SBO

What percentage of patients presenting to a physician with abdominal pain need surgery?

≈33%!

What are the classic sites of anterior referred abdominal pain?

A: Esophagus B: Stomach C: Gallbladder D: Duodenum/pylorus E: Early appendicitis F: Colon G: Kidneys H: Ureter

A

B C D E F G H Anterior


What are the classic sites of posterior referred abdominal pain?

A: Diaphragm B: Biliary colic C: Renal colic/pancreatitis D: Uterus/rectum

A

B C D

Posterior

SIGNS OF ACUTE ABDOMEN What is Markle’s sign?

“Jar” abdominal tenderness, elicited by shaking the bed, foot, or pelvis; sign of peritoneal inflammation

What is Blumberg’s sign?

Rebound tenderness

What intra-abdominal conditions can result in death within minutes?

All involve massive bleeding: ectopic pregnancy with rupture, ruptured abdominal aortic aneurysm, aortic-enteric fistula, ruptured splenic aneurysm, splenic rupture (usually after mononucleosis, malaria, trauma, etc.), ruptured dissecting aorta into the abdomen (very rare), ruptured uterus (during pregnancy), ruptured liver hemangioma (most common benign tumor of the liver), ruptured subcapsular liver hematoma, abdominal trauma

What signs/symptoms are associated with gastroenteritis?

Vomiting, followed by abdominal pain, with or without diarrhea; symptoms usually resolve in <12 hr


What is the classic position to decrease abdominal pain in patients with pancreatitis?

Pain is often relieved by sitting up

What is the classic sequence of vomiting and abdominal pain in acute appendicitis or other surgical abdominal conditions?

Pain followed by vomiting, in most cases The pain activates vomiting via the medulla

What is the most common type of MI associated with abdominal pain, nausea, and vomiting?

Inferior MI

Name the possible unique cause of nonsurgical abdominal pain in the following scenarios: African-American with a history of joint pain

Sickle cell crisis

Child who eats paint, and has a history of recurrent right lower quadrant pain with no evidence of true right lower quadrant tenderness or peritoneal signs

Lead poisoning

Patient with abdominal pain and high porphobilinogen in the urine

Acute porphyria, usually in women 30–40 yr old with a history of recurrent abdominal pain radiating to the back out of proportion to abdominal exam findings; fever; elevated WBC count (often)

Patient on preoperative steroids

Addisonian crisis (acute adrenal insufficiency)

Abdominal wall pain in a patient on warfarin

Rectus sheath hematoma

Patient with a DVT

Pulmonary embolus

Patient with skin hyperesthesia in a dermatomal distribution

Herpes


Individual of Jewish or Armenian background with a history of recurrent epigastric abdominal pain; status post two negative exploratory laparotomies; fever to 39°C

Familial Mediterranean fever (autosomal recessive inheritance)

What are the differential diagnoses of gynecologic causes of lower quadrant pain?

Mittelschmerz, ovarian cyst, endometriosis, fibroids (with or without necrosis; found in ≈20% of women <40 yr old), ovarian torsion, pelvic inflammatory disease (PID), ovarian tumor (e.g., Krukenberg tumor/ teratoma), ectopic pregnancy, adhesions in the pelvis, pregnancy, infection of uterus following gynecologic procedures, threatened abortion, round ligament pain secondary to pregnancy

What is round ligament pain?

Lower quadrant pain secondary to stretching of the round ligament attached to the uterus (remember, the round ligament, instead of the spermatic cord, travels through the inguinal canal in women); may be confused with appendicitis in pregnancy

What are the symptoms of endometriosis?

Classic triad of three Ds: 1. Dyschezia (painful defecation) 2. Dyspareunia (painful sexual intercourse) 3. Dysmenorrhea (painful menstruation); also, spotting, pain, and infertility

PELVIC INFLAMMATORY DISEASE (PID) What are the associated signs/symptoms of PID?

Bilateral lower quadrant abdominal pain, vaginal discharge, cervical motion tenderness, fever

When during the menstrual cycle does PID most commonly occur?

Usually the first half


What organisms are most commonly responsible for PID?

1. Neisseria gonorrhea 2. Chlamydia

What long-term complications are associated with PID?

1. Pelvic pain 2. Ectopic pregnancy 3. Infertility

Chapter 40 Hernias Define the following types of hernias: Petit’s

Hernia through Petit’s triangle (rare)

Grynfeltt’s

Hernia through Grynfeltt’s triangle

Properitoneal

Intraparietal hernia between the peritoneum and the transversalis fascia

Cooper’s

Hernia involving the femoral canal and tracts into the scrotum or labia majus

Velpeau’s

Hernia through the Gimbernat’s ligament (a.k.a. Laugier’s or lacunar ligament hernia)

Hesselbach’s

Femoral hernia that passes laterally to the femoral vessels

Sciatic

Hernia through the sacrosciatic foramen in the pelvis

Cloquet’s

Femoral hernia that penetrates the pectineus muscle fascia (thigh muscle lateral to the adductor longus muscle)

Parastomal

Hernia through the same fascial opening created for a colostomy or ileostomy

Serafini’s

Femoral hernia that travels underneath the femoral vessels

Chapter 40 / Hernias 257

“Herald”

A hernia that “warns” of a more serious medical condition such as colon cancer, prostate cancer, benign prostatic hyperplasia, or lung cancer; due to increase in intra-abdominal pressure (e.g., straining at stool, cough)

Amyand’s hernia

A hernia sac that contains a ruptured appendix

What are the boundaries of Petit’s triangle?

Think: “petit LIE” (just a “little lie”): Latissimus dorsi Iliac crest External oblique Latissimus dorsi muscle External abdominal oblique muscle Inferior lumbar (Petit) triangle Iliac crest

What are the boundaries of the Grynfeltt’s triangle?

Think: Petit’s lie and Grynfeltt’s “SIT”: Sacrospinal muscle Internal oblique muscle Twelfth rib

12th rib Grynfeltt’s triangle Internal abdominal oblique muscle Sacrospinal muscle


What are the boundaries of a femoral hernia?

1. Iliopubic tract 2. Cooper’s ligament 3. Femoral vein

How can you avoid a parastomal hernia after an ileostomy or colostomy?

Place a stoma through the rectus sheath

What is the most common complication that arises after inguinal hernia repair?

Urinary retention

What is the plug and patch inguinal hernia repair?

1. Plug (See Chapter 13) 2. Patch

Which inguinal hernia repair involves merely a tightening up of the internal inguinal ring?

Marcy treatment

Who first described “pants over vest” repair for umbilical hernias?

Mayo (most surgeons now repair the “umbo hold the mayo”)

In what type of patient are infantile umbilical hernias most common?

African-American infants

Why can a reduced incarcerated abdominal wall hernia still progress to strangulation?

The hernia is out of the fascia defect but still in the hernia sac! (a.k.a. reducing en masse)

Why ligate transected nerves?

If a neuroma develops, it will develop in the nerve sheath and thus be less symptomatic

What is the most common causative factor for an incisional hernia?

Wound infection

Chapter 41 / Laparoscopy 259

Chapter 41 Laparoscopy When should a trocar site be sutured? Define the measures that may help prevent common bile duct injuries during a laparoscopic cholecystectomy: Type of scope

Suturing of sites >0.7 cm recommended

30 degrees (especially in obese patients)

Fundus retraction

Firm cephalad

Infundibulum retraction

Lateral retraction

Gallbladder neck dissection

Complete identification and mobilization of the neck

Junction of the gallbladder and cystic duct

Complete identification of the gallbladder and cystic duct junction with 360-degree view

Porta hepatis bleeding

No blind clips or electrocautery

Unclear anatomy

Open incision

Why is electrocautery contraindicated for transection of tissue between clips?

Because of the potential for thermal injury to surrounding tissue and arcing of the current

What is the most common cause of common bile duct injury?

Mistaking the common bile duct for the cystic duct

What is “vanishing duct” syndrome?

Due to chronic inflammation and scarring, the cystic duct is nonexistent and the gallbladder is adherent to the common bile duct

Is there any evidence that routine intraoperative cholangiography decreases the risk of common bile duct injury?

No


What is the “critical” view during a lap chole?

1. The 360° view of the GB cystic duct junction 2. Wide open triangle of Calot 3. Wide open hepatocystic triangle

Which laparoscopic instrument is responsible for the most visceral injuries?

The Veress needle

What action should be taken if a major vascular structure is injured by a cannula trocar?

Opening of the abdomen through a midline incision

How should a Veress needle bladder puncture be treated?

Postoperative Foley drainage

How should a trocar bladder injury be treated?

Suturing and Foley drainage

What is the most common cause of a postoperative periumbilical trocar site urine leak?

Transection of a patent urachal sinus

How can placement of a trocar through an epigastric vessel be avoided?

Transilluminate the abdominal wall and identify the vessels before placing the trocar

What cardiac problem is associated with pneumoperitoneum and distention of the peritoneum?

Vagal stimulation and bradycardia

Can the camera endoscope light cause small-bowel injury?

Yes; the xenon light source can become quite hot and burn a hole in the bowel wall

What is the “trapezoid of doom” associated with inguinal hernia laparoscopic repair?

The trapezoid lateral to the femoral vessels and below the iliopubic tract in which several nerves run; if a staple is placed in this region, a painful neuralgia may occur postoperatively

Chapter 41 / Laparoscopy 261

What nerves are located in the “trapezoid of doom”?

Femoral branch of the genitofemoral nerve Lateral cutaneous nerve of the thigh Femoral nerve

What complication is more common with the Hasson technique?

Wound infection is more common due to more dissection and more manipulation

What complication is more common with the Veress needle trocar placement than with Hasson trocar placement?

Major vascular injury (due to relatively blind placement)

How do you decompress a large distended gallbladder?

Drain out gallbladder fluid with a large GYN needle

What relaxes the sphincter of Oddi?

Glucagon IV

How do you move the bowel out of the way during a lap cholecystectomy?

1. Reverse Trendelenburg (head up) 2. Rotate table to the left 3. OG tube on suction

What may help move IOC contrast into the intrahepatic ducts?

1. Morphine (may cause sphincter of Oddi contraction) 2. Trendelenburg (head down)

What is the safest trimester for laparoscopy in pregnant women?

Second

CO2 GAS EMBOLISM What is it?

Gas embolus (bubble) caused by CO2 release into the bloodstream by Veress needle

How does the end-tidal volume CO2 change with an embolus?

It decreases (CO2 bubble obstructs blood flow through the right side of heart)

What kind of murmur does it cause?

“Mill wheel” murmur


What is the appropriate treatment of CO2 embolism?

Place patient in Durant’s position (Trendelenburg with right side up) and attempt aspiration of gas through a central line

How can a CO2 embolus be prevented when using the laparoscopic argon laser coagulator?

With an open port, so that the intraperitoneal pressure does not build up

Chapter 42 Trauma HISTORY What is the blunt trauma history acronym?

Rat’s Lamps: Restraint? Airbag? Tetanus status? Seat in car? (e.g., driver vs. back seat passenger) Loss of consciousness? Allergies? Meds? Past medical history (PMH) Speed of collision?

PEDIATRIC TRAUMA BASICS What is the ratio of needle cricothyroidotomy ventilation?

1 on, 4 off

Give a rough estimate of ET size in children:

Approximately the size of child’s pinky

Define the “20, 20, 10” rule of pediatric fluid resuscitation:

20 mL LR/kg, then 20 mL LR/kg; if still unstable, then 10 mL pRBCs/kg

What is the primary physiological clinical response to hypovolemic shock in children?

Tachycardia

Chapter 42 / Trauma 263

Describe the Glasgow Coma Scale (GCS) verbal scoring for young children: 5

Words, social smile, fixes and follows

4

Consolable cry

3

Irritable (persistently)

2

Restless, agitated

1

No response

What is the formula for normal systolic blood pressure (SBP) in pediatric patients?

80 plus twice the patient’s age (e.g., in a 5-year-old, normal SBP should be ≈90 = 80 + [5 × 2])

CIRCULATION How should the results of a fluid challenge be monitored clinically?

Urine output, mental status, capillary refill, heart rate, SBP, respiratory rate

What is the laboratory “end point” of resuscitation to follow?

Lactate

GUNSHOT WOUNDS (GSWs) What is a hollow-point bullet?

A bullet with a hollow end that “mushrooms” out upon impact with a solid object (e.g., a human)

Which is larger: a 22-caliber bullet or a 44-caliber bullet?

A 44-caliber bullet; caliber is a rough estimate of bullet size in inches (i.e., a 44-caliber bullet is ≈0.44 in. in diameter)

What is a shotgun?

A large-bore long firearm that shoots multiple pellets per shot (up to 50)

Which is larger; a 28-gauge shotgun or a 12-gauge shotgun?

A 12-gauge shotgun barrel is larger; (gauge is determined by the number of lead balls the same diameter as the barrel that it takes to equal 1 lb; for a 12-gauge, 12 lead balls equal 1 lb, and for a 28-gauge, 28 lead balls)


What is the simplest way to describe small vs. large shotgun pellets?

Small pellets = birdshot Large pellets = buckshot

What is bullet yaw?

Deviation of the bullet from its longitudinal projection

What is bullet tumble?

Head-over-heel somersaults

What material must be sought in all shotgun wounds?

The plastic or cardboard wadding: a small “cup” that holds the pellets

Can the entrance and exit wounds be reliably determined?

Exit wounds are generally larger than entrance wounds; the entrance wound can be reliably determined only by evidence of gunpowder tattoos

What is cavitation?

When a high-powered bullet enters the body, it transfers its kinetic energy to the surrounding tissues, which are then violently thrown out from the bullet’s path in a radial direction, forming a “cavity” and thus injuring tissues not in the bullet’s actual path


EMERGENCY DEPARTMENT (ED) THORACOTOMY Why perform an ED thoracotomy?

As a last-ditch effort to save a patient in severe extremis Goals: 1. Increase blood flow to brain and heart 2. Stop distal bleeding

What are the Western Trauma Association’s indications for an ED thoracotomy?

No vital signs (no pulse, no blood pressure) or severe hypotension (SBP <60) and in extremis: 1. Penetrating injury with signs of life in ED or in the field, or NO signs of life but CPR <15 min 2. Blunt trauma with signs of life in ED, or NO signs of life and CPR <10 min

Define signs of life:

PERM: Pupillary reaction EKG electrical activity Respirations Movement

What incision is used in an ED thoracotomy?

Left anterolateral thoracotomy (fifth intercostal space)


What is done after entering the chest?

Clamp aorta Open pericardium Ligate internal mammary artery!

Where do you open the pericardium?

Anterior to the phrenic nerve (think: AP = Anterior-Posterior = Anterior to Phrenic)

What if you need to get to the right chest?

Perform a clamshell incision


How do you open the pericardium with a tense hemopericardium? Describe the outcomes after ED thoracotomy for: Blunt trauma, no vital signs Penetrating stab wound, no vital signs

Scalpel

1%–2% survive 7% (5% for GSWs)

TRAUMA MANAGEMENT Why should the leg of a trauma patient be prepped in the field?

For access to a saphenous vein for vascular procedure

What percentage of patients with penetrating trauma to the pancreas will have an elevated serum amylase?

Only ≈15%

What is the appropriate treatment of each of the following wounds: Pancreatic contusion from a GSW cavitation injury?

Hemostasis and wide external closed drainage

Distal pancreatic duct transection from a GSW?

Distal pancreatectomy (almost always with splenectomy)

Proximal pancreatic duct injury?

1. Distal pancreatectomy, or 2. Roux-en-Y pancreaticojejunostomy (especially if distal resection would leave <15% pancreatic remnant)

Small laceration to the small bowel from a GSW?

Close in two layers in a transverse fashion (better short than narrow)

What is the appropriate treatment for two small-bowel perforations that are side by side?

Make into one perforation, and close transversely


Which types of retroperitoneal hematoma from a GSW should not be explored?

Stable retrohepatic hematoma Stable renal hematoma (controversial)

What is the appropriate treatment of pelvic hematoma from penetrating trauma?

Open it up after proximal (aorta/vena cava) and distal (iliac vessels) control, in contrast to blunt trauma

Can the portal vein be ligated?

Repair if at all possible; otherwise, it can be ligated if the injury is isolated, but with a mortality of at least 50%

What major operative and postoperative complications can follow ligation of the portal vein?

1. Massive fluid sequestration in the splanchnic vascular bed; massive amount of crystalloid resuscitation 2. Bowel necrosis

Can the common or proper hepatic artery be ligated?

Yes, especially proximal to the gastroduodenal branch, because this artery then provides collateral flow from the superior mesenteric artery via the pancreaticoduodenal arcades

Can the right or left hepatic artery be ligated?

Yes, especially if the portal vein is intact, because the portal vein delivers ≈50% of the liver O2

Can a lobar bile duct be ligated?

Yes, and without jaundice in most patients

How do you close a stomach laceration?

Two layers: 1. Absorbable running 2. Silk Lembert outer layer

What is the appropriate treatment of the following wounds: Popliteal vein-penetrating injury? Suprarenal vena caval injury?

Repair; may ligate

Repair; do not ligate


Infrarenal vena caval injury?

Repair if at all possible; otherwise, ligate

Internal jugular vein injury?

Lateral venography, if possible; otherwise, ligate

Bilateral internal jugular vein injury?

Must repair at least one internal jugular vein

Transection of the femoral vein?

Repair if possible; otherwise, ligate

Transection of a single artery of the lower leg below the knee?

Ligate

How many trifurcation arteries need to be patent to the foot for a viable foot?

One

What procedure must be performed with a common or proper hepatic artery ligation for trauma?

Cholecystectomy

In the patient with penetrating wounds to both the stomach and the diaphragm, what should be done besides closing the holes?

Irrigate pleural cavity via the diaphragm hole or via a chest tube, because empyema is often a problem after this combination of injuries

What is a lower chest wound?

Below the nipple and above the costal margin

What is a safe treatment of a lower chest GSW?

Abdominal exploration, because of frequent diaphragm injury

What percentage of penetrating solitary lung parenchymal injuries are treated solely by a chest tube?

>85%


What are the options for treatment of severe retrohepatic venous hemorrhage?

1. Vascular isolation with direct suture repair 2. Atriocaval shunt 3. Retrograde balloon catheter vena caval occlusion

What is the atriocaval shunt?

Usually, a modified chest tube that is placed into the right atrium and descends in the IVC past a retrohepatic vena caval injury; allows treatment of retrohepatic venous injury, control of blood loss, and venous return to the heart (associated with significant mortality); rarely, if ever, performed


Define the signs and symptoms of the following injuries with penetrating neck trauma: Esophageal neck injury

Odynophagia Dysphagia Subcutaneous crepitus Hematemesis

Vascular neck injury

Expanding/stable hematoma Bleeding Shock Loss of pulse Focal neurological deficit

Laryngeal/tracheal injury

Subcutaneous air/crepitus Change in voice Hemoptysis Dyspnea

What determines peritoneal penetration from an abdominal stab wound more accurately: probing or local exploration?

Local exploration

After penetrating trauma to the abdomen, is there any benefit to administering perioperative antibiotics for >24 hr?

No; as long as the antibiotics have anaerobic and aerobic coverage, 24 hr is satisfactory

How long do you give IV antibiotics after a penetrating colon injury (regardless of soilage)?

Only 24 hr!

Are sternal fractures in patients who were wearing shoulder seat belts associated with aortic injury?

No

What is the difference between exposure for left vs. right “proximal control” in proximal subclavian injuries?

Right = median sternotomy Left = second intercostal thoracotomy


How should you prep and drape the trauma patient for a laparotomy?

Expose the bilateral groins so you can harvest the vein, expose the chest so you can do a thoracotomy, and expose the neck so you can do a median sternotomy

What is the textbook incision for proximal control of the right subclavian artery?

Median sternotomy


What is the textbook incision for proximal control of the left subclavian artery?

Second or third ICS anterior lateral thoracotomy

Should you close the skin after a colon resection for trauma?

No; leave skin open; otherwise, there is a very high rate of wound infection (≈50%)

Is ABI associated with leg arterial injury?

<0.9

Should you open a pericolonic hematoma?

Yes; to rule out perforation.

What is the open book pelvic fracture rule of 5s?

5% of all pelvic fracture and 50% of all pelvic fracture deaths

How long should you wait to order a second chest x-ray for a patient with a penetrating chest wound without pneumothorax on admission?

6 hr

DAMAGE CONTROL What is the damage control “trilogy”?

1. Abbreviated operation (classically a laparotomy) 2. ICU for resuscitation 3. Return to OR for the definitive operation (Rotondo et al. J Trauma 1993; 35:375–383)


Why do damage control?

To avoid or ameliorate the lethal triad (or vicious cycle) of acidosis, hypothermia, and coagulopathy

How do you remember the lethal triad?

Think ACHe = Acidosis, Hypothermia, Coagulopathy

Does acidosis affect coagulation?

Yes; it inhibits coagulation

Does hypothermia affect coagulation?

Yes; it inhibits clotting factors and platelet function

What is the classic maneuver for damage-control laparotomy?

Pack off bleeding with laparotomy pads

Should the abdominal fascia be closed immediately after a damage control laparotomy?

No; leave it open with a temporary closure (e.g., wound vac, Bogota bag, etc.)

Why?

To avoid the complication of the abdominal compartment syndrome (ACS)

What is DCR?

Intravenous resuscitation to accompany damage control surgery

What are the three tenets of DCR?

1. Replace the hemorrhage of whole blood with components that reflect whole blood “PRBCs:FFP:Platelets” in a “1:1:1” ratio 2. Minimize crystalloid 3. Hypotension until surgical hemostasis (<90 SBP)

What are the signs of ACS?

1. Decreased urine output 2. Increased peak airway pressure 3. Bladder pressure >25

What percent of patients are not able to have the abdominal fascia closed?

≈20%


What are the goals in the ICU after damage control?

Warm >36°C Correct acidosis Fix PT with FFP (± factor VIIa if severe), platelets >50,000, base deficit >–5 Normalize lactate Urine output >50 cc/hr Cryoprecipitate if fibrinogen <100

What do you do at the definitive operation?

Remove packing, wash out, anastomose bowel, mature colostomies, perform vascular repair, attempt fascial closure

What is involved in vascular damage control?

Placement of a shunt or if patient is in severe extremis, then even ligate

What should be considered with every patient receiving damage control LE (lower extremity) vascular procedure?

Leg 4 compartment fasciotomy

What is the classic orthopedic damage control measure?

Rapid placement of external fixators

What is the morbidity with damage control laparotomy?

40%

What is the mortality of damage control laparotomy?

50% (reports of much improved outcomes with DCR)

TRAUMA INJURY SCALES Which trauma scales do you most need to know?

Liver Spleen

Which two types of injuries define most of the liver and spleen grades?

1. Hematoma 2. Laceration


Liver Injury Scale Define the following: Grade 1 liver injury

Hematoma—subcapsular blood <10% of surface area of the liver (nonexpanding) Laceration <1 cm deep, capsular tear (nonbleeding) (Think: Grade 1 = 1 cm deep and 10% surface area)

Grade 2 liver injury

Hematoma—subcapsular, <50% of surface area; intraparenchymal, <10 cm in diameter (both nonexpanding) Laceration 1–3 cm deep and <10 cm long


Subcapsular hematoma, >50% of surface area (nonexpanding); or expanding; or ruptured with active bleeding Intraparenchymal hematoma, >10 cm in diameter, or expanding Laceration >3 cm deep (think: 3 = 3)


Laceration—massive parenchymal destruction: 25%–75% of hepatic lobe or 1–3 Couinaud segments (Couinaud segments are segments in the French system)


Laceration—massive parenchymal destruction >75% of hepatic lobe, or >3 Couinaud segments Vascular injury—retrohepatic venous injury (i.e., IVC, major hepatic vein injury)


Vascular injury—total hepatic avulsion


What is the “finger fracture” technique for liver hemostasis?

“Fracture” away liver parenchyma with fingers to expose bleeding liver vessels, which are then ligated

Power Review of Liver Injury Grades Define the grade of the following injuries: Liver avulsion

6

Laceration 1 cm deep

1

Expanding 25 and subcapsular hematoma

3

Nonexpanding 11% subcapsular hematoma

2

Intraparenchymal hematoma 3.4 cm in diameter

3

Central ruptured hematoma

4

36% parenchymal lobe destruction

4

Nonexpanding 10% subcapsular hematoma

1


90% parenchymal lobe destruction

5

Laceration 2.4 cm deep and 8 cm long

2

Retrohepatic IVC injury

5

Laceration 3.5 cm deep

3

Spleen Injury Severity Scale Define the following: Grade 1 spleen injury

Subcapsular hematoma, <10% surface area, nonexpanding (just like liver Grade 1) Laceration <1 cm deep with capsular tear, but nonbleeding (just like liver Grade 1)

Grade 2 spleen injury

10%–50% surface area subcapsular hematoma; <5 cm intraparenchymal hematoma Laceration—capsular tear 1–3 cm deep, but must not involve a trabecular vessel


>50% subcapsular hematoma or expanding subcapsular hematoma; ruptured subcapsular or parenchymal hematoma; contained hematoma >5 cm; or contained expanding subcapsular hematoma >3 cm deep parenchymal laceration, or involving trabecular vessels


Ruptured intraparenchymal hematoma with active bleed; laceration involving segmental or hilar vessels with major devascularization (>25% of spleen)


Laceration—shattered spleen (massive) Vascular injury—hilar injury that completely devascularizes the spleen


What ligaments need to be transected prior to spleen mobilization?

1. Splenorenal (sharply) 2. Phrenosplenic (sharply) 3. Splenocolic: ligated due to large vessels, then brought into midline by nondominant hand Ligaments: Phrenosplenic Splenorenal Splenocolic

Kidney Injury Scale Grade 1

Kidney contusion

Grade 2

Minor laceration

Grade 3

Major laceration

Grade 4

Shattered kidney

Grade 5

Major vascular injury


RETROPERITONEAL TRAUMA Define the retroperitoneal trauma zones: Zone 1

Central and medial aspects of the retroperitoneum

Zone 2

Flanks

Zone 3

Pelvis

Should a pelvic hematoma be opened: In blunt trauma?

No

In penetrating trauma?

Yes

Power Review of Retroperitoneal Hematomas Name the appropriate treatment of each of the following hematomas from penetrating injury: Pelvic?

Open

Paraduodenal?

Open

Portal?

Open


Retrohepatic?

Do not open in stable patients with stable hematomas

Midline supramesocolic?

Open

Midline inframesocolic?

Open

Perirenal?

If stable, do not open (controversial)

Pericolonic?

Open

What action should be taken with the following retroperitoneal hematomas from blunt trauma: Pelvic?

Do not open

Retrohepatic?

Do not open if the hematoma is stable

Portal?

Open

Pericolonic?

Open

Midline supramesocolic?

Open

Midline inframesocolic?

Open

Perirenal?

Do not open

What are the major postop complications of a negative laparotomy for blunt trauma?

1. Small-bowel obstruction (≈5%) 2. Incisional hernia (5%)

URETHRAL TRAUMA What percentage of patients with urethral injuries have pelvic fractures?

95% (usually involve rami or symphysis)

DUODENAL INJURIES What is the appropriate treatment of an intramural duodenal hematoma?

May be treated conservatively if perforation is excluded (i.e., nasogastric tube decompression, IV fluids, and TPN)


What is the classic cause of duodenal hematoma in pediatrics?

Bicycle handlebars to the abdomen

What is pyloric exclusion?

1. Close pylorus (stapled or sutured) 2. Gastrojejunostomy

Pylorus sutured or stapled closed


What is duodenal diverticulization?

What is the best surgical treatment for severe duodenal injury with significant tissue loss?

Duodenal augmentation: Roux-en-Y side-to-side anastomosis to injury


BOWEL INJURIES What is the mechanism of injury of most bowel injuries?

Penetrating trauma (>90%)

What is the most common organ injured in penetrating trauma?

Small bowel

MISCELLANEOUS TRAUMA FACTS Which has a higher mortality rate: a frontal MVC or a side impact MVC?

Side impact has twice the mortality rate!

What is the RICE treatment for extremity injuries?

Rest Ice Compression (e.g., Ace bandage) Elevation

Name a memory aid for remembering the arm position of decorticate vs. decerebrate?

Decorticate: the arms and hands form an “o” as in dec “o” rticate (or hands toward the “core”)

What is the “tertiary” exam?

Physical exam looking for missed injuries after the trauma workup; studies have found up to 40% of patients have missed injuries (usually extremity)

What are the “deadly dozen” thoracic injuries?

Lethal 6: obstructed airway, tension pneumothorax, cardiac tamponade, massive hemothorax, flail chest, open pneumothorax Hidden 6: severe cardiac contusion, pulmonary contusion, esophageal rupture, thoracic aortic injury, tracheobronchial injury, diaphragmatic rupture


Which timing has a higher rate of pneumothorax after chest tube pull: end expiration or end inspiration?

No difference!

What is a sciwora?

Spinal Cord Injury WithOut Radiographic Abnormality

When does a chest wound become a “sucking” chest wound?

When the area of the chest wall injury becomes larger than the cross-sectional area of the trachea!

What is the major risk factor for infection after colon injury?

Blood transfusions!

What is pulsus paradoxus?

>10 mm Hg drop in SBP with inspiration (seen with pericardial tamponade)

What is a “Marcus Gunn” pupil?

Clinically, placing light intermittently into both eyes (“swing light test”) results in dilation of pupil with severe retinal or optic nerve injury

What is the McKenney hemoperitoneum score on a FAST exam?

The anteroposterior depth of the largest abdominal fluid collection plus the number of all other areas positive for fluid (score >3 equals 85% chance of therapeutic laparotomy)

What is Waddle’s triad?

Pedestrian hit by car (PHBC) triad of injuries: 1. Tibia–fibula fracture 2. Truncal injury 3. Head injury

What are the signs of infection with postoperative leukocytosis from trauma splenectomy?

1. WBC >15 2. Platelet to WBC ratio <20


What is the “box”?

Clavicles, nipples to line across costal margin (a.k.a “Box of Death”)

What if a patient has a penetrating injury to the Box and is in extremis?

ER thoracotomy

What if a patient has a penetrating injury to the Box and is stable?

FAST evaluation of pericardium

Should you probe a thoracic penetrating injury?

Never—may cause a pneumothorax!

With open tibial fractures, should you use low or high pressure irrigation?

Low pressure

What is the only thing evidenced to show a mortality benefit in combat wounded in the prehospital arena?

Tourniquets!

To decompress tension pneumothorax, how long does the needle for decompression need to be?

At least 3.25 in long

Chapter 43 / Burns 287

Chapter 43 Burns What is a Watson knife?

Knife used for tangential excision of large areas of burned skin

What is a Goulian (also called a “WECK”) knife?

Knife used for tangential excision of small areas of burned skin


What are the three zones of injury after burn injury?

Coagulation, stasis, hyperemia

Zone of coagulation

Zone of stasis Zone of hyperemia

Define the following: Zone of coagulation

Epidermis

Dermis

Zone of direct burn injury/contact characterized by coagulation/necrosis; i.e., all cells are dead

Zone of stasis?

Zone characterized by vasoconstriction and capillary leak; i.e., some cells are alive

Zone of hyperemia?

Zone characterized by vasodilation; i.e., all cells can live but it may take a week for them to recover

What prophylaxis should every burn patient get?

1. Tetanus toxoid 2. H2 blocker 3. Lovenox (or heparin DVT prophylaxis)

After a major burn, what burn-specific labs need to be ordered?

Cyanide, carbon monoxide

How do you treat cyanide toxicity?

1. Sodium nitrite 2. Sodium thiosulfate


Where do you make classic escharotomy incisions?

In what type of patient is silver sulfadiazine (Silvadene) contraindicated?

Those with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency and allergy to sulfa drugs

What is the major side effect of silver nitrate?

Electrolyte wasting (salt, calcium, potassium; think of silver nitrate as two electrolytes, thus, electrolyte wasting is the side effect)


Define the following types of grafts: Autograft

A skin graft from the same individual

Allograft

A skin graft from an individual of the same species (cadaver)

Homograft

Same as an allograft

Xenograft

A skin graft from a different species (porcine)

What are the signs of burn-wound infection?

1. Peripheral wound edema 2. Conversion of second-degree burn to third-degree burn 3. Ecthyma gangrenosum 4. Hemorrhage of underlying tissue 5. Green fat 6. Black skin around wound 7. Rapid eschar separation 8. Focal areas on a burn wound that turn black, brown, or purple-red, or show generalized discoloration

What is the most common topical agent for an infected third-degree burn?

Mafenide

What topical agent has the greatest eschar penetration?

Mafenide (think: Mafenide = Most)

What is a side effect of mafenide acetate?

Pain and metabolic acidosis, allergic reaction (Think Mafenide ACetate = Metabolic ACidosis)

What is the most common viral infection of burn wounds?

Herpes (type I)

What tissue organism counts correlate with the absence of burn-wound invasive infection?

<105 organisms per gram of burn-wound tissue


What percentage of patients with tissue counts >105 organisms per gram of burn tissue will have an invasive burn-wound infection?

Only ≈50%; histology is necessary to diagnose an invasive infection

What is the appropriate treatment of thrombophlebitis in burn patients?

Complete excision of the vein/pus (changing IV sites/central lines every 3 d helps prevent this complication)

What is the most common cause of death in burn injuries?

Smoke inhalation

What is the best clinical indication in burn patients of adequate fluid resuscitation?

Urine output

Which vitamin can decrease initial fluid requirements and wound edema in burns?

Vitamin C (ascorbic acid) in high IV dose

How do you estimate percentage of burn in children?


What is the hemoglobin CO affinity vs. oxygen?

CO has 240 × greater affinity than oxygen

What is the treatment for hydrofluoric acid burn?

Calcium gluconate → gel, subcutaneous, and rarely intra-arterially

Should the burn patient or patient with inhalation injury get prophylactic antibiotics?

No

How do you protect the airway if the patient has carbonaceous sputum?

Intubate—airway edema gets worse over time

What is the treatment for carboxyhemoglobin?

100% oxygen

Which electrolyte needs to be followed closely with burn resuscitation?

Sodium

What can convert a partial-thickness burn into a full-thickness burn?

Infection

How do you treat myoglobinuria due to an electrical injury?

Think: HAM = Hydration (urine output >100 cc/hr), Alkalize urine with bicarbonate (2 ampules IV), and Mannitol (25 g IV)

Which is generally worse: an acid burn or an alkali burns?

Alkali

What is the best method for feeding a burn patient?

Enteral

What are the nutritional requirements of burn patients?

Up to twice the normal!

What is the best irrigation fluid for acid and alkali burns?

Water

What is the half-life of carboxyhemoglobin?

2.5 hr


By how much does 100% oxygen reduce the half-life of carboxyhemoglobin?

Five-fold, or ≈30 min

What is the minimal burn percentage that requires fluid resuscitation?

Adults: >15% Children <10 yr of age: >10%

In what time period is the capillary “leak” the worst?

First 8 hr

Do gastric feedings decrease burn stress ulcerations?

No

Are inhalation burns due to heat of the fire?

No; they are due to chemicals (the upper airway cools the gases very efficiently)

What must you consider for a patient with an 80% total body surface area (TBSA) burn and decreasing tidal volumes and increasing peak airway pressures?

Escharotomy of chest

What is a common ophthalmological finding with electrical injury?

Cataracts

What are contraindications to Silvadene?

1. Sulfa allergy 2. G-6-PD deficiency

What is a “combined skin graft” or a “sandwich graft”?

Widely meshed autograft (patient) covered with a less widely meshed allograft (cadaver); used when autograft is meshed 3 to 1 or greater

Are IV boluses preferred during initial burn resuscitation?

No; boluses increase capillary pressure, increasing capillary “leak”

What electrolyte may be elevated with rhabdomyolysis?

Hyperkalemia

What is the voltage of a low-tension electrical injury?

<1,000 V


What is the voltage of a hightension electrical injury?

>1,000 V

What is the tissue with the lowest electrical resistance?

Nerve

What is the tissue with the highest electrical resistance?

Bone (and thus generates the most heat!)

Rank the common tissues from least to most electrical resistance:

#1 #2 #3 #4 #5 #6

nerve blood vessels muscle skin fat bone

LEAST

MOST

Why do alkali burns cause more tissue damage than acid burns?

Acids cause coagulation, preventing deep invasion of acid; alkali cause liquefaction, allowing the alkali fluid to diffuse deeper into the tissues!

Can carboxyhemoglobin be picked up by low O2 saturation?

No; O2 saturation can be normal with significant carboxyhemoglobin

What must you consider if you see isolated buttock burns on a child?

Child abuse until proved otherwise from immersion injury

Do inhalation injuries decrease fluid requirements?

No; they increase fluid requirements

What is the temperature of tar?

Up to 300°F

What is the treatment for tar burn injury?

Tap water, then lipophilic solvent

What are the serum lab findings with cyanide inhalation injury?

Lactic acidosis

What is a major cellular mediator of inhalation injury?

Neutrophils

What is the increased heat-carrying capacity of steam vs. dry air?

Steam carries 4,000 times the heat capacity of dry air!!!


What has been shown to decrease mortality in pediatric burn patients with inhalational injury?

Mucomyst with inhaled heparin

What vasoactive amine is released in burns?

Histamine

What is the effect of this vasoactive amine?

Histamine results in edema local and distant to burn! … also increases vasodilation

What is the posterior pituitary response to burn injury?

ADH release

What is the source of endogenous burned skin bacteria?

Hair follicles and sebaceous glands (103 strept/staph)

What percentage burn results in capillary “leak” in areas away from the burn injury?

>25%

Which factor in the complement cascade is the major source of inflammation in burns?

C5a

What are the actions of this complement factor?

C5a increases histamine, xanthine oxidase, and TNF

What does xanthine oxidase do?

It increases free oxygen radicals.

What are the commonly inhaled substances in household fires?

1. CO 2. Cyanide

What is the treatment for hydrofluoric acid burn?

Calcium gluconate (locally)

What is an electrolyte abnormality with a hydrofluoric acid burn?

Hypocalcemia


Platelets secrete what substance in burned tissue that increases edema?

Serotonin

EXFOLIATIVE SKIN DISEASES What are they?

Diseases that cause necrosis and exfoliation of skin

What causes them?

Immunological reaction to foreign antibodies

What is the most common entity causing it?

80% are caused by medications; fungi, bacteria, and viruses are also causes


Being female or elderly


7/1,000,000

What are the signs?

Prodromal: Cough, fever, fatigue Cutaneous: Vesicles, bullae, epidermolysis, epidermal sloughing, Nikolsky’s sign, mucosal lesions, conjunctivitis

What is Nikolsky’s sign?

Finger pressure causes epidermis to be removed in sheets

What are the two most common exfoliating diseases?

1. Stevens-Johnson Syndrome (SJS) 2. Toxic Epidermal Necrolysis (TEN)

What is the major determinant in diagnosis between SJS and TEN?

TBSA

What is the TBSA of SJS?

<10% (Think SJS = Small)

What is the TBSA for TEN?

>30% TBSA

What if the patient has a TBSA between 10% and 30% TBSA?

Then (believe it or not), it is called SJS/TEN

Chapter 44 / Upper GI Bleeding 297


IV fluids, remove sloughed epidermis, and then provide skin coverage (silver nitrate is commonly used), and consult ophthalmology; do not use Silvadene if the cause is sulfa use!

Have steroids or IGG been clearly shown to be of benefit?

No


#1, pneumonia; then epiglottic swelling requiring intubation and ophthalmological complications

What are the ophthalmological complications?

Conjunctival scarring, lacrimal duct obliteration, ectropion, entropion, infection, blindness

What is the mortality?

SJS—≈25% (again think SJS = Smaller) TEN—≈50%

If a patient has SJS or TEN caused by Bactrim use, why should Silvadene be avoided?

Silvadene is silver sulfadiazine, and thus contains a sulfonamide component!

Chapter 44 Upper GI Bleeding Which patients with GI tract bleeding can be worked up as outpatients?

Melena or occult bleeding in hemodynamically stable patients (those with hematochezia and hematemesis must be hospitalized)

What is the treatment for a bleeding gastric leiomyoma?

Wedge resection

What is a Cameron’s ulcer?

Linear ulcer at level of diaphragm in patients with paraesophageal hiatal hernias (rarely, may cause massive upper GI bleeding)

What is the treatment of aortoenteric fistula?

Resection of graft and extra-anatomic bypass


What is the treatment of bleeding duodenal or jejunal diverticula?

Resection

ACUTE HEMORRHAGIC GASTRITIS What is the initial treatment?

Reduce acid production with H2 blocker or proton pump inhibitor and treat for Helicobacter pylori

What are the options with uncontrolled refractory hemorrhage?

1. Vasopressin via left gastric artery 2. Last resort: gastric resection

HEMOSUCCUS PANCREATICUS What is it?

Blood from pancreatic duct into ampulla of Vater, then into duodenum

What are the signs?

Upper GI bleed via ampulla of Vater, upper abdominal pain, melena

What is the main risk factor?

Chronic pancreatitis

What are the anatomic causes?

1. Bleeding into a pseudocyst 2. Spleen artery pseudoaneurysm 3. Erosion into smaller pancreatic or splenic arterial branch


Often requires distal pancreatectomy and ligation of splenic artery, or angiogram embolization

BLEEDING DUODENAL ULCER How do you suture ligate a bleeding duodenal ulcer?

By the “principle of three-point vessel ligation” of the posterior ulcer exposed through a duodenotomy or as part of a pyloroplasty

Which arteries are ligated?

1. Proximal gastroduodenal artery 2. Distal gastroduodenal artery 3. Transverse pancreatic artery

Chapter 45 / The Stomach 299

Illustrate the three-point ligation for bleeding duodenal ulcer:

Proximal gastroduodenal

Transverse pancreatic

Distal gastroduodenal

Chapter 45 The Stomach GASTRIC ULCERS (SEE ALSO DIAGRAMS IN CHAPTER 36) Define: Type I?

Along the lesser curvature

Type II?

In the body of the stomach, in combination with a duodenal ulcer (think: Type II = 2 ulcers)

Type III?

Prepyloric ulcer (think: Type III = prepyloric)

Type IV?

Next to the gastroesophageal (GE) junction (think: Four = next to the door—GE junction)

Type V?

Any location due to NSAIDS

What are the most common operations for each of the following types of ulcers: Type I?

Distal gastrectomy with Billroth I (3% recurrence rate; 15% recurrence)


Type II?

Antrectomy with truncal vagotomy (because acid secretion is elevated, as evidenced by the duodenal ulcer), truncal vagotomy and pyloroplasty, or truncal vagotomy and drainage

Type III?

Antrectomy and vagotomy with incorporation of the ulcer in the specimen

Type IV?

Excision of the ulcer or distal gastrectomy with vertical extension of the resection specimen to include the ulcer

Is it necessary to perform a vagotomy with a type I ulcer in a patient with no history of duodenal ulcers?

No

What is a Dieulafoy ulcer?

A gastric vascular malformation in which a small (2–4 mm) mucosal defect bleeds from a large submucosal artery, resulting in painless hematemesis

What is the appropriate treatment of a Dieulafoy ulcer?

Endoscopic coagulation or surgical resection

GASTRIC CANCER When is a splenectomy indicated?

Only if the cancer is invading the spleen directly

When is a distal pancreatectomy indicated?

Only when invaded by cancer directly

Name the stages of gastric cancer by tumor (T), node (N), metastasis (M) [TNM] staging system: Stage Ia? Stage Ib?

T1 (to lamina propria/submucosa), N0, M0 1. T1 with N1 (+ perigastric lymph nodes [LNs]) 2. T2 (muscularis propria/subserosa), N0, M0


Stage II?

1. T2 (muscularis propria/subserosa), N1 (+ perigastric LN), M0 2. T1 (lamina propria/submucosa), N2 (+ LN >3 cm from stomach/hepatic/ splenic/celiac) 3. T3 (through serosa), N0, M0

Stage IIIa?

1. T2, N2, M0 2. T3, N1, M0 3. T4 (invades surrounding tissues), N1, M0

Stage IIIb?

1. T3, N2, M0 2. T4, N1, M0

Stage IV?

1. Distant METS (any T, any N, M1) 2. T4, N2, M0

How are the lymph nodes designated? Define: D1?

D1, D2, D3, D4

Six nodes: left cardia, right cardia, lesser curve, greater curve, suprapyloric, infrapyloric

2 4

1 5

3 4 6 4

D1


D2?

Left gastric artery, common hepatic artery, celiac artery, splenic hilum, splenic artery

2 4 7 1

8 5

9

11

10

3 4

6

D2 What percentage of patients have metastases at the time of diagnosis?

75%

GASTRIC LYMPHOMA At what age is the highest incidence noted?

Peaks at 60–70 yr

What is the most common GI site?

Stomach (>50% of GI lymphomas arise in this location; most common organ involved in extranodal non-Hodgkin’s lymphoma)

What are the associated symptoms?

Epigastric pain, anorexia, nausea and vomiting, weight loss


Endoscopy is the method of choice; biopsy with brushings provide diagnosis in more than 90% of cases

What else should be done if biopsy for lymphoma is positive?

Evaluation for systemic involvement is necessary and includes CT of the chest and abdomen, bone marrow biopsy, and biopsy of enlarged peripheral lymph nodes


Define the following stages of gastric lymphoma: Stage I?

Confined to the stomach

Stage II?

Spread to the perigastric nodes

Stage III?

Spread to nodes other than perigastric

Stage IV?

Spread to other abdominal organs

What is the treatment of gastric lymphoma?

(Controversial) Either: 1. Chemotherapy with radiation therapy or surgery for recurrent or refractory disease (M.D. Anderson), or 2. Gastrectomy

Which chemotherapy is used?

Doxorubicin and cyclophosphamide

GASTRIC SARCOMA What is the incidence?

Mean age is 60–70 yr old; incidence is the same in men and women

What is the histology?

Most are leiomyosarcomas

What are the associated symptoms?

Similar to those of adenocarcinoma; masses usually attain a large size before causing symptoms

What is the appearance?

Grossly, they are firm gray-white masses that occasionally contain a pseudocapsule

What determines the behavior of these tumors?

The number of mitoses per high-power field (hpf), with 5–10 mitotic figures/hpf demonstrating increased propensity for metastases

What is the most common route of metastasis?

Hematogenous (90%)



Surgical resection of the tumor with negative margins

What is the prognosis?

Low grade: 75% 5-year survival rate High grade: 33% 5-year survival rate

GASTRIC CARCINOID What is a leading risk factor?

Pernicious anemia

What test confirms the diagnosis?

Esophagogastroduodenoscopy (EGD) with biopsy

What are the associated findings?

Yellow or pink submucosal gastric nodules


Resection for cure

Chapter 46 Bariatric Surgery What is the long limb gastric bypass?

Lengthening of the Roux-en-Y limb to add a malabsorptive component to the gastric bypass

Who is eligible for the long limb gastric bypass?

The “Superobese”

What is the operative mortality of a gastric bypass?

0.5%–1%

What is the most feared operative complication after a gastric bypass?

Anastomotic leak!

What are the signs of an anastomotic leak?

Tachycardia, tachypnea; fever and increased WBC later; peritonitis is often hard to detect in morbidly obese!

Chapter 46 / Bariatric Surgery 305

What is the treatment for an anastomotic leak?

OR STAT for repair, washout, ± drain placement

What complication may postoperative hiccups herald?

Roux limb obstruction at the anastomosis of the jejunojejunostomy (distended gastric pouch on abdominal x-ray) may lead to gastric pouch perforation!

What percentage of patients develop a marginal ulcer?

10%

What is the treatment for a gastrojejunostomy stenosis?

Balloon dilation

What is the most common cause of postoperative neuropathy after gastric bypass?

Thiamine deficiency

What percentage of patients will develop gallstones after a gastric bypass and weight loss?

33%

How is the postoperative complication of gallstones prevented?

1. Cholecystectomy, or 2. At least 6 mo of oral ursodeoxycholic acid

What is a lap-band?

Laparoscopically placed band around stomach with a subcutaneous port to adjust constriction; results in smaller gastric reservoir


What is a jejunoileal bypass?

Surgery initially used for morbid obesity; bypasses the ileum with an end-to-end anastomosis between the proximal jejunum and distal ileum; no longer performed because of complications

Chapter 47 Ostomies What is another name for continent ileostomy?

Kock pouch

What is the usual sodium concentration in ileostomy effluent?

∼115 mEq/L

In the immediate postoperative period, what IV fluids should be used to replace ileostomy output?

Normal saline or LR with 40 KCl/L at equal volumes (mL for mL)

Patients with ileostomies typically have what type of body fluid abnormality?

Mild dehydration with a chronic state of sodium and water depletion

Which type of stomas are candidates for the irrigation method of bowel control?

Descending colon and sigmoid colostomies

Chapter 47 / Ostomies 307

What does the eversion technique of Brooke ileostomy help prevent?

Serositis, leading to obstruction and high-output ileostomy diarrhea with associated dehydration/electrolyte abnormalities; protects skin

What does placing the ostomy through the rectus muscle help to prevent?

Parastomal hernia Prolapse

In general, ostomies should be placed through the anterior abdominal wall within a triangle composed of what landmarks?

Stoma triangle: umbilicus, pubis, and anterior superior iliac spine

Upon completion of an end ileostomy, how far beyond the skin should the “bud” protrude?

2–3 cm

Through which muscle should proper ileostomy formation always place the ostomy?

Rectus abdominis muscle

Where should a stoma be placed on a small lower abdominal fat fold?

If feasible, at the apex (not above, not below fold)

In general, in a very obese patient with many skinfolds, where should a stoma be placed: upper or lower abdomen?

Upper abdomen, above the panniculus

What length of ileum should be brought out above skin to fashion an end ileostomy?

4–6 cm

When creating a stoma, how many “average”-size fingers should you be able to admit through fascia and skin?

Two

What is the average incidence of small-bowel obstruction following loop ileostomies?

10%


Is the incidence of smallbowel obstruction with loop ileostomies higher or lower than for loop colostomies?

Higher

Is parastomal hernia more common in ileostomy or colostomy?

Colostomy

What is the most common dermatological problem associated with stomas?

Chemical irritation from effluent

What is the most common organism associated with peristomal skin infection?

Candida albicans

What are the five most common colostomy complications?

1. 2. 3. 4. 5.

What is diversion colitis?

Inflammation of the distally diverted portion of the colon

What is the cause of diversion colitis?

Thought to be secondary to a lack of trophic factors to mucosa, particularly short-chain fatty acids

What is the appropriate treatment of diversion colitis?

Reversal of the colostomy is curative (if feasible)

What is the best surgical option for parastomal hernia?

Relocation of the stoma

What sodium and potassium abnormalities do patients with profuse ileostomy diarrhea usually have?

Hyponatremia and hypokalemia

What is the most common cause of colostomy stenosis?

Ischemia

What is the most common cause of pericolostomy abscess?

Perforation caused by an irrigating device

Ischemia Retraction Stenosis Prolapse Peristomal hernia

Chapter 47 / Ostomies 309

What is the most common technical error in stoma construction leading to peristomal hernia?

Stoma brought out laterally to the rectus

What is the most common complication following closure of a colostomy?

Wound infection

What is the most frequent cause of ileostomy fistulas?

Crohn’s disease

What is the most common cause of ischemia insufficiency in colostomy?

Excessive clearance of mesentery from the bowel

What is the appropriate treatment of mild colostomy strictures?

Dilation

How can the depth of ischemia/necrosis be assessed in an ileostomy?

By inserting a small test tube into the stoma and illuminating with a flashlight to assess mucosa down to and below the fascia

Why do patients with ileostomies have increased incidence of gallstones?

Ileal disease or resection interrupts the enterohepatic circulation by decreasing the availability of bile acids and favoring precipitations of cholesterol stones

Which limb is usually involved in prolapse of a loop colostomy?

Distal

High ileostomy output can result in which type of acid–base disorder?

Metabolic acidosis, secondary to excessive bicarbonate loss from ileostomy

What is the most common type of urinary stone in ileostomy patients?

Uric acid stones (60%)

What medical condition can result in peristomal venous complexes?

Portal hypertension (basically peristomal caput medusae)


Chapter 48 Small Intestine SMALL-BOWEL OBSTRUCTION (SBO) Ileus What is it?

Paralytic ileus is a functional obstruction of the small bowel that occurs in most patients following abdominal surgery, and is caused by neural, humoral, and metabolic factors; it also occurs with inflammatory processes in the abdomen (e.g., pancreatitis, peritonitis), retroperitoneal hemorrhage, spine injury, electrolytes, and medication

What are the associated signs of ileus?

Lack of bowel sounds, bowel distention, no flatus, no stool, ± emesis

What are the other common causes of ileus?

Opiates, hypokalemia, hyponatremia

What is the order of return of motility following abdominal surgery?

1. Small intestine 2. Stomach 3. Colon

What is one theory regarding the physiological mechanism of ileus?

Sympathetic hyperactivity, which slows GI propulsion and constricts sphincters

How is the diagnosis of ileus confirmed?

History and physical examination Abdominal plain film demonstrating air throughout the GI tract with or without air–fluid levels

What is the appropriate treatment of ileus?

Conservative: Nothing by mouth, nasogastric tube (NGT), IV fluids until patient passes flatus; electrolyte replacement as needed

Chapter 48 / Small Intestine 311

Anticoagulant-Induced Obstruction What is anticoagulant-induced obstruction?

Patients taking warfarin may develop an intramural hematoma of the small bowel

What is the most frequent site?

Proximal jejunum

What are the associated signs/laboratory findings?

Elevated prothrombin time (PT), ecchymoses, hematuria

What are the associated radiological findings?

Affected segment appears narrow and rigid; “picket fence” appearance of mucosa

What is the appropriate initial treatment?

Discontinue the anticoagulant, vitamin K Nasogastric suction/IV fluids

Small-Bowel Obstruction How can you remember the five impending signs of bowel ischemia/necrosis with small-bowel obstruction?

FATAL: Fever Acidosis Tachycardia Abdominal pain Leukocytosis

SMALL-BOWEL TUMORS What is the differential diagnosis of benign tumors of the small intestine?

Leiomyoma, lipoma, lymphangioma, fibroma, adenoma, hemangioma

What is the most common benign tumor of the small intestine?

Leiomyoma (followed by lipoma and adenoma)

What is the differential diagnosis of malignant tumors of the small intestine?

Adenocarcinoma, carcinoid tumor, lymphoma

What is the most common malignant small-bowel tumor?

Adenocarcinoma

What is the incidence of small-bowel malignancies?

<2% of all malignancies arise in the small bowel


What five factors are important in preventing malignancies in the small bowel?

Fast transit time, thus limiting contact of carcinogens with mucosa Alkaline pH and decreased bacterial contamination High activity of benzopyrene hydroxylase, which detoxifies carcinogens Rapid turnover of mucosal cells Secretory IgA

What is the usual presentation?

Insidious onset, weight loss, anorexia, malabsorption with steatorrhea, dull aching pain, symptoms of obstruction, occult or massive bleeding

How are the tumors identified?

Upper gastrointestinal (UGI) series with enteroclysis Esophagogastroduodenoscopy (EGD) for duodenal lesions

ADENOCARCINOMA OF THE SMALL BOWEL What is the incidence of adenocarcinoma?

Most common small-bowel neoplasm; 30%–50% of all small-bowel cancers

What is the mean age?

Peaks at 60–70 yr (parallels colonic adenocarcinoma)

What is the most common location of adenocarcinoma?

The duodenum, especially in the periampullary region, which accounts for two-thirds of all small-bowel adenocarcinomas; occurs least frequently in the ileum

What are the signs of duodenal/ampullary adenocarcinoma?

Extrahepatic biliary obstruction

What is the usual presentation of adenocarcinoma?

Duodenal/periampullary—obstructive jaundice Jejunoileal—slow, progressive obstruction

What is the appropriate treatment of adenocarcinoma?

Surgical resection with removal of draining lymph nodes



Usually poor, because patients present with advanced disease With lymph node metastases—5-year survival rate of 15% Without lymph node metastases—5-year survival rate of 50%–70%

How does the prognosis of periampullary neoplasm compare with that of pancreatic cancer?

More frequently resectable for cure than pancreatic cancer; 5-year survival rate is 40%, compared with <10% for pancreatic cancer

LYMPHOMA OF THE SMALL BOWEL What is the incidence of lymphoma?

10%–15% of all small-bowel malignancies; primary involvement of the small bowel is the second most common site after the stomach

What is the mean age of occurrence?

Peaks at 50–60 yr

What is the associated cell type?

Virtually all primary small-bowel lymphomas are non-Hodgkin B-cell lymphomas

What is the most common location in the small bowel?

Ileum (remember Peyer’s patches = lymphatic tissue)


Fatigue, malaise, weight loss, abdominal pain, bowel obstruction, fever and night sweats, malabsorption, guaiac-positive stool

How is the diagnosis made?

UGI series with enteroclysis (demonstrates submucosal nodules, ulcerations, or diffuse mucosal thickening) CT (demonstrates bulky nodes and bowel wall thickening)

What are the associated medical conditions?

Celiac disease, Crohn’s disease, AIDS, Systemic Lupus Erythematosus (SLE), Wegener’s disease, X-linked agammaglobulinemia


What is the staging?

Follows Ann Arbor classification: Stage I—confined to the small bowel Stage II—with regional lymph nodes Stage III—with nonresectable lymph nodes beyond regional nodes Stage IV—metastases to other organs in and beyond the abdomen


Surgery; resection with primary anastomosis and removal of draining lymph nodes

What is the indication for postoperative chemotherapy?

Intermediate/high-grade lymphoma

ENTERIC INFECTIONS Through what mechanisms do enteric infections act?

Osmotic Secretory (i.e., cholera) Inflammatory (i.e., Shigella)

Which diagnostic tests are indicated?

Stool smear, Wright’s stain for WBCs, Hemoccult testing, stool culture, examination for ova and parasites

What are the sites of intestinal involvement?

Small intestine (cholera, Escherichia coli, Giardia, viruses) Ileum and colon (Salmonella, Yersinia, Campylobacter) Colon (Shigella E. coli [invasive, hemorrhagic], Amoeba, Giardia)

What is the most common cause after drinking from a mountain stream?

Giardia

What causes food poisoning?

Preformed toxins elaborated by Staphylococcus aureus, Clostridium perfringens, or Bacillus cereus

What part of the history differentiates gastroenteritis?

Vomiting is followed by pain and diarrhea


BLIND LOOP SYNDROME What is blind loop syndrome?

Bacterial overgrowth in the small intestine; the organisms that tend to overgrow are not the normal flora of the small bowel, but are more representative of colonic flora (e.g., gram-negative bacteria [E. coli]); often overgrowth of strictly anaerobic bacteria, such as Clostridium and Bacteroides

What are the causes?

Anything that disrupts the normal flow of intestinal contents (i.e., causes stasis): strictures, Crohn’s disease, postvagotomy, scleroderma, diverticula, decreased gastric acid secretion, and incompetent ileocecal valve

What are the associated signs and symptoms?

Diarrhea, steatorrhea, malnutrition, abdominal pain, hypocalcemia, B12 deficiency, and resultant megaloblastic anemia

What is the pathogenesis of B12 deficiency?

1. Bacterial utilization of B12 2. Bacterial toxins inhibit the absorption of B12 across the small-bowel mucosa


Schilling test—demonstrates an intrinsic factor-resistant B12 malabsorption Hydrogen breath test—lactose is swallowed and hydrogen expiration is monitored; with bacterial overgrowth, there is increased H2 production earlier than normal


Surgical correction of the underlying disorder, if feasible; otherwise, antibiotics to inhibit bacterial overgrowth

What are the other causes of B12 deficiency?

Gastrectomy (decreased secretion of intrinsic factor) and excision of terminal ileum (site of B12 absorption)


Chapter 49 The Appendix Who first described the pathogenesis of acute appendicitis?

Fitz in 1886 (Harvard pathologist)

What was the mortality for acute appendicitis in 1886?

45% died!

What is Dunphy’s sign?

Exacerbation of abdominal pain with coughing (seen with peritonitis from appendicitis)

What is the “hamburger” sign?

Ask patients with suspected appendicitis if they would like a hamburger or favorite food; if they can eat, seriously question the diagnosis

What often happens to the leukocytosis seen with acute appendicitis soon after appendiceal perforation?

WBC count falls!

What lab value (rarely used) is almost always elevated with acute appendicitis?

C-reactive protein

What percentage of the time will you see free air on abdominal x-rays with a perforated appendix?

≈1% of the time

What kind of CT scan should be obtained for evaluation of acute appendicitis?

Spiral CT

What are the CT findings with acute appendicitis?

1. 2. 3. 4. 5. 6.

Thickened appendix >6 mm Fat stranding Cecal thickening Appendicolith No contrast in appendix (unopacified) Arrowhead sign

Chapter 49 / The Appendix 317

What is the CT “arrowhead” sign of acute appendicitis?

Contrast in the cecum forms an “arrowhead” pointing to the occluded appendiceal orifice

Where is the appendix anatomically in the right lower quadrant with pregnancy by month 5?

3 mo Normal

8 mo 7 mo 6 mo 5 mo 4 mo

Umbilicus

McBurney

What is the fetal mortality with acute nonperforated appendicitis in pregnancy?

<10%

What is the fetal mortality with perforated appendicitis in pregnancy?

33%

What is the incidence of wound infection after nonperforated appendectomy?

Only ≈3%!

What is pyelophlebitis?

Rare postappendicitis complication marked by fever and jaundice due to septic clot in portal vein

While incidental appendectomy is controversial, in which group is it almost never indicated?

Elderly


What is the mortality for a perforated appendix in the elderly vs. the young?

Young: <1% Elderly: 5%

What should you order if a patient’s appendiceal specimen returns with a rare opportunistic pathogen?

HIV test for the patient

What percentage of all appendiceal specimens will reveal a tumor?

1%

What is “pseudomyxoma peritonei”?

Peritoneal cavity is filled with mucinous secretions and diffuse spread and implants of mucinous carcinomatous cells

What appendiceal tumor can cause pseudomyxomatous peritonei?

Mucinous cystadenocarcinoma of the appendix after rupture of appendiceal mucocele

What is an appendiceal mucocele?

Blockage of the appendiceal lumen and accumulation of mucus forming a large mucous-filled mass of the appendix

What causes an appendiceal mucocele?

Benign cystadenoma or malignant cystadenocarcinoma

What is the treatment of pseudomyxoma peritonei?

1. Wide resection of primary (right hemicolectomy) 2. Wide débridement of all feasibly removed peritoneal implants

What is the treatment of appendiceal cystadenoma?

Appendectomy

What is the treatment of ruptured appendiceal cystadenoma with mucinous ascites?

Appendectomy alone (benign mucinous ascites has no cells)

Chapter 50 / Carcinoid Tumors 319

Chapter 50 Carcinoid Tumors PATHOLOGY/HISTOLOGY What are tachykinins?

A family of vasoactive peptide hormones with very short half-lives

What percentage of patients with carcinoid tumors have elevated serotonin levels?

≈60%

What percentage of patients with serotonin overproduction are symptomatic?

≈66%

Are elevated serotonin levels responsible for the carcinoid syndrome?

Not entirely; excessive serotonin levels seem to be involved in diarrhea and valvular disease; however, the other classic symptoms seem to be due to other vasoactive/endocrine products

What are the associated valvular lesions?

Most commonly tricuspid, regurgitation, and pulmonic stenosis (predominantly right-sided valvular lesions)

What causes the valvular lesions?

Subendocardial fibrosis, thought to be secondary to elevated serotonin levels

Why are the valvular lesions predominantly right sided?

The lungs (like the liver) act as a filter to deactivate the bulk of the humorally active substances and thus protect the left side of the heart

Do desmoplastic (fibrotic) changes occur at other sites as well?

Yes; most commonly, the gut wall, mesenteric vessels, and retroperitoneum; less commonly, the penile fascia and joints

Can these fibrotic changes cause trouble?

Absolutely; the intense mesenteric and gut wall fibrosis is the most common cause of bowel obstruction in carcinoid tumor patients; the mesenteric vascular fibrosis can lead to intestinal ischemia


Which humoral product causes flushing?

Bradykinin is thought to be the most likely culprit

CLINICAL MANIFESTATIONS Is GI bleeding common with carcinoid tumors?

No; carcinoids are submucosal and do not commonly bleed; however, bleeding is seen with rectal carcinoids

What disease is associated with carcinoid tumors of the ampulla of Vater?

Neurofibromatosis

In patients with multiple endocrine neoplasia-I (MEN-I), what are the most frequent locations of carcinoid tumors?

Men—thymus Women—lung

Which primary site(s) are most commonly associated with carcinoid syndrome?

66% of all cases occur with ileal primaries

TREATMENT Where are appendiceal carcinoids located?

Tip—70% Body—20% Base—10%

What is the 5-year survival rate for appendiceal carcinoids?

99%

How common are metastases from appendiceal carcinoids?

Very rare, and almost always limited to the regional lymph nodes

What is the most common metachronous primary GI malignancy?

Colon adenocarcinoma

What is octreotide, and how does it work?

A synthetic somatostatin analog; thought to inhibit release of humoral products by the carcinoid

What are the side effects of octreotide?

Steatorrhea Cholelithiasis secondary to biliary stasis

Chapter 50 / Carcinoid Tumors 321

How effective is octreotide?

Response rate of 60%–80%, with excellent relief of diarrhea and flushing; however, tachyphylaxis occurs with time in most patients because of receptor downregulation, with a median response time of 9 mo

How effective is alpha interferon (α-IFN)?

Response rate of 50%–80% with symptom alleviation; tachyphylaxis also occurs with α-IFN, most likely because of the development of antibodies

In what cases should hepatic resection be attempted?

Only in low-risk patients in whom >90% of a metastatic tumor mass can be extirpated safely

Can hepatic resection ever be considered curative?

Yes, if all primary abdominal diseases and all metastatic diseases are resected

Why is cholecystectomy indicated at the time of initial operation for carcinoid tumors?

Two reasons: 1. To prevent potential gallbladder ischemia, if future hepatic artery embolization is necessary 2. Due to increased risk of gallstones with octreotide

What is the blood supply for most carcinoid liver metastases?

Hepatic artery (not the portal vein)

What is the rationale for hepatic artery embolization?

The liver has dual blood supplies, and thus two oxygen sources; the hepatic artery branches supplying the tumor can be interrupted without causing excessive damage to the normal liver

What are the potential side effects of embolization in carcinoid patients?

Increased release of humoral substances from the tumor; infection of necrotic liver

What precautions must be taken prior to any tumor embolization, manipulation, or anesthesia induction?

Octreotide “blockade,” to prevent excessive humoral product release from the tumor


What is the proper surgical therapy for bronchial carcinoid?

For typical carcinoids, local excision is adequate If carcinoid is atypical, the lesion should be treated as a bronchogenic carcinoma

What is carcinoid crisis?

Severe cramping, abdominal pain, and diarrhea, with or without cardiac disturbances (hypotension and/or tachycardia) and wheezing

What causes carcinoid crisis?

Extremely high humoral product levels (especially serotonin, which in high levels can cause mesenteric vasoconstriction) GI symptoms are caused by ischemia, not by mechanical obstruction.

Why should catecholamines be avoided in the treatment of carcinoid bronchospasm?

There is evidence that humoral product release by enterochromaffin cells may be controlled by adrenoreceptors, and thus catechols/agonists may actually worsen the bronchoconstriction by increasing the release of the causative factors!

What is the appropriate therapy for carcinoid crisis?

Octreotide; administer fluids to alleviate hypotension acutely; administer aprotinin for bronchospasm, if present

What is aprotinin?

An inhibitor of kallikrein

Can carcinoid tumors cause paraneoplastic syndromes?

Yes; carcinoids are a common cause of ectopic cortisol secretion (Cushing’s syndrome); acromegaly and hypercalcemia have also been reported

What nutritional deficiency occasionally occurs secondary to carcinoid tumors?

Pellagra

What causes pellagra in carcinoid?

Tryptophan is a precursor of niacin; in carcinoid all the tryptophan is converted to serotonin, resulting in niacin deficiency

When is cytotoxic chemotherapy considered?

In anaplastic variants of carcinoid, etoposide and cisplatin yield response rates of 67%; this therapy is not useful in other variants

Chapter 51 / Fistulas 323

Chapter 51 Fistulas What is the most common cause of enterocutaneous fistulas?

Abdominal operations (anastomotic leak and inadvertent enterotomies)

Which FRIEND factor (Foreign body, Radiation, Infection, Epithelialization, Neoplasm, Distal obstruction) is the most common reason for keeping a fistula open?

Distal obstruction

What is the difference between external and internal fistulas?

External is cutaneous (e.g., colocutaneous) Internal connects to internal hollow organs (e.g., colovesical)

Define the following: Simple fistula

One tract (complicated fistulas have multiple tracts)

Low-output fistula

<500 cc output per day

High-output fistula

>500 cc output per day

What is the most common cause of death with a fistula?

Infection

What are the medical therapy options for decreasing output from a proximal (e.g., gastric) fistula?

H2 blocker (e.g., ranitidine) and somatostatin

After a definitive surgical operation for an enterocutaneous fistula, what is the recurrence rate postoperatively?

10%

What length of enterocutaneous fistula is more likely to close?

>2 cm long


What percentage of enterocutaneous fistulas close in 6 wk?

≈60% (think: 60% in 6)

Has octreotide (somatostatin) been shown to decrease enterocutaneous fistula output?

Yes (50%–85% decrease)

Has octreotide been shown to speed up the closure of an enterocutaneous fistula?

No

Chapter 52 Colon and Rectum COLON ANATOMY AND PHYSIOLOGY Where is the rectosigmoid junction consistently located?

15–18 cm from the anal verge

What is the arc of Riolan?

Proximal collateral in the colonic mesentery that links the Superior Mesenteric Artery (SMA) and the Inferior Mesenteric Artery (IMA)

Should a sigmoid colostomy be brought through the rectus or oblique muscles?

Rectus muscles (lower incidence of peristomal hernias)

Which procedure has the higher morbidity, takedown of an end colostomy or a loop colostomy?

End colostomy

Which ion is preferentially absorbed from the normal colonic lumen?

Na+

Chapter 52 / Colon and Rectum 325

Which ions are preferentially secreted by the normal colonic epithelium?

K , HCO3−

Where in the GI tract does the majority of H2O absorption take place?

Ascending colon

By what mechanism does H2O absorption occur?

Passive diffusion, which is linked to active Na+ transport

What is the effect of bile acids on colonic epithelium?

Bile acids produce secretory diarrhea by inducing Na+ and H2O secretion

+

COLON CANCER What are the indications for colon resection after endoscopic malignant polypectomy?

1. Positive margin 2. Angiolymphatic invasion 3. Invasion of muscularis mucosa (Haggitt level 3) 4. Invasion of submucosa in sessile polyp (Haggitt level 4) 5. Poorly differentiated

Which is more accurate for assessing the distance of a rectal tumor from the anus: rigid or flexible sigmoidoscopy?

Rigid

What is the value of the Valsalva maneuver when performing a digital rectal exam?

A high rectal tumor may descend within reach of the examiner’s finger

Which procedure should come first: colostomy maturation or abdominal closure?

Abdominal closure (decreased risk of infection)

Which chemotherapeutic agents are considered standard for: Stage III colon cancer? Stage IV colon cancer?

5-fluorouracil (5-FU) and levamisole 5-FU and leucovorin


Why is radiotherapy (RT) not a standard adjuvant therapy for colon cancer?

Because of frequent complications of radiation enteritis and renal injury

What are the contraindications for hepatic resection of colon cancer liver metastases?

1. >5 metastases 2. Other distant metastases 3. Positive portal/celiac lymph nodes

What margins do you need with resection of liver metastases?

1 cm

What percentage of patients survive 3 yr after liver resection?

≈33% are alive at 3 yr

What percentage of patients are alive 5 yr after resection of a SOLITARY liver metastasis?

Up to 60% are alive at 5 yr!

What do you do in the event of recurrence after successful resection for liver colorectal metastases?

Redo the resection with 1-cm margins

COLON OBSTRUCTION With colon obstruction, is perforation more likely with competent or incompetent ileocecal valve?

Competent; results in a closed-loop obstruction through the one-way valve

What is the diagnostic workup for colon obstruction?

Abdominal x-ray (AXR), Gastrografin enema study

What are the major causes of colon obstruction?

Cancer (#1 cause) Volvulus Diverticulitis Inflammatory bowel disease

What are the indications for a cecostomy with colon distention with colonic obstruction?

Unstable, very poor prognosis


What do you use for an open cecostomy tube?

Malecot or Foley catheter

OGILVIE’S SYNDROME What is Ogilvie’s syndrome?

Nonobstructive colon distention (pseudo-obstruction)

What is the workup?

AXR (to rule out free air/measure cecum) Gastrografin enema (to rule out obstruction) Electrolyte levels

At what cecal diameter is there danger of perforation?

>12 cm at high risk of perforation

What is the treatment if no free air is seen?

Neostigmine IV (parasympathomimetic), or colonoscopic decompression

How does neostigmine work?

As a cholinesterase inhibitor

At what cecal diameter is treatment mandated?

>12 cm, or if no improvement in 36 hr

ISCHEMIC COLITIS What is ischemic colitis?

Low blood flow to colon

What are the signs and symptoms of ischemic colitis?

Abdominal pain, hematochezia, diarrhea

What is the diagnostic test?

CT scan

What is the role of angiography with colon ischemia?

No role!


NPO, IV fluids, broad-spectrum antibiotics

What are the indications for laparotomy and resection?

Peritonitis, free air, transmural necrosis


After resection, what procedure should be done?

Colostomy/mucus fistula is safest choice

RECTAL CANCER Give the original Dukes’ staging (simplified): A

Limited to the mucosa/submucosa

B

Invasion of muscularis propria

C

Positive regional lymph nodes

D

Dukes’ did not describe a stage D!

For what tumor was the Dukes’ classification originally described?

Rectal cancer (not colon cancer)

What is TRUS?

TransRectal UltraSound

What are the ultrasound rectal cancer stages for: uT1?

Tumor confined to mucosa/submucosa

uT2?

Invades muscularis propria

uT3?

Invades perirectal fat

uT4?

Invades adjacent organ

N0?

No lymph node enlargement seen

N1?

Lymph node enlargement

Which rectal tumors get preop chemotherapy and radiation therapy (neoadjuvant)?

All rectal tumors except uT4

What treatment is used for neoadjuvant rectal cancer?

5-FU and leucovorin 5000 cGy radiation therapy Followed postoperatively by chemotherapy and radiation therapy for 6 wk


What is total mesorectal excision?

Total removal of the mesorectum with its lymph nodes

What is a coloanal anastomosis?

For distal rectal tumors: anastomose a colon J pouch to the anus

What are the criteria for transanal rectal cancer resection?

Small (<4 cm), well or moderately differentiated, distal, less than a third of lumen circumference, no biopsyproven lymphatic or vessel invasion, T1 (submucosa), no positive nodes


MISCELLANEOUS What is the Delorme procedure for rectal prolapse?

Chapter 53 The Anus ANAL CANCER Define the anal verge, anal margin, and anal canal:

The anal verge separates the anal canal from the anal margin; the anal margin is 5 cm of perianal skin

Dentate line

Anal canal

5 cm Anal margin

Anal verge

Chapter 53 / The Anus 331

What are the risk factors for anal cancer?

Human papillomavirus (HPV), HIV, any immunosuppressive state, anal-receptive intercourse

What are the signs and symptoms of anal cancer?

Bleeding, pain, pruritus, tenesmus, change in bowel movement habits

Define tenesmus:

Feeling of need to have bowel movement with “ineffectual” painful straining

What is the diagnostic test for anal canal tumors?

EAUS = EndoAnal UltraSound

Describe the stages of anal cancer: Stage I

Tumor <2 cm, no nodes, no metastases (T1, N0, M0)

Stage II

Tumor >2 cm, (T2, N0, M0)

Stage IIIA

1. Tumor >2 cm with positive perirectal lymph nodes, no metastases (T1–3, N0, M0) 2. Tumor invades adjacent organ (T4, N0, M0)

Stage IIIB

1. Tumor invades adjacent organs and has positive perirectal nodes (T4, N1, M0) 2. Any tumor with positive inguinal or iliac nodes (any T, N2–3, M0)

Stage IV

Distant metastases (any T, any N, M1)

In general, to what lymph node basin does anal cancer distal to the dentate line (anal margin and distal anal canal) spread?

Inguinal nodes

In general, where do anal canal tumors proximal to the dentate line spread?

Inferior mesenteric lymph nodes, mesorectum, paravertebral lymph nodes (like rectal cancers)


What should be done if residual tumor remains in the anal canal after treatment according to NIGRO protocol?

Chemotherapy with different agent radiation therapy

What should be done if disease recurs or residual tumor remains in the anal canal after two attempts of chemotherapy and radiation?

AbdominoPerineal Resection (APR)

What percentage of patients have a complete response to treatment with modified NIGRO protocol?

90%

After treatment with modified NIGRO protocol, what percentage of patients are alive at 5 yr?

85%

What is the most common site of distant metastases with anal cancer?

Liver

ANORECTAL ABSCESS Define the abscess:

1. 2. 3. 4.

Supralevator Perianal Intersphincteric Ischiorectal

1 3

2

Where should a simple isolated supralevator abscess be drained?

4

Through the rectum

Chapter 54 / Lower GI Bleeding 333

What test is very helpful when entertaining the thought of supralevator abscess?

CT scan

ANAL CONDYLOMA What causes anal condyloma?

HPV

What is the incubation period?

6 wk until signs

What are the nonsurgical treatments?

Aldara®, 5-fluorouracil (5-FU) cream, intralesional interferon injection, podophyllin

What is Aldara®?

Imiquimod—a cream that is an immunostimulant

What is the treatment of anal canal disease?

Surgical resection and intralesional interferon injections

What is the treatment of external perianal disease?

Surgical excision and/or topical medication

MISCELLANEOUS What is the most common cause of anal stricture?

Hemorrhoidectomy

What is the most common cause of anal pruritus?

Idiopathic; other causes include tumors, infections, anorectal disorder, skin disorder (e.g., psoriasis), jaundice

Chapter 54 Lower GI Bleeding What is massive lower GI bleeding?

>3 units of blood in 24 hr

Why is a nuclear-tagged RBC study not used with massive lower GI bleeding as the first-line test?

Because >50% of patients will not be localized until after 6 hr!


What causes lower GI bleeding in patients acutely after abdominal aortic aneurysm (AAA) repair?

Left colon ischemia due to loss of Inferior Mesenteric Artery (IMA)

What condition causes bright red blood per rectum and per mouth?

Duodeno-aortic fistula (large volume bleeding!)

The small bowel is the source of lower GI bleeding in what percentage of cases?

≈4%

What is the most common cause of small bowel lower GI bleeding?

Angiodysplasia

How do you evaluate the small bowel for mass or mucosal abnormality?

Enteroclysis (not upper GI study), but this does not diagnose angiodysplasia!

What is the most common cause of lower GI bleeding in children and adolescents?

Meckel’s diverticulum with ectopic gastric mucosa resulting in an ulcer

What percentage of significant bleeding originates in the upper vs. lower GI tract?

85% are upper GI (“most common cause of massive blood per rectum is upper GI bleeding”)

What is angiodysplasia?

a.k.a. arteriovenous malformation; dilated (ectatic) vessels in the submucosa; breakdown of overlying mucosa results in bleeding

What is the most common location of colon angiodysplasia?

Right sided

Why does right-sided angiodysplasia bleed more often than left sided?

Thought to be because the right colon wall has less muscle (i.e., it’s thinner)

Chapter 55 / Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis 335

Give the differential diagnosis of lower GI bleeding in adolescents:

Meckel’s diverticulum (ectopic gastric mucosa), Inflammatory Bowel Disease (IBD), polyps

What is the one exam that many patients require prior to laparotomy for lower GI bleeding?

Esophagogastroduodenoscopy (EGD; to rule out UGI bleed)

How can you mark the spot of colon bleeding for localization at laparotomy?

Inject India ink via colonoscope!

How often is colonoscopic treatment of colonic angiodysplasia definitive?

≈85% of the time

What percentage of patients with lower GI bleeding that spontaneously stops will rebleed?

Up to 25%!

What is the differential diagnosis of lower GI bleeding and pain?

IBD, ischemic bowel, ruptured AAA with occlusion of IMA, Meckel’s diverticulum with ulcer, intussusception

Chapter 55 Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis What is the treatment for short segment small bowel strictures in Crohn’s disease?

Heineke-Mikulicz stricturoplasty


What is the surgical treatment of long segment small bowel stricture in Crohn’s disease?

Isoperistaltic side-to-side stricturoplasty: Transect strictured bowel Overlap ends Anastomose side to side to enlarge lumen

In general, should the small bowel ever be surgically bypassed in Crohn’s disease?

No (increased risk of cancer, bleeding, perforation)

What is the one exception regarding bypass in Crohn’s disease?

Duodenal involvement: “bypass” with gastrojejunostomy

When is colonic resection in Crohn’s disease relatively contraindicated?

In a patient who has had many small bowel resections, the bowel becomes very important for water and electrolyte absorption; consider “stricturoplasty” of large bowel

Chapter 55 / Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis 337

What is a popular surgical anastomosis after total abdominal colectomy for ulcerative colitis?

Ileoanal anastomosis—create pouch of ileum and then anastomose to anus/ rectum

II

I

15–20 cm

I

15 cm

II

III II

I

III

12 cm

IV

What is the function of the “pouches”?

Act as a reservoir for stool

What is a relative contraindication for ileoanal anastomosis?

Controversial, but most believe that an ileoanal anastomosis should not be performed with Crohn’s disease

How many bowel movements per day do patients have after an ileoanal anastomosis?

Average 4–7

What is the treatment for colon to other organ fistulas in Crohn’s disease?

Resect colon segment


What is the role of Infliximab in Crohn’s disease?

Immunosuppressive; an antibody against tumor necrosis factor receptors, which results in lysis of inflammatory cells

What is the role of cyclosporine in inflammatory bowel disease (IBD)?

Usually as a last resort (in refractory cases)

What is olsalazine?

5-ASA dimer (cleaved by colonic bacteria)

What percentage of patients with Crohn’s disease have anal involvement?

33% (rectal involvement is rare)

What is the treatment for ulcerative colitis with severe intractable bleeding?

Subtotal colectomy

Chapter 56 Liver ANATOMY What fissure does the falciform ligament enter?

Umbilical fissure

What are the borders of the caudate lobe?

IVC, umbilical fissure, transverse hilar fissure

What are the three borders of the quadrate lobe?

Transverse hilar fissure Umbilical fissure Gallbladder fossa

Do the hepatic veins follow the segmental lobar anatomy of the liver?

No

Does the portal vein have valves?

No

Chapter 56 / Liver 339

What is the obliterated umbilical vein called?

Ligamentum teres

What percentage of left hepatic arteries are replaced entirely by a branch from the left gastric artery?

≈10%

What percentage of left hepatic arteries are partially replaced by a branch of the left gastric artery?

≈10%

What percentage of right hepatic arteries arise from the superior mesenteric artery?

≈10% (Is there a pattern here?)

What percentage of right hepatic arteries pass anteriorly to the common hepatic bile duct?

≈25%

What percentage of right hepatic arteries pass posteriorly to the portal vein?

≈10%

What is the name of macrophages located in the liver?

Kupffer cells

What are the three components of a portal triad?

1. Arteriole (hepatic) 2. Portal venule 3. Bile duct

HYDATID LIVER CYSTS What is the appropriate treatment of cyst rupture and bile duct obstruction?

Endoscopic Retrograde CholangioPancreatography (ERCP) with papillotomy

What are the three layers of a hydatid cyst?

Host pericyst Ectocyst (from parasite) Endocyst (from parasite)


Which layers must be removed in the OR?

The endocyst and the ectocyst, because both layers may contain live parasites

What is the recurrence rate of postoperative hydatid cysts?

≈20%

TUMORS OF THE LIVER Cavernous Hemangioma What are the two types of hepatic hemangioma?

Capillary hemangioma Cavernous hemangioma

What is the significance of capillary liver hemangiomas?

Clinically insignificant

How common are cavernous hemangiomas?

≈7% incidence (autopsy studies)

What percentage of cavernous hemangiomas are multiple?

≈10%


Right upper quadrant pain/mass, shock, CHF


Hemorrhage, CHF, coagulopathy


CT with IV contrast

Should biopsy be performed?

No; there is a chance of severe hemorrhage with biopsy


Observation; resection if the patient is symptomatic/hemorrhaging

What are the nonoperative treatment options?

Steroids, radiation

Bile Duct Adenoma What is a bile duct adenoma?

Benign tumor <1 cm composed of bile ducts and fibrous material



Nearly one-third of all people have these lesions


Leave it alone

Hepatoma (Hepatocellular Carcinoma) What is the most common site of metastasis?

Lungs

What percentage of patients who receive a liver transplant for hepatoma will have a recurrence?

≈50%

What options are available for treating a solitary, small hepatoma in a patient who is not an operative candidate?

Ethanol injection under US guidance Radiofrequency ablation

Which subtype has the best prognosis?

Fibrolamellar hepatoma (young adults); not associated with alpha-fetoprotein (AFP) elevations

Describe the staging of hepatoma: Stage I

Tumor <2 cm (T1, N0, M0)

Stage II

T2, N0, M0: 1. Tumor <2 cm with vascular invasion 2. Tumor >2 cm without vascular invasion 3. Multiple tumors in one lobe <2 cm without vascular invasion

Stage III

Positive nodes (T1–3, M0)

Stage IVA

T4, any N, M0: 1. Multiple tumors in >1 lobe 2. Invasion of major venous structure

Stage IVB

Distant metastases with multiple tumors in >1 lobe or invasion of major venous structure (T4, any N, M1)


What are the standard liver resections?

Lateral segmentectomy Right lobectomy

Left lobectomy

Right trisegmentectomy Left trisegmentectomy

What three factors are most related to mortality and morbidity during and after liver resection for hepatoma?

Blood loss, blood transfusion, and operative time

Benign Liver Cysts What is the difference between simple cyst and cystadenoma or cystadenocarcinoma?

Simple cyst: No septa or associated mass, regular margins Cystadenoma/cystadenocarcinoma: Septations, irregular margins, loculations

What is the treatment of cystadenomas?

Complete resection due to risk of transformation into a cystadenocarcinoma

What is the treatment of asymptomatic simple liver cysts?

Observation

What is the surgical treatment for symptomatic simple liver cysts?

Unroofing/fenestration (in poor operative candidates, radiographically guided aspiration with alcohol injection is an option)


MISCELLANEOUS LIVER FACTS What is Kasabach-Merritt syndrome?

Seen with liver hemangiomas: hemolytic anemia, platelet trapping, loss of fibrinogen

What 5-year survival rate is associated with colorectal carcinoma metastases to the liver without surgical resection?

0%–7%

What 5-year survival rate is associated with colorectal liver metastases in patients who undergo resection?

≈25%–35% (with negative margins)

If a kidney from a patient with hepatorenal syndrome is transplanted into a patient with normal liver function, does the kidney recover function?

Yes

If a patient with hepatorenal syndrome receives a liver transplant, what happens to the kidneys?

They recover function

From what source do metastatic tumors to the liver receive their blood supply?

The vast majority receive their blood from the hepatic artery

What is the liver’s “favorite” amino acid for gluconeogenesis (making glucose)?

Alanine

Which two serum tests are most sensitive for liver parenchyma damage?

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT)

What is the most sensitive and specific test for hepatocyte injury?

ALT


Which three tests are sensitive for bile duct damage or pathology?

1. Alkaline phosphatase 2. GGT 3. 5′ nucleotidase

What is the most common liver tumor?

Metastatic disease outnumbers primary tumors 20:1 (Primary site is usually in the GI tract)

What hepatic defect is associated with Dubin-Johnson syndrome?

Faulty excretion of conjugated bilirubin from the liver (think: Dubin = Departure defect)

What is Gilbert’s syndrome?

Partial deficiency of glucuronyltransferase, leading to intermittent asymptomatic jaundice in the second to third decade of life

What is Crigler-Najjar syndrome?

Rare genetic absence of glucuronosyltransferase activity, causing unconjugated hyperbilirubinemia, jaundice, and death from kernicterus (usually within the first year)

What hepatic defect is associated with Crigler-Najjar syndrome?

Faulty conjugation of bilirubin (think: Crigler = Conjugation defect)

What hepatic defect is associated with Rotor’s syndrome?

Faulty excretion of conjugated bilirubin due to a defect in the storage of bilirubin (think: Rotor = Release defect)

What do the Denver and LeVeen shunts do?

Drain ascitic fluid (fluid from ascites) from the peritoneal cavity into the central venous system

What dreaded complication is associated with the Denver and LeVeen shunts?

DIC (If refractory DIC occurs, the shunt must be emergently ligated!)

What type of amino acid should be limited in patients with liver failure?

The aromatic amino acids, because they are thought to be precursors of the false neurotransmitters involved with hepatic encephalopathy

Chapter 57 / Portal Hypertension 345

Which amino acids are thought to be beneficial to patients with hepatic encephalopathy?

Branched amino acids (Leucine, Isoleucine, Valine; think: LIV = LIVer)

What vitamin should every patient with liver failure and a coagulopathy receive?

Vitamin K (remember: 2, 7, 9, 10 are liver clotting factors)

Define the Pringle maneuver

Compression of hepatoduodenal ligament and its contents (i.e., hepatic artery and portal vein) to help control bleeding from the liver

What is hepatorenal syndrome?

Renal failure of unknown cause in patients with liver failure (kidneys work fine when transplanted into a patient with a normal liver!)

Chapter 57 Portal Hypertension What level of portal pressure is associated with portal hypertension?

>18 mm Hg

What is the most common cause of portal hypertension in the world?

Schistosomiasis

What are the three classes of portal hypertension?

Presinusoidal Sinusoidal Postsinusoidal

Give two examples of presinusoidal portal hypertension

Schistosomiasis Portal vein thrombosis

Give an example of sinusoidal portal hypertension

Cirrhosis

Give an example of postsinusoidal portal hypertension

Budd-Chiari’s syndrome (most common cause of portal hypertension with upper GI bleed in children)


What is the major cause of isolated gastric varices?

Splenic vein thrombosis secondary to pancreatitis

What is the common long-term medical treatment of portal hypertension?

β-blocker (e.g., propranolol, nadolol) +/− long acting nitrate (e.g., isosorbide 5-mononitrate)

If rebleeding takes place after multiple sclerotherapy episodes, what are the options?

TIPS, Shunt procedure, or transplant

What does TIPS stand for?

Transjugular Intrahepatic Portacaval Shunt: a metallic shunt is placed from the hepatic vein to the right portal vein via a catheter introduced through the internal jugular vein

Which patients are good candidates for TIPS?

Those most likely to undergo liver transplantation subsequently Poor operative candidates


Picture the following shunts: Mesocaval shunt “H” graft

End-to-side portacaval shunt

Side-to-side portacaval shunt


Warren distal splenorenal shunt

Which vein must be tied off with a distal splenorenal shunt?

The coronary vein

What is the advantage of a Warren distal splenorenal shunt?

Lower rate of encephalopathy

What are the relative contraindications for the Warren shunt?

Poorly controlled ascites (i.e., the Warren shunt often causes ascites)

What is a partial shunt?

Does not shunt all of the portal blood (i.e., decreases variceal bleeding but allows some liver blood flow to avoid encephalopathy) as illustrated:


What is a Sugiura procedure?

Used rarely, the esophagus is transected and reanastomosed, with splenectomy and gastric devascularization

PORTAL HYPERTENSION AND ASCITES Why do patients with cirrhosis and portal hypertension have high aldosterone levels?

Low glomerular filtration rate (GFR) and low renal blood flow

Are sodium levels in the urine low or high?

Low

Why do patients with portal hypertension and ascites have a low GFR and decreased renal blood flow?

With portal hypertension, the splanchnic blood volume drastically increases with significant venous vasodilation, which leads to reduction in intravascular volume and results in decreased renal blood flow and decreased GFR

What are the two most common electrolyte abnormalities in patients with cirrhosis and ascites?

Hyponatremia Hypokalemia

What is the best way to prevent hyponatremia in patients with cirrhosis and ascites?

Limit H2O intake, because total body sodium is normal or elevated

How does spironolactone work?

It is an aldosterone antagonist (results in sodium/H2O loss and potassium retention)

What is the risk of spironolactone therapy in the patient with cirrhosis and mild renal dysfunction?

Hepatorenal syndrome


Chapter 58 Biliary Tract BILIARY ANATOMY What is the hepatocystic triangle?

1. Liver edge 2. Cystic duct 3. Common hepatic duct

What are Rokitansky-Aschoff sinuses?

Branching evaginations from the lumen into the mucosa and muscularis of the gallbladder

What causes these sinuses to form?

Increased intraluminal pressure in the gallbladder

Is the predominant blood supply to the bile ducts arterial or venous?

Arterial

Describe the anatomy of the arteries to the bile duct:

Two main vessels running axially (longitudinally) at approximately 3 o’clock and 9 o’clock Arise mainly from retroduodenal artery below, and right hepatic artery above Majority of the axial blood supply to the common bile duct (CBD) is from below

What are the effects of vagal innervation on the gallbladder?

Excitatory (emptying)

What is the effect of sympathetic stimulation on the gallbladder?

Predominantly inhibitory motor effect on the gallbladder

BILE METABOLISM/PHYSIOLOGY What are the main chemical components of bile?

Water, electrolytes, bile salts, cholesterol, lecithin, bile pigments (bilirubin)

What does bile do?

Emulsifies fats

Chapter 58 / Biliary Tract 351

What is the volume of bile secreted per day?

≈600 mL

From what substance are bile acids formed?

Cholesterol

What is the source of this substance?

1. Cholesterol is synthesized de novo in the liver 2. Diet

What are the two primary bile acids?

Cholic acid and chenodeoxycholic acid

What are the two secondary bile acids?

Lithocholate and deoxycholate

What makes the secondary bile acids?

Bacterial action

What step do the primary bile acids undergo prior to secretion as bile salts?

They are conjugated in the liver with glycine or taurine

What is a bile salt?

Conjugated bile acid at a neutral pH results in an ionic salt and thus a bile salt

What is the enterohepatic circulation?

Secretion of bile salts into the gut, reabsorption, and return to the liver

In what part of the bowel are the bile salts reabsorbed?

In the terminal ileum, by active transport

What is the main bile pigment?

Bilirubin glucuronide

From what substance does it arise?

80%–85% of bilirubin is derived from the catabolism of senescent red blood cells by the reticuloendothelial system (from heme)

Which enzymes participate in this conversion?

1. Heme oxygenase converts heme to biliverdin 2. Biliverdin reductase converts biliverdin to bilirubin


What is bilirubin conjugated to?

Glucuronic acid, by glucuronic transferase

What is the significance of urobilinogen in the urine?

Urobilinogen is produced in the terminal ileum from the breakdown of bilirubin glucuronide by bacterial action; some of it is reabsorbed into the bloodstream; if urobilinogen is present in the urine (after being absorbed from the GI tract), then complete biliary obstruction must not be present

What inhibits gallbladder emptying?

Somatostatin Sympathetic stimulation (think: It is impossible to digest food and “flee” at the same time)

What are the effects of female reproductive processes on gallbladder contraction?

Efficiency of gallbladder contraction is significantly reduced during the latter half of the menstrual cycle and in the last trimester of pregnancy

At what level of serum total bilirubin is jaundice usually evident?

Usually, 2.5–13 mg/dL

Classically, at what anatomic site is jaundice first evident?

Under the tongue

What is the difference in jaundice associated with stone obstruction vs. malignancy?

Stones “ball valve” and usually is <6; cancer can cause complete obstruction and is often >6

What is the approximate maximum bilirubin level?

When urinary daily losses of bilirubin match bilirubin production, jaundice stabilizes at a level of ≈30 mg/dL

What enzyme is found in the biliary endothelium?

Alkaline phosphatase (also found in bone!)

BILIARY IMAGING How often can US diagnose ductal dilatation?

>80% of the time


How often can US diagnose choledocholithiasis?

Only about 33% of the time!

How often can US diagnose the cause of biliary obstruction?

Only about 50% of the time

What is distal obstruction vs. proximal biliary obstruction?

Proximal bile ducts are in or near the liver and distal is near the duodenum (Bile flows proximal to distal—like arterial blood!)

What is the diagnostic test for biliary dyskinesia?

1. US (rule out stones) 2. Nuclear scan (HIDA) with cholecystokinin (CCK) and ejection fraction

What is the positive predictive value of a sonographic Murphy’s sign and gallstones?

≈90%

BILIARY DYSKINESIA What is biliary dyskinesia?

Biliary colic due to gallbladder dysfunction—not stones

What are the signs of biliary dyskinesia?

Nuclear scan: EF <35%, and/or reproducing of pain with injection of CCK

What are the indications for surgery?

EF <35% Pain consistent with biliary colic


Laparoscopic cholecystectomy

What percentage of patients will be asymptomatic after surgery?

If EF <35% and biliary colic pain was present preoperatively, ≈90% will be asymptomatic

What percentage of patients will have signs of chronic inflammation on pathology?

>66%


GALLSTONES How are gallstones classified?

What percentage of all gallstones do the following classes comprise: Cholesterol?

Cholesterol stones (predominant in the United States) Pigment stones, brown or black (predominant in Asia)

≈75%

Black?

≈20%

Brown?

≈5%

Which type of stone is most likely to be intrahepatic?

Pigment stones (≈95%)

What are the three steps in the formation of cholesterol gallstones?

1. Cholesterol saturation 2. Nucleation 3. Stone growth

What is Admirand’s triangle?

A tricoordinate phase diagram describing the concentrations of bile salts, cholesterol, and lecithin; note the small (shaded) area where cholesterol is entirely soluble!

ro ste ole Ch

)

60

80

Micelles only

80

(%

What substances are implicated in the nucleation of cholesterol gallstones?

Solid crystals Micelles

40

in

0 100

Solid crystals Liquid crystals Micelles

cith

40

20

20

80

60

0 Le

l (%

)

100

Liquid crystals Micelles

60 40 Bile salt (%)

20

Calcium, gallbladder mucus

100 0


Which tumor is associated with gallstone formation?

Somatostatinoma

What six factors predispose patients to pigment stone formation?

Hemolytic disorders Cirrhosis Biliary infections Parasitic infection Ileal resection Long-term TPN

What is the mechanism of formation of pigment stones?

Unconjugated bilirubin precipitates to yield calcium bilirubinate and insoluble salts; calcium bilirubinate is the main component in pigment stones

What are the characteristics of “black” pigment stones?

Typically black and tarry Frequently associated with hemolysis or cirrhosis Almost always located in the gallbladder Almost never associated with infection

What are the characteristics of “brown” pigment stones?

Earthy, brown, friable Typically found in Asian patients Frequently associated with infection Primary common duct stones are almost invariably of this type

What is the mechanism of formation of “brown” pigment stones?

Stagnant bile with bacteria allows enzymatic hydrolysis of bilirubin glucuronide into free bilirubin and glucuronic acid; the free unconjugated bilirubin (insoluble) combines with calcium in the bile to produce a calcium bilirubinate matrix—the predominant component of most pigment stones

Which enzyme is involved in this process?

Bacterial β-glucuronidase

Which bacteria commonly produce this enzyme?

Escherichia coli and Klebsiella


What is Mirizzi’s syndrome?

Impaction of a large gallstone in the cystic duct, with extrinsic obstruction of the adjacent common hepatic duct

Which antibiotic is associated with cholestatic jaundice and gallbladder sludge?

Ceftriaxone

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)/ EXTRACTION OF CBD STONES What morbidity rate is associated with endoscopic stone extraction?

≈5%–10%

What is the associated mortality rate?

≈1%

What 4 specific complications are associated with this procedure?

GI hemorrhage Duodenal perforation Biliary sepsis Pancreatitis

Should you routinely check post-ERCP labs the following A.M. for amylase and lipase?

No! Unless the patient has abdominal pain, almost all patients will have a “chemical” pancreatitis after ERCP

CBD EXPLORATION What CBD size is a relative contraindication to CBD exploration?

<6 mm


What maneuver must be performed before a CBD exploration?

Kocher maneuver

How do you repair the following CBD injuries during a lap cholecystectomy? <50% diameter injury

Repair with absorbable sutures around a T-tube

>50% diameter injury

Roux-en-Y choledochojejunostomy

What type of suture must be used in suturing the CBD after T-tube placement?

Absorbable

What is the correct orientation for incisions on the CBD?

Longitudinal (parallel to the blood supply) between two stay sutures


What backup procedure can be used in the rare instance that a stone is impacted in the distal common duct and cannot be removed with transductal manipulation?

A transduodenal sphincterotomy

BILIARY STRICTURES What is the most common source of benign biliary strictures?

Iatrogenic

What procedures classically precede postoperative benign strictures?

>90% result from cholecystectomies (an incidence from 1/400 to 1/500 cases) ≈5% follow exploration of the biliary ducts Partial or subtotal gastrectomy Pancreatoduodenectomy Liver resection for trauma

What are some noniatrogenic conditions causing biliary stricture?

Mirizzi’s syndrome Radiotherapy (rare) Idiopathic

Describe the Bismuth classification of benign biliary strictures: Grade I

Stricture of CHD >2 cm from confluence of left and right hepatic ducts

Grade II

Stricture of CHD <2 cm from confluence of left and right hepatic ducts

Grade III

Stricture at confluence of left and right hepatic ducts

Grade IV

Obliteration of all extrahepatic ducts by stricture


What is the success rate of biliary repair based on the Bismuth classification? Bismuth grade I or II stricture

75%–90% long-term success rate for repair

Bismuth grade III lesions

≈70% success rate

Bismuth grade IV lesions

50% of patients will have recurrent cholangitis on follow-up

Is there benefit in the use of external percutaneous transhepatic biliary drainage before surgery in cases of biliary obstruction with jaundice?

No; preoperative drainage has failed to show benefit

ORIENTAL CHOLANGIOHEPATITIS What is oriental cholangiohepatitis?

Recurrent cholangitis, in association with recurrent formation of primary common duct stones

With what other disorders is it associated?

Parasitic infection: Clonorchis sinensis, Ascaris lumbricoides, Trichuris trichiura (parasites may cause stasis, damage to bile ducts) Bacterial colonization with E. coli (produces β-glucuronidase, which causes deconjugation of bilirubin and subsequent production of pigment stones)

What is the endemic area?

Asia

What is the appropriate therapy?

Choledochoenterostomy and antiparasitic medications

CAROLI DISEASE What is it?

A type V choledochal cyst; congenital dilatation of the intrahepatic biliary ducts


What are the four “C”s of Caroli disease?

Caroli Congenital Choledochal cyst Cholangitis

What is the clinical presentation?

Often presents as recurrent cholangitis

Is surgical therapy recommended under any conditions?

Hepatic lobectomy is the therapy of choice if only one lobe of the liver is involved

PERIAMPULLARY TUMORS What is the definition?

Malignant tumors arising adjacent to or from the ampulla of Vater

What are the four possible anatomic sites of origin?

Distal pancreatic duct (40%–60%) Ampulla itself (20%–40%) Distal bile duct (10%) Duodenum (10%)

What are the most common cell types?

Adenocarcinoma, but the cancer may arise from any cell type in the region

Why are these grouped, despite their variations in anatomy and histology?

Because they have the same mode of presentation (jaundice), and the same operation (pancreatoduodenectomy) is performed for curative intent

How do periampullary tumors usually present?

Jaundice is the most common sign (80%–90% of patients); 75% of patients lose weight

What is the tumor marker for periampullary tumors?

CA 19–9 has the best sensitivity and specificity (both close to 90%)

What is the operative mortality rate of pancreatoduodenectomy, past and present?

Operative mortality has decreased from 25% in older reports to 1%–2% in most current series


What is the survival rate after pancreatoduodenectomy performed “for cure”?

5-year survival rate depends on cell type: Pancreatic (15%–20%) Distal bile duct (40%) Duodenal (40%) Ampullary (50%–70%)

GALLBLADDER TUMORS What is the incidence of gallbladder cancer in comparison with cancer of the CBD?

Gallbladder cancer is approximately four times as common

What are the risk factors for gallbladder cancer?

Gallstones, porcelain gallbladder, gallbladder adenoma, infection by Salmonella typhi of bile ducts/gallbladder

What is the rate of incidental presentation of gallbladder cancer?

≈1% of all laparoscopic cholecystectomy specimens

What percentage of all gallbladder cancer is discovered incidentally?

≈20%–30%

What are the symptoms of gallbladder cancer?

Pain, nausea/vomiting, weight loss, jaundice

How effective is US in diagnosing gallbladder cancer?

≈75% of gallbladder cancers can be diagnosed by US, but ≈50% of US diagnoses of gallbladder cancer are false positives

What is the most common cell type?

Adenocarcinomas (85%); the remainder are undifferentiated or squamous carcinomas

Describe the stages of gallbladder cancer: Stage I

Stage II

T1, N0, M0: invades mucosa, no nodes, no distant metastases T2, N0, M0: invades perimuscular connective tissue (below serosa)


Stage III

T3, N0, M0: through serosa, <2 cm into liver parenchyma

Stage IVA

T4, N0–1, M0: tumor >2 cm into liver, or invades 2 adjacent organs

Stage IVB

1. Any T, any N, M1: distant metastases 2. Any T, N2, M0: positive nodes around pancreas/duodenum/superior mesenteric artery/celiac

Describe the treatment of gallbladder cancer by stage: Stage I

Laparoscopic cholecystectomy

Stage II

Radical cholecystectomy, node dissection (N2)

Stage III

Radical cholecystectomy, node dissection (N2)

Stage IVA

Radical cholecystectomy and node dissection (N2 peripancreatic/duodenal, superior mesenteric artery/celiac)

Stage IVB

Nonoperative—palliative only

What is the rate of resectability at presentation?

Most patients present with advanced disease characterized by extensive local invasion and a low resectability rate (25%)

What is a radical cholecystectomy?

Resect gallbladder bed with gallbladder en bloc, with 2 cm liver margins around gallbladder


5-year survival for stage I: ≈50% 5-year survival for stage IVB: 0%

What is the appropriate management of porcelain gallbladder?

Resection upon identification, because 25%–75% of patients develop malignancy


HEMOBILIA What are the causes?

Trauma, other disease, accidental tumors, blunt or penetrating trauma, operative/ interventional aneurysms, gallstones, and inflammation

What is the appropriate workup?

Arteriography, which is often therapeutic by means of embolization

PRIMARY BILIARY CIRRHOSIS (PBC) What is the etiology/histology?

An autoimmune disease causing granulomatous destruction of the medium-sized intrahepatic bile ducts

What is the final common pathway?

The final event is an attack by cytotoxic T cells on biliary epithelium; suppressor T cells are reduced in number and function

What is the usual presentation/clinical course?

Ductal destruction leads to cholestasis, with subsequent cirrhosis, portal hypertension, and liver failure


Fatigue and pruritus (usually occur early) Jaundice (usually occurs later; does not always correlate with pruritus) Xanthelasmas and xanthomas (appear as signs of chronic liver disease) Evidence of an associated extrahepatic autoimmune disorder, such as Sjögren’s syndrome or rheumatoid arthritis (incidence of up to 80%)

Is medical therapy effective?

No; a variety of immunosuppressive drugs and penicillamine have proved unsuccessful

What is the appropriate surgical therapy?

Liver transplant; PBC is the most frequent indication for transplantation in the cholestatic group of patients


Chapter 59 Pancreas ANATOMY On what structure does the pancreatic head rest?

The IVC, renal vessels

On what structure does the uncinate process (a prolongation of the pancreatic head) rest?

The aorta

What lies behind the pancreatic neck?

The superior mesenteric vessels

How is blood supplied to the head of the pancreas from the celiac axis?

The gastroduodenal artery branches into the superior posterior and anterior pancreaticoduodenal arteries

How is blood supplied to the pancreatic head from the SMA?

The SMA branches into the inferior posterior and anterior branches of the pancreaticoduodenal arteries

Which arteries supply the body and tail of the pancreas?

The dorsal pancreatic artery from the splenic artery branches and joins a branch from the SMA to form the inferior pancreatic artery; multiple branches from the splenic artery, along with the inferior pancreatic artery, supply the tail

Into which veins do the pancreatic veins drain?

The splenic vein and the portal vein

Which nodal groups drain the pancreas?

From the head—nodes in the pancreaticoduodenal groove drain into subpyloric, portal, mesocolic, and aortocaval nodes From the body and tail—retroperitoneal nodes in the splenic hilum drain into the celiac, mesocolic, mesenteric, or aortocaval nodes

Chapter 59 / Pancreas 365

PHYSIOLOGY What do the islets of Langerhans produce?

Insulin—β cells Glucagon—α cells Somatostatin—δ cells Pancreatic polypeptide, gastrin, and vasoactive intestinal peptide (VIP)

What types of cells constitute the exocrine pancreas?

Acinar, centroacinar, intercalated ductal, and ductal cells

Describe the composition of pancreatic secretions: pH

pH = 8

Concentration of HCO3

30–120 mEq/L

Cl

30–100 mEq/L

Enzymes

Inactive forms of peptidases: trypsin, chymotrypsin, elastase, kallikrein, carboxypeptidase A and B, phospholipase, lipase, colipase, carboxylesterase, amylase, ribonuclease, deoxyribonuclease

What stimulates exocrine secretion?

Vagal efferents and secretin stimulate HCO3 secretion; cholecystokinin and acetylcholine stimulate enzyme secretion

What other GI hormone is structurally similar to cholecystokinin?

Gastrin, which may explain why it is a weak stimulator of pancreatic enzyme secretion

How are the peptidases activated?

Intraluminally by enterokinase

PANCREATITIS Chronic Pancreatitis What is a Duval procedure?

Resection of the tail of the pancreas, and then anastomosis of the pancreatic remnant and the limb of the Roux-en-Y


Gallstone Pancreatitis What is the most common cause of deadly severe pancreatitis?

Gallstones

What are the indications for preop endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis?

Cholangitis Severe refractory pancreatitis with choledocholithiasis

PANCREATIC FISTULAE How are pancreatic pleural and peritoneal effusions managed?

Initially, nonoperatively: NPO, repeated evacuation percutaneously, and TPN

What defines a high-output pancreatic fistula?

>200 cc/day

How should pancreatocutaneous fistulae be managed?

Initially, nonoperatively with TPN, electrolyte replacement, and skin care; octreotide may help reduce output; most fistulae will close spontaneously

What is the operative management for refractory pancreatic fistule?

Refractory distal duct fistulae are best managed by distal pancreatectomy, proximal duct fistulae with pancreaticojejunostomy

What side effect is associated with somatostatin?

Gallstones and gallbladder sludge

PANCREATIC NECROSIS Should patients with necrotic pancreatitis receive prophylactic antibiotics?

Yes; antibiotics decrease rate of conversion of pancreatic necrosis to infected pancreatic necrosis

What has been shown to work as a prophylactic antibiotic?

Imipenem

What type of bacteria is usually found infecting necrotic pancreatic tissue?

Gram-negative organisms (e.g., Escherichia coli, Pseudomonas)


What is the indication for operative débridement?

Infected necrotic pancreatic tissue

PANCREATIC DIVISUM How does pancreas divisum occur?

The primordial ductal systems do not fuse

What percentage of the population has pancreatic divisum?

≈5%

What percentage of patients undergoing ERCP for idiopathic pancreatitis has pancreatic divisum?

Up to 50%

How does a surgeon determine if the tumor has invaded the IVC?

Kocher maneuver; then, if hand cannot pass through plane between pancreas and IVC, consistent with invasion of IVC

How does the surgeon make sure that the pancreatic cancer has not invaded the superior mesenteric vein (SMV)?

Index finger to index finger dissection underneath pancreatic neck and above the SMV

OTHER PANCREATIC TUMORS What are the various endocrine tumors of the pancreas?

Insulinoma, glucagonoma, vasoactive intestinal peptide tumors (VIPoma), somatostatinoma, gastrinoma; also, tumors secreting pancreatic polypeptide, calcitonin, and neurotensin

Which is the most common pancreatic endocrine tumor?

Insulinoma


How do insulinomas classically manifest?

Whipple’s triad: fasting blood sugar <50 mg, symptoms of hypoglycemia when fasting, symptomatic relief following glucose replacement

How is insulinoma diagnosed?

Monitored 72-hour fast with blood glucose and insulin levels, insulin/glucose ratio >0.4, elevated C-protein and proinsulin

Should an imaging study be performed with a presumed pancreatic endocrine tumor?

Yes; CT with contrast often helps localize the tumor

Where are insulinomas located?

Head (1/3) Body (1/3) Tail (1/3)

How should insulinomas be treated?

Resection: enucleation for small lesions, distal pancreatectomy for large lesions

What is the role of diazoxide for patients with unresectable disease?

It can attenuate hypoglycemia

What is Zollinger-Ellison syndrome?

Peptic ulcers in unusual places, refractory hypersecretion of gastric acid, pancreatic endocrine tumor that secretes gastrin (gastrinoma)

Is a hereditary factor associated with Zollinger-Ellison syndrome?

Yes, in some cases; most cases are sporadic, but some are associated with MEN I syndrome

What is Verner-Morrison syndrome?

WDHA syndrome: Watery Diarrhea Hypokalemia Achlorhydria, associated with VIPoma

Where are VIPomas located?

Typically in the body and tail

Should VIPomas be resected?

Yes, although more than one-half of patients have metastases at diagnosis


What action should be taken if no tumor is identified in a patient with WDHA syndrome?

Occasionally, diffuse islet-cell hyperplasia can cause WDHA; in this case, subtotal pancreatectomy is an option

What condition would a patient with diabetes and a migratory rash be likely to develop?

Glucagonoma is the characteristic necrolytic migratory erythema associated with this tumor; these patients may also have anemia, glossitis, and weight loss

How is it diagnosed?

Elevated serum glucagon level

Where are these tumors usually found?

Body and tail

How should they be treated?

Resection for cure is possible in only one-third of cases; steroids, zinc, and octreotide have helped in treatment of the rash; octreotide may also help control hyperglycemia

What is a somatostatinoma, and what is the appropriate treatment?

A very rare tumor, usually of the head of the pancreas; may present with diabetes, steatorrhea, and gallstones; if possible, it should be treated by excision with cholecystectomy

Why a cholecystectomy?

There is a high rate of gallstone formation with somatostatinoma

Are nonfunctional islet-cell tumors malignant?

Yes, in 90% of cases; however, they usually run an indolent course

What is the most common benign neoplasm in the pancreas?

Cystadenoma

What is the most common cystic lesion of the pancreas?

Pancreatic pseudocyst

What is the appropriate management of cystic lesions of the pancreas that are incidentally found?

Tissue diagnosis must be confirmed; it is impossible to distinguish malignancy radiographically; if the lesion is not associated with pancreatitis (i.e., not a pseudocyst), it should be resected


How is pancreatic lymphoma diagnosed and treated?

Percutaneous radiographically guided needle biopsy with appropriate staging, followed by chemotherapy

Chapter 60 The Breast ANATOMY/HISTOLOGY When raising a skin flap, between which layers should dissection be performed?

In the bloodless plane located just subdermally; the final thickness of the flap should be ≈4 mm at the edge and <6 mm at the base

What structure is responsible for the mobility of the breast, and between what layers of fascia is it located?

Retromammary bursa, formed by the deep layer of superficial fascia and deep investing fascia of the pectorales major muscle

Which three arteries supply blood to the breast?

1. Internal mammary artery (via perforators) 2. Intercostal arteries 3. Axillary artery (via the lateral thoracic and thoracoacromial arteries)

Which three veins drain blood from the breast?

1. Axillary vein (main route of drainage) 2. Internal mammary vein 3. Intercostal veins

Which plexus probably mediates much of breast cancer metastases to the skull, vertebral column, CNS, and pelvis?

Batson’s vertebral plexus of veins: encircles the vertebrae from skull to sacrum and communicates with thoracic, abdominal, and pelvic viscera

Which nerves provide sensory innervation to the breast?

Lateral and anterior cutaneous branches of intercostal nerves 2 through 6

How many lactiferous duct orifices are there on the nipple?

≈15–20

Chapter 60 / The Breast 371

At what stage of the menstrual cycle do breasts tend to be engorged and painful?

Premenstrual (i.e., late luteal) phase

Why is this clinically significant?

Breasts may be rather nodular, possibly causing concern for malignancy—hence, least favorable time for a breast exam

PHYSIOLOGY Prolactin (PRL) Secretion What primarily controls the secretion of PRL? Define the role of each of the following hormones in mammary development: Estrogen?

Dopamine

Starts ductal development, upregulates epithelial E and P receptors

Progesterone?

Involved in epithelial cell differentiation and lobule development

PRL?

Involved in the development of mammary epithelial and adipose tissue; upregulates E receptors; synergizes with E in ductal development and with P in lobular development

Breast Discharge What type of discharge suggests an underlying malignancy?

Unilateral, bloody (or heme-positive) discharge coming from one duct

What is the likelihood that such a discharge indicates an underlying carcinoma (in the absence of a palpable mass)?

Cancer is found in only ≈5% of cases

What is microdochectomy?

Surgical excision of breast duct and lobule after marking duct with dye injection


BREAST CANCER What is the “triad of error” with breast cancer?

The triad of risk for missing a breast carcinoma diagnosis: 1. Young patient (<45 yr of age) 2. Negative mammogram 3. Mass found by patient

What is relative risk?

Ratio of [risk of disease in the presence of some characteristic] to [risk in the absence of the characteristic]

What relative risk of breast cancer is associated with the following factors: Family history of a mother <60 yr old with breast cancer?

2

Family history of two firstdegree relatives (i.e., mother, sister) with breast cancer?

5

Age of menarche <15 vs. 16 yr old?

1.3

Nulliparous vs. <20 yr old at first childbirth?

2

Menopause past 55 yr vs. 45–54 yr?

1.5

Atypical hyperplasia vs. never biopsied?

4

In which breast quadrant is cancer most commonly found?

Upper outer (≈50%) 50%


MAMMOGRAMS What type of mass is most likely to be missed, and in what kind of breast?

Large, noncalcified lesions in radiographically dense breasts (common in premenopausal women)

What percentage of palpable masses are missed by mammography?

≈5%–15%

For the mammographic diagnosis of breast cancer, what is the: Sensitivity?

>90%

Specificity?

>90%

Positive predictive value?

10%–40%

How many more cancers are likely to be detected if mammograms are “double-read” (read by two different radiologists)?

≈15%

What percentage of breast cancers are detected by mammograms as a mass and/or cluster of calcifications?

≈80%

Do breast cancers tend to be more or less radiodense than normal breast tissue?

Cancer is usually more radiodense

How often does a radiolucent lesion turn out to be cancer?

Rarely

What mammographic quality of a lesion is most highly suggestive of breast cancer?

An irregular or spicular margin

How frequently will a mass with a sharp margin be cancer?

≈5% of cases


What percentage of breast cancers have mammographically detected calcifications?

As many as 50%

Roughly what percentage of clustered microcalcifications in the absence of a mass will ultimately prove to be cancer?

Up to 33%

What is the mammographic technique of displacing a breast implant to visualize the breast tissue?

Eklund

What are the indications for open biopsy after a core or Mammotome biopsy?

1. Atypical hyperplasia 2. Radial scar 3. Pathology doesn’t make sense based on mammographic finding

BREAST CANCER STAGING What does an “X” indicate?

Parameter cannot be assessed

What does “0” indicate?

No evidence for that feature

What does “Tis” represent?

Carcinoma in situ or Paget disease of nipple with no other tumor

What are the key divisions in diameter that separate T1 through 3?

T1: <2 cm T2: 2–5 cm T3: >5 cm

Define T4:

Invading chest wall and/or skin (any size) or inflammatory carcinoma

Define N1 through N3:

N1: ipsilateral; positive axillary nodes N2: same as N1, but matted or fixed N3: ipsilateral; positive internal mammary nodes

Define M1:

Distant metastases or positive supraclavicular nodes


Stages 0 Through IV What is stage IV?

M1 plus anything else

What is stage 0?

Tis/N0

What is stage I?

T1/N0

What is stage IIIB?

The worst T (T4) with any N, or the worst N (N3) with any T (think: 3B = worst N or T; now you can forget about T4 and N3!)

What primarily separates stages II and III?

Once you’ve gotten up to N2, or T3, N1, you are in stage III

What is the difference between IIA and IIB?

IIA: sum of T and N is less than or equal to 2 IIB: sum of T and N is 3 (think: IIB = 3; remember, no N2s in this stage)

What is stage IIIA?

N2 with any T, but add T3, N1

Which staging factor most reliably predicts long-term survival?

Number of pathologically positive nodes (physical examination is not reliable prognostically)

What is the approximate 5-year survival rate for each of the following numbers of pathologically positive axillary nodes: None

80%

1–3

60%

>3

30%

What is the most common distant site to which breast cancer metastasizes?

Bone metastases present in ≈50% of cases

What are some other common sites to which breast cancer metastasizes?

Lung (20%), pleura (15%), soft tissues (10%), and liver (10%)


Nodal Metastases What is the general sequence in which levels I through III become positive?

I–II–III

Which level is an ominous sign if positive?

III

Define the following types of recurrence: Local?

Regrowth of malignancy in ipsilateral– lateral breast, skin, chest wall, underlying muscles, and other associated soft tissues

Regional?

Regrowth of malignancy in regional nodes (i.e., internal mammary, axillary, supraclavicular, and/or Rotter’s)

How should breast biopsy incisions be oriented for optimal cosmetic results?

Curvilinear; following Langer’s lines


ESTROGEN RECEPTOR (ER) AND PROGESTERONE RECEPTOR (PR) LEVELS EXPRESSED IN BREAST CANCERS Is ER/PR positivity generally more common for breast cancers in pre- or postmenopausal women?

Postmenopausal women

Roughly what percentage of breast cancers are positive for both ERs and PRs?

About one-half (45% in premenopausal women, 65% in postmenopausal women)

Roughly what percentage of breast cancers are negative for both ERs and PRs?

≈10% (15% in premenopausal women, 5% in postmenopausal women)

Give the approximate response rate to endocrine therapy in patients with the following ER and PR status: ER+ PR+

80%

ER+ PR−

35%

ER− PR+

45%

ER− PR−

10%

HER-2/NEU (C-ERB B2) In what fraction of breast cancers is it amplified (and overexpressed)?

One-third

To what receptor is it homologous?

The epidermal growth factor (EGF) receptor

What is its purported prognostic significance in breast cancer?

Overexpression correlates with decreased disease-free survival


CATHEPSIN D What is it?

Lysosomal protease secreted by estrogen-stimulated breast tumor cells

What process is it thought to facilitate in the natural history of breast cancer?

Metastasis

What is its purported prognostic significance?

Higher levels correlate with decreased disease-free and overall survival

What oncogene is amplified (in gene-copy #) in 20%–30% of breast cancers?

Myc

Why is this fact important?

Portends a poor prognosis

TUMOR SUPPRESSOR GENES/PROTEINS What tumor suppressor is (at least functionally) missing in about one-half of breast cancers?

p53

What does it normally do?

Prevents DNA replication if DNA damage is detected

Why is this function important?

It helps prevent widespread mutations/ rearrangements of genomes and, hence, transformation to malignancy

BRCA1/BRCA2 What are they?

Inherited genes associated with breast cancer; they are tumor suppressor gene mutations

How are they inherited?

Autosomal dominant with varying degrees of penetrance

What percentage of all breast cancers are thought to be associated with these inherited genes?

Only 5%

Chapter 61 / Endocrine 379

Of all “inherited” breast cancers, what percentage are due to BRCA1 or BRCA2?

>75%

What is the risk of developing breast cancer if the patient is a carrier of BRCA1?

>50% (50%–85%)

What is the risk of developing ovarian cancer if the patient is a carrier of BRCA1?

≈33% (15%–45%)

What are the options for breast and ovarian cancer prevention in women who carry BRCA?

1. Very aggressive screening 2. Bilateral prophylactic mastectomies and prophylactic oophorectomy

DUCTAL CARCINOMA IN SITU (DCIS) What chemotherapy is now used for the treatment of DCIS?

Tamoxifen, postoperatively, for cancer prophylaxis

Chapter 61 Endocrine ADRENALS Anatomy What is the normal weight?

≈4 g

What is the source of arterial supply?

Variable; usually from the inferior phrenic, renal arteries, and branches directly off the aorta

What is the venous drainage of the right adrenal gland?

IVC

What is the venous drainage of the left adrenal gland?

Left renal vein


What embryological tissue gives rise to the adrenal cortex?

Mesoderm

What are the three histological layers of the adrenal cortex?

1. Zona Glomerulosa (think “salt”) 2. Zona Fasciculata (think “sugar”) 3. Zona Reticularis (think “sex”) (Think: GFR = salt, sugar, sex)

What is produced in the zona glomerulosa?

Mineralocorticoids (e.g., aldosterone) = “salt”

What is produced in the zona fasciculata?

Glucocorticoids = “sugar”

What is produced in the zona reticularis?

Androgens and estrogens = “sex”

What embryonic tissue gives rise to the adrenal medulla?

Neural crest

What is produced in the adrenal medulla?

Catecholamines

What are the two most common sites for ectopic adrenal medullary tissue?

Sympathetic paraganglia along the aorta Mediastinum

What is the organ of Zuckerkandl?

Sympathetic paraganglia near the aortic bifurcation (common location for extra-adrenal pheochromocytoma)

What are the three most common sites for extra-adrenal cortical tissue?

Ovary, testes, and kidney

GLUCOCORTICOIDS Where are they produced?

Zona fasciculata

How are they regulated?

AdrenoCorticoTropic Hormone (ACTH), from pituitary corticotropin-releasing factor


MINERALOCORTICOIDS Where are they produced?

Zona glomerulosa

PHEOCHROMOCYTOMA Where are catecholamines produced?

In the adrenal medulla

What normally controls catecholamine synthesis and release?

Sympathetic innervation

What are the four adrenergic receptor subtypes?

α-1, α-2, β-1, and β-2

What does α-1 receptor mediate?

Vasoconstriction, pupillary dilation, intestinal relaxation, and uterine contraction

What does α-2 receptor mediate?

Vasoconstriction, feedback inhibition of NE release from sympathetic neurons; inhibits renin release and insulin release

What does β-1 receptor mediate?

Increases force and rate of cardiac muscle contraction; increases lipolysis; increases amylase production

What does β-2 receptor mediate?

Relaxes smooth muscle; increases glycogenolysis; increases insulin and glucagon secretion; increases renin secretion

Which familial syndromes are associated with pheochromocytoma?

Isolated familial pheochromocytoma MEN IIa MEN IIb Von Recklinghausen neurofibromatosis

Do patients with pheochromocytoma have nonepisodic hypertension?

Yes; half of patients may have sustained hypertension only as a manifestation of pheochromocytoma


What are the classic postoperative complications?

Persistent hypertension Hypotension Hypoglycemia Bronchospasm

Why does hypoglycemia occur?

Decreased circulating catecholamines; increased insulin release

Why does postoperative bronchospasm occur?

Decreased β-2 activation after removal of pheochromocytoma

What is the recurrence rate after resection?

≈5%–10% (monitor catecholamine levels annually for the first 5 years)

What percentage of patients with von Hippel– Lindau syndrome have a pheochromocytoma?

50%!

What is the most likely tumor site in a patient with palpitation, headache, and diaphoresis with urination?

Bladder pheochromocytoma

What risk is associated with angiography to localize a pheochromocytoma?

May precipitate a hypertensive crisis

CUSHING’S SYNDROME What findings on HIGHdose dexamethasone test are associated with the following conditions? Healthy patient

Decreased urinary 17-hydroxycorticosteroid (OHCS)/serum cortisol level less than half the previous baseline levels

Cushing’s disease (pituitary cause)

Decreased urinary 17-OHCS/serum cortisol to about half the previous baseline levels

Ectopic ACTH-producing tumor

No effect in >70% of cases (no response to cortisol; autonomous ACTH production)


Adrenal tumor

What findings on corticotropin-releasing hormone (CRH)-stimulation test are associated with the following conditions? Healthy patient

No effect (autonomous cortisol production)

Mild increase in ACTH/cortisol

Cushing’s disease (pituitary cause)

Great increase in ACTH/cortisol

Ectopic ACTH-producing tumor

No effect (ACTH is already high)

Adrenal tumor

No effect (cortisol production does not respond to ACTH)

What type of “sampling” may distinguish a pituitary versus an ectopic source of ACTH?

Inferior petrosal sinus sampling

What is mitotane?

Medication that selectively kills the cells that produce cortisol (kills zona fasciculata and zona reticularis); used in inoperable cases of adrenal carcinoma (Think: MITotane = unMITigated murder of cortisol-producing cells)

ADRENOCORTICAL INSUFFICIENCY What eponym refers to this disorder?

Addison’s disease

What is the most common cause?

Iatrogenic suppression of ACTH secretion by exogenous steroids

What other causes are possible?

Autoimmune disease Histoplasmosis Bilateral adrenal hemorrhage Bilateral adrenal TB Adrenal fungal infection


Memory aid for Addison’s disease?

Think: ADDison’s = ADD = ADrenal Down

What is Waterhouse– Friderichsen syndrome?

Acute hemorrhagic adrenal necrosis caused by bacteremia, usually Meningococcus

What is Addisonian crisis?

Acute adrenocortical insufficiency (medical emergency)

What type of patient is most likely to develop this condition?

Patients with chronic insufficiency who are subjected to stress (e.g., surgery)

What is the pathophysiology?

In response to stress, inadequate mineralocorticoids and glucocorticoids result in an inability to retain Na+, secrete K+, and maintain adequate intravascular volume; hypovolemia and electrolyte imbalance are exacerbated by vomiting

What are the associated signs/ symptoms of adrenocortical insufficiency?

Weakness, fatigue, weight loss, nausea, vomiting, hypotension, abdominal pain, fever, diarrhea; progresses rapidly to lethargy, weakness, and cardiovascular collapse

What are the associated laboratory findings?

Hyponatremia, hyperkalemia, hypoglycemia, acidosis, elevated BUN, decreased chloride, depressed plasma cortisol

What is the appropriate initial treatment?

1 L NS plus 200 mg hydrocortisone over 30 min Followed by NS plus 100 mg hydrocortisone/L, with glucose, replace electrolytes Identify and treat underlying causes (e.g., infection, trauma)

What preventative measures should be taken in patients with known adrenal insufficiency undergoing surgery?

Stress-dose steroids: 100 mg cortisol IV on the day of surgery and then every 8 hr Taper as tolerated postoperatively to maintenance dose


NEUROENDOCRINE GI TUMORS What are the cells of origin?

APUD cells (Amine Precursor, Uptake, and Decarboxylation); tumor = APUDoma

What is the etiology?

Sporadic Familial (MEN I) ≈5% of insulinomas are associated with MEN ≈30% of gastrinomas are associated with MEN

What is the overall incidence?

<10 cases per million per year

What is the average age at diagnosis?

Fourth decade

What is the most common source of symptoms?

Usually caused by a single secreted hormone; a mass effect is rare

Are multiple hormones secreted from a single tumor?

Rarely


Surgical removal

How does octreotide work?

As a somatostatin analog; it inhibits hormone release

What is the major complication of octreotide?

Gallstones, in 25%–30% of cases

What is the best way of preventing complications?

Cholecystectomy at the time of surgery for those undergoing chronic octreotide treatment

GLUCAGONOMA From which islet cells do these tumors arise?

α-cells

What percentage of all islet cell tumors do they comprise?

≈1%


What is the clinical triad for diagnosing glucagonoma?

1. Necrolytic migratory dermatitis 2. Diabetes mellitus 3. Weight loss

What laboratory test confirms the diagnosis?

Elevated plasma glucagon >150 pg/mL (many patients will be >1,000 pg/mL)

What is the rate of malignancy?

66% of cases

What is the most common location?

Pancreas

Which test is used for localization?

CT


Surgical; removal of tumor should include a rim of normal tissue or distal pancreatectomy if located in tail of pancreas

What other treatments may be beneficial?

Chemotherapy or octreotide

What is the appropriate treatment for metastases?

Surgical removal, if possible

What are the most common metastatic sites?

Liver and nodes


Only 33% of patients are cured; recurrence is common; aggressive therapy may be indicated because the tumor is slow growing; overall, the 5-year survival rate is 50%

INSULINOMA What percentage of islet cell tumors do they comprise?

≈25%; almost all are small, single adenomas

From what islet cell do these tumors arise?

β-cells

How can insulinoma be distinguished from factitious hyperinsulinemia?

Insulinoma—C-peptide:insulin = 1:1 Factitious disease — C-peptide: insulin <1:1


What is the normal insulin: glucose ratio?

≤0.25; useful for detecting abnormal insulin secretion in the setting of normal insulin levels


≈10%

How is malignancy determined?

Only by evidence of local invasion or metastases to nodes or liver

What tests provide localization prior to surgery?

CT and MRI (poor tests) Endoscopic ultrasound Angiography Venous sampling Octreotide indium scan


Surgery, ranging from enucleation to subtotal pancreatectomy, depending on location


Possibly diazoxide, octreotide, or 5-fluorouracil (5-FU) and streptozotocin


Up to 95% cure rate

NONFUNCTIONING ISLET CELL TUMOR What is it?

An islet cell tumor that does not cause a syndrome related to excess hormone secretion

What percentage of all islet tumors do they comprise?

Up to 30% (second to insulinomas among apudomas)

What is the average age at onset?

Sixth decade (as opposed to fourth decade for other islet cell tumors)

What are the associated histologic findings?

Islet cell type staining for neuronal-specific enolase or chromograffin


Vague epigastric or back pain, usually from mass effect, or possibly jaundice


Almost 100%


What is the usual size of tumors?

Large (≈10 cm)

Are metastases common?

Yes, to liver, nodes, peritoneum, bones, and lung


History, normal serum hormone levels, and histologic findings

What tests provide localization?

Ultrasound, CT, MRI


Pancreas


Surgical resection, depending on location (e.g., subtotal or total resection of pancreas)

What is the appropriate nonsurgical treatment?

Possibly 5-FU and streptozotocin


Variable, but 10-year survival rate may be as high as 50%

VIPOMAS What does VIP stand for?

Vasoactive Intestinal Polypeptide

What is a VIPoma?

A tumor arising from VIP-secreting cells of the GI tract

What are the other names for this condition?

Verner–Morrison syndrome; WDHA syndrome (See Chapter 52)

What percentage of all islet cell tumors does it comprise?

<2% (rare)


Severe secretory diarrhea, leading to dehydration, hypokalemia, and acidosis, achlorhydria


Usually VIP will be increased Electrolyte abnormalities, especially hypokalemia and acidosis


What other hormones may be elevated?

Pancreatic polypeptide Neurotensin Prostaglandin (PGE2)

What tests provide localization?

Ultrasound, CT (often tumor is 3 cm or larger), angiography (second line)

Where is it usually found?

Pancreas (≈90% of cases)


≈50%


Enucleation or surgical resection, depending on location

SOMATOSTATINOMAS What percentage of all islet cell tumors do they comprise?

<1%

Where are they usually found?

In the pancreas—50% Outside of the pancreas (e.g., duodenum, ampulla of Vater)—50%

Is metastasis common?

Yes; usually to the liver and nodes

What is the usual number and size of primary tumors?

Single and large (≈5 cm)

Is there a relationship between somatostatinomas and MEN I syndrome?

Yes; ≈50% of patients with somatostatinomas have MEN I

What are the associated clinical symptoms?

Usually none, but there is an associated inhibitory syndrome triad: Mild diabetes mellitus Cholelithiasis Diarrhea


Markedly elevated somatostatin level

What is the normal somatostatin level?

<100 pg/mL


Is localization necessary prior to surgery?

Yes; CT, ultrasound, or angiography is sufficient, because this type of tumor is often large


Resection and cholecystectomy

What is the appropriate management of unresectable disease?

Debulking

What is the appropriate medical therapy?

Possibly streptozotocin and 5-FU

Is cure possible?

Yes, for localized disease Poor prognosis for advanced disease (15% 5-year survival rate)

Chapter 62 Thyroid Gland ANATOMY

Chapter 62 / Thyroid Gland 391

What is a nonrecurrent laryngeal nerve?

Variant in which the laryngeal nerve passes from the vagus directly into the larynx at the level of inferior horn of thyroid cartilage

How common are nonrecurrent laryngeal nerves?

1/200 cases

On what side is a nonrecurrent laryngeal nerve likely to be found?

Almost always on the right (can be seen with an aberrant right subclavian artery)

What is the function of the superior laryngeal nerve?

Motor to the cricothyroid and sensory to the supraglottic pharynx

What structure is closely associated with the superior thyroid nerve?

Superior thyroid artery

To avoid damaging the superior laryngeal nerve, where should the superior thyroid artery be ligated?

The point at which the superior thyroid artery enters the thyroid gland

What is the relationship of the posterior recurrent laryngeal nerve to the inferior thyroid artery?

Variable; nerve is inferior to the thyroid artery between the branches of the artery (7%); the nerve is superficial to the artery (20%)

What is the incidence of lingual thyroid?

1/3,000


Dysphagia or problems speaking because of goiter enlargement

PHYSIOLOGY Outline the basic steps in thyroid hormone synthesis and release:

1. Iodine uptake by synthesis in the GI tract and conversion to I–; I– concentrated by thyroid 2. Peroxidases couple I– to tyrosine residues on thyroglobulin, forming mono- and diiodotyrosine (MIT and DIT)


3. Coupling of MIT and DIT forms T3; DIT and DIT form T4 (still attached to thyroglobulin) 4. Upon secretion, lysosomal enzymes cleave T3 and T4 from thyroglobulin What is T3?

3,5,3′ Triiodothyronine

What is T4?

Thyroxine = 3,5,3′,5′-tetraiodothyronine

What is Wolff–Chaikoff–White block?

The phenomenon in which iodine binding by thyroid and production of T3 and T4 are inhibited as plasma iodine levels accumulate beyond a critical level (≈25 mic/100 mL)

Clinically, why is this relevant?

Iodine is the most effective means to rapidly decrease thyroid hormone levels (Lugol’s solution, Na ipodate)

What is Lugol’s solution?

Potassium iodide

Where is T4 produced?

Thyroid gland (only source)

What do the parafollicular cells of the thyroid secrete?

Calcitonin, in response to increased serum Ca2+

What does calcitonin do?

Inhibits osteoclast activity


What do osteoclasts do?

Resorb bone

What do osteoblasts do?

Form bone

What is reverse T3 (RT3)?

More inactive form of T3 produced by the same enzyme that converts T4 to T3

When is RT3 elevated?

Severe illness (e.g., sick euthyroid states; See Chapter 69)

THYROID FUNCTION TESTS What does serum T4 measure?

Total serum T4

What does free thyroxine (FT4) measure?

Circulating, unbound T4

In what situations is FT4 useful?

It is the test of choice for following thyroid after treatment of hyperthyroidism

What does resin T3 uptake (RT3U) measure?

Relative levels of thyroid-binding globulin (TBG)

What does an elevated RT3U indicate?

Hyperthyroid or decreased TBG

What does a decreased RT3U indicate?

Hypothyroid or increased TBG

What are the differential diagnoses for increased 123I uptake by the thyroid?

Graves’ disease, toxic nodular goiter, early Hashimoto’s nephrotic syndrome, pregnancy, iodine-deficient diet

What are the differential diagnoses for decreased 123I uptake?

Subacute thyroiditis, thyroid gland damage (from surgery, radiation, thyroiditis), circulating iodine contrast dyes, ectopic thyroid, hypopituitarism, severe Graves’ disease

What test is the single most sensitive and specific indicator of thyroid function?

Thyroid-stimulating hormone (TSH)


THYROIDITIS Acute Thyroiditis What is it?

Inflammation of the thyroid gland, usually caused by bacterial infection (most uncommon form of thyroiditis)


Suppurative infection, usually arising from contiguous structures of thyroid; may be caused by hematogenous seeding local trauma (rare)

What is the most common cause of recurrent cases?

Piriform sinus fistula

Is the condition associated with hyperthyroidism?

No; usually thyroid function tests (TFTs) are normal


Sudden onset, diffuse, painful enlargement of thyroid with fever, chills, and dysphagia

What is the most common infection prior to acute thyroiditis?

Almost always follows upper respiratory infection in children and adolescents

What are the associated diagnostic findings?

Normal TFTs, normal radioiodine uptake; ultrasound may show abscess

What are the most common causative organisms?

Streptococcus, Staphylococcus, Pneumococcus


Surgical drainage and antibiotics Fistulectomy, if indicated Recovery usually occurs in 48–72 hr

Subacute Thyroiditis What is another name for this disorder?

de Quervain thyroiditis


Viral

Who is most likely to develop this condition?

Adults 30–50 yr of age; women five times more likely than men



Diffuse enlargement, sore throat

Hyperthyroid or hypothyroid?

Both—transient hyperthyroid, followed by euthyroid, then hypothyroid


Elevated erythrocyte sedimentation rate (ESR) and serum γ-globulin; normal or elevated thyroid hormones; low radioiodine uptake


Self limiting within 2–6 mo Nonsteroidal anti-inflammatory drugs (NSAIDs), β-blockade (antithyroid drugs not effective in treating hyperthyroid phase)

Chronic Thyroiditis What is another name for this disorder?

Hashimoto’s thyroiditis


Common (1.5/1,000); most common cause of goitrous hypothyroidism in adults

Who is most likely to develop this condition?

Women 10 times more likely than men; peak age 30–50 yr


Autoimmune

What is Pemberton’s sign?

Facial plethora seen when both arms are raised; caused by goiter occlusion of the internal jugular veins


Painless, diffusely enlarged gland, sometimes with nodularity; hypothyroidism

What are the associated diagnostic findings?

Increased serum antimicrosomal and thyroglobulin antibodies; T3 and T4 may be within normal limits; decreased radioiodine uptake


Long-term thyroid hormone replacement


Fibrous Thyroiditis What is another name for this disorder?

Riedel’s thyroiditis


Very rare


Thyroid replaced by fibrous tissue; unknown etiology


Stony hard gland, with or without invasion into adjacent structures; pressure symptoms, hypothyroidism (differential diagnosis is malignancy)


Surgery, if pressure symptoms require relief Subtotal thyroidectomy may be required, although surgery may be difficult because of extensive fibrosis

THYROID NODULE Workup of Thyroid Nodule What does initial workup involve?

History and physical examination, thyroid function test (TFT), calcitonin (if medullary cancer is suspected)

What test is then used if TFTs are normal?

Fine needle aspiration (FNA)

What test is used if TFTs are elevated?

131

How accurate is FNA?

≈70%–97% (varies with the experience of the surgeon and cytopathologist)

What is the false-positive rate associated with FNA?

≈6%

What is the false-negative rate associated with FNA?

≈5%

What percentage of FNAs are positive?

≈10%

I scan


What percentage of FNAs are negative?

≈70%

What proportion of FNAs are indeterminate?

≈20%

Of the indeterminate lesions, what percentage turn out to be malignant?

≈20%

Nodule Suppression Therapy What is it?

Attempt to shrink thyroid nodules by thyroid hormone replacement (thyroxine) to suppress TSH

What percentage of benign nodules will shrink with suppressive therapy?

20%

Why is suppression therapy controversial?

Even if nodule shrinks, cannot be 100% sure it is not cancer; up to 50% of benign nodules shrink spontaneously at some subsequent point!

RECURRENT LARYNGEAL NERVE INJURY What action should be taken preoperatively?

Assess vocal cord nerve function and document any abnormalities

What is the risk of damage to the recurrent laryngeal nerve during thyroidectomy?

<5%

What preventative steps should be taken?

Identify the nerve intraoperatively

What are the points at which risk of injury to the recurrent laryngeal nerve is greatest?

Dissection around the ligament of Berry Ligation of the inferior thyroid artery Dissection around the thoracic inlet

How can recurrent laryngeal nerve injury be diagnosed?

Postoperative laryngoscopy


What findings are associated with unilateral injury?

Cord on the affected side is in the paramedian position

What findings are associated with bilateral injury?

Both cords are in the midline position (airway compromise with stridor)

In cases of temporary paralysis, when should function be expected to return?

Within 6–8 wk

If the nerve is obviously injured intraoperatively, should repair be attempted?

Controversial; repair is associated with less cord atrophy, but more cord adductor spasm because of random reinnervation

POSTOPERATIVE HYPOPARATHYROIDISM What are the associated risk factors?

Magnitude of surgery (i.e., risk of total thyroidectomy is greater than that of isthmectomy) Previous thyroid surgery Surgery for large thyroid cancer with lymphadenectomy


Between 0.6% and 17% (depending on the experience of the surgeon)

What is the most common cause?

Devascularization of the parathyroid gland

What is the major source of blood supply to the parathyroids?

Inferior thyroid artery (80%)

How can postoperative hypoparathyroidism be prevented?

Avoid ligating the inferior thyroid artery at the main trunk; ligate branches close to the thyroid gland

What is the treatment for mild asymptomatic hypocalcemia?

1. Calcium carbonate PO 2. Vitamin D (1,25-dihydroxyvitamin D3)

What is the treatment for hypocalcemic tetany?

IV calcium gluconate or IV calcium chloride

Chapter 63 / Parathyroid 399

Chapter 63 Parathyroid Who discovered parathyroid glands, and how?

Legend has it that Sir Richard Owen discovered parathyroid glands while performing an autopsy on a rhinoceros!

PHYSIOLOGY What is the significance of the calcium–phosphate product?

If product is >40, there is a chance of salt precipitation in tissues

How much calcium is ionized?

≈50%

What is the normal parathyroid hormone (PTH) level?

≈20 mEq/mL or less

What PTH levels are associated with hyperparathyroidism?

≈60 mEq/mL or more

How does PTH work?

Increases bone resorption of calcium and phosphate Increases renal resorption of calcium Increases renal secretion of phosphate Stimulates vitamin D formation

What stimulates PTH secretion?

Decreasing calcium

How does vitamin D work?

Increases intestinal calcium and phosphate absorption

How does calcitonin work?

Inhibits bone resorption and probably increases urinary excretion of calcium

How does mithramycin work?

Inactivates osteoclasts, inhibits RNA synthesis

Where is calcium absorbed?

Duodenum and proximal jejunum


PERSISTENT AND RECURRENT POSTOPERATIVE HYPERPARATHYROIDISM (THE “MISSED” GLAND) What percentage of parathyroidectomies will result in postoperative “missed gland” with postoperative hyperparathyroidism?

≈5%

What are the potential sites of an ectopic parathyroid gland?

Define the following: Persistent hyperparathyroidism?

Postoperative hyperparathyroidism <6 mo after the operation

Recurrent hyperparathyroidism?

Postoperative hyperparathyroidism >6 mo after the operation

What is the differential diagnosis of postoperative hyperparathyroidism?

1. Missed parathyroid gland at first operation 2. Five glands 3. Metastatic spread of parathyroid cancer 4. Residual parathyroid cancer 5. Ectopic gland 6. PTH secreted by another carcinoma (e.g., lung carcinoma) 7. Hyperplasia of autotransplanted parathyroid tissue

Chapter 63 / Parathyroid 401

After a parathyroidectomy, where are the missing glands found?

Are any preoperative localization tests needed?

Common sense would dictate preoperative localization for any reoperation

What are the best studies for localizing neck parathyroid?

Sestamibi scan (technetium Tc 99m Sestamibi) Ultrasound Venous sampling for PTH

What are the best studies for localizing an ectopic gland in the mediastinum?

Sestamibi CT MRI Venous sampling Angiogram

HYPERCALCEMIC CRISIS What are the symptoms of hypercalcemic crisis?

Polyuria, dehydration (leading to increased calcium), muscle weakness, nausea, vomiting, lethargy, coma

What is the appropriate treatment of hypercalcemic crisis?

Fluids Furosemide (if hydrated) Calcitonin Mithramycin Biphosphonates


PARATHYROID AUTOTRANSPLANTATION What site is used for autotransplanting a parathyroid?

1. Parathyroid pathology = nondominant forearm 2. No parathyroid pathology (e.g., inadvertent parathyroid injury during thyroidectomy) = sternocleidomastoid muscle

How is parathyroid transplanted into the forearm?

Slice into small pieces (≈1 × 1 × 3 mm), implant ≈20 pieces into several sites in nondominant forearm muscle, then mark with Prolene

Why mark autotransplanted parathyroid gland?

Prolene stitch allows for identification if parathyroid tissue needs to be removed later

When does the transplanted tissue resume endocrine function?

≈3 wk

Chapter 64 Spleen What is the largest single mass of lymphatic tissue in the body?

The spleen

By which ligament is the spleen attached to the stomach?

The gastrolienal ligament

What important structures are contained in the gastrolienal ligament?

The short gastric vessels and the left gastroepiploic vessel

Which ligament attaches the spleen to the kidney?

The lienorenal ligament

Which organ is in close proximity to the spleen?

The tail of the pancreas (which is prone to injury during splenectomy); the tail is classically said to “tickle” the spleen

Chapter 64 / Spleen 403

What portion of the circulating platelets are usually within the spleen?

≈33%

What are Howell–Jolly bodies?

Nuclear remnants of RBCs, usually removed by the spleen

Why is the absence of Howell–Jolly bodies on a patient’s blood smear important following splenectomy?

May signify the presence of unresected accessory splenic tissue

When is the best time to vaccinate after a trauma splenectomy?

At 14 d postoperatively is the optimal timing (but not always possible because many patients do not return for follow-up!)

How do you differentiate between normal postsplenectomy leukocytosis and leukocytosis due to postoperative infection?

The following, if present, are highly associated with postoperative infection: 1. WBC >15,000 2. Platelet count to WBC ratio of <20

How do you find accessory spleen(s) in a postop ITP splenectomy patient?

Autologous platelets with indium 111 radionuclide scintigraphy (preoperative and intraoperative localization)

DISEASES OF THE SPLEEN Immune Thrombocytopenic Purpura (ITP) What is the etiology of ITP?

Circulating immunoglobulin (Ig)G is directed against platelet-associated antigen, resulting in destruction of platelets by the reticuloendothelial system


Persistently low platelet count, easy bruising, petechiae, mucosal bleeding, menorrhagia, increased megakaryocyte counts on bone marrow aspirate

Is ITP more common in men or women?

Women (particularly young women)



Prednisone Platelet transfusions may be necessary for bleeding complications Plasmapheresis

What is the indication for splenectomy in ITP?

When patients are refractory to medical management

What percentage of patients eventually require splenectomy?

≈75%

What is the prognosis after splenectomy?

In approximately 80% of patients, platelet counts return to normal by the sixth postoperative week; another 15% improve sufficiently to no longer require steroids

What condition may cause thrombocytopenia to recur after splenectomy for ITP?

The presence of an accessory spleen that was not resected during the initial splenectomy

Thrombotic Thrombocytopenic Purpura (TTP) What pentad of clinical manifestations is associated with TTP?

1. 2. 3. 4. 5.

Thrombocytopenia Fever Neurologic changes Renal failure Microangiopathic hemolytic anemia

What is the etiology of TTP?

1. Familial = ADAM TS-13 (A metalloprotease enzyme) 2. Nonfamilial = IgI antibody against a VWF cleaving protease

Who is the typical patient with TTP?

A woman 30–40 yr of age

What are the histological findings associated with TTP?

Capillary and arteriole occlusion by aggregates of fibrin and platelets

What is the current medical treatment of TTP?

Antiplatelet agents, fresh frozen plasma, and corticosteroids

What is the indication for splenectomy in the setting of TTP?

Failure to respond to medical treatment

Chapter 64 / Spleen 405

What percentage of patients will respond to medical treatment?

≈80%

Felty’s Syndrome What are the clinical manifestations?

Triad of “SRG”: Splenomegaly Rheumatoid arthritis Granulocytopenia (Think: Felty SRG = “Felt a Surge”)

What is the underlying cause?

Formation of antibodies against granulocytes

Hereditary Spherocytosis What is the etiology?

A genetic defect results in an abnormal RBC membrane which leads to increased trapping and destruction of RBCs by the spleen

What is the associated molecular deficit?

Defect of the membrane skeletal protein spectrin


Anemia, fatigue, jaundice, pigmented gallstones, and splenomegaly


Splenectomy

Splenic Vein Thrombosis What is the most common etiology?

Pancreatitis

What are the associated signs?

Isolated gastric varices, episodes of upper GI bleeding


Celiac angiography or ultrasound

Is splenic vein thrombosis an indication for splenectomy?

Yes


SPLEEN TUMORS What is the most common primary tumor of the spleen?

Benign hemangioma

What is the most common primary lymphoid tumor of the spleen?

Lymphoma (note: tumors may diffusely involve the spleen and present as splenomegaly rather than as mass lesions)

What are the types of splenic cysts?

Posttraumatic Parasitic (usually Echinococcus) Primary cyst (epithelial lined)

What are the indications for excision of a “true” splenic cyst?

A cyst >10 cm in diameter should be removed because the risk of rupture and subsequent hemorrhage is greatly increased

Chapter 65 Surgically Correctable Hypertension What causes surgically correctable hypertension?

Neuroblastoma Pheochromocytoma Renal artery stenosis Coarctation of the aorta Hyperparathyroidism Conn’s syndrome Cushing’s syndrome Increased intracranial pressure Cancer Renal parenchymal disease

What percentage of hypertensive patients has one of these conditions?

Between 5% and 10%

Who should be evaluated for one of these conditions?

Young patients with hypertension Patients with no family history of hypertension Patients with diastolic blood pressure >110 mm Hg that cannot be controlled medically

Chapter 65 / Surgically Correctable Hypertension 407

What is the appropriate initial evaluation?

History and physical examination Serum electrolytes Serum BUN and creatinine Chest x-ray

NEUROBLASTOMA What is it?

Embryonal tumor of neural crest origin; seen in children

What causes hypertension (HTN) in neuroblastoma?

Increased catecholamines

PHEOCHROMOCYTOMA What is it?

Tumor of the adrenal medulla and similar tissues (e.g., sympathetic ganglion) that produces catecholamines (epinephrine, norepinephrine, dopamine)

What causes HTN in pheochromocytoma?

Increased catecholamines

RENAL ARTERY STENOSIS What is it?

Narrowing of the renal artery, resulting in decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the aldosterone-renin-angiotensin system


Most patients asymptomatic Some may have headache, diastolic HTN, flank bruits (present in 50% of cases), and decreased renal function Note: ≈7% of patients with essential HTN also have flank bruits

COARCTATION OF THE AORTA What is it?

Congenital abnormality consisting of narrowing of thoracic aorta, with or without intraluminal “shelf ” (infolding of the media), usually found near the ductus/ ligamentum arteriosum


What causes HTN in coarctation?

Increased resistance to flow to the distal body and, thus, increased flow to the upper body

HYPERPARATHYROIDISM (INCREASED PARATHYROID HORMONE [PTH]) What is increased PTH?

Increased secretion of PTH

What percentage of patients with hyperparathyroidism have HTN?

≈10%

What causes HTN in hyperparathyroidism?

Hypercalcemia

CONN’S SYNDROME What is it?

Hyperaldosteronism; aldosterone is abnormally secreted by an adrenal adenoma/carcinoma/hyperplasia or by an ovarian tumor

What are the two classic signs of Conn’s syndrome?

HTN and hypokalemia

What causes HTN in Conn’s syndrome?

Hypervolemia

CUSHING’S SYNDROME What is it?

Excessive cortisol production

What percentage of patients with Cushing’s syndrome have HTN?

>75%

What causes HTN in Cushing’s syndrome?

Hypervolemia

INCREASED INTRACRANIAL PRESSURE (ICP) What causes HTN in increased ICP?

The Cushing’s response (reflex), consisting of HTN and bradycardia

Chapter 66 / Soft Tissue Sarcomas and Lymphomas 409

CANCER What causes HTN in cancer?

Paraneoplastic syndromes

RENAL PARENCHYMAL DISEASE What causes HTN in renal parenchymal disease?

Hypervolemia Increased renin (which increases angiotensin [vasoconstriction] and aldosterone [hypervolemia])

Chapter 66 Soft Tissue Sarcomas and Lymphomas NON-HODGKIN’S LYMPHOMA (NHL) What is NHL?

A lymphoma other than Hodgkin’s disease NHL has an established cellular origin (usually monoclonal B cells, but may also originate in T cells) based on the stages of lymphocyte differentiation

How is NHL classified?

Nodular (low grade) vs. diffuse (high grade); the Working Classification groups NHL according to natural history and therapeutic response

Which is worse, high grade or low grade?

High grade

How does the presentation differ compared with that of Hodgkin’s disease?

Patients with NHL are usually older (often debilitated), but less often have B symptoms NHL often presents with peripheral nodal (especially epitrochlear) or extranodal disease; it may present as a retroperitoneal or mesenteric mass or as hepatomegaly and/or splenomegaly

How does NHL spread?

Via the bloodstream, thereby involving noncontiguous areas


What are some of the more dramatic presentations of NHL?

Superior vena cava syndrome Acute spinal cord compression syndrome Ureteral obstruction Meningeal involvement


Biopsy

What are the most common malignancies requiring abdominal surgery in patients with AIDS?

NHL Kaposi’s Sarcoma (KS)

When is splenectomy indicated in NHL?

Symptomatic splenomegaly Pancytopenia, secondary to hypersplenism Recurrent splenic infarcts

What is hypersplenism?

Hyperfunctioning spleen Documented loss of blood elements (WBCs, hematocrit, platelets) Splenomegaly Bone marrow

GASTRIC LYMPHOMA What is the most common site of extranodal NHL?

The stomach

What are the signs/symptoms of gastric lymphoma?

Abdominal pain and weight loss (80%) B signs (40%) Nausea, vomiting, malaise (possibly) Upper GI bleeding (rare)

What are the major differential diagnoses?

Gastric adenocarcinoma Ménétrier’s disease Zollinger–Ellison syndrome Hypertrophic gastritis


Upper GI endoscopy with biopsy is the method of choice Grossly, lesions are superficial, well-demarcated, stellate ulcers that involve a large area of the stomach


What signs appear on upper GI series?

May show a mass, ulcers, enlarged mucosal folds, and/or decreased gastric mobility

What is the appropriate treatment of disease confined to the stomach?

Controversial: 1. Surgical resection ± postoperative radiation therapy and chemotherapy, or 2. Chemotherapy and radiation therapy alone

What is the incidence of gastric perforation with chemotherapy?

5%

SOFT TISSUE SARCOMA (STS) What type of tumor is associated with polyvinyl chloride and arsenic exposure?

Hepatic angiosarcoma

Where is polyvinyl chloride found?

In plastics industry

What is Stewart–Treves syndrome?

An angiosarcoma that develops in an extremity with lymphedema, classically following radical mastectomy and axillary lymph node dissection for breast cancer

What is the importance of surgical clips after sarcoma resection?

Sites of highest risk of recurrence should be marked with radiopaque clips for radiation therapy

PULMONARY METASTASES What is the appropriate treatment?

Isolated pulmonary metastases may be resected; aggressive resection improves survival

What factors are associated with an improved prognosis?

Slower doubling time Unilateral disease On CT, three nodules or less


MALIGNANT FIBROUS HISTIOCYTOMA (MFH) What is MFH?

A sarcoma that originates from fibroblastic cells (histiocytes)

Where does it present?

Most commonly in the deep soft tissues of the extremities and in the abdominal/ retroperitoneal areas

How common is it?

Accounts for ≈20% of all cases of adult STS Pleomorphic MFH is the most common postradiation sarcoma

What is the rate of local recurrence?

≈25%

What are the two routes of metastases?

Via blood (most cases), most commonly to the lung (90% of cases) Via lymphatics (rare)


Radical surgery plus adjunctive radiation therapy or chemotherapy

LIPOSARCOMA What is it?

A sarcoma originating from adipose cells


More common in men than in women Often develops singularly in the thigh or retroperitoneum, but may be multicentric Rarely found in subcutaneous tissue

What is unique about this type of sarcoma?

Common adult STS (23%) Largest sarcoma (on average) Most common retroperitoneal sarcoma

What are the various types?

Well-differentiated—does not metastasize; extensive local recurrence; 10-year survival rate 40%–60%; may dedifferentiate Myxoid Pleomorphic/round cell—metastasizes early; poor prognosis (<20% 5-year survival rate)



Surgery plus radiation therapy

RHABDOMYOSARCOMA (RMS) What is RMS?

A sarcoma that originates from skeletal muscle cells

How common is it?

Embryonal RMS is the most common soft tissue sarcoma in infants and children

What are the three various types of RMS?

1. Embryonal 2. Alveolar 3. Pleomorphic

What is embryonal RMS?

One of the “malignant small blue cell” tumors of children; occurs in first two decades of life; presents in head, neck, or genitourinary regions

What is alveolar RMS?

Seen in teenagers/young adults

What is pleomorphic RMS?

Rare; seen in adults

What are the other “malignant small blue cell” tumors?

Lymphoma, Ewing’s sarcoma, and neuroblastoma

What is sarcoma botryoides?

An embryonal RMS consisting of grape-like masses that involve the mucosal surface or tubular viscera

What percentage of patients with RMS have lymph node metastases?

≈10%

What percentage of patients with RMS have distant metastatic disease at diagnosis?

≈30%

What is the appropriate treatment of localized (stage I) RMS?

Complete surgical resection plus adjuvant chemotherapy


What is the appropriate treatment of advanced (stage II or higher) RMS?

Combined modality therapy: surgical resection, radiation therapy, and chemotherapy; if the tumor is considered initially unresectable, primary chemotherapy, or primary chemotherapy with radiation therapy may be administered, followed by surgery and adjuvant chemotherapy

What is the 5-year survival rate for embryonal RMS?

80%–90%

What is the 5-year survival rate for alveolar RMS?

≈50%

FIBROSARCOMA What is it?

A sarcoma originating from intermuscular or intramuscular fibrous tissues, fascial tendons, and aponeuroses

How common is it?

Second most common sarcoma in children; less common in adults

What type of patient is at greatest risk?

African-American men


Occurs most frequently in the deep soft tissues of the extremities

What is the 5-year survival rate?

≈50%


Wide excision plus radiation therapy

DESMOID TUMORS What are they?

Benign fibrous tumors occurring in fascial tissues; may occur in areas of previous scarring


Anterior abdominal wall


Is this type of tumor likely to metastasize?

No; desmoid tumors are nonencapsulated and spread by local invasion


Pain, intestinal/ureteral obstruction, fistulas


Wide surgical excision ± chemotherapy and radiation therapy

What is the appropriate drug treatment?

1. Tamoxifen 2. The nonsteroidal anti-inflammatory drug sulindac


Local recurrence highly likely (19%–77% with adequate margins; 90% with minimal margins)

With what syndrome are desmoid tumors associated?

Gardner’s syndrome

KAPOSI’S SARCOMA (KS) What is KS?

A vascular sarcoma involving endothelial cell proliferation with reactive lymphoreticular elements

How does KS usually present?

Begins as blue to purple patches, which become plaques and nodules

What are the various types?

Classic—affects patients of Mediterranean and European-Jewish ancestry African—affects young black men in the sub-Sahara Iatrogenic/immunosuppressed—affects renal transplant recipients Epidemic—affects HIV-positive individuals (AIDS)

How do the classic and epidemic forms differ in presentation?

Classic: affects elderly males on their lower extremities, with only occasional visceral involvement Epidemic: preferential distribution in head, neck, and trunk, with oral/perioral mucosal involvement in 55% of cases


How do the classic and epidemic forms differ in prognosis?

Classic: slowly progressive; 10–15-year survival rate is average Epidemic: rarely the cause of death in HIV-positive persons; its treatment is palliative

What is the appropriate treatment of localized lesions?

Local radiation therapy or intralesional vinblastine

What is the appropriate treatment of disseminated KS?

Chemotherapy plus immunotherapy

How often does GI involvement occur in epidemic KS?

≈40% of cases

What are the associated signs/symptoms of GI involvement?

Abdominal pain, massive hemorrhage, perforation, malabsorption, protein-losing enteropathy, bowel obstruction, obstructive jaundice, tenesmus, ulcerative colitis-like syndrome, or dysphagia

What is the most common tumor associated with AIDS?

KS

Chapter 67 Skin Lesions What are the most common cancers in the United States?

Nonmelanoma skin cancers

What percentage of all cancers are they?

33%

What are the three types of basal cell carcinoma (BCC)?

1. Nodular 2. Morpheaform 3. Superficial

What is the most common type of BCC?

Nodular (>75%) Superficial (10%) Morpheaform (2%)

What does a morpheaform BCC look like?

Plaque, often resembling a stellate scar

Chapter 68 / Melanoma 417

Did a dermatologist invent Mohs’ surgery?

No; Frederic Mohs was a general surgeon

What is the treatment of Kaposi’s sarcoma skin lesions?

Nonsurgical; observe if asymptomatic, or use cryotherapy; radiation therapy, or chemotherapy

What is a Merkel cell carcinoma?

Highly aggressive skin lesion that is highly metastatic

What does a Merkel cell carcinoma look like?

Red/purple nodule with telangiectasia

What other cancer must be ruled out with a Merkel cell carcinoma?

Oat cell carcinoma of the lung, as skin metastases look just like Merkel cell carcinoma microscopically

Chapter 68 Melanoma From what embryological tissue do melanocytes arise?

Neural crest cells

Where do melanocytes reside in normal skin?

In the basal layer of the epidermis

What is an amelanotic melanoma?

Amelanoma that is not pigmented; occurs when malignant transformation of the melanocyte results in loss of pigment production Patients present with nonpigmented melanomas, which may go unnoticed and untreated for an extended period of time

What is local recurrence?

A tumor that is <5 cm from the primary site

What is the incidence of local recurrence in treated melanoma?

≈15%


What is regional recurrence?

Typically, lymph node metastases, which are the most common manifestation of recurrent melanoma

What are the most common sites of distant metastases in melanoma?

Lungs and liver

What percentage of melanomas are ocular lesions?

2%–5%

Where in the eye does ocular melanoma occur?

In the uveal tract (iris, ciliary body, and chorioid), conjunctiva, or retina

What is the most common site of metastasis from an ocular-tract lesion?

The liver (the uveal tract lacks lymphatic drainage)

Are visceral primaries common among melanoma patients?

No; they account for <0.1% of all melanomas

What percentage of melanomas present as metastases from unknown primaries?

≈5%

How do most unknown primaries present?

With lymph node metastases

What is the appropriate management of such lesions?

Rule out cutaneous, ocular, or mucous membrane primary lesions; then, treat metastases, usually by resection

True or false; survival rate after melanoma that occurs during pregnancy is worse than that of nonpregnant patients with melanoma?

False; recent reports have indicated that although patients who present with melanoma during pregnancy may have a predilection to develop lymph node metastases, survival is comparable to that of matched controls

What mortality rate is associated with pulmonary metastases?

Pulmonary metastases are associated with a 70% mortality rate within 1 yr and a 4% 5-year survival rate

Chapter 68 / Melanoma 419

How should isolated pulmonary metastases be managed?

Isolated pulmonary metastases should be resected

How are GI metastases generally discovered?

Usually, they cause bleeding, intussusception, or small-bowel obstruction

What percentage of melanomas <1 mm (“thin”) have positive nodal metastases?

10%

What percentage of melanomas 1–4 mm (“intermediate”) have positive lymph node metastases?

25%

Has routine sentinel node biopsy in patients with melanoma been shown to improve survival?

Yes (“suggestive” data)

When performing lymphoscintigraphy, what gamma counts are considered classic for a melanoma sentinel node?

Gamma counts 10× more than background counts

Should you do a FROZEN section of the sentinel node?

No

What margins do you need for local recurrences?

1 cm

What is “in-transit disease”?

Skin or subcutaneous metastases in between primary and regional nodal basin

What percentage of patients will develop “in-transit disease”?

2%

What is the treatment of “in-transit disease”?

Resection with 1-cm margins


Chapter 69 Surgical Intensive Care INTENSIVE CARE UNIT (ICU) FORMULAS Define: VO2?

Oxygen consumption

DO2

Oxygen delivery

Co?

Cardiac output

CaO2?

Arterial oxygen content

CVO2?

Venous oxygen content

PAP?

Pulmonary artery pressure

PCWP?

Pulmonary capillary wedge pressure

What is the formula for O2 that is bound to the hemoglobin formula?

Hgb × SaO2 × 1.34

What is the formula for O2 content that is not hemoglobin bound?

PaO2 × 0.0031

What is the full formula for total CaO2?

Hgb bound plus dissolved O2 = (Hgb × SaO2 × 1.34) + (PaO2 × 0.0031)

What is the formula for DO2?

Co × CaO2 × 10

What are normal values for DO2?

600–1,000 mL/min

What is the formula for VO2?

Co × (CaO2 – CVO2) × 10

What are normal values for VO2?

110–150 mL/min/m2

Chapter 69 / Surgical Intensive Care 421

What is the formula for pulmonary vascular resistance (PVR)?

80 × (PAP − PCWP)/Co

What are normal values for PVR?

100–200 dynes/sec/cm−5

What is the formula for alveolar–arterial (A-a) oxygen gradient?

Alveolar O2 – arterial O2 = P(A-a)O2

What are the normal values for alveolar–arterial oxygen gradient?

FIO2 21% = 4 – 25 FIO2 100% = 10 – 60

What is compliance?

Change in volume divided by change in pressure ( V/ P)

What is CPP (cerebral perfusion pressure)?

MAP – ICP

What is the normal value for CPP?

>70 mm Hg

END POINTS OF RESUSCITATION Why are end points of resuscitation so important?

Underresuscitation leads to poor outcomes: death, multiple organ failure (MOF), systemic inflammatory response syndrome (SIRS)

What is the substrate for lactate?

Pyruvate (anaerobic pathway: lactate is made from pyruvate by lactate dehydrogenase)

Describe the fate of lactate:

Converted into glucose in liver (or kidney) via Cori cycle

What is base deficit?

Indirect measurement of acidosis on arterial blood gas (ABG)

What is the weakness of base deficit as an end point of resuscitation?

Nonspecific; resuscitation with normal saline results in hyperchloremic acidosis


What is the best currently available end point of resuscitation?

Lactate

RESPIRATORY SYSTEM Define the spirometry waves:

1. 2. 3. 4.

TV—Tidal volume ERV—Expiratory reserve volume RV—Residual volume IRV—Inspiratory reserve volume (Think top to bottom: “IRV watches TV with ERV in the RV”)

What is the normal I:E ratio?

Inspiration to expiration time; normal is 1:2

What is “reverse” I:E ratio?

Inspiration to expiration time of >1.1:1

What is static lung compliance?

Compliance of lung parenchyma ONLY = Tidal volume divided by plateau pressure (minus any positive end-expiratory pressure [PEEP]; remember, compliance = V/ P)

What is dynamic lung compliance?

Compliance of lung parenchyma AND airways = Tidal volume divided by peak inspiratory pressure (minus any PEEP)

What is the Tobin index?

RR divided by Vt in liters; if >105, unlikely to have a successful extubation

What is auto PEEP?

Alveolar pressure accumulating after incomplete exhalation (think of blowing up a balloon, and then letting the balloon deflate incompletely before reblowing up the balloon)

What is the treatment for auto PEEP?

Decrease RR, decrease tidal volume, increase expiratory time: ↑ E time


OXYGEN DELIVERY (DO2) AND CONSUMPTION (VO2) What are some causes of hypoxia?

1. 2. 3. 4.

Decreased inspired oxygen V/Q mismatch Shunt Decrease in barometric pressure (↑ altitude) 5. Diffusion (pulmonary edema or ARDS) 6. Hypoventilation (airway obstruction)

What are the three determinants of oxygen delivery (DO2)?

1. Cardiac output 2. Hemoglobin (most important) 3. Oxygen saturation of hemoglobin

Why does giving too much blood decrease oxygen delivery?

Increases the viscosity

What is the meaning of consumption (VO2)?

Amount of oxygen extracted by the tissue

What is the difference between measured and calculated VO2?

VO2 can be measured directly by determining the oxygen inspired vs. expired or indirectly calculated using a Swan–Ganz catheter

Which is more accurate?

Measured (metabolic cart)

Are tissue perfusion and oxygenation related?

NO!

What are some laboratory measures of tissue perfusion?

Mixed venous oxygen saturation (SvO2), lactate, oxygen delivery (DO2), base deficit

Does the oxygen saturation correlate with ventilation?

NO! Get an arterial blood gas (ABG) if concerned about the breathing

What is the best marked for ventilation?

PaCO2 (on the ABG)

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) Why was the name changed from adult to acute (respiratory distress syndrome)?

Children get the syndrome as well


How is the diagnosis of ARDS made?

Capillary wedge pressure <18, chest x-ray with bilateral infiltrates, ratio PaO2:FIO2 <200

What is the difference between acute lung injury and ARDS?

Acute lung—PaO2:FIO2 ratio <300 (and >200); ARDS <200

How do you remember the ratio of ARDS?

PaO2:FIO2 or “PF”—think “PuFf ”

What two barriers constitute the “alveolar–capillary” barrier?

1. Microvascular endothelium 2. Alveolar epithelium

What is the pathogenesis of the early acute phase of ARDS?

Breakdown of the alveolar–capillary barrier and accumulation of transudate fluid (protein filled) in the alveolar air sac

What happens as the alveolar epithelial cells die?

No surfactant production; less removal of alveolar fluid; hyaline membranes replace the epithelial cells

What is the “fibrotic lung injury”?

Latter stage of ARDS; deposition of cells, collagen, and fibronectin, resulting in “fibrosis” of lung

What is the treatment for ARDS?

Fix underlying cause, then support with ventilator: low tidal volume (<6 mL/kg), plateau pressure <35, PEEP prn

What is the NEW diagnostic definition of ARDS?

1. 2. 3. 4.

Define each parameter for the diagnosis of ARDS: Timing?

Timing CXR Origin of edema PaO2:FiO2 ratio

Acute—less than 1 wk after insult

CXR?

Bilateral infiltrates

Origin of edema?

Noncardiogenic or fluid overload

PaO2:FiO2 ratio?

<300 mm Hg


What defines mild, moderate, and severe ARDS? Identify the PaO2:FiO2 ratios for: Mild? Moderate?

PaO2:FiO2 ratio

200–300 mm Hg 100–200 mm Hg

<100 mm Hg

CRITICAL CARE MEDICATIONS Acetazolamide (DIAMOX) What is carbonic anhydrase inhibitor?

Diuretic with ability to remove bicarbonate in urine; use in metabolic alkalosis

Aminophylline What is it?

Bronchodilator

How does it work?

Increases cyclic adenosine monophosphate (cAMP), resulting in increased catechols

Milrinone What is the site of action?

Phosphodiesterase III inhibitor (PDE III); decreases breakdown of cAMP and therefore increases intracellular cAMP and intracellular calcium

How does it act?

Increases inotropy, decreases afterload (SVR), little or no increase in chronotropy with no net increase in myocardial oxygen consumption (MVO2)

What is the usual dosage?

Load—50–75 μg/kg over 10 min Maintenance—0.375 to 0.7 μg/kg/min

What should you do if milrinone loses its inotropic effect?

Add low-dose epi/norepinephrine to increased cAMP intracellularly


Isoproterenol What is the site of action?

+ + +(β1- and β2-agonist)

How does it act?

Increases inotropy, increases chronotropy (+ vasodilation of skeletal and mesenteric vascular beds)

Esmolol What is the site of action?

β-Adrenergic antagonist with very short half-life (≈9 min), which necessitates intravenous infusion, but allows it to be easily titrated and turned off

In what cases is it indicated?

Control of ventricular response rate in patients with atrial fibrillation and rapid ventricular response, or with other supraventricular tachyarrhythmias; control of blood pressure (often in conjunction with sodium nitroprusside [SNP]) in patients with hypertensive emergency or with aortic dissection/traumatic aortic injury

ANTIDOTES Narcotic overdose (e.g., morphine)?

Narcan

Benzodiazepine overdose?

Flumazenil

Calcium channel blocker overdose?

Calcium

Malignant hyperthermia?

Dantrolene

Heparin?

Protamine (1:100)

Cardiac effects of hyperkalemia?

Calcium

Phenergan-induced dystonia?

Benadryl

Tylenol overdose?

Acetylcysteine

β-blocker overdose?

Glucagon


Brown recluse spider bite?

Dapsone

Hydrofluoric acid burn?

Calcium gluconate

Cyanide toxicity from burn inhalation injury? (2)

1. Sodium nitrite 2. Sodium thiosulfate

LANDMARK ICU PAPERS What should the tidal volume and plateau pressures be in patients with ARDS?

Tidal volume 4–6 mL/kg and plateau pressures <35 have been shown to decrease mortality; (ARDS Network. N Engl J Med. 2000;342:1301–1308)

What works better for prophylaxis against upper GI bleeding in ventilated patients: Zantac or sucralfate?

Zantac has a lower rate of GI bleeding and no difference in pneumonia; (Cook et al: N Engl J Med 1998;338:791–797)

When should ICU patients who do not have cardiac disease be transfused?

Hemoglobin <7, unless acute MI or unstable angina (Herbert et al: N Engl J Med. 1999;340:409–417)

Who needs prophylaxis for upper GI bleeding in the ICU?

All patients intubated >48 hr, all coagulopathic patients, burn patients, brain-injured patients, and all patients with recent history of peptic ulcer disease (Cook et al: N Engl J Med. 1994;330:377–381)

What works best to avoid decrease in renal function due to radiocontrast agents?

1. Saline alone works better than saline with Lasix or mannitol; (Solomon et al: N Engl J Med. 1994;331:1416–1420) 2. Acetylcysteine PO the day before and the day of contrast administration also has been shown to protect renal function; (Tepel et al: N Engl J Med. 2000;343:180–184) 3. Sodium bicarbonate (Merten et al: JAMA. 2004;291(19):2328–2334)

What index is one of the most accurate predictors of extubation success?

Tobin shallow breathing index: Respiratory rate/tidal volume in liters (RR/Vt) ≤105 will result in successful extubation in most patients (Yang and Tobin: N Engl J Med. 1991; 324:1445–1450)


What is the effect of stopping sedation once a day and letting ventilated ICU patients wake up?

Decreases ventilator days and ICU days! (Kress et al: N Engl J Med. 2000; 342: 1471–1477)

Does epoetin prevent transfusions?

In contrast to previous studies, this study found use of epoetin alfa did not reduce red cell transfusions, but did increase the risk of thrombotic events; trauma patients had lower mortality (Corwin HL, et al: N Engl J Med. 2007;357:965–976)

Are daily chest x-rays needed in the ICU?

Daily CXR is not needed unless clinically indicated with no change in length of ventilation, ICU stay, or mortality (Hejblum G, et al: Lancet. 2009;374:1687–1693)

Are daily sedation holidays useful?

The combination of daily sedation holidays and daily spontaneous breathing trials reduced ventilator days and mortality (Girard T, et al: Awake and Breathing Controlled trial. Lancet. 2008;371:126–134)

What is the duration of antibiotics for VAP?

8 d (Chastre J, et al: JAMA. 2003;290: 2588–2598)

Albumin vs. Saline resuscitation outcomes?

No difference in outcomes (The Safe Study Investigators. N Engl J Med. 2004;350:2247–2256)

Does light sedation increase long-term cognitive and psychological problems?

NO! (Jackson JC, et al: Am J Respir Crit Care Med. 2010;2010 Mar 18)

Does a negative D-Dimer rule out pulmonary embolism?

Yes; a low clinical suspicion with a negative D-Dimer rules out PE (Wells PS, et al: Ann Intern Med. 2001;135:98–107)

Does aggressive hemodialysis improve outcomes in acute kidney injury?

No (The ATN Study. Palevsky PM, et al: N Engl J Med. 2008;359:7–20)

Do pretreatment steroids reduce postextubation laryngeal edema?

Yes; multiple doses seem to be better than a single dose (Francois B, et al: Lancet. 2008;369:1083–1089)


Glucose control in the ICU: tight vs. conventional?

Despite the previous results published by Van den Berghe et al. in 2001, the NICE-SUGAR trial revealed no mortality benefit between tight (81–108 mg/dL) and conventional (144–180 mg/dL) glucose control; however, the tight group had more complications (Finfer S, et al: N Engl J Med. 2009;360:1283–1297)

Does induced hypothermia improve mortality after cardiac arrest?

It is beneficial in the prehospital setting for V-fib and V-tach; it has not been examined on an inpatient basis yet (Bernard SA, et al: N Engl J Med. 2002;346:557–563)

Does prone positioning increase oxygenation?

Yes; however, it has not been shown to increase mortality despite the clear evidence that it increases oxygenation (Taccone P, et al: JAMA. 2009;302: 1977–1984)

Is there any benefit to steroids in ARDS?

No; methylprednisolone administration revealed an increase in mortality (Steinberg KP, et al: N Engl J Med. 2006;354:1671–84)

Which Hgb value is the best transfusion trigger in the ICU: 7 or 9?

The TRICC trial demonstrated a significant decrease in mortality in euvolemic ICU patients with restrictive transfusion strategies (Hebert PC, et al: N Engl J Med. 1999 Feb 11;340[6]:409–117)

Should β-blockers be prescribed to all perioperative patients with cardiac risk factors?

NO! The POISE trial revealed a decrease in myocardial infarction with the routine use of β-blockers but also showed an increase in mortality and stroke in the same group (Devereaux PJ, et al: Lancet. 2008 May 31;371[9627]: 1839–1847) The MAVS study revealed no difference in mortality using β-blockers in high-risk vascular surgery and caused more bradycardia and hypotension (Yang H, et al: Am Heart J. 2006 Nov; 152[5]:983–990)


MISCELLANEOUS What is the most common symptom of pulmonary artery rupture from a Swan–Ganz catheter?

Hemoptysis

What is the treatment for Swan–Ganz pulmonary artery injury?

1. 2. 3. 4. 5.

Does “renal dose” dopamine prevent or help treat renal failure?

No

What is the first step if the ventilator alarms are going off and difficulty with ventilation is apparent?

Take patient off ventilation and hand him or her the bag; remove the ventilator from the equation!

Is there an increased rate of ICU pneumonia with H2 blockers vs. sucralfate?

No; larger studies reveal no difference (smaller studies did show H2 blockers as a risk factor due to bacterial overgrowth in stomach with H2 blocker acid neutralization)

Can you add PEEP to bag ventilation?

Yes; add PEEP valve to bag

What percentage of ICU fevers represents true infection?

36%

What is a “differential blood culture” in patients with a central line?

Draw blood cultures from central line and peripheral vein; if ratio of catheter colony-forming units (CFUs) to peripheral vein CFUs is >8, the diagnosis of catheter infection has a sensitivity of 93% and specificity of 100%

How does Lasix affect fractional excretion of sodium (FENa)?

Because of salt wasting, it may falsely elevate FENa; thus, prerenal azotemia can be missed

Deflation of balloon Withdrawal of catheter Ipsilateral side down (lateral decubitus) Increased PEEP Thoracic surgery consult


What can be done instead of FENa in the patient who has had Lasix?

FEUrea (use urea instead of sodium)

What ICU IV medication bag must be covered with aluminum foil because it will be broken down by light?

SNP (sodium nitroprusside)

What is the physiological effect of increasing dead space ventilation?

Progressive hypoxemia and hypercapnia

What causes increased shunt fraction?

Underventilation (pneumonia, pulmonary edema, respiratory distress syndrome, mucus plugging) or overperfusion (loss of pulmonary vascular autoregulation as in massive pulmonary embolus), SNP, atelectasis

What is the physiological effect of increasing shunt fraction?

Initially, progressive hypoxemia, followed by late hypercapnia

What mechanical situations cause a decrease in respiratory compliance?

Pneumothorax, atelectasis, pneumonia, pulmonary edema, alveolar air trapping, ARDS

What is the maximum O2 that can be given via a nasal cannula?

Never more than 4 L/min—any more and you get no increase in O2 but more uncomfortable and more nasal drying

How much diaphragm atrophy do you get after 7 d of complete ventilator support?

Loss of up to 50% diaphragm muscle mass!

What do you do if you have a patient with a left bundle branch block and absolute need for a Swann–Ganz catheter?

External pacer, then float!

What percentage of patients with a pulmonary embolus will not have a clinically documented decrease in O2 saturation?

10%


What side down will increase O2 saturation in a patient with a unilateral pulmonary contusion?

Good lung down! Will increase blood flow to the good lung and increase O2 saturation!

What are the factors that affect SvO2 (mixed venous saturations)?

Think “COSH”: Cardiac output, Oxygen consumption, SaO2, Hgb concentration

What percentage of patients with tracheostomies will aspirate if fed orally?

Up to 50%! (Always get a swallowing study prior to feeding patients with tracheostomies!)

What is a contraindication for administering Haldol?

Prolonged QT internal—may result in torsades de pointes!

How can you calculate how much potassium is in potassium phosphate?

Number of millimeters of potassium phosphate × 1.47 = mEq potassium [e.g., 13.6 mm of potassium phosphate = 20 mEq of K+ (13.6 × 1.47 = 19.99)]

How can you detect hypovolemia on an A line tracing?

Cycling—the waveform moves up and down with respiration

Why give a patient with liver and kidney failure Nimbex (cisatracurium)?

Nimbex is metabolized by Hoffman degradation; it breaks down in the blood rather than by kidney or liver metabolism

What is the half-life of amiodarone?

52 d!

What is the equivalent dosing ratio of Bumex to Lasix?

1 mg of Bumex equals about 20 mg of Lasix

What is a common cause of ICU refractory hypertension?

Fluid overload

Which ICU benzodiazepine has the quickest period of time until peak effect?

Valium—about 1 min until peak effect; versed has 5 min and Ativan about 30 min until peak effect


What is a Passy-Muir trach plug?

A speaking valve; it is a one-way valve (air comes in and none goes out) and therefore the trach balloon must be DOWN!

What should you do if milrinone stops working?

Add low-dose epi or NE increase cAMP

What is the antidote for cyanide SNP toxicity?

Sodium thiosulfate

What is the antidote for nitroglycerin toxicity?

Methylene blue

What is the tobramycin/ gentamicin “rule of sevens”?

1. Initial q24h dosing 7 mg/kg 2. Check level at 7 hr post infusion 3. Level at 7 hr should be less than 7 mg/dL

Give the rough formula for pressure support

(PIP – PEEP) × ½

Renal dose dopamine is one of two renal artery dilators; what is the other?

Fenoldopam—a DAI dilator

With neck flexion, how far can an endotracheal tube travel in the trachea?

Up to 4 cm!

What is sick euthyroid syndrome?

Normal thyroid-stimulating hormone (TSH) but decreased thyroxine (T4), decreased free triiodothyronine (T3) with an increase in reverse T3; this syndrome is seen in critically ill patients with previous normal thyroid function

HCT of PRBCs?

60%–70%

What percentage of normal levels of clotting factors does a patient need for maximal clotting function?

Only 30%


What is the most common sign of pulmonary artery rupture due to Swan–Ganz catheter?

Hemoptysis

How should you treat a pulmonary artery rupture from a Swan–Ganz balloon?

1. Deflate and pull balloon back 2. Ipsilateral side down (lateral decubitus position) 3. Increase PEEP 4. STAT page thoracic surgery

What is the differential diagnosis for cause of increased trach secretions?

Bacterial infection, viral infection, fungal infection, or fluid overload

Has renal dose dopamine been shown to help prevent or treat renal failure?

No (but fenoldapam has shown promise)

What might be going on if the BUN rises disproportionately compared to creatinine?

GI bleed

Which ICU endocrine disorder presents with hypothermia and bradycardia?

Hypothyroidism

Which ICU endocrine disorder presents with fever and tachycardia?

Adrenal insufficiency

What is the best measurement to help determine tissue oxygenation and perfusion?

Systemic venous O2 saturation (SvO2)—get O2 saturation from tip of Swan

What is the extraction ratio (ER)?

ER = Arterial O2 saturation—SaO2

What does ER measure?

Indirect measure of consumption (VO2)

What are the factors that affect SvO2?

Think of “COSH”: Cardiac output, Oxygen consumption, SaO2, and Hgb


What are three abnormalities associated with Hgb that decrease DO2?

Decreased oxygen binding from Hgb, decreased oxygen release from Hgb, and low concentration of Hgb

What causes decreased binding of oxygen to Hgb?

Carbon monoxide, methemoglobin, sickle cell, thalassemia, etc.

What is the primary function of the oxygen dissociation curve?

Prediction of the PaO2 compared to oxygen saturation

What is the expected PaO2 with an oxygen saturation of 97%, 90%, 75%, and 50%?

97% = 100 mm Hg 90% = 60 mm Hg 75% = 40 mm Hg 50% = 26 mm Hg

SECTION III Subspecialty Surgery

Chapter 70 Vascular Surgery ARTERIAL OCCLUSIVE DISEASE OF THE LOWER EXTREMITY What named collateral path provides arterial flow to the lower extremity in the setting of complete aortoiliac occlusion? What are the 5-year patency rates for: Aortobifemoral bypass?

Collaterals of Winslow, which connect the subclavian arteries with the external iliac arteries through the internal mammary and inferior epigastric arteries

85%–90% (Rates are reduced by 15%–20% if there is concurrent distal occlusive disease because patent outflow is crucial for long-term graft patency)

Axillobifemoral bypass?

70%–75%

Femorofemoral bypass?

80%–85%

Percutaneous iliac artery angioplasty?

80%–90%

What is the usual route by which blood reaches the foot in cases of superficial femoral artery occlusion?

The profunda femoris artery collateralizes through the genicular artery to the popliteal artery

Tibioperoneal Occlusive Disease What patients are at increased risk for tibioperoneal occlusive disease?

Patients with diabetes or Buerger’s disease

437

438 Section III / Subspecialty Surgery

Why are these lesions more limb threatening than more proximal disease?

Less abundant collateral pathways


Limb salvage and ischemic ulcers only; (Because of the difficulty of successful bypass, the threshold for surgery in the patient with tibioperoneal occlusion is elevated)

What are the surgical options?

Femorotibial or femoropopliteal bypass Multiple short distal-distal grafts for multisegmental occlusions

What are the conduit options if insufficient vein is available for femorodistal bypass?

Composite graft: Proximal segment of polytetrafluoroethylene (PTFE) and distal segment of saphenous vein Venovenous grafts: Anastomosis of short segments of available veins Avoid using prosthetic grafts below the knee!

How is a patient with preoperative forefoot necrosis with infection managed?

Débridement and drainage ± limited amputation and IV antibiotics; once infection clears, distal bypass is performed

How is a patient with preoperative heel or posterior arch necrosis managed?

Extension of necrosis proximal to the forefoot rarely permits successful distal bypass; Below-the-Knee Amputation (BKA) is usually indicated

What is the 5-year patency rate for femorodistal bypass?

50%

Chapter 70 / Vascular Surgery 439

Name the labeled arteries on the anterior view of the lower extremity:

31 30 29 28

1 2 3

27 4 5

26 25

24

6

23 7 22 8 9

21 20

19

10 18 17

11 12

16

13

15

14 Anterior view

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

External iliac artery Deep circumflex iliac artery Superficial circumflex iliac artery Profunda femoris artery Lateral circumflex femoral artery Perforating arteries Popliteal artery Superior lateral genicular artery Inferior lateral genicular artery Perforating branch of peroneal (fibular) artery Lateral malleolar artery Lateral tarsal artery Arcuate artery Dorsal digital artery Deep plantar branch Medial tarsal artery Dorsalis pedis artery Medial malleolar artery Anterior tibial artery Anterior tibial recurrent artery Inferior medial genicular artery Superior medial genicular artery Descending genicular artery Superficial femoral artery Medial circumflex femoral artery Obturator artery External pudendal artery Common femoral artery Inferior epigastric artery Internal iliac artery Common iliac artery


Name the labeled arteries on the posterior view of the lower extremity:

1

1. 2. 3. 4. 5. 6. 7.

2

8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

3 4 5

17 16 15

6

7 14 13

8

9 12 11

10 Posterior view

Superior gluteal artery Inferior gluteal artery Medial circumflex femoral artery Profunda femoris artery Superficial femoral artery Popliteal artery Genicular arteries (originate from the popliteal artery) Posterior tibial artery Medial plantar artery Deep branch of dorsalis pedis artery Plantar arch Lateral plantar artery Peroneal (fibular) artery Anterior tibial artery Inferior lateral genicular artery Popliteal artery Superior lateral genicular artery


What are the incisions for vascular access?


ARTERIAL OCCLUSIVE DISEASE OF THE UPPER EXTREMITY Arterial occlusive disease of the upper extremity accounts for what percentage of cases of extremity ischemia?

5%

What are the etiologies?

Diverse; including atherosclerosis, embolism, trauma, thoracic outlet syndrome, arteritis (e.g., Buerger’s and Takayasu’s diseases), and vasospastic disorders (e.g., Raynaud’s syndrome)

Why are proximal occlusions usually asymptomatic?

Extensive arterial collaterals around the shoulder girdle

What clinical test is performed to evaluate the patency of ulnar and radial arteries?

Allen’s test

How are atherosclerotic lesions of the upper extremity different from those of the lower extremity?

Significantly increased incidence of atheroembolization

What is the most common site of stenosis?

Subclavian artery (75% occur on the left)

What are the treatment options?

Endarterectomy, bypass procedure, or, occasionally, percutaneous balloon angioplasty

What is the procedure of choice for subclavian artery stenosis in a patient without carotid occlusive disease?

Common carotid to subclavian artery bypass with a PTFE conduit; to avoid the use of prosthetic material, transect the subclavian artery and transpose the distal end to perform an end-to-side anastomosis

Chapter 70 / Vascular Surgery 443 1

25 24

26

2 23 22

3 4

21 5

20 19 18

6

17 16 7 15

14 8

13 12

9

11 10

Anterior view


Name the labeled arteries of the upper extremity (See previous page):

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

Subclavian artery Suprascapular artery Axillary artery Thoracoacromial artery Posterior circumflex humeral artery Anterior circumflex humeral artery Profunda brachii artery Radial recurrent artery Radial artery Superficial palmar arch Deep palmar arch Ulnar artery Common interosseous artery Anterior and posterior ulnar recurrent arteries Inferior ulnar collateral artery Superior ulnar collateral artery Brachial artery Subscapular artery Lateral thoracic artery Internal mammary artery Aorta Brachiocephalic trunk Common carotid arteries Vertebral artery Thyrocervical trunk Transverse cervical artery Left subclavian artery


AMPUTATIONS Define the following terms: Syme’s amputation?

Ray amputation?

Amputation of the foot

Removal of a metatarsal head and digit of foot


Transmetatarsal amputation?

Foot amputation at the level of the metatarsals

Hip disarticulation?

Amputation by hip dislocation

What are the four indications for amputation?

1. Gross overwhelming infection/gangrene (refractory) 2. Rest pain or ulcers/infection without any graftable distal arteries 3. Malignant tumors 4. Trauma

What percentage of patients with claudication will receive an amputation in 5 yr?

Only ≈5%

Which type of amputation has the highest healing rate of all the lower extremity amputations?

Above the Knee Amputation (AKA)

What is the significance of a nonhealing AKA?

Bodes poorly; associated with a high mortality rate


What is the best amputation for a grossly infected limb?

Guillotine amputation with formal closure after infection clears

What is the best graft material after an infection clears?

Saphenous vein graft

Which flap—anterior or posterior—has the best blood supply for a BKA?

The posterior flap has more collaterals than the anterior flap because of the closer proximity to the popliteal artery

Should dog ears be removed from the skin closure during a BKA/AKA?

No (controversial)

What is the best type of suture for apposing the muscle fascia layer of a BKA or an AKA?

Absorbable (e.g., Vicryl)

Should electrocautery be used extensively during an amputation?

No; it is associated with a large necrotic tissue load and may cause infection/ ischemia

What are the six principles of operative technique for amputations?

1. 2. 3. 4. 5. 6.

What is the rate of operative mortality for an AKA or a BKA?

≈10%

What is the most common cause of operative mortality in this group?

Heart attack/arrhythmia (accounts for 50%)

What is the mortality rate 3 yr after an AKA or BKA?

≈50%

Will a toe amputation heal in a patient with dry gangrene?

Usually not; therefore, do not perform an amputation until revascularization is completed

Remove bone Avoid tension on closure Administer antibiotics Avoid hematoma Handle tissue with care Do not separate skin from underlying fascia


What percentage of patients with an AKA will walk independently?

Only ≈33%

What percentage of patients with a BKA will walk independently?

≈66%

In a BKA, how long should the fibula be in relation to the tibia?

Approximately 1 cm proximal to the tibia stump

What can help prevent postBKA knee flexion contracture?

A knee immobilizer (or cast)

What bedside sign is used by many experienced surgeons to determine the level of amputation?

Warm skin

What is the best predictor of failure of a BKA to heal?

Absence of popliteal arterial pulsation on palpation or Doppler; <70 mm Hg pressure

What toe pressure is thought to correlate with the failure of a transmetatarsal or toe amputation to heal?

Systolic toe pressures <45 mm Hg (presence of a palpable pedal pulse correlates closely with the healing of a transmetatarsal amputation)

What systolic popliteal pressure is associated with healing of the stump?

>70 mm Hg by Doppler

What percentage of all BKAs will heal?

≈80%

What are the mortality rates for hip disarticulation, AKA, and BKA?

Hip disarticulation: 80% AKA: 15% BKA: 5%


What are the independent (prosthetic) ambulation rates after: BKA?

66%–80%

AKA?

35%–50%

Bilateral BKA?

45%

Bilateral AKA?

10%

What is the overall survival rate at 1, 3, and 5 yr after lower extremity amputation?

By how much do energy requirements increase with walking in each procedure: BKA? AKA?

1 yr: 75% 3 yr: 50% 5 yr: 35% Because of associated atherosclerotic lesions elsewhere (e.g., heart)

50% 100%

What is a Gritti-Stokes amputation?

Amputation through the knee joint

Who benefits from a Gritti-Stokes?

Wheelchair-bound patients

Define the following: Lisfranc’s amputation?

Amputation through the distal tarsal bones

Chopart’s amputation?

Amputation through the tarsal navicular and calcaneocuboid joints (proximal to tarsal bones)

Pirogoff ’s amputation?

Resect foot and pin heel Calcaneal remnant to tibia/fibula


EXTRACRANIAL CEREBROVASCULAR DISEASE Carotid vs. Vertebrobasilar Disease How do the plaques in carotid disease differ from those in vertebrobasilar disease?

Carotid: High incidence of ulcerated plaques Vertebral: Usually a smooth intimal surface

Which type is usually associated with unilateral vs. bilateral neurologic deficits?

Carotid: Usually unilateral Vertebral: Often bilateral

Where is the bruit auscultated in each type?

Carotid: Anterior border of the sternocleidomastoid muscle near the angle of the mandible Vertebral: Supraclavicular fossa

In which situation are “drop attacks” common?

Vertebrobasilar disease; the patient suddenly falls to the ground because of bilateral lower extremity motor deficit (± loss of consciousness with rapid recovery)

Name the labeled structures of a right carotid endarterectomy (CEA):

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Hypoglossal nerve (CN XII) Internal carotid artery Ligated facial vein Sternocleidomastoid muscle Internal jugular vein Superior thyroid vein Common carotid artery Ansa cervicalis Superior thyroid artery External carotid artery Lingual artery Vagus nerve


ANATOMY OF THE VISCERAL BRANCHES OF THE AORTA Mesenteric Arteries What are the three main mesenteric arteries and the territory of bowel that each supplies?

Celiac artery: Stomach to ampulla of Vater (middle of the second portion of the duodenum) Superior Mesenteric Artery (SMA): To the splenic flexure of the colon Inferior Mesenteric Artery (IMA): To the rectum

What is the key “watershed” area?

Splenic flexure of the colon (often has a break in the continuity of the marginal artery of Drummond)

What are the branches of the celiac artery?

Left gastric artery Splenic artery Hepatic artery

What are the first two branches of the SMA?

Inferior pancreaticoduodenal (PD) artery Middle colic artery

What are the branches of the IMA?

Left colic artery Sigmoid arteries Superior hemorrhoidal artery

What is the major arterial collateral path between the celiac artery and the SMA?

Celiac artery → Hepatic artery → Gastroduodenal artery → Superior PD artery → Inferior PD artery → SMA

What is the major arterial collateral path between the SMA and the IMA?

Arch of Riolan: SMA → Middle colic artery (left branch) → Left colic artery (ascending branch) → IMA

What is the “meandering mesenteric artery”?

The tortuous, enlarged, and dilated arch of Riolan that results with increased blood flow through this collateral

Renal Arteries Renal arteries are located at what lumbar level?

L1 to L2

Is the right renal artery anterior or posterior to the IVC?

Posterior


How is the right renal artery exposed intraoperatively?

Cattel and Kocher maneuvers (medial mobilization of the hepatic flexure of the colon and the third portion of the duodenum) ± retraction of the IVC for exposure of the most proximal portion of the renal artery

What is the most common anatomic “anomaly” of the renal artery?

Accessory renal arteries (seen in 20%–25% of the population)

VISCERAL ISCHEMIC SYNDROMES Acute Mesenteric Ischemia What are the etiologies?

Embolus Thrombosis Nonocclusive etiologies (i.e., vasospasm associated with low cardiac output, venous thrombosis)

What is the most common surgically treatable cause?

Arterial embolism

What is the most common site of embolism?

Proximal SMA (at the SMA origin or at the takeoff of the middle colic artery)

Why do emboli tend to enter this vessel?

The SMA is large, and its takeoff from the aorta is at an acute angle vs. the more perpendicular celiac, IMA, and renal origins


Early: Severe abdominal pain with fairly benign abdominal findings; pain is classically “out of proportion to the signs” on physical exam Later: Fever, tachycardia, hypotension, vomiting, diarrhea (often heme positive), abdominal distension, peritonitis

What is the general presentation of embolus vs. thrombosis?

Embolus: Acute, rapidly progressive symptoms Thrombosis: More insidious; patients usually have a history consistent with chronic mesenteric ischemia


What are the laboratory findings?

Severe leukocytosis (often >20,000 if infarcted) Metabolic acidosis (later in the course) Elevated amylase and lactate values (nonspecific, but helpful)

Which patients often do not have leukocytosis?

Elderly patients

What are the abdominal x-ray findings?

Distended loops of bowel, air–fluid levels, and edematous bowel wall; in the setting of infarction, gas may be seen in the bowel wall or portal venous tree

What is the diagnostic study of choice?

Angiogram (Duplex ultrasound is gaining popularity)

Which view is most helpful, and why?

The lateral view because it facilitates visualization of the classic atherosclerotic ostial lesions

What are the classic angiographic findings for embolus, thrombosis, and nonocclusive etiologies?

Embolus: Abrupt occlusion with a “meniscus sign,” usually 5–8 cm from the origin of the SMA Thrombosis: Occlusion of the origin itself or a very proximal region of the mesenteric arteries Nonocclusive: Smooth, gradual tapering of more distal branches (because of vasospasm)

When is bowel nonviability determined?

After the revascularization procedure

How is bowel viability assessed intraoperatively?

Gross examination: Palpable pulses, pink color, visible peristalsis Wood’s lamp inspection after IV fluorescein Doppler ultrasound of the mesenteric artery adjacent to the bowel in question

When is the decision made to perform a second-look laparotomy?

At the time of the original surgery!


What do the terms “antegrade” and “retrograde” refer to in describing aortovisceral bypass?

The site of aortic anastomosis with respect to the origin of the mesenteric vessel being bypassed (i.e., antegrade is proximal to the origin, retrograde is distal)

Which site is usually preferred, and why?

Antegrade, because it offers better long-term patency, but retrograde is a faster/easier procedure

What is the mortality rate for acute mesenteric ischemia?

55%–85%

What factor accounts for much of this high mortality rate?

Delayed diagnosis

ANEURYSMS Abdominal Aortic Aneurysm (AAA) What is the characteristic gross appearance of inflammatory AAAs?

Dense, white, fibrotic inflammatory reaction that covers the aorta and adjacent abdominal structures (e.g., duodenum, ureters)

What are the most common etiologies of mycotic AAAs?

Staphylococcus epidermidis and Staphylococcus aureus Salmonella (“Mycotic” does not imply fungal causes in AAAs)

What is the presentation of inflammatory AAA?

Chronic abdominal pain Weight loss Increased erythrocyte sedimentation rate

What are the examples of the structural anomalies that can be seen on CT scan?

Retroaortic left renal vein; there is a risk of injury to this vein with aortic cross-clamp Horseshoe kidney

What is the classic finding of ruptured AAA on physical exam INSPECTION?

Ecchymosis in the inguinal and groin region (tracking of blood around the abdominal wall from the retroperitoneum)

What complication is common in inflammatory AAAs?

Ureteral obstruction; inflammatory reaction results in fibrotic attachments with ureters, IVC, etc.


How are most AAAs treated today?

With endovascular graft placement

What surgical procedure is used?

“Resection,” which is a misnomer because the AAA is usually merely filleted open; aortic continuity is restored with a prosthetic tube or bifurcation graft (aortoaortic, aortoiliac, or aortofemoral bypass)

What is the graft material of choice?

Dacron (woven or knitted, ± collagen impregnation) Second choice: PTFE

What are the two surgical approaches?

Transabdominal approach through a midline laparotomy incision Retroperitoneal approach through a left flank incision

How do you get to the aorta via the retroperitoneal approach?

In a patient with a ruptured AAA, what is the first step after midline laparotomy?

Immediate compression of the supraceliac aorta against the vertebral bodies through the lesser sac

What are the next steps?

The left crus of the diaphragm is divided, the supraceliac aorta is clamped, the neck of the AAA (usually infrarenal) is exposed and clamped, the supraceliac clamp is removed, and the graft is placed

What frequently obstructs access to the neck of the AAA in the transabdominal approach?

Left renal vein

What is the presentation of aortocaval fistula?

High-output CHF, hypotension, cyanosis, venous distension of the lower extremities, abdominal bruit, and palpable abdominal thrill



The fistula is closed: achieve proximal and distal control of the aorta and IVC; make an incision in the aortic graft; repair the fistula from within graft with large suture bites; and close the aortic graft

What is excluded in the setting of pseudoaneurysm?

Graft infection

Peripheral Artery Aneurysm What is the most common etiology of true peripheral aneurysm?

Atherosclerosis

What are the most common etiologies of false peripheral aneurysm?

Vascular bypass procedures Trauma

What are the most common locations of true aneurysms?

Popliteal artery (70%) Femoral artery (15%–20%)

What diagnostic study is performed in patients with true peripheral artery aneurysms, and why?

Complete arteriogram of the abdominal aorta and its branches to the lower extremity; between 75% and 85% of these patients have an additional aneurysm elsewhere

What is the most common complication of true aneurysms?

Distal arterial occlusion caused by emboli from a mural thrombus within the aneurysm (rupture is rare)

What percentage of true aneurysms are bilateral?

60%–75%


Symptoms caused by embolic events or local compression Size

What is the surgical procedure?

Excision or exclusion (proximal and distal ligation) of the aneurysm (to prevent further embolic events) plus a bypass procedure


Visceral Artery Aneurysm What is the etiology?

Medial degeneration of the arterial wall

What are the most common locations?

Splenic artery (60%) Hepatic artery (20%)

What is the presentation?

Vague upper quadrant or epigastric pain is occasionally present, but most patients are asymptomatic

What is the most common complication?

Rupture

What is the incidence of splenic artery and hepatic artery aneurysm rupture?

Splenic artery: 2% Hepatic artery: 20%

What is the classic sequence of events in splenic artery aneurysm rupture?

“Double rupture”: Herald bleed into the lesser omental sac (± transient hypotension); then rupture into the peritoneal cavity (± exsanguination)

What factor significantly increases the risk of rupture in patients with splenic artery aneurysm?

Pregnancy

What is the mortality rate if rupture occurs in the pregnant patient?

>70%

What are the indications for treatment?

Symptomatic patient Aneurysm >2 cm Splenic artery aneurysm in a patient who is pregnant or who plans to become pregnant

What surgical procedure is performed?

Excision or exclusion of aneurysm ± bypass procedure Splenectomy is performed For intrahepatic aneurysms, hepatic resection may be indicated


NONATHEROSCLEROTIC VASCULAR DISEASE What feature common to these disorders may facilitate their diagnosis?

Symptoms of limb ischemia in a preatherosclerotic age group of patients

Thromboangiitis Obliterans (TAO; Buerger’s Disease) What is the target patient population?

Young men (20–35 yr old) who are heavy tobacco abusers

What are the classic histologic findings?

Nonnecrotizing, segmental panarteritis with fibrous obliteration of the arterial lumen on healing; intraluminal thrombosis

How does TAO differ from atherosclerotic disease?

Involves all three layers of artery; involves more peripheral vessels (small and medium arteries)

What percentage of patients have symptomatic upper extremity involvement?

≈40%


Uncertain, but believed to be autoimmune (possible association with human leukocyte antigens [HLAs] A9 and B5)


Excruciating rest pain Tender, bilateral digital ulceration and gangrene Occasionally, claudication (but much less frequently than with atherosclerotic occlusive disease)

What are the classic arteriographic findings?

Uninvolved large vessels with abrupt occlusion in medium and small arteries; “corkscrew” or “tree root” appearance (thought to be caused by dilated vasa vasorum collaterals around the occlusion)

What treatment is most effective?

Abstinence from tobacco (disease usually goes into remission)


What is the surgical treatment?

Sympathectomy (for vasodilation; yields transient improvement in symptoms) Digital amputation for gangrene

Why is surgical bypass rarely possible?

Diffuse distal disease (i.e., no target for bypass)

Popliteal Entrapment Syndromes What is the target patient population?

Young men (<40 yr old)


Congenital anomaly in the development of the popliteal artery or neighboring muscles, resulting in arterial compression

What structure is most often responsible for compression?

Medial head of the gastrocnemius muscle (>80%)

Is involvement usually unilateral or bilateral?

Unilateral (75%)

Popliteal artery Gastrocnemius muscle (medial head) Medial epicondyle Entrapment

What is the most common symptom?

Intermittent claudication of the leg or foot; rest pain or gangrene is rare


What is the classic finding on physical examination?

Loss of pedal pulses with ankle flexion or knee extension (contraction of the gastrocnemius muscle)

What diagnostic study is performed?

Arteriogram taken with the leg in various positions to show intermittent occlusion


Myotomy to divide the entrapping muscle ± Femorodistal popliteal bypass (frequently necessary because of popliteal stenosis or aneurysm)

What disorder mimics popliteal entrapment syndrome?

Adventitial cystic degeneration of popliteal artery (enlarging, subadventitial mucincontaining cysts causing obstruction)

How is this disorder distinguished from popliteal entrapment?

Arteriogram of adventitial cystic degeneration shows the pathognomonic “scimitar sign” (external compression of popliteal lumen by expanding cysts)

Takayasu’s Arteritis What is the target patient population?

Young women (<30 yr old), often with Asian ancestry

What vessels are most commonly involved?

Thoracic aorta ± arch vessels (types I–IV) Abdominal aorta (types II and III) Occasionally, the pulmonary arteries (type IV)

What are the early symptoms?

Fever, arthralgia, myalgia, anorexia

What is the medical treatment?

High-dose steroids


Bypass procedures for stenoses (Endarterectomy fails in this disorder)

What is the relative contraindication to surgery?

Active arteritis; the vascular inflammation must be reduced with steroids before a bypass procedure is attempted



Stroke Hypertension (usually caused by renal artery stenosis) CHF

VENOUS AND LYMPHATIC DISEASE Venous Anatomy and Physiology What is the basic gross anatomy of the venous circulation?

The superficial venous system is connected to the deep venous system by perforating veins that pass through the fascial layer of the extremity; the perforating veins have valves that are oriented to permit flow to pass only from the superficial to the deep system (except in the foot, where the reverse is true)

What are the two main superficial veins of the lower extremity and the deep veins they feed?

Greater saphenous vein: Empties into common femoral vein Lesser saphenous vein: Empties into popliteal vein

What is the main mechanism by which blood is returned to the heart?

Pumping action of the muscles of the leg, especially the calf muscles; venous pressure normally decreases to less than half its resting level with exercise

What are the sinusoids?

Thin-walled venous cavities within the muscles of the lower extremity; they play an essential role in the musculovenous pump

Diagnosis of Venous Insufficiency What three basic lesions lead to venous hypertension in the lower extremity?

Valvular incompetence Ineffective musculovenous pump Venous obstruction

What two clinical tests are used to evaluate the venous system of the lower extremity?

Trendelenburg test Perthes test


How each test is performed?

1. In Trendelenburg test: The leg is raised to drain the venous system, and a venous tourniquet is applied over the saphenofemoral junction; the patient then stands 2. In Perthes test: A venous tourniquet is applied proximal to varicoses or suspected incompetent perforators; then the patient ambulates

What is the purpose of each test?

Trendelenburg test: To exclude saphenofemoral and perforator valvular incompetence Perthes test: To exclude perforator valvular incompetence and deep venous occlusion

In the Trendelenburg test, what do the following observations suggest: Slow filling of varicosities before the tourniquet is released? Rapid filling of varicosities when the tourniquet is released? In the Perthes test, what do the following observations suggest: Increase in varicosities with exercise? Decrease in varicosities with exercise? What is the diagnostic study of choice for venous disease, and why?

Competent perforators (if filling is rapid, incompetent)

Incompetent saphenofemoral valve

DVT

Normal deep venous system and competent perforators Duplex ultrasound: Shows the two basic pathological venous lesions (valvular incompetence and venous occlusion)

Lower Extremity Varicosities What is the claim to fame of lower extremity varicosities?

Most common lower extremity vascular disorder; affects 10%–20% of population


What are the “types” and their main etiologies?

Primary varicosities: Genetic predisposition (exact mechanism is uncertain) Secondary varicosities: DVT, resulting in shunting of blood through incompetent perforators to the superficial system


Fatigue, heaviness, or aching of the limb, especially when standing erect

What is the conservative therapy?

Elastic support stockings; elevation of the affected extremity when sitting


Cosmetic Symptomatic (e.g., aching) Occasionally, complications of chronic venous insufficiency (e.g., recurrent superficial thrombophlebitis, ulcer)

What is the most frequently performed procedure?

Simple sclerotherapy (injection of a sclerosing agent into the varicose veins) or laser

What agent is used?

Sodium tetradecyl sulfate

What is the contraindication to this therapy?

Incompetent saphenofemoral or saphenopopliteal valves

What is the procedure of choice if simple sclerotherapy is contraindicated?

Proximal ligation and division of the greater saphenous vein at the saphenofemoral junction Sclerotherapy or vein stripping (either of these ablation techniques is satisfactory)

What is the contraindication to proximal ligation or vein stripping?

DVT, which results in venous drainage, primarily through the superficial system

What are the other surgical options?

Procedures typically used for chronic venous insufficiency (e.g., subfascial ligation of perforators, valve transplant); rarely indicated for simple varicose veins


Chronic Venous Insufficiency What are the etiologies?

Valvular venous incompetence (90%) Venous obstruction (10%) secondary to postphlebitic syndrome

What is the primary physiological derangement?

Chronic venous hypertension

What is the result?

Local hypertension reduces capillary perfusion and causes interstitial accumulation of hemosiderin and fibrin (through dilated endothelial pores); oxygen transport to tissue is reduced

What are the clinical manifestations of reduced tissue oxygenation?

Poor healing of cutaneous traumatic lesions, eventually followed by spontaneous breakdown of the skin

What are the classic cutaneous changes of chronic venous insufficiency?

Brawny edema, hyperpigmentation, stasis dermatitis Liposclerosis (thick, hardened subcutaneous tissue because of fibrin deposits) Venous ulceration

What is the classic location of venous ulcers?

Superior and posterior to medial malleolus, the site of five to six perforators from the greater saphenous vein of the superficial venous system to the deep posterior tibial vein

Are these ulcers painful or painless?

Usually painless (unless infected)

What are the most common organisms associated with infected venous ulcers?

S. aureus Streptococcus faecalis Klebsiella

What is Marjolin’s ulcer?

Malignant transformation of a chronic venous ulcer

What is the conservative management of chronic venous insufficiency?

Meticulous skin care, limb elevation, elastic compression stockings, and hydrophobic dressing


What additional therapy is useful in the management of venous ulcer?

Unna boot (gauze with calamine, zinc oxide, and gelatin firmly wrapped around the foot or lower leg, and changed every week for 6–12 wk)

When is this therapeutic adjunct contraindicated?

Patients with concurrent arterial occlusive disease

How successful is conservative therapy?

90%–95%


Persistent venous ulcer in: 1. Relatively young, active patients; repetitive calf muscle contraction usually prevents healing with conservative therapy alone 2. Compliant patients despite aggressive conservative management

What are the surgical options for incompetent valves?

1. Subfascial ligation of incompetent perforators (Linton procedure) 2. Correction of incompetence of deep venous valves by suture plication of the cusps (valvuloplasty) 3. Venous segment transposition, valve transplant, or valve banding

What is the procedure for venous obstruction?

Saphenous vein venous bypass procedure

What is the surgical management of venous ulcers?

Excision or débridement, followed by coverage with split-thickness skin graft

Upper Extremity Deep Venous Thrombosis (DVT) What are the most common etiologies?

Effort-induced thrombosis (Paget–von Schrötter syndrome) Subclavian thrombosis caused by a central IV catheter


Edema, mild cyanosis, pain, and heavy sensation of the arm


Why is massive thrombosis rare?

Extensive venous collaterals around the shoulder girdle

What is the incidence of pulmonary embolus?

10%–15% (higher than previously believed)

What is the treatment of effort-induced thrombosis?

Regional thrombolytic (urokinase) therapy; correction of thoracic outlet obstruction (if present)

What is the treatment of catheter-related thrombosis?

The catheter is removed if possible, and systemic heparinization is followed by 1–2 mo of Coumadin therapy

Why are these etiologies managed differently?

Effort-induced thrombi occur in young, healthy individuals who are at low risk for hemorrhage; in an ill or elderly patient with a central venous catheter, thrombolytic therapy is more likely to cause bleeding


Only 15%–30% of patients have complete resolution of symptoms

VASCULAR ACCESS FOR HEMODIALYSIS What is the minimum flow rate required to drive the hemodialysis process?

150 mL/min

Access for Chronic Hemodialysis What are the two general types of chronic access procedures?

1. Autogenous fistula; direct anastomosis of artery to vein 2. Interposition AV fistula: Interposition of a prosthetic graft between artery and vein

Which specific type is the preferred first operation, and why?

Brescia–Cimino (a.k.a. “Cimino”) autogenous fistula: Radial artery to cephalic vein; autogenous fistulas are associated with improved long-term patency and reduced risk of infection; further, the Brescia–Cimino fistula requires minimal, superficial dissection


What percentage of patients are candidates for an autogenous fistula?

15%–20%; these patients, who often have a long history of illness, have few patent upper extremity veins

What is the prosthetic material of choice for interposition AV fistula?

PTFE

What is the most common site used?

Forearm of the nondominant hand: PTFE loop between the radial (or brachial) artery and the antebrachial region vein (e.g., cephalic, basilic)

Compare, and explain the rationales for, the postoperative waiting periods required before the use of autogenous and interposition AV fistulas:

Autogenous: 3–6 wk, to allow fistula to mature; the vein must hypertrophy and “arterialize” to permit repeated punctures with the large hemodialysis needle Interposition: 2 wk; the prosthetic material will be the site of needle puncture, but a fibrous scar must develop around the graft so that hematomas will not develop at the puncture sites (Hematomas predispose patients to infection)

What is the most common cause of failure of an AV fistula?

Thrombosis as a result of poor venous outflow (acutely because of technical error, chronically because of neointimal hyperplasia)

What are the treatment options for thrombosis?

Thrombectomy (first-line procedure) Percutaneous balloon angioplasty Thrombolytic (urokinase) therapy Operative revision of fistula (e.g., patch angioplasty, new venous anastomosis)

In a patient who has distal extremity pain, what must be ruled out?

Arterial steal syndrome (ischemia distal to a fistula caused by retrograde flow through the distal artery)


Acutely, pressure is applied to the fistula to restore antegrade flow to the limb; banding or ligation of the fistula or revision of arterial anastomosis is then performed


What are the other complications of AV fistula?

Venous aneurysmal dilation caused by needle puncture Limb edema caused by venous hypertension distal to the fistula Pseudoaneurysm at the anastomosis or needle puncture site Infection Rarely, high-output cardiac failure caused by AV shunting

What are the 1-yr and 5-yr patency rates between autogenous and interposition AV fistulas?

1 yr: Autogenous 65%–80%; interposition: 75%–80% 5 yr: Autogenous 65%–80%; interposition: 40%–50%

OTHER VASCULAR TOPICS Carotid Body Tumor What is it?

Tumor in the carotid body (bifurcation of common carotid artery)

What is the origin?

Afferent ganglion of the glossopharyngeal nerve

What are the gross characteristics?

Well encapsulated and tightly adherent to the adventitial surface of the carotid arteries


Asymptomatic mass at the angle of the jaw

What is the classic finding on physical exam?

Mass that is mobile in the horizontal axis (anteriorly and posteriorly), but fixed in the vertical axis

What is the classic radiographic finding?

Splaying of the bifurcation of the carotid artery; the carotid body rests in the crotch of the bifurcation


Preoperative embolization to reduce blood loss at the time of surgery (very vascular tumors); usually reserved for masses >3 cm Excision of tumor ± carotid reconstruction

What is the incidence of metastasis?

5%

Chapter 71 / Pediatric Surgery 469

Chapter 71 Pediatric Surgery What are the caloric requirements by age for the following patients (kcal/kg/d): Premature infants?

80 kcal,

Children <1 yr old?

100 kcal,

Children 1–7 yr old?

85 kcal,

Children 7–12 yr old?

70 kcal,

Youths 12–18 yr old?

40 kcal,

What is the unique IV fluid route in children <6 yr of age?

Intraosseus Anterior tuberosity


Define the ExtraCorporeal Membrane Oxygenation (ECMO) circuit:

Aortic arch Right atrium

Blood drainage Blood return

Bridge Heat exchanger Servoregulation Membrane lung

Heparin Fluids

Pump


What is the Kasai procedure for biliary atresia?

Roux-en-Y to fibrous cord representing the atretic bile duct Porta hepatis

Hepatic artery Portal vein


FOREIGN BODIES: TRACHEA What age group is affected most often?

2–4 yr of age


1. Cough, wheezing, dyspnea, inspiratory and expiratory stridor, and/or fever 2. Unilateral diminished breath sounds or wheezing

A tracheal foreign body is often confused with what other diagnosis?

Severe asthma


Neck and chest plain x-ray may show a radiopaque foreign body, a hyperinflated lobe or segment, or an atelectatic lobe or segment

What are the indications for intervention?

Highly suggestive signs and symptoms with confirmatory x-rays or a suspicious history in a toddler

What is the usual treatment?

Rigid bronchoscopy with forceps retrieval of foreign body

FOREIGN BODIES: ESOPHAGUS What are the common esophageal levels of lodgment?

Sites of esophageal narrowing: 1. Cricopharyngeal muscle 2. Arch of the aorta (level of carina) 3. Gastroesophageal junction


Drooling, dysphagia, and pain

What is the life-threatening sequela of a long-standing untreated esophageal foreign body?

Mediastinitis after erosion through the esophageal wall


Plain x-ray showing radiopaque objects



1. At the level of the cricopharyngeus and carina: Rigid or flexible esophagoscopy with mechanical retrieval by forceps 2. At the gastroesophageal junction: Observation Most surgeons discourage the use of a Fogarty balloon catheter to retrieve esophageal foreign bodies

What are the risks of treatment?

1. Esophageal perforation 2. Aspiration, which is prevented by placing the patient in the prone position

EVENTRATION OF THE DIAPHRAGM What is it?

Lack of a normal muscular component of the diaphragm; results in an intact yet elevated diaphragm

What are the two types and the etiology of each?

1. Congenital: Embryologic muscular defect 2. Acquired: Usually caused by phrenic nerve injury


Varies from asymptomatic to respiratory distress, especially in infants, elevated diaphragm (usually left)

What diagnostic study is performed?

Fluoroscopy, which shows paradoxic motion of the diaphragm


1. Asymptomatic patient: None 2. Symptomatic patient: Plication and stabilization of the diaphragm in the expiratory position

CONGENITAL PULMONARY CYSTIC DISEASES What are the four types?

1. Cystic Adenomatoid Malformation (CAM) 2. Pulmonary sequestration 3. Bronchogenic cyst 4. Congenital lobar overinflation


Describe each type: CAM?

Cystic and solid masses of immature lung tissue that communicate with the normal airway

Pulmonary sequestration?

Collection of abnormal lung tissue with systemic venous drainage

Bronchogenic cyst?

Extrapulmonary cysts, formed from immature bronchial tissue separated from the lung during early embryonic development, lined with ciliated columnar epithelium, and surrounded by a fibrous wall that contains cartilage

Congenital lobar overinflation?

Normal lung tissue with abnormally formed bronchus that causes air trapping and overinflation


1. Respiratory distress caused by compression of a normal lung in the newborn 2. Recurrent infections in the older child 3. Bronchogenic cysts and extrapulmonary sequestrations are usually asymptomatic

What diagnostic studies are performed?

1. Chest CT scan (study of choice) 2. Ultrasound 3. Esophagoscopy for patients with dysphagia 4. MRI and aortography, which can show systemic vasculature in sequestration


1. Bronchogenic cysts are excised 2. Lobectomy is the treatment of choice for other congenital cystic diseases of the lung; it is well tolerated in infants, the complication rate is lower than that for segmental resections, and the lung parenchyma is still growing in small children, with resultant formation of new alveoli


IMPERFORATE ANUS Why is hyperchloremic acidosis associated with imperforate anus?

Colon absorbs Cl- from urine from a bladder/urethra fistula

CHOLEDOCHAL CYST What are the anatomic variants of choledochal cyst?

Type I—Dilation of the common bile duct Type II—Lateral saccular cystic dilation Type III—Choledochocele represented by an intraduodenal cyst Type IV—Multiple extrahepatic cysts, intrahepatic cysts, or both Type V—Single or multiple intrahepatic cysts

DUODENAL OBSTRUCTION IN THE NEWBORN What are the causes of duodenal obstruction in the newborn?

1. 2. 3. 4.

Duodenal stenosis Duodenal atresia Duodenal web Annular pancreas


What is an annular pancreas?

What are the usual locations?

90% occur distal to ampulla of Vater; 10% occur proximal to ampulla


1. Feeding intolerance and bilious vomiting in the first 24–48 hr of life 2. Distended stomach with an otherwise scaphoid abdomen

Are associated anomalies common?

Yes

What is the most common anomaly?

20%–40% also have trisomy 21 (Down’s syndrome); congenital heart defects are also seen

What is the classic finding on x-ray?

Plain x-rays may show a “double bubble” (air-distended (1) stomach and (2) duodenum)

What additional study may be performed, and why?

Upper GI series, if the diagnosis is in doubt or malrotation is suspected

Why is surgery performed promptly?

Lethal malrotation is often included in the differential diagnosis

What is the usual surgical treatment?

1. Duodenostomy (primary or bypass) 2. Duodenojejunostomy, if distal duodenal obstruction is present

What procedure is usually performed for duodenal webs?

Web resection with longitudinal duodenotomy


ENTERIC DUPLICATIONS What is an enteric duplication?

An “extra” short parallel GI tract tissue forming a mesenteric cyst or cyst within bowel wall

What is the most common site of duplication?

Small bowel


Surgical resection

What percentage of duplications communicate with bowel lumen?

20%

INTESTINAL ATRESIA What is intestinal atresia?

Intestinal obstruction from stenosis or atresia of the jejunum, ileum, or colon; thought to be caused by a vascular accident in utero or by intrauterine volvulus, hernia, intussusception, or malrotation

What are the types?

Type I: Intraluminal diaphragm or web Type II: Fibrous cord connecting two blind ends, with the mesentery intact Type IIIa: Discontinuous bowel with a V-shaped mesenteric defect (most common type) Type IIIb: Apple-peel deformity Type IV: Multiple atretic segments separated by relatively normal bowel


1. 2. 3. 4.

What contrast study is performed to aid diagnosis?

Contrast enema; upper GI is often unnecessary and may complicate surgery

What type of bowel biopsy may be performed during the evaluation?

Suction rectal biopsy

Antenatal polyhydramnios Bilious vomiting Abdominal distension Failure to pass meconium


Why is this biopsy performed?

To rule out Hirschsprung’s disease


Resection of the affected bowel with primary anastomosis

What technical points should be considered for an optimal surgical result?

1. Preservation of bowel length, regardless of the number of anastomoses needed 2. Tapering of the dilated proximal end, to reduce the size discrepancy 3. Preservation of the ileocecal valve

GASTROINTESTINAL HEMANGIOMAS What is the most common complication?

Bleeding (characteristically chronic and intermittent)

What four syndromes are associated with GI hemangiomas?

1. 2. 3. 4.

What radiological studies are usually performed?

1. Barium enema or enteroclysis to show mucosal filling defects or pseudopolyps 2. Selective angiography to show large aberrant vessels, dilated small vessels, rapid venous filling, or vascular tufts


Careful cautery, laser, or ligature ablation of lesions; if multiple lesions are present, conserve bowel length by careful harvesting and segmental resection of clustered lesions

Osler–Weber–Rendu syndrome Klippel–Trénaunay syndrome Turner’s syndrome von Hippel–Lindau syndrome

PEDIATRIC HEPATOBILIARY AND PANCREATIC DISORDERS Hepatic Neoplasms Hemangioma What is the usual location of hemangiomas?

Multicentric origin; therefore, often confused with metastases


What is the claim to fame of hemangiomas?

Most common benign liver tumor (>50%)


Upper abdominal discomfort


Doppler ultrasound, dynamic CT, MRI, angiography, and tagged RBC scan (technetium-99, 99mTc)

What are the associated complications?

1. Intraperitoneal bleeding 2. Chronic or subacute heart failure secondary to AV shunting through tumor vasculature 3. Thrombocytopenia and angiopathic anemia secondary to platelet or RBC trapping in tumor vasculature


1. Can be watched if the tumor is small (<4 cm) and asymptomatic 2. Surgical resection or embolization (interventional radiology) if complications (see above) occur

Hepatic Hamartomas What is a hepatic hamartoma?

Hepatoblastoma Is hepatoblastoma benign or malignant?

Benign tumor secondary to new growth of normal epithelial tissues in the liver

Malignant


1 yr

What laboratory value is frequently elevated?

α-fetoprotein (>90%)

Hepatoblastoma is associated with what: Orthopedic abnormalities, and why?

Multiple pathological fractures caused by abnormal calcium metabolism


Genitourinary abnormalities, and why?


Isosexual precocity, with genital enlargement and pubic hair secondary to human chorionic gonadotropin (hCG) production (10% of males) Surgical resection and chemotherapy (doxorubicin, cisplatin)

Hepatocellular Carcinoma How is hepatocellular carcinoma histologically distinguished from the adult form?

Histologically indistinguishable: Invasive, multicentric, and frequently bile stained (unlike hepatoblastoma)

What are the usual sites of metastatic spread?

Metastases to regional nodes, lung, and bone are common at diagnosis


9–10 yr

What is the usual clinical presentation?

Abdominal pain, anorexia, and weight loss are common; jaundice is seen in 20% of patients

What laboratory values are frequently elevated?

1. α-fetoprotein (in 50%); levels are lower than in hepatoblastoma 2. Liver enzymes and alkaline phosphatase


Same as hepatoblastoma (combination of surgical resection and chemotherapy), but chemotherapy is not as effective

Rhabdomyosarcoma What is it?

Striated muscle sarcoma

Define the stages of rhabdomyosarcoma: Stage I?

Localized, completely excised tumor

Stage II?

Microscopic residual disease


Stage III?

Gross residual disease

Stage IV?

Distant metastases

What is the 3-year survival rate at each stage: Stage I?

≈80%

Stage II?

≈70%

Stage III?

≈50%

Stage IV?

≈25% (55% at 5 yr)

PANCREAS DIVISUM What is pancreas divisum?

Anatomic variant that occurs when the dorsal and ventral duct structures of the pancreas do not fuse during embryological development

What is the main pancreatic duct?

Duct of Wirsung

What duct persists in pancreas divisum?

Duct of Santorini


10% of the population


Endoscopic retrograde cholangiopancreatography (ERCP) Stomach Gallbladder

Pancreatic buds


What is the most common complication?

Repeated bouts of pancreatitis

What is the most common indication for surgery?

Documented recurrent acute pancreatitis

What is the procedure of choice?

Open dorsal duct sphincteroplasty

What procedure is performed in a patient with chronic pancreatitis and a dilated dorsal duct?

Anterior longitudinal pancreaticojejunostomy with a Roux-en-Y loop

PEDIATRIC GENITOURINARY DISORDERS Horseshoe Kidney What is a horseshoe kidney?

Renal fusion anomaly in which the lower poles of two distinct renal masses are joined by renal parenchyma or fibrous tissue (isthmus of kidney)

What is its claim to fame?

Most common renal fusion anomaly


≈1:1,000

What causes most complications?

Collecting system anomalies that result in hydronephrosis, infection, and renal stones

Affected individuals are at increased risk for what tumors?

Hydronephromas, Wilms’ tumor, and collecting system and parenchymal tumors

Infantile Polycystic Kidney Disease What is the claim to fame of infantile polycystic kidney disease?

Although rare, it is the most common genetically determined cystic disease of the kidney in childhood

What is the route of genetic transmission?

Autosomal recessive

What is the finding on physical exam?

Palpable, often visible, massively enlarged hard flank masses at birth


What is included in the differential diagnosis?

1. Hydronephrosis 2. Renal neoplasm 3. Renal vein thrombosis

What diagnostic tests are performed?

1. Excretory urography: Radial streams of contrast material from the medulla to the surface of the cortex, with alternating radiolucent and radiodense areas (sun ray effect) 2. Ultrasound: Hyperechogenic masses and disseminated small cysts

What other organ is also diseased in these patients?

Liver: Proliferation and dilation of the bile ducts, with varying amounts of periportal fibrosis and, occasionally, portal hypertension

What is the prognosis for these patients?

Poor; death usually occurs in the first several months of life

Ureteropelvic Junction (UPJ) Obstruction What is UPJ obstruction?

Fibrosis or interruption of smooth muscle continuity across the UPJ, interrupting the orderly transmission of peristaltic waves

What are the associated complications?

1. Hydronephrosis 2. Urinary tract infection (UTI) 3. If uncorrected, renal failure


1. Ultrasound: Renal pelvic dilation 2. Renal scintigraphy if ultrasound shows persistent hydronephrosis; persistence of the radioactive label in the renal pelvis suggests UPJ obstruction

What additional study is included to rule out vesicoureteral reflux?

Voiding cystourethrogram (VCUG)


Pyeloplasty to enlarge the UPJ


When is antenatal intervention considered?

Only if ultrasound shows significant oligohydramnios, no cystic changes of kidneys, bilateral hydronephrosis, and impending pulmonary hypoplasia

Vesicoureteral Reflux What is vesicoureteral reflux?

Retrograde passage of urine from the bladder into the ureter

What is the sex predilection?

Girls account for 85% of cases


1. UTI 2. Renal failure


For most patients, nonoperative management is successful, which includes suppression antibiotics and close follow-up with urine cultures, cystourethrograms, and measurement of serum creatinine values


1. 2. 3. 4.


Ureteral reimplantation with a long segment of the intravesicular ureter

Recurrent UTI Progressive renal injury Noncompliance Severe reflux

Urethral Valves What are urethral valves?

Exaggerated forms of the normal small fold in the male urethra


UTI, bed wetting, poor urinary stream, urinary frequency, hematuria, and acute urinary retention


VCUG


Endoscopic valve resection; if the infant is too small to permit use of the scope, temporary vesicostomy is performed until the infant is several months old


Exstrophy of the Bladder What is exstrophy of the bladder?

Defect in the ventral abdominal wall coverage of at least part of the bladder, with pubic diastasis

Males have a 10-fold increased risk of what disorder?

Cryptorchidism

What hernia is common with bladder exstrophy?

Inguinal hernia

If untreated, all patients are at increased risk for what disorder?

Bladder carcinoma


Multistage procedure: 1. Primary bladder closure (accompanied by herniorrhaphy and orchiopexy, if indicated), which causes incontinence 2. Epispadias repair during the next years as bladder enlarges; bladder neck reconstruction to achieve continence at age 3–4

Hypospadias What is hypospadias?

Anomaly in which the urethral meatus opens onto the ventral surface of the penis, proximal to the end of the glans


1:300 live male births


Defect in androgen stimulation of the developing penis, precluding complete formation of urethra and surrounding structures

What are the indications for surgical treatment?

All patients are offered surgical treatment for psychological reasons

What is the timing of surgery?

Within the first year of life

What are the primary goals of surgery?

Straightening the penis and placing the meatus at the tip of the glans


Prune Belly Syndrome What is the triad of physical findings?

1. Congenital absence or hypoplasia of abdominal wall musculature 2. Urinary tract abnormalities, with a large hypotonic bladder, dilated ureters, and dilated prostatic urethra 3. Bilateral cryptorchidism

What is another name for this syndrome?

Eagle–Barrett syndrome

MISCELLANEOUS UROLOGIC Define the following terms: Phimosis?

Fibrous attachment of the foreskin to the underlying penile glans; the foreskin will not retract

Paraphimosis?

Inability to place the foreskin over the glans of the penis (foreskin stays retracted) (Think: para = around)

Posthitis?

Foreskin infection

What is the disadvantage of a foreskin?

Associated with: phimosis, paraphimosis, posthitis, hygiene, UTIs, penile cancer (very small, but real, risk)

TESTICULAR TORSION What is it?

Torsion (twist) of the spermatic cord resulting in venous outflow obstruction and subsequent arterial occlusion → infarction of the testicle

What is the classic history?

Acute onset of scrotal pain after vigorous activity or minor trauma

What is a “Bell clapper” deformity?

Bilateral nonattachment of the testicles by the gubernaculum to the scrotum (like the clappers of a bell)



Pain in the scrotum, suprapubic pain

What are the signs?

Very tender, swollen, elevated testicle; nonillumination

What is the differential diagnosis?

Testicular trauma, inguinal hernia, epididymitis, appendage torsion


Surgical exploration, U/S (solid mass) and Doppler flow study, cold Tc-99m scan


Surgical detorsion and bilateral orchiopexy to scrotum

Within how much time from the onset of symptoms must the testicle be detorsed?

Less than 6 hr yields the best results

TERATOMAS What are teratomas?

Germ cell tumors containing elements of all three layers (endoderm, mesoderm, ectoderm); they contain tissue foreign to the anatomic location (formed from tissue that could not have resulted from metaplasia of cells normally found there)

What are the five common components?

1. 2. 3. 4. 5.

Why do they cause symptoms?

Obstruction or compression of viscera

What are the three tumor markers?

1. hCG: Choriocarcinoma 2. α-fetoprotein: Tumors containing yolk sac carcinoma and embryonal carcinoma; teratoma containing immature tissue 3. Lactate dehydrogenase isoenzyme 1: Yolk sac tumors (not specific)

Skin Teeth CNS tissue Respiratory and alimentary mucosa Cartilage and bone


Which type of teratoma: Is most common in neonates?

Sacrococcygeal

Is most common in adolescents?

Ovarian

Presents as a suprapubic mass?

Ovarian

Is extragonadal and is seen only in males?

Gastric

Is the most common extragonadal type?

Sacrococcygeal

What is the characteristic appearance of the sacrococcygeal type?

Protruding from the space between anus and coccyx, and usually covered with normal intact skin

What is included in the differential diagnosis of sacrococcygeal teratoma?

1. Myelomeningocele 2. Pilonidal cyst

What is the treatment of sacrococcygeal teratoma?

1. Surgical excision in continuity with excision of coccyx 2. If malignant, aggressive chemotherapy

What is the usual presentation of gastric teratoma?

Palpable epigastric mass and/or GI bleed

What is the treatment of gastric teratoma?

Surgical excision

What is the prognosis for gastric teratoma?

If excised completely, no additional therapy is required because these tumors are benign

Which teratoma is often called a “dermoid” tumor?

Ovarian

What is the source of pain from this teratoma?

Volvulus of the ovarian pedicle


What must be included in the differential diagnosis?

Pregnancy

What is the treatment of ovarian teratoma?

Surgical excision, leaving functional ovarian tissue only if tumor is clearly benign

MISCELLANEOUS What is a Breslow tape?

Tape used in trauma to estimate body weight of children based on height, IV fluid boluses, etc.

What is the #1 cause of death in children 1–15 yr of age?

Trauma

What is the rule of 3s for barium reduction of intussusception?

3 ft high 3 tries

What is torticollis?

Benign fibrotic mass in the sternocleidomastoid muscle in a newborn, usually due to “birth trauma”

What is the bacteria that causes CAT scratch fever?

Bartonella henselae

What is Pierre Robin syndrome?

Glossoptosis, micrognathia, ± cleft palate; patient is at risk for airway compromise

What is choanal atresia?

Posterior nares obstruction

What is a possible complication of paraumbilical infection in a newborn?

Portal vein thrombosis


Chapter 72 Plastic Surgery What are the facial Langer’s lines?

ABNORMALITIES OF WOUND HEALING What is a hypertrophic scar?

A cicatrix that shows excessive deposition of collagen within the margins of the healing wound; the scar usually diminishes over time

What is a keloid?

A scar with excessive deposition of collagen outside the margin of the healing wound; more common in African Americans than in Caucasians

What is the treatment of hypertrophic scars and keloids?

Excision can be attempted, but often results in recurrence; corticosteroid injections and direct compression, sometimes combined with keloid excision, have had success in some patients

Chapter 72 / Plastic Surgery 491

What is crucial for successful excision?

Reapproximation of skin edges without tension

What is “proud flesh?”

Production of excessive granulation tissue in wound

What is the treatment of “proud flesh?”

Excision, chemical cautery (silver nitrate), and electrocautery are all effective

FLAPS What are the indications for the use of flaps?

1. Poor recipient bed vascularity 2. Full-thickness defects of eyelid, ear, nose, and lip 3. Exposed tendons 4. Tissue bulk needed for function or filling of dead space

What is a random pattern flap?

A flap that bases its blood supply on the dermal and subdermal plexuses; its orientation is random because its blood supply does not rely on a particular anatomically defined vascular bundle

What is an axial or arterial flap?

A flap based on direct cutaneous arteries perforating from an underlying artery

What is a fasciocutaneous flap, and from where does it derive its blood supply?

A flap based on intermuscular septae; its blood supply is derived from vessels which arborize within the septae to form plexuses

What is a muscle flap?

A flap consisting of vascularized muscle; if it includes overlying subcutaneous tissue and skin, it is termed a musculocutaneous flap

What are the advantages of a muscle flap?

The bulk supplied by the muscle and subcutaneous tissue aids in the reconstruction of large defects while offering durability in mechanically active areas


What is a pedicle flap graft?

It is a flap that is kept attached for ≈2 wk; it is cut after capillaries grow into the flap

TISSUE EXPANSION How is tissue expansion accomplished?

Silastic prostheses are implanted beneath the tissue to be expanded; then saline is incrementally infused until tissue expansion is complete

Can expansion damage tissue?

Gradual expansion preserves function and viability of all overlying structures; damage is almost always the result of too rapid an expansion

What are the signs of tissue damage?

Neurapraxia, loss of dermal appendages, necrosis of overlying skin, and ultimately exposure of the implant

What are common complications and their management?

1. Seroma—percutaneous aspiration; use of suction drainage usually avoids seroma formation 2. Hematoma—percutaneous drainage (rarely successful) followed by exploration for continued hemorrhage; prevention through adequate hemostasis is crucial


3. Infections—early infections mandating removal and replacement in 4–6 mo; late infections combined with or resulting from extrusion can be managed with low-volume frequent expansions until expansion is complete Why can an infected expander often be left in tissue?

Expanded tissue, including the implant capsule, has an extensive blood supply, giving it antimicrobial capabilities

MAXILLOFACIAL TRAUMA Emergencies What are the three most commonly encountered emergencies of maxillofacial injuries?

1. Airway obstruction 2. Life-threatening hemorrhage 3. Aspiration

What are some mechanisms of airway obstruction in maxillofacial trauma?

Soft tissue swelling, fractured teeth or denture fragments, blood, or gross anatomical disruption can all obstruct airflow


Endotracheal intubation; in some cases, emergency cricothyroidotomy

Which maxillofacial injuries are commonly associated with serious hemorrhage?

Deep facial lacerations and closed maxillofacial injuries with associated fractures

What is the preferred treatment of hemorrhage in facial lacerations?

Direct pressure and circumferential pressure bandage

What is the danger in blind clamping of vessels through a facial laceration?

Damage to the facial nerve

What is the most common source of bleeding in closed maxillofacial injuries?

Arteries and veins adjacent to the walls of fractured sinuses


What are the four main methods of controlling hemorrhage from these injuries?

1. 2. 3. 4.

Anterior–posterior (AP) nasal packing External compression dressing Selective arterial ligation Maxillary fracture reduction

How is nasal packing frequently accomplished?

Two 30- to 50-mL Foley balloon catheters are inserted through the nares, inflated in the posterior pharynx, and pulled to occlude the posterior choanae; antibioticsoaked Vaseline gauze is then packed anteriorly through the nostrils

Which arteries can be safely ligated to control life-threatening facial hemorrhage?

1. Internal maxillary artery 2. External carotid artery 3. Superficial temporal artery

Soft Tissue Wounds What is the optimal time for facial wound closure?

Due to the excellent blood supply, closure can be performed up to 24 hr after the wound occurs

What are the standard methods of wound cleansing?

Pressure irrigation, scrubbing or mechanical removal of debris, and sharp débridement

What are the long-term sequelae of retained debris?

Nidus for infection and “tattooing” of skin (foreign material can be incorporated into the forming scar); later revision is usually unsatisfactory

What are the common guidelines for extent of débridement?

Conservative resection (1–2 mm) is the rule; “devitalized” tissue often survives in the facial region

Are there any exceptions to débridement?

Resection should be avoided in the area of the vermilion, oral commissures, eyelid margin, nostrils, and distal nose

What are the indications for prophylactic antibiotics?

1. Lacerations of oral cavity, including compound fractures 2. Fractures involving teeth 3. Sinus fractures 4. Animal bites


What is the postoperative wound care?

Suture lines are cleansed with 1:1 peroxide/saline on cotton-tip applicators, followed by bacitracin (facial) or bacitracin ophthalmic ointment tid (periorbital)

What is the postoperative care for intraoral wounds?

Irrigation every 4 hr with bactericidal mouthwash or 1:1 peroxide/saline

Is early scar revision commonly indicated?

No, despite the appearance of initial scarring, revision is indicated only for functional problems (e.g., ectropion or obvious malalignment); maturation with cosmetic improvement occurs for up to 1–2 yr

Facial Nerve What are the six terminal branches of the facial nerve and what muscles do they innervate?

1. Frontal–temporal—muscles of forehead and superficial temporal region, including orbicularis oculi and frontalis and excluding temporalis (trigeminal) 2. Zygomatic—muscles of lower orbit, midface, including orbicularis oculi, but excluding masseter (trigeminal) 3. Buccal—muscles of cheek and mouth, including orbicularis oris 4. Mandibular—muscles of lower lip and chin, including orbicularis oris 5. Cervical—platysma, distal anastomosis to mandibular branch 6. Posterior auricular—occipitalis, auricularis posterior

Which facial nerve lacerations require repair?

Proximal to a line drawn from the lateral canthus to the nasolabial sulcus, all lacerations of facial nerve branches should be repaired, under magnification, with fine sutures; distal to the line, the branches are too small; the cervical branch requires no repair


What components of the facial nerve contribute to lacrimation, salivary secretion, and taste?

1. The chorda tympani passes through the petrotympanic fissure, supplies taste to the anterior two-thirds of the tongue, and innervates the submandibular and sublingual glands 2. The greater petrosal nerve passes through the pterygopalatine fossa to innervate the lacrimal glands

If facial paralysis is accompanied by loss of taste, lacrimation, or salivary secretion, how does this combination add to the diagnostic impression?

Because only the branchial motor branches and a sensory nerve to the posterior auricle exit the stylomastoid foramen, this would imply a more proximal lesion of the facial nerve

Trigeminal Nerve Is the trigeminal ganglion intracranial or extracranial?

Intracranial

Where do the three branches of the trigeminal nerve exit the skull?

The superior orbital fissure (V1), the foramen rotundum (V2), and the foramen ovale (V3)

What muscles does the trigeminal nerve innervate?

Muscles of mastication (temporalis, masseter, and pterygoids), tensor tympani, tensor veli palatini, mylohyoid, and the anterior belly of the digastrics

What is the distribution of sensory innervation among the three branches?

Distribution corresponds to the three embryologic divisions of the face: V1 – frontonasal process: forehead, nasal dorsum, innervation of frontal anterior dura V2 – maxillary processes: cheek, palate, and maxillary half of oral cavity V3 – mandibular process: lower one-third of face, mandibular half of oral cavity, tongue

Are lacerations of the trigeminal nerve routinely repaired?

Yes, because the motor function of the trigeminal is essential, repair of motor branches is usually undertaken


Is sensory nerve repair necessary for protective sensation?

The majority of sensory innervation in the face has a high degree of overlap and does not mandate sensory nerve repair

Parotid Gland Which duct drains the parotid gland?

Stensen’s duct

Where is the duct located?

Extends anteriorly from a point just anterior to the masseter and a finger’s breadth below the zygomatic arch to the region of the second maxillary bicuspid

Is it imperative to repair lacerations of the parotid gland?

No, salivary drainage from parotid trauma stops spontaneously unless Stensen’s duct is involved

How is the duct repaired?

Ductal lacerations are repaired with fine sutures under magnification over a stent

What injury is commonly associated with ductal laceration?

Lacerations and blunt trauma to the buccal branch of the facial nerve, whose course parallels that of the duct

Facial Fractures What are the common signs and symptoms of facial fractures?

Contusions, bruises, or lacerations; pain or localized tenderness; anesthesia or paresthesia; paralysis; malocclusion; visual disturbances; facial deformity, often palpable, or asymmetry; crepitus

Which radiographic evaluation should be performed?

CT scans with coronal reconstructions are the definitive diagnostic modality for facial trauma; however, plain film evaluation may be indicated or sufficient in certain cases.

What are the structures viewed on the following films: Waters’?

Frontal, supraorbital, orbital, zygomaticomaxillary, and nasal areas


Towne’s?

Condylar and subcondylar region of mandible and floor of orbit

Lateral and AP skull?

Sinuses, frontobasilar, and nasoethmoidal areas

AP and lateral oblique mandible?

Body, symphysis, condylar, and coronoid mandible areas

Panorex?

Entire mandible and lower maxilla

Which additional study should be obtained before the reconstruction of fractures involving the occlusion?

Maxillary and mandibular dental impressions

What are the specific signs of a nasal fracture?

Lateral nasal deviation, retrusion, or flattening; dislocation of septum; difficulty breathing; nasal or periorbital hematomas; lacerations over the bridge; bleeding

What treatment is indicated for an isolated nasal fracture?

Closed reduction and manipulation

What are the five anatomic attachments of the zygoma?

1. 2. 3. 4. 5.

What are the 10 common signs of zygoma fractures?

Periorbital and subconjunctival hematoma; depression of lateral canthus; recession of malar prominence; step-off or tenderness of inferior orbital rim, anterior maxillary wall; unilateral epistaxis (through maxillary antrum); orbital entrapment inferiorly; infraorbital nerve numbness; globe dystopia or enophthalmos; intraoral hematoma of superior buccal sulcus; difficulty chewing due to impingement of the arch on the coronoid process

What is a nasoethmoidal orbital (NOE) fracture?

A fracture that includes the nose and medial orbital rim

Posterior—temporal bone Anterior/superior—frontal bone Medial—sphenoid bone Anterior—maxillary bone Anterior/inferior—maxillary alveolus


What percentage of NOE fractures are bilateral?

66%

What are the common signs of an NOE fracture?

Depressed nasal dorsum; tenderness over medial canthal ligament; telecanthus (increased distance between eyes); eyelid “spectacle” hematomas; epistaxis; nasal laceration; mobility of medial orbital rim with direct pressure or intranasal traction

What is the Furnas traction test, and what is its purpose?

The test is accomplished by palpating the medial canthal region while applying lateral traction on the eyelid; if the medial canthal ligament is intact, it should be palpable during this maneuver as a “bowstring”

What are the signs of a frontal sinus fracture?

Soft tissue trauma to forehead; epistaxis; depression of frontal bone

Which frontal sinus fractures require surgery?

Only displaced fractures require open reduction and fixation (wire and/or plates)

What is the treatment for comminuted frontal sinus fractures in which depressed fragments cannot easily be reduced and fixed?

Sinus obliteration or cranialization

What determines whether frontal sinus obliteration or cranialization is performed?

An intact posterior wall mandates sinus obliteration, whereas a severely disrupted wall dictates cranialization

What is a common complication of frontal sinus fractures?

Mucocele (due to incomplete removal of sinus mucosa)

What are the common signs of supraorbital fractures?

Soft tissue trauma; depression or irregularity of superior orbital rim; numbness in supraorbital nerve distribution; eyelid ptosis; downward and outward protrusion of globe; superior orbital fissure or orbital apex syndrome


What are the common signs of an orbital floor fracture?

Periorbital and subconjunctival hematoma; anesthesia of infraorbital nerve; diplopia on upward or downward gaze (entrapment of inferior rectus and/ or inferior oblique); enophthalmos; globe dystopia; orbital emphysema; ipsilateral epistaxis from maxillary sinus; positive forced duction

What is a forced duction exam, and what does it demonstrate?

Forced duction is performed by applying topical anesthetic to the globe, grasping the inferior conjunctiva, and testing whether upward movement of the globe is possible; if movement is restricted, it is likely due to entrapment of the inferior rectus within an orbital floor fracture

Cerebrospinal Fluid Rhinorrhea What fractures are commonly associated with CSF rhinorrhea?

50%–75% of frontal basilar and NOE fractures; 25% of Le Fort II and III fractures

What is the bedside test for CSF rhinorrhea?

If bloody nasal drainage representing CSF is blotted onto a white paper towel, a clear ring extends out from a central spot of blood (double ring sign)

What is the management of CSF rhinorrhea?

Fistulas associated with displaced fractures usually undergo direct repair; those not associated with displaced fractures often resolve over a 2-wk period

Is antibiotic prophylaxis warranted?

Yes

What routine measures should be avoided in the setting of a CSF fistula?

Nasal packing and nasogastric tubes, which block nasal drainage and encourage bacterial growth


Mandible Fracture Identify the labeled regions of the mandible:

1. 2. 3. 4. 5. 6. 7. 8.

Alveolar process Symphysis Body Angle Ramus Coronoid process Mandibular notch Condylar process

What is the anatomic distribution of fractures of the mandible?

A third in the condylar–subcondylar area, a third at the angle, a third in the body– symphysis

What percentage of mandible fractures are bilateral?

>50%

Do mandible fractures more commonly compound externally or intraorally?

Most compound intraorally; thus, a thorough exam of the oral cavity is essential

What are the common signs of a mandible fracture?

Intraoral or external soft tissue trauma; occlusal abnormality; numbness in distribution of mental nerve; bleeding from a tooth socket; fractured or missing teeth; trismus; open bite, abnormality of arch, or intercuspation of teeth; bleeding from the ear (laceration of anterior wall of ear canal from condylar fracture); intraoral odor

RECONSTRUCTIVE PRINCIPLES What are the indications for exploration of orbital floor or medial wall fractures?

Diplopia of primary or downward gaze persistent for 2 wk; enophthalmos >3 mm; other upper facial fractures requiring surgery


What is the primary goal of orbital wall reconstruction?

Restoration of globe support and reestablishment of normal proportions of bony volume to orbital content; this combination almost always requires an implant of the orbital floor, using alloplastic or autogenous materials

Which complicating factors make nasoethmoidal fractures particularly challenging?

1. Fragility of the bones makes comminution and bone loss common 2. Associated injuries to the lacrimal system, medial canthal tendon, and cranial cavity

What is the basic approach to reconstruction of the NOE fracture?

Interosseous plating or wiring with bone grafting as needed; telecanthus is corrected by transnasal canthopexy

Do nondisplaced fractures of the zygomatic arch or zygoma require treatment?

No, unless subsequent displacement is noted

What is the basic approach to displaced zygoma fractures?

Depressed arch fractures require elevation alone; the remainder require reduction and fixation to the maxillary and frontal articulations

What is intermaxillary fixation (IMF)?

Two arch bars are conformed to fit the maxillary and mandibular teeth and then fastened with circumdental wires; the arch bars are then wired to each other to restore the proper occlusal relationship

If used alone, how long is IMF left in place?

6–8 wk

What is the general goal of maxillary fracture treatment?

Restoration of the articulations with the three maxillary buttresses (zygomatic, nasofrontal, and pterygomaxillary), to reestablish the normal occlusal relation

How is this accomplished?

Using IMF, reestablish the occlusion; plate and screw fixation of fracture fragments, with and without bone grafting, restores the maxillary buttresses


What is the general goal for mandibular fracture treatment?

Restoration of normal occlusion

How is this accomplished?

With IMF; however, because the incidence of multiple mandible fractures is high and the muscles of mastication exert considerable force on fracture fragments, open reduction and fixation with heavy plates and screws may be needed to achieve stability of the arch

Which mandibular fractures are rarely treated with open reduction–fixation, and how are they managed?

1. Ramus and coronoid fractures (rarely displaced due to muscle protection)— brief IMF or soft diet is the rule 2. Condylar fractures—if isolated, IMF for 3 wk only, followed by physiotherapy to restore temporomandibular joint (TMJ) function 3. Alveolar fractures—often treated with a single arch bar, with IMF added if unstable

MISCELLANEOUS What are the types of cleft palates?

Subtotal

Prolabium Premaxilla

Total


Chapter 73 Hand Surgery HAND SURGERY Anatomy How does the skin of the hand differ on dorsal and ventral sides, and what are the functional implications?

Palmar skin is thick, tethered, irregularly surfaced, and moist; subcutaneous fat beneath provides padding, stability, and friction, for a strong grip Dorsal skin is thin and mobile, with little fat; provides freedom for motion of the various joints

What is the function of the tendon synovial sheaths?

The sheaths (consisting of tenosynovium) act as a mesentery, providing nutrient blood flow and lubrication for gliding of the tendons

What is the normal hand cascade?

The normal hand at rest is in flexion (the cascade); however, if the flexor tendon is lacerated, the cascade is lost

A Laceration

B

Chapter 73 / Hand Surgery 505

Extrinsic Flexors of the Hand What are the extrinsic flexors of the hand?

Where do the extrinsic flexors have their insertions: FPL and FDP?

Digital—flexor pollicis longus (FPL) Flexor digitorum profundus (FDP) Flexor digitorum superficialis (FDS) Wrist—palmaris longus (PL) Flexor carpi radialis (FCR) Flexor carpi ulnaris (FCU)

Volar base of distal phalanx

FDS?

Volar middle phalanx

FCU?

Pisiform and hamate bones

FCR?

Volar base of second and third metacarpal

PL?

Superficial palmar fascia

How is each extrinsic flexor tested: FPL?

Flexion of thumb IP joint with metacarpophalangeal (MCP) joint extended

FDP?

Flexion of distal IP joint with proximal interphalangeal (PIP) joint held in extension

FDS?

Flexion of PIP with other fingers held in extension

FDP?

Ulnar 3 FDP tendons share muscle belly and must be eliminated through extension of other digits during FDS testing

FCU, FCR, PL?

Wrist flexed while tendons palpated


Where are the tendon sheaths of the flexors located?

The proximal sheaths start 1 finger breadth proximal to the flexor retinaculum and reach to the proximal transverse palmar crease; the separate sheaths unite during development to form a common sheath, except for the sheath of the thumb; distal sheaths begin at the palmar (volar) plate of the MCPs and extend to the distal insertion of the flexor tendons; for the thumb and small fingers, the distal and proximal sheaths are continuous

Does the sheath of the thumb communicate with the other flexor sheaths?

Yes, in 50% of individuals

What are the structure and function of the fibro-osseous tunnels of the flexor tendons?

In each digit, the tunnel is a fibrous sheath that runs from the metacarpal head to the insertion of the tendon on the distal phalanx; thickenings, known as pulleys, guide the tendon during excursion; there are five annular (A–A5) and three cruciate (C–C3) pulleys

Which pulleys are considered the most functionally important?

The A2 and A4 pulleys, over the proximal and middle phalanges, respectively

Extrinsic Extensors of the Hand How many dorsal compartments and extensors are present in the hand? What are the extrinsic extensors of the hand (compartment: extensors [radial to ulnar]): First?

Six dorsal compartments, which contain the nine separate extensors

Abductor pollicis longus (APL), extensor pollicis brevis (EPB)

Second?

Extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB)

Third?

Extensor pollicis longus (EPL)


Fourth?

Extensor digitorum communis (EDC), extensor indicis proprius (EIP)

Fifth?

Extensor digiti minimi (EDM)

Sixth?

Extensor carpi ulnaris (ECU)

What are the insertions of the extensors: APL?

Base of thumb metacarpal

EPB?

Base of proximal phalanx

ECRL?

Base of index metacarpal

ECRB?

Base of middle metacarpal

EPL?

Base of distal phalanx thumb

EDC?

Base of both middle and distal phalanges

EIP?

Dorsal expansion of index finger, which inserts as above

EDM?

Dorsal expansion of small finger, which inserts as above

ECU?

Base of small finger metacarpal

How is each of these muscles tested: APL or EPB?

Abduct or extend, respectively, the thumb while palpating radial side of anatomic snuff-box

ECRL and ECRB?

Extend closed fist and palpate the two adjacent tendons

EPL?

Extend thumb while palpating ulnar side of snuff-box; lift thumb off table with hand flat on palm


EDC?

Straighten fingers, watch for MCP extension

EIP?

Extend index finger only, with hand closed in a fist

EDM?

Extend small finger only, with hand closed in a fist

ECU?

Extend and ulnar-deviate wrist with closed fist; palpate tendon just distal to ulnar head

Where are the synovial sheaths of the extensors?

They extend proximally 1 finger breadth from underneath the extensor retinaculum and distally 1 finger breadth onto the dorsum of the hand; there are six, one corresponding to each of the six compartments

What is extrinsic extensor tightness?

If extensors limit the range of passive flexion of MCP and PIP joints combined, extrinsic tightness exists

How is extrinsic extensor tightness tested?

By passively flexing the PIP joints with MCP joints, first in extension and then in flexion; if flexion of PIP joints is decreased by MCP flexion, tightness has been demonstrated

What are the intrinsic muscles of the hand?

The muscles of the thenar and hypothenar eminences, the lumbricals

What are thenar muscles and their functions?

Abductor pollicis brevis—abducts the thumb with APL Flexor pollicis brevis—flexes thumb MCP Opponens pollicis—pulls thumb medially and forward across palm

How is thenar function evaluated?

Thumb and small fingertips are brought together with nails parallel (apposition); the thumb is raised 90° above the plain of the palm (abduction); the thenar eminence is observed for contraction and symmetry with the opposite side


What is the function of the adductor pollicis, and how is it tested?

Thumb adduction; test by holding a piece of paper between the thumb and radial index proximal phalanx—if weak, the interphalangeal (IP) of the thumb flexes, known as “Froment’s sign”

What is the function of the lumbricals?

Flexion of MCPs and extension of IPs

How are the lumbricals tested?

By simultaneously accomplishing both MCP flexion and IP extension

What are the functions of the interossei (dorsal and palmar)?

Palmar interossei (PIO) adduct digits; dorsal interossei (DIO) abduct digits

How are the interossei tested?

The most stringent test is to place the palm flat on the table, hyperextend the digits, and then abduct and adduct them; the first DIO can be palpated during the abduction of the index finger

What are the muscles of the hypothenar eminence?

Abductor digiti minimi, flexor digiti minimi, and opponens digiti minimi (like the thenar eminence)

How are the hypothenar muscles tested?

To test abduction, abduct the small finger while observing for dimpling of the eminence; opposition can be tested as described above for the thenar eminence

What is intrinsic muscle tightness?

Limited PIP passive flexion during MCP flexion, which puts tension on the intrinsics; it is relieved by MCP extension, which relaxes the intrinsics

NERVES OF THE UPPER EXTREMITY What are the three primary nerves innervating the upper extremity?

Median, ulnar, and radial nerves


What is the anatomic course of the median nerve in the forearm?

The median nerve enters the forearm through the pronator teres and gives off the anterior interosseous branch in the proximal forearm; it then runs between the FDP and sublimis, entering the radial side of the carpal tunnel at the wrist

What is the anatomic course of the ulnar nerve in the forearm?

The ulnar nerve runs behind the medial epicondyle of the humerus, between the two heads of FCU, and lies between the FDP and FCU; it branches from the dorsal cutaneous branch in the distal forearm and then enters Guyon’s canal at the wrist ulnar to the ulnar artery

What is the anatomic course of the radial nerve in the forearm?

The radial nerve enters the cubital fossa between the brachialis medially and the brachioradialis and the ECRL laterally, and divides into superficial and deep branches at the lateral epicondyle of the humerus; the deep branch runs between superficial and deep layers of the supinator, entering the posterior compartment of the forearm; the superficial branch runs under the brachioradialis and above the supinator and pronator teres muscles, eventually coursing dorsally at the wrist

What muscles are innervated by the median nerve in the forearm?

Pronator teres, FCR, PL, FDS, FDP (radial), FPL, and pronator quadratus

What muscles are innervated by the ulnar nerve in the forearm?

FCU, FDP (ulnar)

What muscles are innervated by the radial nerve in the forearm?

ECRB, supinator, EDC, EDM, ECU, APL, EPL, EPB, EIP, anconeus*, brachioradialis*, ECRL*, and triceps* (*innervated above the elbow)


How is sensory testing of the fingers best accomplished?

Tactile gnosia (tested by two-point discrimination) is the best indicator of nerve function; two prongs (e.g., a paper clip) are pressed against the skin while the patient identifies the sensation as a single or double point; this test is done with the probes both stationary and moving, and the minimal distance at which two points can be distinguished is determined; abnormal is defined as >6 mm static or >3 mm moving required for detection of two points

What is the best substitute in the uncooperative or unresponsive patient, or the child?

The immersion test (place the hand in water for 5–10 min, and then observe for wrinkling of the glabrous skin); denervation of the skin prevents wrinkling

What is the course of the median nerve in the hand, and what are the structures that it innervates?

The median nerve exits the carpal tunnel, branching into the thenar motor branch, common digital nerves (to the thumb, index finger, middle finger, and radial half of ring finger), the first and second lumbricals, and the sensory branches to the radial palm

What is the course of the ulnar nerve in the hand, and what are the structures that it innervates?

The ulnar nerve exits Guyon’s canal and divides into deep and superficial branches; the deep branch supplies the hypothenar muscles, the interossei, the third and fourth lumbricals, adductor pollicis, and deep flexor pollicis brevis; the superficial branch supplies the palmaris brevis, the common digital nerves (to small and ulnar half of ring finger), and sensation to the ulnar palm

What is the course of the radial nerve in the hand, and what are the structures that it innervates?

After traveling beneath the brachioradialis tendon, the superficial branch of the radial nerve provides sensation to the radial half of the dorsum of the hand, to the entire dorsum of the thumb, and to the index and radial half of the middle finger dorsum proximal to the PIP joints


HAND EMERGENCIES Traumatic Amputations What is the general cause of life-threatening hemorrhage in the forearm and hand?

Usually a partially transected artery (completely transected arteries can retract into the surrounding tissue and initiate vasospasm effectively, thus reducing the risk of life-threatening hemorrhage)


1. Direct pressure and elevation usually stop severe bleeding 2. A tourniquet 100–150 mm Hg above systolic blood pressure can be applied as a temporizing measure for 30 min at a time, with 5-min rests in between to assess for control of bleeding and for patient comfort

What are the indications for replantation of an amputated digit?

1. Thumb amputations (especially if proximal to IP joint) 2. All amputations in children 3. Clean amputations (sharp division) at the hand, wrist, or distal forearm

Is replantation commonly limited by technical considerations?

No; although restoration of blood supply is not always possible in a severely injured amputated part, more often reattachment and viability are possible (Note: If the reattached part will offer no significant functional advantage over amputation, replantation should be avoided)

What are the relative contraindications to replantation?

1. Severe crush or avulsion 2. Amputation between MCP and PIP joints of a single digit 3. Heavily contaminated wound

What are the absolute contraindications to replantation?

1. Severe medical problems or associated injuries increasing the risk of surgery 2. Multilevel injury to the amputated part 3. Inability to stop smoking for 3 mo post replant 4. Psychiatric illness which precipitated self-amputation


What is the preoperative preparation in a patient with an amputated digit?

Débridement of stump with irrigation and dressing with nonadherent gauze, tetanus prophylaxis, IV antibiotics, and IV hydration

What is the preparation of the amputated part?

Débridement with irrigation, wrapping in gauze moistened with lactated Ringer’s solution (LRS) or normal saline, and placement of wrapped part in sealed container immersed in an ice bath

How is an incompletely amputated part prepared?

The treatment is identical, with the additional step of detorquing intact vessels to restore blood supply; the attached part is cooled in insulated ice packs instead of in an ice bath

What is the initial treatment of mangled parts that are unlikely to regain function, but maintain an adequate blood supply? and why?

Mangled parts (e.g., a severely injured finger) are often left intact because they are an excellent source for autologous grafting of skin, bone, articular surface, nerve, artery, and tendon

Compartment Syndrome What is the mechanism of compartment syndrome?

Accumulation of fluid (either blood or exudate) in a fascial compartment builds pressure that obstructs venous outflow; as arterial inflow continues, the pressure increases until arterial inflow is decreased, causing ischemia and further progression of the fluid accumulation as tissue injury worsens

What compartments can be affected in the forearm and hand?

Volar or dorsal compartments in the forearm; intrinsic muscle compartments in the hand

What are the cardinal signs of a compartment syndrome?

1. Gross appearance—swollen, tense, tender hand or forearm 2. Muscles—tender and increased pain on passive extension 3. Nerves—pain (early), followed by paresthesias (later), followed by anesthesia (late) 4. Pulselessness (late!)


How can compartment syndrome be distinguished from simple swelling?

Compartment pressures can be measured; >30 mm Hg is considered a true compartment syndrome; however, because pressures can evolve rapidly, a high clinical suspicion should lead to repeat measurements or prophylactic fasciotomies even with “normal” pressures

Herpetic Whitlow What is a herpetic whitlow?

A herpes simplex vesicle or ulcer on the finger (often seen in dental or medical personnel who do not use adequate sanitary precautions)

What tests may be used for diagnosis?

Tzanck smear of lesional fluid, scrapings for giant cells, fluorescent antibody testing of lesion fluid, or culture of the lesion for virus


Topical acyclovir ointment applied every 3 hr for 48 hr, with 5 days of oral acyclovir to start simultaneously; incision and débridement should be avoided; antibacterial antibiotics are indicated only in cases of suspected bacterial superinfection

COMPLEX INFECTIONS OF THE HAND Suppurative Tenosynovitis What is suppurative tenosynovitis?

A bacterial infection of the tendon sheath, usually following penetrating trauma

Is it more common in extensor or flexor tendon sheaths?

Flexor

What are Kanavel’s four signs of flexor tenosynovitis?

1. Flexed posture of affected digit 2. Tenderness along the sheath with erythema 3. Pain on passive extension of DIP joint 4. Fusiform swelling (sausage-like finger)


Which sign is the strongest indicator of tenosynovitis?

Pain on passive extension of the DIP joint

What is a horseshoe infection?

Suppurative tenosynovitis that has spread in a horseshoe pattern from either ring or small finger through palm to affect the other digit; may develop because the small finger and thumb tendon sheaths both extend from the palm and often communicate

What is the immediate treatment of suppurative flexor tenosynovitis?

Incisions are made over the proximal sheath and at the level of the middle phalanx; a no. 5 French catheter is inserted between the A4 and A5 pulleys, and the sheath is irrigated with a bacitracin solution

What additional treatment accompanies operative drainage?

IV antibiotics, splinting in the intrinsic plus position with elevation, and irrigation of the sheath every 4–6 hr with bacitracin solution through an indwelling catheter until the infection resolves

Deep-Space Infections What are the two areas for deep-space infections of the hand?

1. Midpalmar (between the flexor tendons and metacarpals of the ulnar 3 digits) 2. Thenar (between the flexor tendon of the index finger and the adductor pollicis)


1. Incision and débridement with drain placement; the midpalmar space is drained with a palmar incision between the third and fourth rays, the thenar space through a dorsal incision of the thumb web space 2. IV antibiotics

What are the common sources of septic arthritis?

1. Direct inoculation from penetrating trauma 2. Hematogenous spread


What are the common pathogens for penetrating trauma?

For trauma, especially of the MCP joint, the infection is often the product of human tooth penetration and inoculation; Staphylococcus aureus is the most common, but mixed gram-positive and gram-negative cultures are frequent

Which organism is classically associated with human bites?

Eikenella corrodens, a gram-negative bacillus

What are the common pathogens for hematogenous spread?

Although any pathogen can cause septic arthritis in this manner, Neisseria gonorrhoeae must always be considered

What is the treatment of septic arthritis?

Incision and débridement with drain placement; antibiotic coverage includes a penicillin with activity against S. aureus and an aminoglycoside

How is mycobacterial infection usually contracted?

From a puncture wound in the setting of soil or water

What is the usual presentation of mycobacterial arthritis?

Synovitis of a tendon sheath or joint develops approximately 6 wk post trauma

How is mycobacterial arthritis diagnosed and treated?

Culture or the finding of multinucleated giant cells confirms the diagnosis Long-term antibiotic therapy is required

TENDON LACERATIONS Which flexor tendon injuries can be treated in the emergency department 4 (ED) setting?

None! Although careful inspection is acceptable in the emergency room, virtually all flexor tendon injuries require operative exploration, therapy, or both.

Which extensor tendon injuries can be treated in the ED?

Any laceration in which both ends can be easily visualized for repair; multiple tendon injuries or those with difficult exposure (i.e., more proximal) should be attempted only in the OR


What are the zones used to describe flexor tendon lacerations?

Zone I—midfinger pad to distal half of middle phalanx Zone II—proximal half of middle phalanx to MCP joint, inclusive of the MCP Zone III—distal palmar crease to midpalm Zone IV—midpalm to wrist crease, carpus included Zone V—wrist crease and proximal

Which zone is also called “no man’s land”?

Zone II

What is the usual mechanism of a Zone I flexor injury?

Avulsion of the tendon insertion during grasping

Why is flexion often intact in a Zone I flexor injury?

The vinculum, a mesentery for the tendon, often stays connected to the distal phalanx

Why are functional results of flexor tendon repair notoriously poor in Zone II?

Zone II requires smooth gliding of the FDS and FDP tendons in the narrow confines of the fibro-osseous tunnel of the tendon sheath; repair without significant adhesion formation is difficult and often requires revision

Injury to which structures often accompanies Zone III flexor injuries?

The superficial transverse vascular arch, the median nerve at its division into terminal branches, and the thenar motor branch of the median nerve


Why is operative exploration mandatory for Zone IV flexor injuries?

Exposure is technically demanding because it is located in the carpal tunnel

Why are Zone V flexor lacerations, which are easily repaired, usually devastating injuries?

Tendon healing (which is generally good) often is overshadowed by a severe accompanying nerve injury (which generally recovers only partially)

What are the initial steps taken before operative repair of flexor tendons?

Débridement, loose closure, splinting in the intrinsic plus position except with the wrist in slight flexion

How long can surgical repair be delayed?

Although some controversy exists on the exact timing, repair within 6 days generally prevents significant contraction

What is the usual method of tendon reapproximation?

A modified Kessler suture is widely used because of its good tensile strength, placement of the knot within the repair, and relatively small amount of ischemia induced

What are the three major complications of partial tendon lacerations?

1. Delayed rupture 2. Trigger phenomenon 3. Decreased range of motion

Which partial tendon lacerations should be repaired?

Any laceration >50% of the diameter or near the proximal pulley should be repaired (Note: Controversy exists over indications for repair, because rates of rupture may be higher in repaired tendons and tensile strength may be decreased)

How is the tendon repaired?

Approximation of the epitenon with fine sutures

What are the zones used to describe extensor tendon lacerations?

Zones I and II—distal phalanx, DIP joint Zones III and IV—central slip or lateral slips of the long extensor tendon, fibers of the intrinsic expansion, and the oblique and transverse fibers of the extensor aponeurosis


Zone V—MCP region Zone VI—digits proximal to MCP and area of extensor retinaculum What is the usual mechanism for Zones I and II extensor injuries?

A blow to the extended digit, forcing flexion of the DIP joint and avulsion of the tendon with or without a fragment of bone

What is the resultant deformity?

Mallet finger (DIP joint flexion); eventually the PIP joint becomes hyperextended through a proximal shift in the action of the extensors after distal rupture, and a swan-neck deformity results

What is the most common resultant deformity of a Zone III or IV injury?

Boutonnière deformity (PIP joint flexion, DIP joint hyperextension)

What is the general treatment of extensor tendon injuries?

Open lacerations—direct repair of the tendon with subsequent splinting for 6–8 wk (K-wire for fixation of joint(s); closed rupture—splinting in neutral or hyperextension for 6–8 wk (±K-wire fixation)

How are lacerations to the extensor aponeurosis treated?

Splinting as previously described, with or without suture closure of the defect

NERVE INJURIES What happens to peripheral nerves proximal to the site of injury?

Retrograde degeneration of axons (1–2 cm) with Schwann cell proliferation; degenerative changes of the neuronal cell body (may reverse in 40–120 days); axonal sprouting within 1 wk that grows centrifugally from the site of transection

What happens to peripheral nerves DISTAL to the site of injury?

Wallerian degeneration (axonal disintegration progressive to the entire length of the distal segment); removal of debris by macrophages; Schwann cell proliferation within the neural tube and outside of the distal stump


Which types of nerve injuries mechanistically have the best prognosis?

From best to worst: laceration, crush, stretch (corresponds to size of the zone of injury)

What other factors worsen prognosis?

More proximal injuries (due to increased length of wallerian degeneration) and older age of patient

What is the initial treatment of nerve injuries?

Thorough débridement and closure (if possible) to best preserve integrity of divided nerve stumps

What is the best timing of repair for nerve lacerations?

Either primary repair or delayed primary repair, in 7–10 days

What is the indication for delayed repair, and how long can the patient wait without significant worsening of functional recovery?

Cases where nerve function may return (i.e., closed injury such as a crush or stretch injury); delays of 5–6 mo are possible

What are the principles of nerve repair?

Tensionless reapproximation with minimal suturing; the least undermining possible; accurate fascicular alignment

What is the indication for nerve grafting?

When tensionless reapproximation is not possible

What nerves are usually used for grafting?

Sural and superficial radial nerves

FRACTURES OF THE HAND Extra-Articular Fractures of the Hand What is the standard treatment for nondisplaced extra-articular fractures of the metacarpals and phalanges?

Splinting in the intrinsic plus position with guarded motion to commence in 10–14 days; stable phalangeal fractures may then be placed in a digital splint or “buddy taped” for 2–3 wk; metacarpal fractures remain splinted for 2–3 wk

When can displaced metacarpal and phalangeal fractures be treated with closed reduction?

Whenever closed reduction is able to correct for angulation or rotational deformity


What is boxer’s fracture?

A fracture of the fifth metacarpal neck

How is this metacarpal fracture unique?

Usually volar angulation is not well tolerated in the metacarpals; however, because of the mobility of the fifth metacarpal, up to 40° of volar angulation can still give acceptable function

Intra-Articular Fractures of the Hand What features of intra-articular fractures must be considered in deciding the most appropriate treatment?

1. Ligamentous injury and consequent joint instability 2. Integrity of the articular surface, which will greatly influence long-term functional recovery

What is the significance of small bone fragments seen on radiographs of intra-articular fractures?

Frequently these fragments point to an avulsion of a ligamentous attachment, which may have important consequences for joint stability

What are the similarities and differences between a Bennett’s fracture and a Rolando’s fracture?

Both are intra-articular fractures of the base of the thumb metacarpal; a Bennett’s fracture is by definition unstable because the APL displaces the shaft proximally and radially away from the other intra-articular fracture fragment; a Rolando’s fracture is a Y- or T-shaped fracture of the base

What is the treatment of these fractures?

Usually requires open reduction and internal fixation (ORIF)

What is the treatment of PIP intra-articular fractures?

Splint if <25% of articular surface; ORIF if >25% and unstable

What are the indications for ORIF in DIP intra-articular fractures?

1. >30% of articular surface involved 2. Palmar subluxation of distal phalanx 3. Proximal displacement of fracture fragment (may result in extensor lag)

What is the nonoperative treatment of an intra-articular fracture of the DIP?

Splinting of the digit in the intrinsic plus position with progression to a digit splint or “buddy taping” for 2 or 3 wk


DISLOCATIONS OF THE HAND Which are the most typical dislocations of the DIP, PIP, and MCP joints?

DIP and PIP—dorsal and lateral MCP (including thumb)—usually dorsal

What is the treatment of these dislocations?

Closed reduction and splinting (degrees of flexion depend on joint)

What is the next step if instability of the joint persists?

Closed reduction and percutaneous fixation, followed by ORIF if this is unsuccessful

What is “gamekeeper’s thumb”?

Disruption of the thumb’s ulnar collateral ligament; usually incurred by lateral stress while grasping an object

How is degree of instability assessed?

Radiographic stress views under digital block for analgesia (Note: A fracture must first be ruled out with x-ray before stressing is allowed)

What is the treatment of gamekeeper’s thumb?

Thumb spica cast if <40° of instability or a nondisplaced fracture; ORIF required for >40° of instability or a displaced fracture

What is the treatment of carpal–metacarpal (CM) dislocation?

Usually the ligamentous disruption is significant and requires at least percutaneous fixation after reduction

Which CM dislocations are frequently associated with fracture?

Thumb dislocations (Bennett’s fracture)

FRACTURES AND DISLOCATIONS OF THE WRIST How is a scaphoid fracture diagnosed?

Snuff-box tenderness; multiple radiographic views of the wrist, especially an oblique, are often needed for diagnosis

What should be done if fracture is suspected, but x-ray examination is negative?

Potential scaphoid fractures should be treated expectantly and followed up with repeat imaging and exams


How is a nondisplaced scaphoid fracture treated?

Cast with wrist in neutral and thumb in abduction for 4–6 wk; continue close radiographic follow-up

What is a classic complication of proximal scaphoid fractures?

Avascular necrosis of the proximal fragment; can be prevented because union can often be obtained with conservative management

What is the usual mechanism for a hook, or hamate, fracture?

Striking a solid object while grasping a solid object

What is the treatment of hook, or hamate, fracture?

4–6 wk of cast immobilization; excision of the hook is indicated for nonunion

What is Kienböck’s disease?

Traumatic malacia of the lunate; susceptible individuals undergo avascular necrosis in response to single or multiple traumas

What is the treatment of Kienböck’s disease?

Complex reconstructive techniques, including bone grafting and fusions

How is a lunate dislocation diagnosed?

Lateral wrist radiograph demonstrates volar displacement of the lunate (Note: Dorsal lunate dislocations are rare)

How is a perilunate dislocation diagnosed?

Lateral wrist radiograph demonstrates alignment of the lunate and dorsal displacement of the capitate and digits (Note: Volar perilunate displacement is rare)

How are lunate and perilunate dislocations treated?

Successful closed reduction followed by casting in thumb spica cast with 20° of wrist flexion; ORIF is often necessary

What is scapholunate dissociation, and how is it diagnosed?

Disruption of the volar radioscapholunate ligament and the interosseous scapholunate ligament; diagnosed by AP wrist radiograph showing a gap between scaphoid and lunate and an axially oriented scaphoid


What is the treatment of scapholunate dissociation?

Closed reduction with K-wire fixation, or ORIF followed by immobilization in volar flexion

Ulnar Nerve Compression What is the most common site of ulnar nerve compression?

At the elbow as the nerve passes through the cubital tunnel


Pain, paresthesias, numbness in the ulnar distribution; weakness of the interossei, adductor pollicis, FCU, and FDP to ring and small fingers

What is the nonoperative treatment of ulnar nerve compression?

Padding at the elbow

What is the operative treatment of ulnar nerve compression?

Release of the nerve from the cubital tunnel with rerouting anterior to the medial humeral epicondyle

As it is uncommon on its own, what other conditions often precipitate ulnar nerve compression at the wrist?

1. Ulnar artery aneurysm or compressing thrombosis 2. Repetitive trauma 3. Anterior dislocation of the ulnar head 4. Ganglion of the pisohamate joint (Note: The location of nerve compression, as with carpal tunnel, can be determined by nerve conduction studies and electromyography)

Where is the radial nerve most susceptible to compression?

The mid humerus posteriorly as it runs along the bone

What is the common mechanism of injury?

Prolonged pressure (e.g., “Saturday night palsy,” trauma, heavy triceps use)


Pain, paresthesias, numbness in radial distribution; weakness of wrist extension, digit extension at the MCPs, and thumb extension



Most ulnar nerve compressions respond to conservative therapy of a “cock-up” wrist splint

FINGER-PAD DEFECTS What is the treatment of tissue defects of the finger-pad with bone and soft tissue mostly intact?

The amputated pad can be used to fashion a full-thickness graft

What are the options for larger defects?

Local V–Y advancement flaps or pedicle flaps derived from the thenar eminence or adjacent finger (cross finger flap)

When are the pedicle flaps divided postoperatively?

2 wk

NAIL AND NAIL-BED INJURIES What is the treatment of subungual hematoma WITHOUT severe disruption of the nail plate from the matrix?

Trephination—holes are punched or burned through the nail plate to allow drainage

Which injury commonly accompanies subungual hematomas?

Distal phalanx fractures

How does the risk of this concurrent injury alter management?

Radiographs should always be obtained, and sterile technique should be used for trephination (can convert a closed fracture into an open one)

What is the treatment of lacerations of the nail bed?

Repair with fine absorbable sutures; exposed matrix may be covered with nonadherent gauze or the nail may be used as a splint

What is the treatment of avulsions of the germinal matrix?

The germinal matrix should be replaced in the eponychial fold and either sutured in place or held with nonadherent gauze


ARTHRITIS Rheumatoid Arthritis What are the common manifestations of rheumatoid arthritis in the hands?

1. 2. 3. 4. 5.

Trigger fingers Wrist tenosynovitis Extensor tendon rupture Carpal tunnel syndrome Fibrosis and shortening of the intrinsics

What are the expected deformities as disease progresses?

1. 2. 3. 4.

Ulnar drift of the digits Extensor lag at the MCPs Swan-neck and boutonnière deformities Degeneration of articular surfaces and bone mass

In osteoarthritic patients, what are the most commonly involved joints of the hand?

IP joints of the digits; basal joint of the thumb

What are Heberden’s and Bouchard’s nodes?

Osteophytes of the DIP and PIP joints, respectively

MISCELLANEOUS HAND CONDITIONS Trigger Finger What is the pathophysiologic mechanism of a trigger finger?

Triggering is caused by a discrepancy between the flexor tendons and the proximal sheath, specifically the A1 pulley


Idiopathic, tenosynovitis post traumatic, and rheumatoid arthritis


Steroid injections into the sheath with or without splinting of the IP joints in extension; if this fails, operative opening of the proximal sheath is performed

De Quervain’s Stenosing Tenosynovitis What is de Quervain’s stenosing tenosynovitis?

A tenosynovitis of the first dorsal compartment (APL and EPB), with or without triggering, secondary to the inflammation



Pain over the tendon sheaths with motion of the thumb; thickness and tenderness over the first compartment

What clinical tests are used to make the diagnosis?

1. Finkelstein’s test—thumb is flexed and grasped by digits; then fist is ulnar deviated, which elicits pain over the radial styloid 2. Forceful abduction or extension of the thumb, which elicits pain

What other pathologic process can mimic the symptoms of de Quervain’s and how can the two be distinguished?

Arthritis of the thumb carpometacarpal joint; this condition can be diagnosed by forcefully grinding the metacarpal on the trapezium, which elicits pain and crepitus in arthritis


Steroid injections within the first dorsal compartment with or without splinting; if unsuccessful, operative release of the fibroosseous sheaths of the first compartment is performed

Dupuytren’s Fasciitis and Contracture What is Dupuytren’s fasciitis and contracture?

Painless thickening of the palmar fascia due to fibrous proliferation, which frequently begins as a nodule and may progress to a contracture of the MCP, PIP, or DIP joint with functional loss of the digit

Whom does it typically affect?

Middle-aged patients, 7:1 ratio of men to women; alcoholics, chronic invalids, epileptics, and patients with liver disease, diabetes mellitus, or pulmonary tuberculosis are at increased risk

What are the most frequently affected regions of the hand?

1. Digits in order of decreasing frequency: ring, small, middle, thumb, index 2. Joints, in decreasing order: MCP, PIP, DIP


Lysis of constricting fascial bands provides temporary relief; to prevent recurrence, removal of the palmar fascia must be complete; local corticosteroid injections are ineffective


Chapter 74 Otolaryngology Head and Neck Surgery SALIVARY GLANDS Anatomy What are the three major salivary glands?

1. Parotid 2. Submandibular 3. Sublingual

Where are the minor salivary glands located?

The entire oral cavity and upper aerodigestive tract (600–1000 glands)

What is the general location for each major salivary gland duct?

1. Parotid—Stensen’s (at second maxillary molar) 2. Submandibular—Wharton’s (in floor of mouth) 3. Sublingual—multiple ducts (in floor of mouth)

What are the primary secretory cell types for each major salivary gland?

1. Parotid—serous 2. Submandibular—both serous and mucous 3. Sublingual—mucous

Which intraoperative technique is most frequently used to find the facial nerve within the parotid gland?

Identification of the nerve at the stylomastoid foramen where it exits the skull and trace distally; alternatively, a branch may be identified peripherally and traced proximally

What are the five motor branches of the facial nerve?

1. 2. 3. 4. 5.

Temporal Zygomatic Buccal Mandibular Cervical (cranial nerve [CN] VII supplies innervation to all muscles of facial expression)

Chapter 74 / Otolaryngology Head and Neck Surgery 529

Which three nerves are in close proximity to the submandibular gland?

1. Marginal mandibular nerve (CN VII) → superficial 2. Lingual nerve (CN V) → deep and superior 3. Hypoglossal nerve (CN XII) → deep to anterior belly of digastric muscle

Salivary Gland Trauma How is traumatic disruption of the extratemporal facial nerve managed?

Immediate primary repair

Which disruptive extratemporal facial nerve injuries do NOT require repair, and why?

Those lying medial to a vertical line through the lateral canthus or involving the cervical branch; the nerve will regenerate spontaneously

How is a Stensen’s duct injury managed?

Repair over polyethylene stent (6–0 to 7–0 monofilament); leave stent in place for 10 days

Which childhood salivary gland neoplasm is the most common?

Hemangioma (capillary hemangiomas tend to occur in infancy, whereas cavernous hemangiomas are seen in older children)

What are the four physical signs of parotid malignancy?

1. 2. 3. 4.

Facial nerve paralysis Lymphadenopathy Skin changes Pain

Sialadenitis What is sialadenitis?

Inflammation of the salivary gland

What causes sialadenitis?

1. Infection 2. Obstruction of duct by calculi, stricture, or mucus plug

Infectious Sialadenitis How does infectious sialadenitis present?

Unilateral gland pain, fever, swelling, pus from duct orifice, and leukocytosis


What are the causes of infectious sialadenitis?

1. Viral—CMV, Coxsackievirus, mumps 2. Bacterial—anaerobes, Escherichia coli, Haemophilus influenzae, Staphylococcus aureus, and Streptococcus

Which of these infectious etiologies are most common?

1. Mumps 2. S. aureus

What is the treatment of infectious sialadenitis?

1. Hydration, massage, sialogogues (agents that stimulate secretion of saliva; e.g., lemon juice), and warm compresses for symptomatic relief 2. Antibiotics for bacterial etiologies 3. Surgical excision if refractory

What are the relative indications for surgery?

1. Failure of antibiotics after 1 wk of therapy 2. Recurrences 3. Multiple stones

What is the most common cause of acute suppurative parotiditis?

S. aureus

Which group of patients is at risk for acute suppurative parotiditis?

Debilitated patients who have a tendency toward dehydration and do not maintain good oral hygiene

What is the treatment of acute suppurative parotiditis?

Same as that of sialadenitis; surgical drainage may be required if abscess develops

Sialolithiasis Which salivary gland is most commonly affected by calculi?

Submandibular—80% (vs. parotid only 20%)

What percentage of salivary gland calculi are radiopaque?

Depends on location (90% of calculi in submandibular gland vs. only 10% in parotid); overall, approximately 75% are radiopaque


Recurrent swelling and pain associated with eating


How is the condition diagnosed?

Plain films, sialography (injection of contrast dye through duct orifice), ultrasound, or CT scan

What is the initial treatment?

Conservative—oral hydration (to stimulate salivary flow) and sialagogues

What is the treatment of chronic sialadenitis?

1. Stone removal (if distal) via duct papillotomy or excision of papilla 2. Gland excision (if proximal)

Identify the numbered structures in this midsagittal view of the right larynx:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Epiglottis Body of hyoid bone Median thyrohyoid ligament Vestibular ligament Vocal ligament Cricothyroid membrane Tracheal ring Cricoid cartilage Arytenoid cartilage Corniculate cartilage Thyroid cartilage Foramen for superior laryngeal nerve and artery 13. Superior horn of thyroid cartilage 14. Thyrohyoid membrane 15. Greater horn of hyoid bone

RECONSTRUCTIVE AND REHABILITATIVE LARYNGEAL SURGERY What are the common nonneoplastic causes of hoarseness in adults?

Vocal cord (VC) nodules and polyps

What is the cause of VC nodules?

Voice abuse

What is the cause of VC polyps?

Smoking, gastroesophageal reflux, and voice abuse


What is the histologic appearance of VC nodules?

Epithelial hyperplasia and submucosal connective tissue fibrosis

What is the histologic appearance of VC polyps?

Subepithelial edema

What is the treatment of nodules and polyps?

Medical: Removal of offending agents, voice therapy Surgical: Microsurgical excision

What is the result of unilateral VC immobility?

1. Voice disturbance 2. Airway protective deficits

What is the rehabilitative therapy for these entities?

1. VC injections (temporary medialization possible with Gelfoam) 2. Medialization thyroplasty

NOSE, PARANASAL SINUSES, AND FACE Anatomy What are the paranasal sinuses?

1. Maxillary sinuses 2. Ethmoid (anterior and posterior) sinuses 3. Frontal sinuses 4. Sphenoid sinuses

What is the first sinus to develop?

Maxillary

At what age do the sinuses reach their final size?

Maxillary: Present at birth; biphasic growth age 3 and 7–18 Ethmoid: Present at birth; full size by age 12 Frontal: Rarely demonstrable radiographically before age 2; full size by 16–19 Sphenoid: Pneumatizes at age 4–5; full size by age 12–15

Which sinus is aplastic in >5% of patients?

Frontal


Where is each paranasal sinus ostia located?

Maxillary: Middle meatus Anterior ethmoid: Middle meatus Posterior ethmoid: Superior meatus Frontal: Middle meatus Sphenoid: Sphenoethmoidal recess

Where is the lacrimal gland ostium located?

Inferior meatus

What are the components of the cartilaginous framework of the nose?

Upper lateral cartilages, lower lateral cartilages, cartilaginous septum, and sesamoid cartilages

What structures contribute to formation of the nasal septum?

Quadrangular cartilage, perpendicular plate of the ethmoid, vomer, maxillary crest, and palatine bone

What is the arterial supply of the nose and their sources?

1. Anterior and posterior ethmoid arteries (branches of the ophthalmic artery from the internal carotid artery) 2. Sphenopalatine and greater palatine arteries (branches of the internal maxillary artery from the external carotid artery) 3. Superior labial artery (branch of the facial artery from the exterior carotid artery)

Why are the veins of the face likely to propagate septic emboli to the brain?

Facial veins are valveless

Traumatic Septal Hematoma What is the treatment of traumatic septal hematoma?

Urgent incision and drainage

Why?

To prevent cartilage necrosis and resulting saddle-nose deformity


Facial Cellulitis What is the treatment of facial cellulitis?

Hospital admission, IV antibiotics, and close observation

Why is this treatment chosen?

To facilitate early detection of intracranial propagation of bacteria via valveless facial veins

Apnea What is apnea?

Absence of respiration for 10 or more seconds

What are the three types of apnea?

1. Obstructive—lack of airflow with continued effort 2. Central—absence of effort 3. Mixed—both

In patients with obstructive sleep apnea (OSA), what is the predominant site of obstruction?

Oropharynx; obstruction can result from tongue, soft palate, tonsillar, adenoid, and pharyngeal wall

How is OSA diagnosed?

1. History—loud snoring, restless sleep, periods of apnea, and daytime somnolence 2. Physical exam—associated with obesity, macroglossia, micrognathia, retrognathia, adenotonsillar hypertrophy, shallow palatal arch, large palate 3. Diagnostic study—sleep study (polysomnogram)

What is the treatment of pediatric OSA?

Adenotonsillectomy

What is the treatment of OSA in adults?

1. Medical therapy—continuous positive airway pressure (CPAP) masks, weight loss, avoidance of CNS depressants, and protriptyline


2. Surgery—may include tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty and tracheotomy, midline glossectomy, mandibular advancements or osteotomy, and hyoid advancement What malformations are found in Pierre Robin syndrome?

1. Glossoptosis 2. Micrognathia 3. Cleft palate Children often present with inadequate oral intake and aspiration which may require tracheostomy and gastrostomy tube

What malformations are found in Apert’s syndrome?

Midface hypoplasia with a small retrodisplaced maxilla, orbital hypertelorism, and a short widened skull

Ludwig’s Angina What is Ludwig’s angina?

The spread of an infectious process into the sublingual, submandibular, and submental spaces

What is the most concerning complication?

Rapid progression of airway compromise (with floor of mouth edema displacing tongue posteriorly)


Limited movement of tongue, swelling of floor of mouth and submental region, fluctuance, and pain on movement of tongue

What is the most common source?

Dental infection (especially mandibular)

What are the most common pathogens?

Mixed oral flora


Same as for peritonsillar abscess


Acute Rhinitis What are the symptoms of acute rhinitis?

Nasal stuffiness, rhinorrhea, sneezing, mild fever, headache, and general malaise; obstruction and thickened/purulent nasal discharge may follow

What are the findings on physical examination?

Swollen, erythematous nasal mucosa with a watery mucus discharge

What is the course/treatment?

Usually lasts 5–7 days; antihistamines and decongestants may help symptoms; interferon shortens the course of the virus

Other Oropharyngeal Abscesses What is the location of a parapharyngeal abscess?

Fascial space between pharyngeal constrictor muscles and superficial layer of deep cervical fascia

What is the location of a retropharyngeal abscess?

Fascial space between posterior pharyngeal wall and prevertebral fascia


1. Airway obstruction 2. Hemorrhage due to erosion into vessels of neck (e.g., carotid) 3. Intracranial infections 4. Aspiration 5. Spread to thoracic cavity (e.g., mediastinitis)


IV antibiotics, incision, and drainage

Should the procedure be performed under local or general anesthesia?

Local; general anesthesia can be dangerous with these abscesses because of sudden airway obstruction; even with local anesthesia, the surgeon must be prepared to perform tracheostomy


EARS Anatomy Identify the labeled landmarks of the external ear or auricle:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Which nerves travel within the internal auditory canal (IAC)?

Vestibulocochlear and facial nerves

What is conductive hearing loss?

Loss of conduction of sound from external ear canal to cochlea (e.g., cerumen, otitis media, ossicle destruction)

What is sensorineural hearing loss?

Damage to cochlea and hair cells/auditory neurons

Which two tests use tuning forks to analyze hearing loss?

Weber’s and Rinne’s

Define these two hearing tests: Weber’s test?

Rinne’s test?

Helix Scaphoid fossa Triangular fossa Concha Antihelix Tragus Antitragus Intertragic incisure Lobule

Tuning fork to forehead = normal = maximal sound center of head Tuning fork against mastoid until no sound → then tuning fork 2 cm from external canal = normal = sound 2× as long in air conduction:


Describe the tuning fork analysis for hearing loss conditions:

Test

Rinne’s

Weber’s

Normal bilateral

+/+

Middle

Unilateral conductive loss

+/−

Lateralization to affected ear

Bilateral conductive loss

+/−

Lateralization to worst ear

Unilateral sensorineural loss

+/+

Lateralization to best ear

Bilateral sensorineural loss

+/+

Lateralization to best ear

Sensorineural Hearing Loss What are the signs?

Air conduction is better than bone conduction, but Weber’s lateralizes to unaffected ear; audiogram loss in high frequencies

Infections of the Ear Serous Otitis Media What is serous otitis media?

Usually an acute response to temporary ventilatory dysfunction of the eustachian tube

What are the precipitating factors?

Nasopharyngeal inflammation; often allergic rhinitis or the common cold

What more serious lesion may have a similar presentation?

Nasopharyngeal carcinoma; be especially suspicious in the adult with prolonged unilateral serous otitis


Sensation of otic fullness, tinnitus, hearing loss

What are the findings on examination?

Amber-colored tympanic membrane (TM) and often a visible fluid line or air bubbles behind the TM, which may be retracted with decreased mobility



Mucoid Otitis Media What age group is most affected?

Most cases resolve without treatment; antihistamines may help; myringotomy with aspiration of fluid has a high certainty of cure but is rarely necessary

Usually seen in children

With what other condition is it associated?

Chronic dysfunction of the eustachian tube, a common sequela of acute otitis media

What is the most common sequela?

Acquired hearing loss in children


Often asymptomatic, though impaired hearing is common

What are the findings on examination?

Otoscopy may reveal a dull, retracted, immobile TM


Search for underlying etiology; antihistamine-decongestant combinations are not efficacious; watch for 2–3 mo for spontaneous resolution; myringotomy with tube insertion is necessary if there is no resolution; audiogram is indicated to document hearing loss

Vestibular Neuritis What is vestibular neuritis?

Severe attack(s) of prolonged vertigo; thought to have a viral origin

What is the typical history?

Healthy adult (30–60 yr old) who has had an upper respiratory infection or sinusitis prior to an acute vestibular crisis characterized by severe vertigo, nausea, vomiting, and nystagmus

What is the course?

Symptoms usually last 3–7 days, with progressive improvement noted following a single episode; recurrences (usually less severe) may occur in the ensuing weeks



IV phenothiazine given slowly will usually stop severe vertigo, nausea, and vomiting; diazepam or meclizine (vestibulosuppressives) may be helpful; mainstay of treatment is early, aggressive vestibular rehabilitation exercises once symptoms have been controlled

Tumors of the Ear Glomus Tumors What percentage of glomus tumors are bilateral?

10%


By location: Pulsatile tinnitus, hearing loss, vertigo, CN palsy

What are the signs?

Conductive hearing loss, mass behind ear drum, CN deficit

What are the steps in evaluation?

Examination, audiogram, CT, MRI, angiogram

Posterior Fossa Tumors What are posterior fossa tumors?

Most commonly (90%) acoustic neuromas, which are benign schwannomas of CN VIII; less common primary tumors are meningioma, cholesteatoma, arachnoid cyst, cholesterol granuloma

Which site is most commonly affected?

Cerebellopontine angle

What are the early symptoms?

Tinnitus, hearing loss, vertigo

What symptoms occur later?

May involve CN IX, X, XI (caudal tumor growth), cerebellum by compression


TI MRI with contrast (gadolinium) is the gold standard Audiometry, brainstem-evoked potentials, radiology (CT and MRI)



Surgical resection Gamma knife for poor operative candidates

Congenital Lesions of the Ear What ear lesions are examples of major malformations?

1. Microtia (rudimentary pinna) 2. Atresia (lack of formation of external auditory canal with bony plate)


Repair of atresia follows repair of microtia Microtia—staged auricular reconstruction begins with contralateral costochondral cartilage Atresia—once conchal position is established with microtia repair, the atretic canal can be drilled out

NECK Anatomy Major Muscular Structures What is the thin sheet-like muscle lying beneath the skin in the anterolateral neck?

Platysma muscle

What muscle divides the neck into anterior and posterior triangles?

Sternocleidomastoid (SCM) muscle

What muscle defines the posterior extent of the neck dissection?

Trapezius muscle

What group of muscles in the anterior neck acts to elevate and depress the larynx?

Strap muscles

What group of muscles defines the deep limit of the neck dissection?

Scalene muscles


What muscle serves to stabilize the scapula and allows abduction beyond 90°?

Trapezius muscle

In what plane are skin flaps raised for neck surgery?

Subplatysmal plane

Major Vascular Structures What landmark roughly approximates the site of the bifurcation of the common carotid artery?

Upper border of the thyroid cartilage

What are the branches of the internal carotid artery in the neck?

There are none

What are the branches of the external carotid artery in the neck?

1. 2. 3. 4. 5. 6. 7. 8.

Fascial Compartments What are the layers of the deep cervical fascia?

Which layers contribute to the formation of the carotid sheath? Other Anatomic Topics What three structures are within the carotid sheath?

Superior thyroid artery Ascending pharyngeal artery Lingual artery Facial artery Occipital artery Posterior auricular artery Superficial temporal artery Maxillary artery

1. Superficial layer—surrounds entire neck; encloses trapezius, SCM, and omohyoid muscles 2. Middle (visceral) layer—surrounds visceral structures of anterior neck 3. Deep (paravertebral) layer—surrounds paraspinous muscles and vertebral column All of the above

Carotid artery, jugular vein, and vagus nerve


What are the lymphatic zones in the neck?

Describe the location of: Jugular vein?

Zone 1—submental and submandibular Zones 2, 3, and 4—equal thirds of the internal jugular chain, with Zone 2 being the most superior Zone 5—posterior cervical triangle

Lies lateral to carotid artery, deep to SCM

Thoracic duct?

Joins the venous system at the junction of the left internal jugular and subclavian veins

Vagus nerve (CN X)?

Exits skull at jugular foramen; travels within the carotid sheath

Spinal accessory nerve (CN XI)?

Exits skull at jugular foramen, passes deep to the posterior belly of digastric muscle, enters SCM about 4 cm below mastoid process, exits SCM 1 cm superior to Erb’s point (greater auricular nerve meets SCM), and enters trapezius 2 finger breadths above clavicle

Hypoglossal nerve (CN XII)?

Exits skull through hypoglossal canal, deep to digastric muscle in the submandibular triangle


Phrenic nerve?

Runs lateral to medial on the surface of the anterior scalene muscle

Brachial plexus?

Passing between the anterior and middle scalene muscles on the way to axilla

What spinal levels contribute to the: Phrenic nerve?

Brachial plexus?

C3, 4, and 5 (think: “C3, 4, 5 keeps the diaphragm alive”) C4–8 and T1

Identify the numbered structures in this cross-section of the neck: 1. Trachea 2. Esophagus 3. Cervical (C7) vertebral body 4. Thyroid gland 5. Anterior jugular vein 6. Sternohyoid muscle 7. Sternothyroid muscle 8. Platysma muscle 9. SCM muscle 10. Omohyoid muscle 11. Vagus nerve 12. Internal jugular vein 13. Common carotid artery 14. Phrenic nerve 15. Scalenus anterior muscle 16. External jugular vein 17. Scalenus medius muscle 18. Vertebral artery 19. Scalenus posterior muscle 20. Trapezius muscle

HEAD AND NECK RECONSTRUCTION What are the three pedicled myocutaneous flaps used in head and neck reconstruction?

1. Latissimus dorsi 2. Pectoralis major 3. Trapezius

Which flap is most commonly used?

Pectoralis major


What pedicled fasciocutaneous flap is used?

Deltopectoral flap

What is the vascular pedicle for each of the previously described flaps?

1. Pectoralis major → thoracoacromial artery 2. Latissimus dorsi → thoracodorsal artery 3. Trapezius → descending branch of the transverse cervical artery and dorsal scapular artery 4. Deltopectoral flap → anterior thoracic perforators of thoracoacromial artery

What are the FREE flaps commonly used for head and neck reconstruction?

Radial forearm, fibula, jejunum, scapula, iliac crest, and rectus abdominis

What tissue source may be used in cases of significant injury to the pharynx and esophagus?

Gastric pull-up

Where is the blood supply for this “pedicle”?

Right gastric and gastroepiploic vessels

MISCELLANEOUS TOPICS Where is the most common neck mass?

Reactive lymph node

What is “quinsy”?

Peritonsillar abscess secondary to acute tonsillitis

What is the most common type of teratoma in the head and neck?

Epidermoid cyst

What is leukoplakia?

White patch in oropharynx

When is biopsy indicated in leukoplakia?

For smokers or alcoholics (high risk of head and neck carcinoma)

What is the most common type of branchial cleft anomaly?

Second cleft


What type of schwannoma arises from CN VIII?

Acoustic neuroma

What is the most common benign laryngeal lesion in both children and adults?

Laryngeal papilloma

What tumors of skeletal muscle have a predilection for the head and neck?

Rhabdomyomas

What is Bezold’s abscess?

Cervical abscesses secondary to ear infection

What is the most common cause of facial paralysis?

Bell’s palsy (etiology uncertain)

What is a maxillary torus?

Benign bony growth found midline in the palate

What is the most common bone tumor in the head and neck?

Osteogenic sarcoma (however, it is actually rarely seen in the head and neck)

Which parotid tumor accounts for 70% of all bilateral salivary tumors?

Warthin’s tumor

What is an esthesioneuroblastoma?

Rare tumor that develops in the olfactory epithelium

Which facial fracture is characterized by complete craniofacial separation?

Le Fort III

What is an orbital blowout fracture?

Direct impact that causes the eyeball to “blow out” of the orbit


What is odynophagia?

Painful swallowing

What is dysphagia?

Difficulty swallowing

What is Ménière’s disease and the classic triad of presentation?

Disorder of membranous labyrinth; the triad is tinnitus, hearing loss, and vertigo

What is a glomus jugulare?

Neoplasm arising from jugular bulb and often extending into the middle ear

What is median rhomboid glossitis?

A congenital defect caused by improper fusion of posterior third of tongue to anterior two-thirds; resembles neoplasm

What is the most common infection of the neck in children?

Acute cervical lymphadenitis

What is the most common infection of the neck in adults?

Acute cervical lymphadenitis

What is the most common head and neck tumor in children?

Hemangioma

What is vestibular neuritis?

Severe attacks of vertigo thought to be secondary to viral infection

What is ankyloglossia?

Limited movement of tongue because of shortened frenulum

What is a perilymphatic fistula?

Fistula (communication) between: 1. Middle ear and 2. Inner ear through round window or stapes footplate

What is presbycusis?

Sensorineural hearing loss due to gradual degenerative changes over a lifetime


Chapter 75 Thoracic Surgery CHEST WALL TUMORS What are the most common benign chest wall tumors and their typical presentations?

1. Osteochondroma (30%–50%); painless mass on the rib metaphysis 2. Fibrous dysplasia (20%–30%); painful rib lesion or pathologic fracture 3. Chondroma (15%–20%); slowly enlarging, painless mass at the costochondral junction

What are the most common malignant chest wall tumors?

1. Locally invasive malignancies (e.g., breast and lung) 2. Metastases to chest wall (e.g., kidney and colon) 3. Primary chest wall malignancies

What are the four most common primary chest wall malignancies?

1. Chondrosarcoma 2. Osteosarcoma 3. Ewing’s sarcoma and primitive neuroectodermal tumor or PNET (an aggressive form of Ewing’s sarcoma) 4. Solitary plasmacytoma, an isolated form of multiple myeloma

Which type demonstrates a classic “onion-peel” appearance on x-ray?

Ewing’s sarcoma

Which type demonstrates a classic “sunburst” appearance on x-ray?

Osteosarcoma

Which of the primary chest wall malignancies are “medical chest wall tumors” (e.g., nonsurgical treatment)?

1. Ewing’s sarcoma/PNET—with chemotherapy ± radiation because of high metastatic potential and advanced presentation 2. Solitary plasmacytoma—with radiation for local control and surveillance for development of systemic multiple myeloma (45%–75%)

Chapter 75 / Thoracic Surgery 549

What is the treatment of benign chest wall tumors?

Wide excision to achieve clear margins

What is the treatment of malignant chest wall tumors?

Wide resection with 4–5 cm margins, including the ribs above and below involved rib (if involved), and adjacent muscles and/or underlying pleura/lung, if adherent

What are the options for chest wall reconstruction?

Gore-Tex patch, Prolene mesh, or ethyl methacrylate “sandwich” with mesh on either side and a muscle or musculocutaneous rotational flap to cover the mesh

PLEURAL EFFUSION What are the two types of effusions and their etiologies?

1. Transudative—Congestive heart failure, nephrotic syndrome, and cirrhosis 2. Exudative—Infection, malignancy, trauma, and pancreatitis

What are the Light’s criteria, whereby if at least one of the criteria is met, the fluid is defined as exudative?

1. Pleural fluid to serum protein ratio >0.5 2. Pleural fluid to serum LDH ratio >0.6 3. Pleural fluid LDH >2/3 upper limit of laboratory’s normal serum LDH

What are the most common causes of the following biochemical findings of an effusion: Glucose <60 mg/100 mL?

Malignancy, tuberculosis (TB), pneumonia, or rheumatoid

Elevated amylase?

Pancreatitis, esophageal rupture, or malignancy

pH <7.2?

Pneumonia, esophageal rupture, malignancy, TB rheumatoid, or hemothorax

What are the risks of draining too much pleural fluid, and what is a safe limit?

Reexpansion pulmonary edema or hypovolemia; limit to 1,500 mL drainage in one sitting


Empyema What is empyema?

Organisms on Gram stain or frank pus on aspiration of pleural fluid

What is the most common etiology?

Pneumonia with parapneumonic effusion

What are the three phases of empyema and corresponding fluid characteristics?

1. Exudative—thin, serous, pH >7.2, glucose >60, LDH <1,000, and no organisms on Gram stain 2. Fibrinopurulent—fibrin deposition, loculated fluid, pH <7.2, glucose <60, LDH >1,000, and positive Gram stain or culture 3. Organizing—solid, inelastic pleural peel causing trapped lung, a.k.a. “fibrothorax”

What is the treatment for each phase?

1. Exudative—antibiotics + drainage (either tube thoracostomy or thoracoscopic) 2. Fibrinopurulent—antibiotics + drainage + fibrinolytics (tPA 10 mg and DNase 5 mg twice daily × 3 d) 3. Organizing—thoracotomy and total lung decortication (removal of fibrous peel on lung and diaphragm)

What are the common organisms in empyema?

Gram-positives (most common), such as Staphylococcus aureus, Streptococcus pneumoniae, anaerobes, and gramnegatives such as Escherichia coli, Klebsiella pneumoniae, and Haemophilus influenzae

Postpneumonectomy, what is the likely diagnosis with a chest x-ray showing a drop in the air–fluid level?

Postpneumonectomy empyema with or without bronchopleural fistula (e.g., bronchial stump leak)

What is the initial management of postpneumonectomy empyema?

Drainage of pleural space, IV antibiotics, and bronchoscopy to evaluate the bronchial stump with repair if necessary


Chylothorax What is chylothorax?

Pleural effusion composed of lymphatic fluid or chyle due to disruption or obstruction of thoracic duct

What is the course of the thoracic duct?

Begins as the cysterna chyli in the abdomen in front of L2 vertebral body, ascends along the right of the aorta through the aortic hiatus, then between the aorta and azygos vein, crosses to left at T5 to T7, and empties into left jugulosubclavian vein junction

What is the normal volume of flow per day through the duct?

Two liters! (Accounts for frequency of massive effusions in chylothorax)

What are the etiologies of chylothorax?

1. Iatrogenic (most common) during dissection along anterior vertebral surface (esophageal or any thoracic surgical procedure) 2. Traumatic 3. Malignancy (lymphoma, chronic lymphocytic leukemia, and metastatic cancer)

How is the diagnosis of chylothorax made?

Pleural fluid triglyceride level >110 mg/dL is diagnostic, whereas triglyceride level <50 mg/dL excludes the diagnosis of chylothorax

When should surgical intervention be considered?

Persistent high-volume (>800 mL/ day) output or failure of nonoperative management after 3 wk

What are the surgical treatment options?

1. Talc pleurodesis 2. Open or thoracoscopic thoracic duct ligation with mechanical pleurodesis 3. Pleuroperitoneal (Denver) shunt

What is the nonoperative management of chylothorax?

1. Tube drainage of chylothorax 2. NPO + total parenteral nutrition (TPN) or reduced fat diet with medium-chain triglycerides (absorbed via intestines into portal vein instead of thoracic duct)


TRACHEA Anatomy What is the typical tracheal length and number of rings in adults?

10–13 cm, 18–22 rings (2 rings per cm)

What supplies blood to the trachea?

1. Inferior thyroid artery (upper trachea) 2. Bronchial arteries (lower trachea and carina), which originate from the aorta

Why is the safest surgical approach in the AP plane?

Blood supply enters via lateral walls, and recurrent laryngeal nerves run along the lateral walls

What percentage of the tracheal length may be safely resected in children vs. adults?

General rule: Children 33%; adults ≈50%; however, appropriate length will vary, taking into account the factors of patient’s age, physical build, height, pathology, and prior surgery; a younger patient with a supple neck may tolerate more tracheal resection than can a heavyset, kyphotic elderly patient

Tracheal Stenosis What are the etiologies?

Postintubation, injury, tracheal tumors, and trauma

What is the criterion for a “critical stenosis” in an adult?

Intraluminal diameter <4 mm


Cough, stridor, dyspnea, wheezing

What are the three causes of postintubation stenosis?

1. Circumferential mucosal ischemia from cuff overinflation for >48 hr with resultant fibrosis 2. Tube tip injuring the wall and causing granulation tissue 3. Tracheostomy stoma scarring and stenosis


What are the treatments for tracheal stenosis?

1. Tracheal dilation, laser ablation, or tracheostomy or T-tube placement (for high-risk patients) 2. Tracheal resection/primary reconstruction (for good candidates)

What preoperative studies should be done for consideration of tracheal resection?

1. CT with contrast with fine cuts through the trachea 2. Rigid bronchoscopy with measurements

What is the primary cause of anastomotic dehiscence after tracheal reconstruction?

Excessive tension

What maneuvers can be performed to reduce this problem?

1. Careful preoperative planning and patient selection (most important) 2. Cervical flexion (secure chin to chest with heavy suture) 3. Suprahyoid laryngeal release 4. Mobilization of the right hilum by transpleural or intrapericardial release 5. Mobilization of the left hilum by intrapericardial release

What can be done to protect the brachiocephalic artery from anastomosis?

Pedicled strap muscle or sternocleidomastoid

What is the most common acute complication of tracheal surgery?

Laryngeal edema

What is the management?

Fluid restriction, nebulized racemic epinephrine, and dexamethasone IV for 24–48 hr

What are the causes of acquired tracheomalacia?

Prolonged intubation, chronic tracheal infections, or inflammatory conditions such as relapsing polychondritis

What is the consequence of this lesion?

With inspiration, the malacic segment collapses (exacerbating airway obstruction)


Tracheal Tumors What is the incidence of malignant tracheal tumors in children vs. adults?

Children <10%; adults >80%

What are the most common malignant types in adults?

1. Squamous cell carcinoma 2. Adenoid cystic carcinoma

What is the most common benign type in adults?

Squamous papillomas

What is the most common type in children?

Hemangioma

Which tumor classically presents with extensive proximal and distal submucosal spread?

Adenoid cystic carcinoma

What is the usual presentation of tracheal tumors?

Cough, dyspnea, stridor, hemoptysis, hoarseness, and wheezing

Why are distant metastases infrequent?

Patients often die early because of asphyxia from tracheal obstruction

How is the diagnosis usually confirmed?

Bronchoscopic biopsy

When is this diagnostic technique contraindicated?

1. Highly vascular tumors (e.g., hemangiomas, carcinoids) 2. Critical tracheal stenosis

How can the bronchoscope be used to temporarily stabilize the critically stenosed airway?

Core out intraluminal tumor with bronchoscope tip or endoscopic dilation

What is the treatment of malignant tumors?

Resection ± radiation therapy (pre- or post-op)

What is the best treatment for high-risk patients?

Placement of Silastic (Montgomery) T-tube stent


Compare incisions used for upper vs. lower tumors:

Upper—Collar incision ± vertical sternal extension Lower—Posterolateral thoracotomy

Acquired Aerodigestive Tract Fistulae What is the usual presentation of small fistulae?

Chronic cough, weight loss, and recurrent lung infections

What is the usual presentation of large fistulae?

Paroxysmal coughing after eating or drinking (One’s sign)

Nonmalignant Fistulae What are the most common etiologies of nonmalignant fistulae?

Erosion by the tracheal tube cuff and blunt chest trauma

What are the usual infectious etiologies?

TB and histoplasmosis

What is the surgical treatment for nonmalignant fistulae?

Divide fistula, primary esophageal repair, primary tracheobronchial repair, interposition of pedicled muscle flap (strap muscle if cervical approach, intercostal muscle if thoracotomy approach) between the two repair lines

Malignant Fistulae What are the most common etiologies of malignant fistulae?

Esophageal (85%) and lung (10%) carcinoma

What are the surgical treatment options in the setting of esophageal carcinoma?

1. Esophageal exclusion and bypass (with stomach or colon anastomosed to cervical esophagus and tunneled substernally or subcutaneously) 2. Double stenting the airway and esophagus (better survival than single stent by preventing death from pulmonary sepsis)

What is the prognosis for malignant tracheoesophageal fistula?

Poor – 3 mo survival of 13% and 6 mo survival of 4% with supportive care


Tracheoinnominate Artery Fistulae (TIF) What is the etiology?

Erosion into innominate artery by tracheostomy tube

How can the potential for the future development of TA fistulae be dramatically reduced at the time of tracheostomy?

Place tracheostomy no lower than the third tracheal ring

How can the risk in patients with chronic tracheostomy be reduced?

Avoid cuff overinflation

What sign occurs in 50% of patients before massive hemorrhage?

Transient sentinel bleed (especially significant if 1–2 wk after tracheostomy)

What is the emergency (bedside) treatment?

Hyperinflate cuff and apply suprasternal pressure; if still massively bleeding, bluntly dissect innominate artery off trachea via the cutaneous stoma, and compress artery anteriorly against sternum

What is the digital compression maneuver also known as?

Utley maneuver

What is the definitive surgical treatment?

Median sternotomy, resect innominate artery segment in contact with trachea, oversew the arterial stumps (bypass rarely indicated due to extensive collateral flow), and secure muscle flap over stumps (Note: Tracheal defect is allowed to granulate closed)


Tracheostomy What are the indications?

1. Chronic respiratory failure 2. Copious tracheobronchial secretions 3. Upper airway obstruction or injury

When should a tracheostomy be performed in a ventilatordependent patient?

Controversial; however, most experts now agree that if longer term ventilatory (>14 d) support is necessary, tracheostomy should be performed within 7 d

Where should the incision be made in the trachea?

Second and third cartilages (thus, do not use “fingerbreadth above sternal notch” as the landmark, but rather use “fingerbreadth or 2–3 rings below the cricoid”)

What are the possible longterm complications?

Sepsis, hemorrhage, and tracheal stenosis

LUNG Anatomy What provides blood supply to the the lung?

Dual blood supply from pulmonary arteries and bronchial arteries, which arise from the aorta directly or intercostal arteries

Where does the right middle lobe vein most commonly drain?

Right superior pulmonary vein (but can also drain into the right inferior pulmonary vein or left atrium)

Which nerve runs anterior to the hilum?

Phrenic nerve

Which nerve runs posterior to the hilum?

Vagus nerve

Which vessel must be divided for adequate exposure to the carina or right mainstem bronchus during right thoracotomy?

Azygos vein


Congenital Lung Lesions What is the most common etiology of lung hypoplasia?

Congenital diaphragmatic hernia or CDH (visceral herniation into the thoracic cavity during critical period of lung development); the degree of lung hypoplasia (lower) determines likelihood of survival

What is the differential diagnosis of congenital cystic or “space-occupying” lung lesions?

1. Bronchogenic cyst 2. Bronchopulmonary sequestration (BPS) 3. Congenital pulmonary airway (cystic adenomatous) malformation (CPAM or CCAM) 4. CDH 5. Congenital lobar emphysema (CLE)

What is a bronchogenic cyst?

A congenital cyst in lung or mediastinum arising from abnormal budding of the foregut during development

How is bronchogenic cyst diagnosed?

CXR (round water-density mass) or CT (cystic mass with soft tissue or water attenuation)


Recurrent coughing, wheezing (could be diagnosed as asthma), and pneumonia

Bronchiectasis What is bronchiectasis?

Chronic dilation of distal bronchial tree (usually the second to fourth-order segmental bronchi)


Destructive pneumonia (bacterial or viral)

What rare congenital syndrome includes bronchiectasis in its triad of lesions?

Kartagener’s syndrome (triad also includes situs inversus and sinusitis)


Chronic cough productive for characteristic copious, purulent, fetid sputum (especially in morning)


What is the gold standard for diagnosis?

Bronchogram (Note: Although thin-cut CT is gaining in popularity, a bronchogram still defines the anatomy best and should be done in any potential candidate for surgery)

What are the indications for surgery for bronchiectasis?

1. Recurrent pulmonary infections 2. Significant hemoptysis 3. Brain abscess due to bacterial emboli

What is the procedure of choice for bronchiectasis?

Resection of affected regions (Note: The diffuse nature of the disease prevents most patients from undergoing surgery)

Tuberculosis (TB) What is the responsible organism and route of transmission?

Mycobacterium tuberculosis by aerosolized droplets

What percentage of infected individuals have clinically significant TB?

Only 5%–15%

What is the most common region of lung to be affected?

Apices of lung

What is the evolution of the parenchymal lesion?

Pulmonary infiltrate—caseous necrosis— fibrosis and calcification (granulomas)

What is a Ghon complex?

Parenchymal lesion plus enlarged hilar lymph nodes

What is a Rasmussen aneurysm?

Dilated branch of pulmonary artery within or near a TB cavity

What is the usual presentation of these aneurysms?

Hemoptysis

What are the indications for surgical resection for TB?

Failure of anti-TB medical therapy (e.g., isoniazid, rifampin, pyrazinamide) as manifested by persistently positive sputum, massive or recurrent hemoptysis, bronchopleural fistula, or mass lesion in a region of TB (to exclude malignancy)


Mycotic Infections What are the most common mycotic infections in the United States?

Histoplasmosis (most common), coccidioidomycosis, Aspergillus, and blastomycosis

What organism has traditionally been grouped with fungal infections but is bacterial in origin?

Actinomycosis

Identify the infection most commonly associated with: Dental abscesses?

Actinomycosis

Thin-walled cavity with air–fluid level?

Coccidioidomycosis

Chronic papulopustular skin ulcers?

Blastomycosis

Abscesses containing “sulfur granules”?

Actinomycosis

What is a mycetoma?

Classic “fungus ball” composed of Aspergillus

What is the usual predisposing lesion of a mycetoma?

Cavity secondary to M. tuberculosis

What is the classic finding on upright CXR?

Radiolucent crescent (small ball in larger round cavity)

What is the medical treatment of pulmonary fungal infection?

Amphotericin B for all infections except actinomycosis, which requires penicillin

What are the indications for surgical intervention for mycotic pulmonary infections?

Most agree that excision is indicated for cavitary lesions refractory to medical treatment and recurrent hemoptysis

Massive Hemoptysis What are the etiologies?

Bronchiectasis, TB, mycotic or bacterial infections, trauma, and cancer



Mycetoma

What is the usual cause of death?

Asphyxia (not hemorrhagic shock)

Which arterial system is most often the source of massive hemoptysis?

Bronchial (not pulmonary) arteries

What is the acute management of massive hemoptysis?

1. Protect the nonbleeding lung by positioning the patient “bleeding side down” 2. Establish an airway with at least #8 endotracheal tube or ETT (for bronchoscopy and intervention)—either single-lumen ETT into nonbleeding lung ± fiberoptic bronchoscopic guidance or double-lumen ETT with bronchial cuff inflated to protect good lung from bleeding lung 3. Reverse any coagulopathies 4. Stop the bleeding

What are the options for controlling the bleeding?

1. Bronchoscopy with 4-Fr Fogarty balloon occlusion, iced saline lavage with 500 mL (10 total 50 mL administrations), topical 1:20,000 diluted epinephrine or vasopressin or thrombin, and/or laser therapy, electrocautery, argon plasma coagulation, or cryotherapy 2. Arteriography and selective bronchial artery embolization

Lung Nodules What is a solitary pulmonary nodule (SPN)?

What is the risk of malignancy when the SPN is sized: <3 mm? 4–7 mm?

An intraparenchymal pulmonary lesion that is <3 cm (considered a “mass” at 3 cm). The causes can be benign (60%) or malignant (40%)

0.27% 0.9%


8–20 mm?

18%

>20 mm?

50%

What is the doubling time of solid lung cancer?

150–170 d (explains the “2-year rule” for observation period)

What is the doubling time for malignant ground-glass opacities?

810 d (explains the need for >2-year observation period)

What are the diagnostic modalities available for tissue diagnosis?

1. CT-guided percutaneous biopsy (excellent accuracy if ≥1 cm) 2. Navigational bronchoscopy; employs CT and electromagnetic guidance to target the bronchus associated with pulmonary nodule for biopsy; may also place markers to aid in thoracoscopic identification for wedge resection 3. Thoracoscopic (better tolerated) or open thoracotomy with wedge resection

What are common benign etiologies of SPN?

1. Infectious granuloma (80% of benign SPN) 2. Hamartoma (10% of benign SPN)

What are the common causes of infectious granuloma?

Endemic fungi (histoplasmosis, coccidioidomycosis), mycobacteria (tuberculous or nontuberculous), and pneumocystis jirovecii

What is the characteristic appearance of hamartoma on CXR?

“Popcorn” calcification

What are common malignant etiologies of SPN?

1. Primary lung cancer (75%), such as adenocarcinoma, squamous cell carcinoma, large cell carcinoma, or carcinoid 2. Metastatic cancer (25%)

What are the most common sources of metastases to the lung?

Melanoma, sarcoma, and adenocarcinomas of the colon, breast, kidney, and testicle


What are the criteria for pulmonary metastasectomy?

1. Completely resectable based on preoperative imaging 2. Primary cancer controlled 3. Absence of extrapulmonary metastatic disease (i.e., metastasis isolated to lung)

What are unfavorable prognostic factors for survival after metastasectomy?

1. 2. 3. 4.

Can repeat pulmonary resection be performed safely to treat isolated, recurrent pulmonary metastases?

Yes; repeat surgery can establish control in the chest for selected patients

Incomplete resection Short (<36 mo) disease-free interval Multiple pulmonary metastases Lymph node involvement

SEGMENTAL ANATOMY OF THE LUNG (JACKSON AND HUBER NOMENCLATURE) Identify the labeled segments:


Right

Left

Upper lobe: 1. Apical segment 2. Posterior 3. Anterior

Upper lobe: 1. and 2. Apical segments 3. Anterior 4. and 5. Superior and inferior (lingular)

Middle lobe: 4. Lateral 5. Medial Lower lobe: 6. Superior 7. Medial basal 8. Anterior basal 9. Lateral basal 10. Posterior basal

Lower lobe: 6. Superior 7. and 8. Anteromedial basal 9. Lateral basal 10. Posterior basal

During a bronchoscopy how do you tell right from left?

The posterior trachea is identified by the membranous tissue vs. the anterior cartilage

MEDIASTINUM Anatomy What are the anatomic compartments of the mediastinum?

Anterior (and superior), middle, and posterior

What are the major landmarks between these compartments as noted on lateral CXR?

A = plane between sternal angle and disc between T4 and T5; B = plane just anterior to pericardium; C = plane posterior to heart and between trachea and esophagus


Mediastinal Masses What is the differential diagnosis of an anterior mediastinal mass (the four “T”s)?

1. Thymic tumor 2. “Terrible” Lymphoma (Hodgkin and non-Hodgkin) 3. Intrathoracic Thyroid goiter or tumor or parathyroid adenoma 4. Germ cell tumor, i.e., Teratoma

What is the differential diagnosis of a middle mediastinal mass?

1. 2. 3. 4. 5.

What is the differential diagnosis of a posterior mediastinal mass?

1. Primarily neurogenic tumors like neuroblastoma or ganglioneuroma 2. Esophageal tumors or duplication (enteric) cysts 3. Hiatal hernia

Which tumor is associated with the following findings: Vertebral anomalies?

Bronchogenic cyst Tracheal tumor Thyroid goiter or tumor Lymphoma Lymphadenopathy due to infectious disease or metastatic cancer or sarcoidosis

Enteric cyst

Radiological evidence of tooth within mass?

Teratoma

Hypoglycemia and why?

Neurosarcoma; secretes an insulin-like substance; known as the Doege–Potter syndrome

Gynecomastia?

Nonseminomatous germ cell tumors

Characteristic fever pattern?

Hodgkin’s lymphoma (Pel–Ebstein fever)

Hypertension?

Pheochromocytoma and chemodectoma

Red cell aplasia?

Thymoma

Cushing’s syndrome?

Thymoma, primary carcinoma, and carcinoid (mediastinal)

Ulceration into bronchus, esophagus, or lung?

Enteric cyst (gastric mucosa subtype)


Large size, and why?

Mesenchymal tumors; these tumors characteristically do not fix to or invade adjacent structures, so they remain asymptomatic until late

Identified chromosomal abnormalities (Klinefelter’s syndrome, 5q deletion, trisomy 8)?

Nonseminomatous germ cell tumors

Ptosis and diplopia?

Thymoma with associated myasthenia gravis

Increased levels of VMA (vanillylmandelic acid) and HVA (homovanillic acid) in urine?

Pheochromocytoma

Increased uptake with 131 I-MIBG (metaiodobenzylguanidine) scan?

Pheochromocytoma

Cerebellar and truncal ataxia with darting eye movements?

Neuroblastoma; called opsomyoclonus

Night sweats and pruritus?

Lymphoma

Cells from all three germ layers: endo-, meso-, and ectoderm?

Teratoma

Eaton–Lambert syndrome?

Thymoma (Note: Thymomas are associated with more systemic syndromes than any other mediastinal mass)

ESOPHAGUS Anatomy What are the anatomic narrowings of the esophagus?

Upper esophageal sphincter (UES), midthorax (due to external compression by left bronchus and aortic arch), and lower esophageal sphincter (LES)


Which is the most narrowest?

UES

Which type of muscle makes up the muscularis layer?

Skeletal muscle (upper third), smooth muscle (lower third), mixed smooth and skeletal (middle third)

Which named muscle forms the UES?

Cricopharyngeal muscle

At what tracheal and vertebral level is it located?

Cricoid cartilage and T1 vertebra

Unlike most of the gastrointestinal tract, the esophagus lacks what gross feature?

Serosa

What is the arterial supply of the esophagus?

1. 2. 3. 4. 5.

Which named nerves travel with the esophagus?

Right and left vagus nerves

Which of these nerves is located on the anterior surface?

Left

Which nerves form the intramural autonomic nervous system of the esophagus?

Auerbach’s plexus (between the longitudinal and circular muscle layers) and Meissner’s plexus (within submucosa)

Inferior thyroid artery Bronchial arteries “Esophageal arteries” from aorta Inferior phrenic artery Left gastric artery

Esophageal Motility Disorders What are the types of primary motility disorders?

1. Oropharyngeal dysphagia 2. Achalasia 3. Diffuse esophageal spasm

What is the classic type of secondary motility disorder?

Scleroderma


Dysphagia (difficulty swallowing), notably of both solids and liquids


Which type is associated with increased risk of carcinoma?

Achalasia

What diagnostic tests should be administered?

1. Barium esophagogram 2. Manometry

Which feature of these disorders often makes diagnosis difficult?

Intermittent nature of symptoms; during asymptomatic intervals, esophagogram and manometry findings are usually normal!

Oropharyngeal Dysphagia What is the physiological lesion in oropharyngeal dysphagia?

UES does not relax during swallowing

What are the general groups of etiologies?

Neurogenic disorders (e.g., stroke, brain tumor, multiple sclerosis); myogenic disorders (e.g., muscular dystrophy, myasthenia gravis); structural causes (Zenker’s diverticulum); mechanical causes (e.g., webs, tumors); postoperative scarring; and gastroesophageal reflux


Cervical dysphagia, intermittent hoarseness, weight loss, and excessive saliva expectoration

What is the finding on barium esophagogram?

Prominent posterior cricopharyngeal bar


Varies widely depending on the etiology

What must be confirmed before surgery, and why?

Competence of LES (by manometry and acid reflux test); myotomy makes the UES incompetent, and in the presence of LES incompetence, tracheobronchial aspiration occurs

If surgery is undertaken, which procedure is performed?

Cervical esophagomyotomy (longitudinal incision of muscular layers of the esophagus) to reduce resistance to swallowing

What incision is used?

Oblique left cervical incision, parallel to the anterior border of sternocleidomastoid muscle


Why is it important to avoid disruption of mucosa during the procedures for treatment of esophageal motility disorders?

1. Perforated mucosa increases incidence of postoperative strictures and infection 2. Risk of life-threatening mediastinitis

What is the management of intraoperative injury to esophageal mucosa?

Primary repair of mucosa; esophagogram on post-op day 1. If leak present or if esophageal emptying unsatisfactory, drains (neck drain or chest tube and nasogastric tube) should remain in place and alternative nutrition (preferably enteral via nasojejunal or laparoscopic feeding jejunostomy) started; then, on post-op day 10, follow up esophagogram to confirm closure of leak before removal of drains

Scleroderma What percentage of patients with scleroderma have symptoms referable to esophageal involvement?

>50%

What characteristic pathological changes occur in the esophagus?

Atrophy of muscularis and fibrotic replacement of the smooth muscle (distal two-thirds of esophagus)

What is the resultant physiological lesion?

Weak, nonpropulsive contractions of distal esophagus and loss of LES tone


Heartburn (due to reflux), epigastric fullness, and sensation of slow emptying of esophagus


Antireflux procedure (e.g., Belsey); in advanced cases, esophagectomy may be required

Esophageal Diverticula What are the general mechanisms of esophageal diverticula formation?

Pulsion—Pushing out of segment of esophageal wall by intraluminal force Traction—Pulling out of segment by external traction


What are the most common primary etiologies of diverticula due to each mechanism?

Pulsion—Abnormal esophageal motility Traction—Inflamed mediastinal lymph nodes

What are specific examples of each type of diverticula?

Pulsion—Pharyngoesophageal (Zenker’s) and epiphrenic diverticulae Traction—Midesophageal (parabronchial) diverticulae

Which are “true” vs. “false” diverticula?

Pulsion types are false diverticula (mucosa and submucosa protrude through a defect in muscular portion of wall); traction types are true diverticula (mucosa, submucosa, and muscular portion of wall)


Dysphagia, retrosternal chest pain, regurgitation of undigested food, cough, severe halitosis, and gurgling sounds in throat

Which diagnostic study is indicated?

Barium esophagogram (Note: Avoid esophagoscopy because of the increased risk of perforation)

What other study should also be done as part of workup?

Manometry (to assess the esophageal motility disorder in pulsion types)


All symptomatic patients should undergo surgical repair

Which type rarely requires treatment?

Midesophageal (because rarely symptomatic)

Pharyngoesophageal (Zenker’s) Diverticulum What is the specific location in the esophagus?

Posterior midline within inferior pharyngeal constrictor between thyropharyngeus and cricopharyngeal muscles (Killian’s triangle)

Which anatomic landmark is used to locate the sac intraoperatively?

Cricoid cartilage


What motility disorder is associated with pharyngoesophageal diverticulum?

Oropharyngeal dysphagia

What is the current standard surgical treatment?

1. One stage cricopharyngeal myotomy and diverticulectomy 2. Other options are cricopharyngeal myotomy and diverticulopexy to the prevertebral fascia or transoral stapling of the common wall between the diverticulum and the esophagus with diverticulum ⱖ3 cm (to fit the stapler)

What alternative surgical procedure is gaining popularity, and why?

Diverticulopexy (mobilize, invert, and tack pouch to the anterior spinal fascia); significantly reduced risk of postoperative leak/fistula

What occurs if myotomy is not performed?

Diverticulum recurs

Epiphrenic Diverticulum What is the location in the esophagus?

Distal esophagus (usually within 10 cm of cardia)

What motility disorder is associated with epiphrenic diverticulum?

Diffuse esophageal spasm and achalasia


Diverticulectomy; long esophagomyotomy or modified Heller myotomy, ± antireflux procedure (controversial)

Which incision should be used?

Left posterolateral thoracotomy (best access to distal esophagus)

Esophageal Perforation What is the most common etiology?

Iatrogenic (esophageal endoscopy or dilatation procedures, paraesophageal, surgical procedures)


What are the other etiologies?

Boerhaave’s syndrome (most common noniatrogenic etiology), trauma, swallowed foreign body, and caustic injuries

Why does the esophagus tend to rupture at lower pressures than the remainder of the gastrointestinal tract?

Lacks serosa (collagen fibers of serosa provide considerable strength to alimentary tract wall)


Chest pain, dysphagia, nausea, fever, tachycardia, and (not infrequently) hypotension

What is the classic sign of cervical rupture?

Subcutaneous (SQ) emphysema in neck and anterior thorax (crepitus)

What is the classic sign of intrathoracic rupture?

Hamman’s crunch (crackles auscultated as heart beats against emphysematous mediastinum)

What is the first study performed if perforation is suspected?

CXR

What are the classic findings on this study?

SQ or mediastinal emphysema, or both; widened mediastinum; pleural effusion or pneumothorax (PTX) (if pleura torn)


Contrast esophagogram (first, use watersoluble Gastrografin)

What biochemical test from thoracentesis sample of effusion would suggest perforation?

Elevated amylase (especially if isoenzyme from salivary glands)

What life-threatening condition develops with esophageal perforation?

Mediastinitis (primarily due to the virulent oral flora bacteria free in the mediastinum)

What is the key prognostic factor?

Duration between event and corrective surgery

Why?

Infection usually does not establish until 18–24 hr after the event (but once it develops, treating resultant empyema and suppurative mediastinitis is very difficult)


What is the treatment of cervical esophageal perforations?

Surgical exploration, drainage of retropharyngeal space and upper mediastinum with Jackson-Pratt drains, repair of perforation (if located), and IV antibiotics

What is the postoperative management regimen of cervical perforations?

Closely follow for evidence of mediastinitis; on day 5–7, perform contrast esophagogram with Gastrografin, then barium; if no leak, drains may be removed and PO intake initiated

In the treatment of thoracic (and abdominal) esophageal perforations, what is the most important factor in determining the course of treatment?

Interval between perforation and diagnosis

Why?

With late diagnosis, mediastinitis is well established, and any esophageal repair will likely break down because of inflammation, tissue friability, and infection

What are the generally accepted intervals for “early” vs. “late” diagnosis?

Early: <12 hr Late: >24 hr (The interval between 12 and 24 hr is controversial and best left to the surgeon’s judgment)

What is the treatment for early diagnoses?

Upper endoscopy to localize injury and determine approach, then direct repair with pedicled intercostal muscle buttress, pleural and mediastinal drainage ± definitive treatment of underlying pathology (i.e., myotomy on opposite side of injury for achalasia), draining gastrostomy, and feeding jejunostomy

What is the treatment for late diagnoses (controversial)?

T-tube drainage ± esophageal diversion (end esophagostomy and distal cervical esophagus stapled), draining gastrostomy, and feeding jejunostomy


What alternative nonsurgical approach has been increasingly used to manage esophageal perforation or leak?

Esophageal stenting

What are Cameron’s criteria for use of nonoperative treatment for patients with thoracic perforation?

1. Contained leak (isolated within mediastinum) 2. Selfdraining back into esophagus 3. Minimal symptoms 4. No (or minimal) signs of clinical sepsis

What are the components of nonoperative management?

NPO, enteral nutrition via laparoscopic feeding jejunostomy, and IV antibiotics (including antifungal)

Iatrogenic Perforation What are the most common sites of iatrogenic perforation? Are iatrogenic perforations usually diagnosed earlier or later than those in Boerhaave’s syndrome?

Just proximal to UES, gastric cardia, or an esophageal pathology (e.g., stricture) Earlier, because the procedure forces the surgeon to consider perforation early in the symptomatic patient (perforation is often initially missed in Boerhaave’s syndrome because of the relative infrequency of the disease)

Benign Esophageal Tumors Benign esophageal tumors account for what percentage of esophageal tumors?

Only 1%

What are the two most common types?

1. Leiomyoma (66%) 2. Enteric or esophageal duplication cyst


1. Barium esophagogram 2. Esophagoscopy (to rule out carcinoma)

Leiomyoma What are the symptoms?

Dysphagia, chest pain (if <5 cm in size, often asymptomatic)


What is the classic finding on barium esophagogram?

Smooth narrowing of lumen with intact mucosa (intramural mass)

How is esophagoscopic protocol different from leiomyoma vs. carcinoma, and why?

Mass is not biopsied


1. Symptomatic patient (chest pain, dysphagia) 2. Mass >5 cm in size

What is the procedure?

Surgically enucleate from esophageal wall via extramucosal approach

What incision should be used?

Posterolateral thoracotomy (right if in upper two-thirds, left if in lower one-third)

Why should endoscopic removal be avoided?

Increased risk of esophageal rupture and late stricture (due to disruption of mucosa)

Caustic Esophageal Injuries How are these burns classified?

First degree—Only mucosal erythema and edema Second degree—Erythema, edema, and ulceration (partial esophageal circumference) Third degree—Circumferential esophageal ulceration and mucosal sloughing

Which diagnostic studies should be performed on initial evaluation?

Esophagoscopy followed by barium esophagogram

What is the contraindication for diagnostic evaluation of the esophagus?

Evidence of laryngeal or pharyngeal burn (stridor, hoarseness, dyspnea); admit and monitor for airway obstruction (edema development can occur anywhere from 6 to 24 hr afterwards!) before diagnostic evaluation of the esophagus


What is the treatment of each type/degree of burn?

First degree—brief observation; continue PO intake, and discharge home Second degree—Antibiotics for 3 wk; continue PO intake, follow up endoscopy after 3 wk with early dilation to prevent stricture formation Third degree—Same as second plus gastrostomy with placement of string for retrograde dilation, later

What are the late sequelae of corrosive injury?

Stricture formation (most common), malignant degeneration, and hiatal hernia (fibrotic esophagus retracting stomach into chest)

What is the long-term management of these esophageal strictures?

Serial dilations if patient has symptomatic improvement; esophagectomy if nonresponsive to dilation

Other Esophageal Lesions Esophageal Webs What is the most common symptom?

Dysphagia

What are the types and general location of each in the esophagus?

Plummer–Vinson syndrome (PVS) web—Upper esophagus Schatzki’s ring—Distal esophagus (at squamocolumnar junction)

What is the etiology of each type?

Uncertain; presumed etiology for PVS is iron deficiency, and for Schatzki’s gastroesophageal reflux

What is the target population of PVS?

Middle-aged women

What are the characteristic findings on physical exam of this population?

Edentulous, spoon-shaped fingers with brittle nails, and strophic oral mucosa


Dilation of web plus iron supplements in PVS; antireflux procedure in Schatzki’s


Barium Esophagogram What is the most likely diagnosis for each of the following line drawings of various barium studies? (Several possibilities are present; try to pick the best)

A. Diffuse spasm B. Achalasia (moderate) C. Carcinoma: Annular type D. Zenker’s diverticulum E. Diffuse spasm with epiphrenic diverticulum F. Leiomyoma G. Carcinoma: Fungating type H. Sliding hiatal hernia (type I) with Barrett’s esophagus and esophageal stricture due to reflux I. Schatzki’s ring J. Achalasia (severe)


THORACIC TRAUMA Tracheobronchial Trauma What is the most common mechanism of injury?

Motor vehicle accidents (hyperextended neck striking dashboard or steering wheel)

What are the classic findings on physical exam?

SQ emphysema (especially with cervical tracheal injury), auscultation of mediastinal emphysema (Hamman’s crunch)

What are the associated CXR findings?

Pneumomediastinum, PTX, and SQ emphysema

What would significantly increase suspicion of tracheobronchial disruption after placement of tube thoracostomy?

1. Persistent air leak 2. Incomplete reexpansion of lung 3. Worsening respiratory status/symptoms when tube placed to suction because of resultant increase in flow through tracheobronchial lesion (almost pathognomonic)

How is definitive diagnosis made?

Bronchoscopy

What is the acute management of tracheobronchial trauma?

Establish a secure airway via intubation (use flexible bronchoscope to guide endotracheal tube if tracheal injury present)

What are the indications for surgical repair?

1. Persistent air leak 2. Large air leak with respiratory compromise due to incomplete expansion of lung

What approach is used, and how is the repair done?

1. For proximal 2/3 tracheal injury, transcervical approach and primary repair with rotational strap muscle or sternocleidomastoid muscle flap 2. For distal 1/3 tracheal, carina, and proximal right or left mainstem bronchial injuries within 2 cm of carina, right thoracotomy and primary repair with intercostal muscle buttress (not wrap) 3. For left mainstem bronchial injuries >2 cm from carina, left thoracotomy with repair and intercostal muscle buttress


What procedure can be performed if primary repair of trachea is not feasible at time of injury?

Bronchoscopic placement of a silicone tracheal T-tube (Montgomery)

What is the major chronic sequela of unrecognized tracheobronchial disruption?

Stricture formation with increased risk of necrotizing infection (seen more frequently in partial obstruction than complete)

Pulmonary Trauma Pulmonary Contusion What is the mechanism?

Blunt chest trauma—increased pulmonary capillary pressure—extravasation of blood cells, plasma, and serum proteins into interstitium and alveoli

What is the physiological result of this injury?

Intrapulmonary shunting (and hypoxia), reduced pulmonary compliance (and hypercarbia due to hypoventilation)

What is the classic finding on CXR?

Hazy infiltrate in region of blunt trauma

How long after injury before CXR findings become evident?

Variable: within several minutes in 70% of cases; up to 6 hr in 30%; regardless, over next 24 hr, size and density often dramatically increase

What may mimic pulmonary contusion on CXR in the trauma patient?

1. Atelectasis distal to aspiration of foreign body (e.g., tooth, dentures, food) 2. Hemothorax in supine patient (generalized haziness over entire lung field)

What is the treatment of pulmonary contusion?

Most cases require only supplemental oxygen; ± mask continuous positive airway pressure (CPAP), intubate and ventilate as needed; judicious use of IV fluids

Traumatic Asphyxia What is the mechanism of injury?

Crush injury to the thorax


What is the classic triad of physical findings?

1. Facial and upper torso edema with cyanotic appearance 2. Subconjunctival hemorrhage 3. Petechiae (due to retrograde flow through valveless veins of upper body associated with sudden increase in intrathoracic pressure)


Supportive, head elevation, and supplemental oxygen

Traumatic Air Embolism What is the most common cause?

Penetrating wound to chest resulting in injury to abutting pulmonary vessel and tracheobronchial lumen

What dramatically increases the risk of air embolus?

Positive pressure ventilation


1. Cerebral ischemia (e.g., seizures) and cardiac ischemia (infarction, arrhythmias) due to the resultant air emboli and platelet—fibrin aggregates 2. Coagulopathy and bronchospasm due to activation of inflammatory cascades


Left lateral decubitus position, feet elevated 30–60 degrees (unfortunately often difficult in the trauma patient); aspirate air from CVP line (consider cardiopulmonary bypass or hyperbaric oxygen)

MISCELLANEOUS What is the differential diagnosis for thoracic outlet syndrome?

Cervical spine Ruptured intervertebral disk Osteoarthritis Spinal cord tumors Peripheral neuropathy (e.g., carpal tunnel syndrome) Brachial plexus palsy Arterial


Aneurysm Embolism Occlusive disease Thromboangiitis obliterans Raynaud’s disease Venous Thrombophlebitis Vasculitis, collagen disease What are three causes of vena cava syndrome other than malignant tumors?

1. Chronic mediastinitis 2. Benign tumors 3. Thrombosis (often resulting from a long-term central line)

What may aggravate the symptoms of superior vena cava (SVC) syndrome?

Lying flat or bending over

What is the clinical course of SVC syndrome?

Depends on rapidity of onset; rapid onset of severe obstruction with no time to develop collateral circulation leads to severe symptoms and possibly fatal cerebral edema; chronic onset, as in fibrosing mediastinitis, may be very insidious and mild as collateral drainage develops

How is the diagnosis of SVC syndrome made?

1. Measure upper extremity venous pressure 2. Venography localizes the obstruction 3. CT scan evaluates for tumor 4. Obtain MRI/MRA

What are the classic locations of aspiration pneumonia?

RUL—Posterior segment RLL—Superior segment

Which bronchus is inadvertently intubated most often?

The right mainstem (less of an angle from the trachea than the left)


Chapter 76 Cardiovascular Surgery CONGENITAL HEART DISEASE What is the incidence of congenital heart disease in the United States?

4–10 per 1,000 live births

What three general physiological disturbances are associated with congenital heart disease?

Left to right (L to R) shunts, R to L shunts, and ventricular outflow obstruction

What are the three most common defects and their relative frequencies among all congenital heart defects?

Ventricular septal defect (VSD; 30%–40%) Atrial septal defect (ASD; 10%–15%) Patent ductus arteriosus (PDA; 10%–20%)

What are the most common general INITIAL presentations of congenital heart lesions?

CHF, central cyanosis, and poor peripheral perfusion

Which presentation is classic for each of the classes of lesions?

CHF (acyanotic): L to R shunt, ventricular outflow obstruction Cyanosis: R to L shunt CHF and cyanosis: Complex defects; rarely, shunts may also eventually develop into CHF, but cyanosis is the presenting sign

What are the symptoms of CHF in children?

Infants—tachypnea and diaphoresis (especially with feeding), failure to thrive, easy fatigability, irritability, hepatomegaly Young children—nausea, vomiting, failure to thrive, respiratory complaints (chronic cough or wheeze) Adolescents—similar to adults with CHF—angina, syncope, exercise intolerance, dyspnea, edema

How is central cyanosis recognized?

Bluish discoloration of highly vascularized tissues (i.e., lips, mucous membranes, nail beds, and conjunctiva)

Chapter 76 / Cardiovascular Surgery 583

What types of defects are associated with pulmonary overcirculation?

L to R shunts: PDA, VSD, ASD, truncus arteriosus, AV septal defect, transposition of the great arteries, TAPVR

What is a detrimental long-term consequence of pulmonary overcirculation?

Pulmonary hypertension

What types of defects are not characterized by pulmonary overcirculation?

R to L shunts: Tetralogy of Fallot, tricuspid atresia/stenosis, pulmonary atresia/stenosis

Which shunt classically reverses if untreated, and what is the syndrome called?

L to R shunts; Eisenmenger’s syndrome

Cyanotic Congenital Heart Disease What is the most common cyanotic congenital heart defect diagnosed during the neonatal period?

Transposition of the great arteries

What is the most common cyanotic congenital heart defect diagnosed after the neonatal period?

Tetralogy of Fallot

Sequelae of Cyanotic Heart Disease What are the classic sequelae Hypertrophic osteoarthropathy (clubbing), of cyanotic heart disease? polycythemia, hypercyanotic spells, cerebrovascular accidents, brain abscesses, coagulation disorders, and endocarditis What are hypercyanotic (or hypoxic) spells?

Abrupt increase in cyanosis associated with cerebral anoxia that may result in unconsciousness, seizure, or death

What is the usual mechanism of these spells?

Infundibular muscle spasm in the right ventricular outflow tract, resulting in a sudden reduction in blood flow to the lungs


Why are brain abscesses common in patients with cyanotic heart disease?

R to L shunt permits venous blood to bypass the lungs, which are an important filter for bacteria; it is by the same mechanism that adults with a patent foramen ovale can have paradoxical embolization

What are the most common organisms in these abscesses?

Gram-positive cocci (staphylococcus and streptococcus)

Brain abscesses are most often seen with which anomaly?

TOF

What is the hallmark physical finding of CHF and central venous congestion in a child?

Hepatomegaly

What finding typically complicates cardiac surgery for complex cyanotic heart disease?

The formation of aortopulmonary collateral blood vessels; these are branches of systemic arteries that supply blood to the pulmonary circuit

What lesions are associated with development of aortopulmonary collateral blood vessels?

Tetralogy of Fallot, pulmonary valve atresia, and defects leading to single ventricle physiology

Ventricular Septal Defects What is the anatomic lesion?

Abnormal communication between the left and right ventricles

What are the locations (“types”) of VSD?

Infundibular or canal septum (beneath the semilunar valves), membranous septum, inlet septum, and muscular septum

Which type is most common?

Membranous septum (80%–85%)

What is a “large” VSD?

Diameter ≥ aortic orifice

What percentage of patients with VSD have additional congenital cardiac lesions?

>50%


What is the main physiological problem in VSD?

L to R shunting, leading to pulmonary overcirculation

What classic syndrome may develop if VSD is untreated?

Eisenmenger’s syndrome

Describe the murmur associated with VSD:

Harsh pansystolic murmur at the left sternal border

When do infants with large VSDs become symptomatic, and why?

6 wk to 3 mo; pulmonary vascular resistance (PVR) must decrease from its high fetal baseline value before L to R shunt is possible; (PVR does not reach the normal adult level until after 3 mo of age)

What are the complications of VSD?

Large VSD: CHF and pulmonary hypertension Small VSD: Increased risk of endocarditis

Why is nonoperative management initially warranted in many cases?

Many patients (25%–50%) have spontaneous closure; the chance of closure decreases with increasing age at presentation (80% of defects noted at 1 mo will close, vs. only 25% noted at 12 mo)

What “closes” VSDs that close spontaneously?

Hypertrophy of adjacent muscular septum or the septal leaflet of the tricuspid valve

Atrial Septal Defects What is the anatomic lesion?

Abnormal communication between the right and left atria

What are the types, and the general location of each type in the septum?

Sinus venosus: High in the atrial septum Ostium secundum: Middle (fossa ovalis region) Ostium primum: Low

Which type is the most common?

Ostium secundum (80%)

What is the main physiological problem in ASD?

L to R shunt


Why is this problem minimal during the first few years of life?

Right ventricular hypertrophy of infancy takes time to subside; in infancy, compliance of the right ventricle (RV) is similar to that of the left ventricle (LV), thus minimizing the shunt

What are the primary factors that determine the degree of shunting in ASD?

Compliance of the ventricles, PVR, and size of the ASD; size is less important than in VSD

What percentage of the general population has a patent foramen ovale (PFO)?

10%–25%

Why is PFO not considered an ASD?

It usually permits only unidirectional (R to L) shunt because of the relation between the remnants of the septum primum and the septum secundum

At what age do UNTREATED patients with isolated ASD become symptomatic?

30–40 yr old (usually asymptomatic until then)

At what age do UNTREATED patients with ASD show a clear increase in mortality rate?

20 yr old; the survival rate (untreated) is 85% at 20 yr, 40% at 40 yr, and 25% at 50 yr

How does ASD present?

CHF (e.g., dyspnea)

Describe the murmurs associated with ASDs

Systolic ejection murmur at the left sternal border due to increased pulmonary blood flow; middiastolic murmur due to increased blood flow across the tricuspid valve; wide fixed splitting of the second heart sound

What is the primary contraindication to surgery?

Irreversible pulmonary hypertension (>10 Wood units)

What corrective procedure is performed?

Transcatheter septal occlusion or surgical closure via primary closure or patch closure (prosthetic or pericardial)


What is the main operative complication?

Injury to the conduction system

Patent Ductus Arteriosus (PDA) PDA is the embryological remnant of what structure?

Sixth left aortic arch

What is the normal function of the ductus arteriosus?

Shunts blood from the pulmonary trunk to the aorta (R to L) to bypass the uninflated lungs (blood oxygenated at the placenta)

When does it usually close?

In the first few days of life (96% closed by 48 hr); complete closure, through fibrosis and intimal proliferation, to form the ligamentum arteriosus takes several months

What stimulates this initial closure?

It is theorized that increased arterial oxygen tension may constrict the muscle in the ductus

What physiological conditions may prevent closure of the ductus?

Hypoxia and increased levels of prostaglandins

PDA is common in what group of infants?

Premature infants, especially girls

Describe the murmur associated with PDAs

Continuous “machinery” murmur with a late systolic peak, widely transmitted to the precordium and neck; the diastolic component of the murmur is absent in infancy because of elevated PVR (normal physiology); thus, it often is not continuous until 1 yr of age

What is the other classic finding on cardiovascular physical exam?

Wide pulse pressure with bounding pulse (large PDAs only)

What are the most common causes of death in adults with UNTREATED PDA?

CHF and bacterial endocarditis, especially Streptococcus viridans


What is the medical treatment of PDA?

Indomethacin (prostaglandin E1 inhibitor); if unresolved in 1 wk, surgery is indicated

In which patients is medical treatment ineffective?

Full-term infants; children


Left posterolateral thoracotomy and PDA ligation

What is the catheter-based treatment?

Percutaneous (transcatheter) coil embolization or placement of closure device

What limits percutaneous closure of PDA?

Child size (cannot catheterize neonates safely)

Care is taken to avoid injury to which nerve that courses close to the PDA?

Left recurrent laryngeal nerve

When is surgery performed?

If the PDA is large and CHF develops, surgery is performed immediately, regardless of patient age; otherwise, surgery is performed at 1–2 yr of age or thereafter, whenever the diagnosis is made

What is the primary contraindication to surgery, and why?

Cyanosis caused by an untreated cyanotic cardiac anomaly or severe pulmonary hypertension, both of which depend on the patency of the PDA for patient survival (one as a source of blood to the lung, the other as a means to shunt blood away from the high-pressure pulmonary bed)

What common therapy could potentially worsen pulmonary overcirculation with a large PDA?

Oxygen, which may increase shunting across PDA due to decreased PVR


Truncus Arteriosus What is the anatomic lesion?

Single large vessel that straddles the ventricular septum (instead of a separate aorta and pulmonary artery), with a 3–6-leaflet truncal valve

Type I

Type II

Type III

Type IV

What additional congenital cardiac lesion is always seen in these patients?

VSD, usually immediately under the truncal valve

What is the palliative surgical procedure?

Pulmonary artery banding to permit growth for infants with severe concurrent noncardiac disease (rarely used)

What is the corrective procedure?

Excision of the pulmonary artery confluence (of right and left pulmonary arteries) from the main truncus (depending on type of defect) closure of the aortic defect, and placement of a conduit (homograft, bovine, or porcine graft) to establish continuity between the RV and the confluence of the pulmonary arteries, and closure of the VSD

What finding leads to increased mortality in patients with truncus arteriosus?

Truncal valve insufficiency


Tetralogy of Fallot (TOF) What are the four classic anatomic features?

1. Overriding aorta (dextroposition of the aorta) 2. Infundibular or pulmonary valvular stenosis 3. VSD 4. Right ventricular hypertrophy

1 Overriding aorta 2 Valvular and infundibular pulmonary stenosis 3 Large ventricular septal defect 4 Hypertrophic right ventricle

What are the surgically correctable defects in TOF?

Infundibular or pulmonary valvular stenosis and VSD

What is the pentalogy of Fallot?

TOF plus ASD

What is the surgical procedure for correcting TOF?

Age and size at time of repair dictate management; palliative systemic to pulmonary shunt (i.e. modified Blalock– Taussig shunt), RV to PA conduit (i.e., Sano shunt), or pulmonary valvectomy and transannular patching of the right ventricular outflow tract (RVOT) for neonates may be a bridge to corrective procedure at 6 mo to 2 yr of age; definitive corrective procedure is placement of a RVOT to PA conduit and closure of the VSD; some surgeons now prefer early total correction


Ebstein’s Anomaly What is the basic anatomic lesion?

Tricuspid valve is positioned abnormally low within the RV (with a large “sail” anterior leaflet and septal and posterior leaflets originating from the wall of the RV); the RV is divided into a thin “atrialized” supravalvular portion and a normal trabeculated apical and infundibular portion; ASD is also usually present

Ao

PA LA

LV RA

RV

Prenatal exposure to which drugs may increase the risk of developing Ebstein’s anomaly?

Lithium and benzodiazepines


Tricuspid valvuloplasty, followed by reconstruction with plication of the atrialized portion of the RV, followed by ASD closure; occasionally, tricuspid valve replacement (the procedure of choice in the past) is necessary


Transposition of the Great Vessels What is the anatomic lesion?

Ventriculoarterial discordance (e.g., aorta originates from the RV; the pulmonary artery from the LV) with AV concordance (ventricles are connected to the appropriate atria); this condition results in parallel, rather than serial, systemic and pulmonary circulations Pulmonary artery Aorta

Left atrium

Right atrium Right ventricle Left ventricle

What is the claim to fame of this condition?

Most common congenital defect that causes cyanosis and CHF in the newborn period (>90% by day 1)

What is the palliative surgical procedure?

Balloon atrial septostomy (Rashkind procedure)

What determines if definitive procedure is applicable?

The ability of the left ventricle to pump blood systemically

When should definitive repair take place? Why?

Within the first 2 wk of life. In children with untreated TGA, the LV adapts to the low pressures of the pulmonary circuit and will fail if switched to pump against the high-pressure systemic circuit


What are the options for corrective procedure?

Atrial switch procedure: Intra-atrial baffle to redirect venous blood toward the appropriate great vessel (i.e., Mustard procedure) Arterial switch procedure: Switching of the aorta and pulmonary artery and reimplantation of the coronary arteries into the aorta (Jatene procedure)

Coarctation of the Aorta What is the anatomic lesion?

Narrowing of the aorta

What is the physiologic disturbance caused by the lesion?

Left ventricular outflow obstruction

Where does the coarctation typically develop?

At the insertion of the ductus arteriosus distal to the left subclavian artery (juxtaductal)

How is blood flow preserved distal to the coarctation?

Blood flows into the descending aorta via the PDA

What physical exam findings indicate coarctation of the aorta?

Differential cyanosis—cyanosis of the lower portion of the body; a femoral pulse that is not palpable or delayed in comparison to brachial pulse; hypertension in the upper extremities, corresponding to vessels proximal to the coarctation

What are the options for corrective procedure?

Aortic advancement, subclavian flap aortoplasty

What percentage of coarctations recurs?

20% among newborns

What is the initial treatment for recurrence?

Balloon dilation of the coarctation

Total Anomalous Pulmonary Venous Connection (TAPVC) What is the general anatomic lesion?

No pulmonary veins directly drain into the left atrium (LA) ± pulmonary vein stenosis


What are the four types and their relative frequencies?

Supracardiac: Pulmonary venous drainage into the SVC (50%) Intracardiac: Pulmonary venous drainage into the coronary sinus or right atrium (RA) (25%) Infracardiac: Pulmonary venous drainage into the IVC (20%) Mixed: Two or more different venous connections (5%)

What is partial APVC (PAPVC)?

Some, but not all, pulmonary veins empty into the LA

What is scimitar syndrome?

PAPVC in which the pulmonary veins from the right lung join to form a single vertical vein that curves downward to join with the IVC


Hypoplastic Left Heart Syndrome What is the anatomic lesion?

The left side of the heart and ascending aorta are hypoplastic; aortic valve atresia or severe hypoplasia (primary lesion), LV hypoplasia, mitral valve atresia or hypoplasia, and ASD; the interventricular septum is usually intact

What is the surgical therapy?

Staged therapy to convert the functioning right ventricle to pump blood systemically; pulmonary blood flow is maintained via a systemic to pulmonary shunt

What are the stages of surgical therapy and when are they typically done?

Neonatal period—Norwood procedure (creation of a neoaorta from the pulmonary trunk, aortic reconstruction; creation of a shunt to deliver blood to the pulmonary arteries [Blalock–Taussig, modified Blalock– Taussig, or Sano shunt]) 4–8 mo—bidirectional Glenn (SVC to PA confluence) 12–24 mo—extracardiac Fontan (SVC and IVC are joined and drain directly into the PA confluence) or intracardiac Fontan (SVC and IVC are rejoined to a baffled, isolated portion of the right atrium that is joined to the PA confluence)

Why are the operations staged?

Systemic venous to pulmonary shunts require decreased pulmonary vascular resistance to ensure forward flow

Vascular Rings What is the embryonic origin of a vascular ring?

Anomalous development of the aorta and pulmonary artery from the embryonic aortic arches

What is the most common type?

Double aortic arch, in which the right aortic arch persists, and the left and right aortic arches encircle the trachea and esophagus

What is the most prominent symptom?

Stridor due to tracheal compression by the vascular ring


What is the classic finding on barium swallow?

Posterior compression of the esophagus

Although a variety of anomalies and multiple operative techniques exist, what is the basic surgical procedure?

The compressive arteries are divided, and bypass performed if necessary

Pulmonary Artery Sling Define the anatomic defect?

Origin of the left pulmonary artery from the right pulmonary artery; the abberrant left pulmonary artery courses around the trachea posteriorly toward the hilum of the left lung

What is the classic finding on barium swallow?

Anterior compression of the esophagus

What is the basic surgical procedure?

Division of the left pulmonary artery to bring it anterior to the trachea, where it is anastomosed to the main pulmonary trunk

Aneurysm of the Sinus of Valsalva What are the sinuses of Valsalva?

Outpouchings of the aortic root corresponding to leaflets (indentations where commissures meet the aortic wall)

What are the etiologies of aneurysms of these sinuses?

Congenital: Aortic wall media does not meet the aortic annulus Acquired: Endocarditis, myxomatous degeneration, syphilis, and chronic aortic dissection

Eisenmenger’s Syndrome What is Eisenmenger’s syndrome?

Reversal of a long-standing untreated L to R shunt (i.e., becomes R to L shunt)

Why does it occur?

L to R shunt increases pressure in the right side of the heart; reactive changes (e.g., medial hypertrophy, sclerosis) occur in the pulmonary arterioles, followed by pulmonary hypertension; eventually, the shunt reverses


What is the most common cardiac lesion associated with this syndrome, if left untreated?

VSD


New onset of cyanosis in a patient with L to R shunt

What is the most common cause of death?

Massive hemoptysis; patients often die by 30–40 yr of age


Heart–lung transplant; thus, the condition is considered inoperable by many

Palliative Shunts for Congenital Heart Disease What is one potentially harmful complication associated with systemic arterial shunts?

Systemic arterial shunts can lead to diastolic steal from the coronary arteries, leading to decreased coronary artery perfusion

ACQUIRED CORONARY ARTERY DISEASE Coronary Anatomy Identify the labeled arteries:

1. 2. 3. 4. 5. 6. 7.

Sinoatrial nodal artery Right coronary artery AV nodal artery Right marginal artery Left main coronary artery Circumflex artery Left anterior descending (LAD) artery 8. Obtuse marginal arteries 9. Diagonal arteries 10. Posterior descending artery


What is meant by “three-vessel disease”?

Greater than 50% occlusion of all the three main coronary arteries (right, LAD or left main, left circumflex)

What is significant about three-vessel disease?

It is an indication for coronary artery bypass grafting (CABG)

What percentage of patients with CAD has three-vessel disease?

50%

Are most individuals right or left “dominant,” and what does this designation mean?

90% are right dominant (posterior descending artery originates from the right coronary circulation); in leftdominant individuals, the posterior descending artery originates from the circumflex artery

What are the multiple secondary branches of the LAD and the circumflex artery?

LAD: Septal and diagonal arteries Circumflex: Marginal arteries

Coronary arteries arise from which aortic region?

Sinuses of Valsalva

Which coronary artery supplies the sinus node vs. the AV node?

Both are usually supplied by the right coronary artery

Most atherosclerotic lesions are located in what general region of the coronary arteries?

Proximal one-third to one-half; this feature permits coronary artery bypass, except in the occasional patient with severe distal disease

Coronary Artery Bypass Grafting (CABG) What options exist for bypass grafts?

Saphenous vein, internal mammary artery, free arterial grafts (radial artery)

Which types of grafts have the best long-term patency and are thus preferred?

Internal mammary artery


Why is use of both internal mammary arteries avoided?

Risk of sternal wound infection and dehiscence

What patient characteristics increase the risk of sternal wound complications?

Obesity, COPD, and diabetes

After CABG, what percentage of patients are free of ischemia: In the early postoperative period?

90%

At 5 yr?

75%

At 10 yr?

50%

What is the most common cause of recurrence of angina <5 yr vs. >7 yr after CABG?

<5 yr: Progression of atherosclerotic disease in native coronary arteries >7 yr: Atherosclerotic disease in bypass grafts

What decreases the risk of future graft thrombosis?

Aspirin

What is the mortality rate for: Elective CABG?

1%–2%

Emergent CABG?

3%–8% (often even higher in the setting of postinfarction angina)

Emergent CABG in the setting of cardiogenic shock?

>50%

Elective redo CABG?

7%–8%

Emergent redo CABG?

25%

Acute MI?

10%–25% (e.g., surgery is worth the risk to prevent or delay MI)


Mechanical Complications of Ischemic Heart Disease What are the most common mechanical complications following MI?

Acquired VSD Acute ischemic mitral regurgitation Left ventricular free wall rupture Left ventricular aneurysm

What type of patient typically has these complications?

Patients with single-vessel disease, no history of angina, and uncomplicated MI with acute decompensation in the early post-MI period; after AMI, patients with delayed inhospital treatment (greater than 24 hr) and postinfarction angina are at increased risk

Why are patients with multivessel disease less likely to develop mechanical complications after AMI?

Collateral coronary blood flow with total occlusion of the LAD artery

Acute Ventricular Septal Defect When does acute VSD classically present?

5–7 d after MI

What is the classic presentation?

Acute onset of CHF with a new, harsh pansystolic murmur and thrill at the left sternal border

What is the usual Swan–Ganz catheter finding?

“Step-up” of oxygen saturation (>10%) between the RA (proximal port) and pulmonary artery (distal port)


Afterload reduction to minimize flow across the VSD and increase systemic flow; this therapy is also used to temporarily stabilize the surgical patient before repair

What is the surgical procedure for acute VSD?

Left ventriculotomy through the infarcted area with patch repair of VSD and patch closure of ventriculotomy; (Although repair was often delayed for several weeks in the past, it is now performed acutely)


Compare the timing of surgery if cardiac output (CO) is normal vs. decreased:

When calculated using a Swan–Ganz catheter, CO is artifactually increased in patients with VSD because the thermodilution curve is altered by the L to R shunt; CO does not affect timing

Acute Ischemic Mitral Regurgitation What are the mechanisms of Papillary muscle dysfunction, annular acute ischemic MR? dilation, and rupture of either papillary muscles or chordae tendinae When does acute ischemic MR usually present?

7–10 d after AMI

What territory is usually involved in MI associated with MR?

Posterolateral territory with injury to the posteromedial papillary muscle (usually posterior descending artery territory)

Why is the posteromedial papillary muscle more commonly affected, compared with the anterolateral papillary muscle?

The posteromedial papillary muscle has a single source of coronary blood flow, whereas the anterolateral papillary muscle has a dual source of blood flow


Heart failure, hypotension, and pulmonary edema accompanied by a new holosystolic murmur loudest at the mitral area that radiates to the axilla

What are the Swan–Ganz catheter findings?

Large V wave on the pulmonary capillary wedge pressure (PCWP) tracing; no “step-up” of oxygen saturation

What percentage of deaths due to AMI are due to papillary muscle rupture?

5%

What is the mortality rate in UNTREATED patients with MI complicated by ischemic MR?

70% in the first 24 hr; 90% in the first 2 wk


What key question must be answered to guide patient management?

Will the etiology of MR likely resolve with supportive medical therapy (stunning), or is acute surgical correction required (ruptured papillary muscle)?

What is the hemodynamic goal of medical treatment?

Afterload reduction to minimize regurgitant flow by maximizing flow from the LV; this therapy is also used to temporarily stabilize the surgical patient before repair

What is the treatment of the hypotensive patient?

Dobutamine and intra-aortic balloon pump (IABP)

What is the surgical procedure for acute ischemic MR?

Mitral valve repair (preferred), mitral valve replacement (MVR) if papillary muscle necrosis is present and CABG to the infarcted territory (and other territories at risk)

Left Ventricular Aneurysm What is the most common etiology of left ventricular aneurysm?

Large transmural MI (infarcted tissue replaced by a fibrous scar that permits localized dilation of the ventricle) with total occlusion of the LAD artery

What is the incidence of this complication?

8%–15% of patients with MI

What region is most commonly involved?

Anterior-apical surface of the LV (LAD territory)

What is the most common presentation?

Left ventricular failure (LVF)


Dyskinesia (paradoxical outward bulge of the region during systole and diastole) seen on ventriculogram or echocardiogram (Because of transient functional changes associated with stunned myocardium, the diagnosis of left ventricular aneurysm cannot be made at the time of acute MI)


What is the classic ECG finding?

Persistent ST elevation in the involved territory after MI (vs. in pericarditis, ST elevations occur in almost all leads)

What are the usual complications?

LVF, arrhythmias, angina, and, infrequently, emboli from mural thrombus; these aneurysms rarely rupture

What is the medical treatment for left ventricular aneurysm?

Afterload reduction and medications to reduce LV modeling, such as angiotensin-converting enzyme inhibitors. Anticoagulation is indicated if thrombus is present within the aneurysm or if there is significant LV dysfunction on echocardiography

What are the indications for surgery for left ventricular aneurysm?

Symptomatic patient; heart failure not improved by medical therapy or catheter-based therapies alone; arrhythmias refractory to medical therapy; systemic embolization in a patient with contraindications to anticoagulation


Aneurysmectomy and CABG to the ischemic territory

What is the waiting period after MI for elective repair, and why?

At least 2 mo, to permit the aneurysm to become well demarcated and the rim to become fibrotic (vs. necrotic and difficult to suture)

ACQUIRED VALVULAR HEART DISEASE Aortic Valve What is the normal patent surface area of the aortic valve?

3–4 cm2

What gross changes occur in the heart as a result of aortic stenosis (AS) vs. aortic regurgitation (AR)?

AS: Left ventricular hypertrophy (LVH) (concentric) because of pressure overload AR: Left ventricular dilation (and LVH) because of volume overload


Compare AS with AR: Which is generally less well tolerated?

AS; strain on the LV caused by increased intraventricular pressure is greater than that of volume overload

Which has a male:female ratio of 8:1?

AS

Which may be associated with ascending aortic dilatation?

Both; in AS, it may develop as a result of poststenotic turbulence; an ascending aortic aneurysm with associated dilation of the aortic annulus may cause AR

Which studies are used to diagnose and quantify the severity of AS and AR?

Echocardiogram (with Doppler) and cardiac catheterization (ventriculogram)

What variables are measured with these studies?

AS: Transvalvular pressure gradient and valvular surface area AR: Severity of regurgitation Valvular surface areas are calculated with the Grolin formula, using estimates of flow and gradients; thus, the criteria for severity of valvular lesions are rough guidelines; the patient’s symptoms are far more important!

Which patients should also have a coronary angiogram?

Any patient >35 yr old or with symptoms of MI (angina), regardless of age

What cardiac structures are at risk for injury during aortic valve replacement (AVR)?

Coronary artery ostia and the bundle of His in the membranous ventricular septum, specifically at the commissure between the right and noncoronary cusps

Which patients are at greatest risk for postoperative ventricular failure after AVR?

Patients with a low preoperative ejection fraction (<40%)

What is the treatment of postoperative ventricular failure?

Vasodilators (for afterload reduction) and inotropic support, + IABP until the ventricle recovers or adapts to increased afterload


What is the target systolic blood pressure (SBP) after AVR, and why?

Goal SBP is <120 mm Hg to reduce the risk of bleeding from the aortic suture line; (The ascending aorta is incised to gain access to the valve)

What conduction disturbance may occur after AVR?

Heart block, usually caused by edema around the bundle of His and therefore transient; occasionally, permanent heart block occurs because of intraoperative mechanical trauma (i.e., suturing through the bundle)

What is the treatment of postoperative conduction disturbances?

Temporary pacing with pacing wires (placed intraoperatively) until the edema resolves; a permanent pacer if heart block persists

What is the 10-year mortality rate for untreated symptomatic AS vs. AR?

AS: ≈100%; AR <40%

Valvular Aortic Stenosis What is the claim to fame of valvular AS?

Most common isolated valvular lesion


Calcification of congenitally bicuspid aortic valve (50%), rheumatic fever (33%), and senile (idiopathic) calcification of a normal (trileaflet) aortic valve

What are the three nonvalvular etiologies of left ventricular outflow obstruction?

Hypertrophic cardiomyopathy (septal hypertrophy), subvalvular stenosis (focal LV outflow tract stenosis or web), and supravalvular stenosis (aortic narrowing or web)

When is valvular stenosis considered critical?

Transvalvular systolic pressure gradient >50 mm Hg Valvular surface area <1 cm2

How is CO maintained as stenosis progresses?

Gradual LVH to overcome increasing afterload


What is the usual age at initial presentation?

40–60 yr if AS is caused by calcification of the bicuspid valve; otherwise, 60–80 yr


Angina, syncope, and exertional dyspnea as a result of CHF

What is the average life expectancy (if untreated) after the onset of each of these symptoms?

Angina: 3–5 yr; syncope: 2–3 yr; dyspnea: 1–2 yr; symptoms are characteristically late, and once they develop, there is rapid clinical deterioration if left untreated

What is the usual mechanism of angina in AS?

Increased myocardial oxygen demand because of increased afterload plus decreased oxygen delivery because of LVH; (Angina may also be caused by concurrent CAD)

AS is rarely symptomatic before the valve surface area is reduced to what size?

1 cm2 (about one-third of the normal area)

Why may loss of sinus rhythm cause acute decompensation in AS?

LVH results in reduced ventricular compliance, and the synchronized atrial contraction of diastole becomes an important component of ventricular filling

Describe the murmur associated with AS:

Crescendo–decrescendo systolic murmur in the second right intercostal space with radiation to the carotids; intensity does not correlate with severity; in fact, the most severe cases often have barely audible murmurs

What are the other classic findings of AS?

Pulsus parvus et tardus (delayed, slow carotid upstroke, with decreased amplitude); narrowed pulse pressure; paradoxic split of S2 because of delayed closure of the aortic valve (A2 follows P2); decreased intensity of S2; ejection click after S1; LV lift or heave


What valvular lesion often masks the clinical findings of AS?

Mitral stenosis (MS)

What are the usual ECG findings?

Evidence of LVH: S (V1 or V2) + R (V5 or V6) >35 mm, R (V5 or V6) >27 mm, or R (AVL) >11 mm Evidence of LV strain: Repolarization changes (ST depression with upward convexity and T-wave inversion)

What are the usual CXR findings?

Normal cardiac silhouette, except for some rounding of the apex because of LVH, + calcifications at the level of the aortic valve, + widening of the cephalad mediastinum because of poststenotic dilatation of the aorta

When is echocardiography often inaccurate in its assessment of AS?

In the presence of concurrent MS (or AR) or low CO

What is the most feared common complication of AS?

Sudden death because of ventricular fibrillation

What is the etiology of this complication?

Hypertrophy increases the risk of subendocardial ischemia and, thus, ventricular ectopy


Symptomatic patient (angina, syncope, CHF) Critical AS The surface area criteria for surgery vary from 0.5 to 1 cm2, depending on the surgeon as well as the patient’s overall condition; asymptomatic patients are rarely considered for surgery


AVR ± annuloplasty (incision of the annulus to accommodate placement of a larger prosthetic valve in a patient with a small aortic root)


What are the treatment options for the poor surgical candidate?

Percutaneous balloon valvuloplasty; unfortunately, 50%–75% restenose in 6 mo Palliative medical therapy for CHF + angina (i.e., digitalis, diuretics, nitrates)

What is the 5-year survival rate for patients who have had AVR for AS?

80%–90%; if ventricular function is impaired at the time of surgery, the 5-year survival rate is reduced by 15%–25%

Aortic Regurgitation (AR) What are the etiologies of AR?

Myxomatous degeneration (i.e., Marfan’s disease), rheumatic fever, bacterial endocarditis, ascending aortic aneurysm or dissection with dilation of the aortic annulus, calcification of a congenitally bicuspid valve


Uncomfortable palpitations as a result of arrhythmias, ectopic ventricular beats, or powerful contractions of the dilated LV against the chest wall; symptoms of left heart failure (e.g., dyspnea, orthopnea); and angina

What is the classic presentation of ACUTE AR?

Fulminant heart failure (vs. adaptive changes in the LV that permit gradual tolerance of chronic AR over time)

What is the classic blood pressure finding and the mechanism?

Wide pulse pressure (often 80–100 mm Hg) because of increased SBP associated with increased CO and decreased diastolic blood pressure associated with regurgitation

What is the classic character of the pulse?

Bounding because of collapse during diastole (Corrigan’s pulse); double-peaked (“bisferious” pulse); Traube’s sign or “pistol shot” femoral pulse (systolic and diastolic bruit over the femoral arteries), Hill’s sign (excessively high popliteal compared with brachial SBP)


What are the usual ECG findings?

Evidence of LVH and strain, as in AS

What are the usual CXR findings?

Enlarged cardiac silhouette with downward displacement of the LV apex because of LV dilation, widening of the cephalad mediastinum if AR is caused by ascending aortic aneurysm

Why is the timing of surgical intervention more controversial with AR than with AS?

AR causes more indolent deterioration of LV function

What are the indications for surgical treatment of AR?

Acute significant AR Symptomatic patient with moderate exercise or at rest (New York Heart Association [NYHA] class III or IV) Asymptomatic patient with evidence of deteriorating LV function (LV ejection fraction <50% or LV dilation)


AVR ± tube graft for an ascending aortic aneurysm (often as a composite graft); occasionally, aortic valve repair (valve resuspension, replacement of leaflets, or simple suture closure of the cusp perforation)

What is the 5-year survival rate after AVR for AR?

75%–80%, if ventricular function is impaired at the time of surgery, the 5-year survival rate is reduced by 15%–25%

Mitral Valve What is the normal patent surface area of the mitral valve?

4–6 cm2

Is MR or MS associated with LA enlargement?

Both are

What are the classic signs of LA enlargement on anteroposterior CXR?

Double contour sign (round, double density noted within the cardiac silhouette), straightened left heart border, + elevated left bronchus


What is the classic ECG finding with LA enlargement?

P mitrale: Broad, notched P wave in lead II

What systemic complication is associated with LA enlargement?

Systemic embolization (thrombus formation caused by stasis in the dilated low-pressure chamber)

What is the incidence of thromboembolism in MS and MR?

MS: 15%–30%; MR: <5%; (MS has the highest risk of thromboembolism of any valve lesion)

What step is taken preoperatively to reduce the risk of thromboembolism?

Anticoagulation with warfarin (Coumadin)

What step is often undertaken intraoperatively to reduce the future risk of thromboembolism?

Ligation of the left atrial appendage, which frequently harbors a thrombus

What common arrhythmia is associated with LA enlargement?

Atrial fibrillation

Mitral Stenosis (MS) What is the etiology of MS?

Rheumatic fever, which is noted in the patient’s history only about 50% of the time because of the 20–30-year interval between infection and the symptoms of valvular disease

What is the criterion for critical MS?

Valve surface area <1 cm2

What is the primary physiologic effect of MS?

Pulmonary hypertension

What are the symptoms of MS?

Dyspnea (most common), fatigue, orthopnea, and palpitations

Why may hemoptysis develop?

Chronic pulmonary hypertension causes dilation of the collaterals between the pulmonary and bronchial veins, forming submucosal varices in the bronchus



Multiple indications, including NYHA class III or IV, critical MS, CHF, pulmonary hypertension, atrial fibrillation, systemic emboli, endocarditis, and transvalvular gradient >10 mm Hg

What is a catheter-based alternative to surgical therapy?

Purcutaneous mitral balloon valvotomy (PMBV)

Patients with which features are typically candidates to undergo PMBV?

1. Morphology amenable to dilation (lack of calcifications of the mitral annulus, leaflet rigidity/thickening) 2. Absent atrial thrombus 3. Significant mitral regurgitation (In these patients, PMBV is preferred over surgery)

What is the first-line surgical procedure?

Open commissurotomy (sharp separation of fused leaflets)

When is this technique contraindicated?

Extensive calcification of the valve

What is the restenosis rate at 5 yr?

Only 10%; unlike in the aortic valve, mitral commissurotomy is effective in selected patients

What procedure is usually performed if MS recurs?

MVR

Mitral Regurgitation (MR) What are the etiologies of MR?


Rheumatic fever (40%–45%), myxomatous degeneration, severe mitral valve prolapse, senile (idiopathic) calcification of mitral valve, infectious endocarditis, trauma, hypertrophic cardiomyopathy, and MI or ischemia (see Postoperative Myocardial Ischemia section) Fatigue, dyspnea, and palpitations; symptoms are similar to those of MS, but are characteristically insidious and late, unless caused by MI


Describe the murmur associated with MR:

Holosystolic at the apex, with radiation to the axilla

What is the characteristic finding on pulmonary artery catheter tracing?

Prominent V wave because of regurgitant systolic flow

What is the medical treatment of MR?

Salt restriction, diuretics, and digitalis; can be palliative for many years


Acute MR (i.e., ischemic MR) NYHA class III or IV status Progressive increase in regurgitant fraction


MVR or mitral valve repair, including leaflet repair, annuloplasty (reducing size of dilated annulus with sutures or a prosthetic ring), chordae tendineae reconstruction, or reimplantation of ruptured papillary muscle

Annuloplasty Why may LVF develop in the early postoperative period?

LV no longer has a low-pressure vent (LA) into which it can unload blood during systole; with correction of MR, LV ejects all of its volume into the high-pressure aorta

What is the treatment of postoperative LVF?

Vasodilator therapy for afterload reduction; inotrope therapy + IABP (See the Mechanical Complications of Ischemic Heart Disease section for a discussion of MR caused by myocardial ischemia)


Mitral Valve Prolapse What is mitral valve prolapse?

Bulging of the mitral leaflets into the LA during systole because of redundant MV tissue ± chordae tendineae

What is the incidence in the general population?

3%–4%

What is the target population?

Girls and women 15–30 yr old; it is often seen in patients with myxomatous degenerative disorders, and thus appears to be genetic


Most patients are asymptomatic; the most common symptoms are fatigue, nonspecific chest pain, palpitation, and dyspnea

What is the classic auscultatory sign?

Mid to late systolic click

What percentage of these patients develop significant MR?

5%–7%

Tricuspid Valve Does tricuspid valve disease (TVD) present more frequently as tricuspid regurgitation (TR) or tricuspid stenosis (TS)?

TR (75%)

What is the most common etiology of isolated acquired TVD?

Infectious endocarditis caused by IV drug abuse; venous return from injected veins slowly bathes the tricuspid valve before reaching the lungs, which filter many of the bacteria

What is the most common etiology of primary acquired TVD?

Rheumatic heart disease (almost always accompanied by MS)


Pulmonary Valve What is the most common acquired pulmonary valve lesion?

Functional pulmonary regurgitation caused by dilation of pulmonary annulus; it usually occurs secondary to pulmonary hypertension associated with MS

Rheumatic Heart Disease What is the etiology of rheumatic heart disease?

Systemic immune disease associated with antecedent hemolytic group A streptococcal pharyngitis (rheumatic fever); patients have high antistreptolysin (ASO) titers

What are the gross effects on the affected valve?

Leaflet fibrosis, shortening of the chordae tendineae, and commissural fusion

What are the most commonly involved valves?

Mitral valve: 85% of cases Aortic valve: 30% of cases Tricuspid and pulmonary valves: <5% of cases

Prosthetic Valves Mechanical Valves What are the most commonly used mechanical valves?

St. Jude (low-profile, bileaflet hinged valve), Starr–Edwards (caged-ball valve)

What is the primary disadvantage of these valves?

Lifelong anticoagulation (Coumadin) because of the high risk of thromboembolism; most institutions also anticoagulate tissue valves for 3–8 wk postoperatively until Dacron and suture lines endothelialize

What are the contraindications to the use of mechanical valves (i.e., indications for tissue valves)?

Absolute: History of major bleeding Relative: Unreliable noncompliant patient; patient >65 yr old (because of increased risk of stroke associated with anticoagulation); pregnancy (current or planned)


Tissue Valves What is the most common type of tissue valve?

Xenograft (glutaraldehyde-fixed porcine valve) (porcine = pig)

What is the primary disadvantage of these valves?

Deterioration over time

When do 50% of the valves require replacement?

13 yr

What are the contraindications to tissue valves (i.e., indications for mechanical valves)?

Rapid calcification of valve occurs in young patients (especially children, but anyone <30 yr old) and patients who are receiving renal dialysis

What three additional types of tissue valves are occasionally used?

1. Bovine pericardial valves 2. Homograft (human donor valve) 3. Autograft (autotransplant of valve)

What are the major disadvantages of homograft valves?

Limited supply; more difficult procedure, longer cross-clamp time

What is the valve autograft procedure?

Diseased aortic valve is excised; the pulmonary valve is excised and sutured into the aortic position; a bioprosthetic valve is sutured into the pulmonary position (i.e., Ross procedure)

Complications of Valve Replacement What are the early Conduction abnormalities (the AV-His postoperative complications of bundle travels close to the valvular annuli, valve replacement? and multiple sutures must be placed near this region), endocarditis, systemic thromboemboli, and ventricular failure What are the late complications of valve replacement?

Systemic thromboemboli, endocarditis, and bleeding as a result of anticoagulation

What is the most common late complication of mechanical valves?

Cerebral thromboemboli


What is the incidence of this complication?

1%–5% each year, even with anticoagulation; incidence varies with the type of valve (e.g., for St. Jude valve, only 1%–2% per year)

Cerebral thromboemboli occur most frequently with replacement of which valve?

Mitral valve

Three-Dimensional Relation Among Cardiac Valves 1. Tricuspid On CXR, the valve that was 2. Mitral replaced can be identified by its 3. Aortic position. In these illustrations 4. Pulmonary of anteroposterior and lateral 5. Pulmonary views of the heart on CXR, which valves would be placed in 6. Aortic 7. Tricuspid positions 1 through 8? 8. Mitral

Infectious Endocarditis (IE) Which native valve is at greatest risk for endocarditis?

Mitral valve (accounts for 80% of cases)

What distinguishes acute from subacute native valve endocarditis (NVE)?

Acute: Rapid onset; usually caused by virulent organisms Subacute: Indolent onset; usually caused by less virulent organisms


Are normal or diseased valves the target in acute vs. subacute NVE?

Acute: Normal, although some minor lesion must be present to cause the turbulence that permits the bacteria to invade the valve Subacute: Diseased (e.g., rheumatic heart disease, congenital bicuspid aortic valve)

A prosthetic valve in which position is at greatest risk for IE?

Aortic valve (accounts for 60% of cases)

Define early vs. late prosthetic valve endocarditis (PVE)

Early: <2 mo after surgery Late: >2 mo after surgery

What is the incidence of PVE in tissue vs. mechanical valves?

5%–10% (same for both)

Why is aggressive therapy necessary for early PVE?

Mortality rate of 60%–70%

Name the most common organisms responsible for IE in the following settings: Acute NVE?

Staphylococcus aureus and group A streptococcus

Subacute NVE?

Streptococcus viridans, enterococci

Early PVE?

S. epidermidis, S. aureus, and diphtheroids

Late PVE?

Enterococcus, S. aureus, and gram-negative bacteria

Fungal endocarditis?

Candida and Aspergillus

Right-sided endocarditis in IV drug abusers?

S. aureus, Candida, and gram-negative bacteria (Pseudomonas)

What are the most common signs of IE?

Fever and new murmur


What are the classic findings on physical exam (in decreasing order of frequency)?

Skin and conjunctival petechiae (most common), nail bed splinter hemorrhages, Osler nodes (painful nodules on pads of digits), Janeway lesions (painless macular lesions on palms and soles), Roth’s spots (pale oval lesions on retina with surrounding hemorrhage)


Positive blood culture (3) Echocardiography: Detects vegetations, regurgitation, and paravalvular leakage caused by ring abscess


4–6 wk of IV antibiotic therapy

What is the most common indication for surgery?

CHF

What are the other indications for surgery?

Early PVE, unstable (i.e., rocking) prosthetic valve caused by PVE, positive blood culture findings after 2 wk of IV antibiotics, fungal infections, recurrent emboli, septic shock while receiving antibiotics, and conduction defects in heart because of ring abscess


Excision of the valve and aggressive débridement of any surrounding infected necrotic myocardium, followed by valve replacement; the tricuspid valve may not require replacement if pulmonary hypertension is absent

What is the reinfection rate of the new valve?

Only 5%–10%

DISEASES OF THE GREAT VESSELS Thoracic and Thoracoabdominal Aortic Aneurysms What are the etiologies of thoracic and thoracoabdominal aortic aneurysms?

Atherosclerosis, myxomatous degeneration (i.e., Marfan’s disease), aortic dissection, and infection (i.e., syphilis)


What is the incidence of aneurysms in the various thoracic aortic regions?

Ascending aorta: >40% Descending aorta: 35% Aortic arch: 10% (thoracoabdominal aorta: 10%)

What is the most common etiology of ascending aortic aneurysms?

Myxomatous degeneration

What is the cardiac lesion most frequently associated with ascending aortic aneurysms?

Aortic insufficiency because of dilation of the aortic valve annulus (annuloaortic ectasia); it is rarely seen in patients with an atherosclerotic etiology

What is the gross difference in appearance between atherosclerotic and myxomatous ascending aortic aneurysms?

Atherosclerotic: Fusiform shape Myxomatous: Pear shape

Why are aortic arch aneurysms difficult to manage?

Because they involve the aortic arch vessels, the risk of intraoperative cerebral ischemia is significant

What is the most common etiology of descending or thoracoabdominal aortic aneurysms?

Atherosclerosis

Which etiology is classically associated with saccular aneurysms?

Syphilis

What is the most common presentation of thoracic aneurysm?

Incidental finding on CXR in an asymptomatic patient

What is the most common symptom of thoracic aneurysm?

Chronic dull or “boring” pain in the back or precordium


What is the classic, although less common, presentation of: Ascending aortic aneurysm?

Descending aortic aneurysm?

CHF (e.g., dyspnea) because of aortic insufficiency Cough and dyspnea because of compression of left main bronchus

What is the primary complication of aortic aneurysms if untreated?

Rupture and death

How does the rate of expansion compare with that of abdominal aortic aneurysms?

More rapid expansion, as well as greater risk of rupture

What is the 5-year survival rate if untreated?

20%


CT arteriogram (CTA) chest, abdomen, and pelvis

What are the indications for surgery for thoracic aortic aneurysms?

1. Ascending aorta: 5.5 cm (5 cm if Marfan’s syndrome) or acute expansion by >0.5 cm/yr 2. Arch aorta: 8 cm (or 5 cm if acute expansion, hoarseness, pain, intimal tear or dissection, extension from ascending or descending aorta, mycotic aneurysm, or recurrent atheroembolism) 3. Descending aorta: 6.5 cm (5.5 cm if Marfan’s syndrome) or acute expansion by >0.5 cm/yr

What is the usual surgical procedure?

1. Tube graft replacement (Dacron, homograft, or polytetrafluoroethylene [PTFE]) of diseased segment of aorta 2. Thoracic endovascular aneurysm repair (TEVAR) using stent graft can be performed for descending thoracic aortic aneurysms


3. TEVAR can also be performed in conjunction with or as a second stage of “debranching” the arch vessels and anastomosing to the ascending aorta, thus allowing a landing zone in the arch What procedure is often used for ascending aortic aneurysms caused by Marfan’s disease?

Bentall procedure: Replacement of ascending aorta and aortic valve with a composite graft because of the frequency of dilation of the valve annulus

What is the Crawford (or inclusion) technique and where is it most frequently used?

Incorporation or implantation of a group of arteries (as an island or cuff) into the prosthetic tube graft rather than multiple individual implantation sites; used primarily for arch vessels, visceral arteries, and intercostal–lumbar arteries

What technique is necessary to minimize cerebral ischemia during the repair of aortic arch aneurysms?

Deep hypothermic circulatory arrest (selective antegrade cerebral perfusion can help extend the time on circulatory arrest)

What is the overall operative mortality rate?

<10% (<6% in high-volume medical centers)

What is the most common cause of death?

MI

What are some postoperative complications?

Respiratory insufficiency (most common), MI, acute tubular necrosis, paraplegia, and stroke

What classic syndrome is associated with spinal ischemia?

Anterior spinal artery syndrome

Repair of which types of aortic aneurysm increases the risk of spinal ischemia?

Thoracoabdominal and descending aortic aneurysms

What are the signs and symptoms associated with the anterior spinal artery syndrome?

Paraplegia, incontinence (bowel or bladder), and sensory loss for pain and temperature


What is the rate of spinal cord ischemia based on Stanley-Crawford extent of thoracoabdominal aortic aneurysm (TAAA)?

I. (descending thoracic to above celiac artery): 15% II. (descending thoracic down to iliacs): 31% III. (midthoracic down to iliacs): 7% IV. (intra-abdominal): 4%

What is the inflow to the anterior spinal artery (e.g., blood supply to the spinal cord)?

1. Branches of the subclavian artery: vertebral arteries and superior intercostal arteries (T1–T2) 2. Intercostal and lumbar segmental arteries of T3–L5 3. Internal iliac artery and middle sacral arteries

What long-term medical therapy is often prescribed after aortic aneurysm surgery?

1. Antihypertensives for blood pressure control and prevention of future aneurysm or dissection 2. β-blockers (decreases shear force, dP/dt, or the force of ejection of blood from the left ventricle)

What is the primary reason for close long-term follow-up?

Increased risk of development of dissection or aneurysm in any residual aorta

What is the 5-year survival rate after surgery?

50%

HEART TRANSPLANTATION What are the indications for heart transplantation?

Ischemic cardiomyopathy (“endstage” CAD), idiopathic (primary) cardiomyopathy (i.e., dilated, restrictive), secondary cardiomyopathy (i.e., viral, alcoholic, infiltrative, toxic, metabolic), some types of congenital heart disease, and retransplantation for severe acute or chronic rejection

What are the absolute contraindications to transplantation?

Pulmonary hypertension (>6 Wood units and uncontrollable with oral pharmacologic therapy), active infection, active malignancy, irreversible hepatic disease, irreversible renal disease (if renal transplant is not possible), and age >65 yr (age criteria are institution dependent)


What is the major limiting factor in the number of heart transplants currently performed?

Scarcity of donor cardiac allografts

What are the potential future alternatives to allograft transplantation?

Long-term left ventricular assist devices (LVADs), xenotransplants (use of animal hearts), and artificial hearts

Preoperative Period and Procedure What interventions are used to support the patient who is awaiting transplantation?

Pharmacologic treatment to reduce volume overload and maintain CO (i.e., diuretics, digoxin, dopamine, dobutamine, milrinone), IABP, and mechanical circulatory assist devices (LVADs or biventricular assist devices, the “bridges to transplantation”)

What criteria are used to match donors and recipients for heart transplantation?

ABO compatibility (because of shortage of donors and limits of myocardial preservation, human leukocyte antigen [HLA] matching is not feasible) and CMV status; in adults, size matching plays a minor role

What is the accepted limit of ex vivo ischemic time for the donor heart?

Only 4–6 hr!

What are the 2 types of heart transplantation?

Orthotopic: Removal of recipient ventricles (accounts for >95% of transplants performed) Heterotopic: Piggybacking of donor heart onto recipient heart

How is the recipient heart excised?

The patient is placed on cardiopulmonary bypass and the aorta is cross-clamped; the aorta and pulmonary artery are transected, and a circumferential incision is made proximal to the AV groove, leaving most of the left and right atria in the recipient


Effects of Donor Heart Denervation What does “denervation” of donor heart refer to?

Harvesting of a donor heart necessitates transection of its innervating fibers

What are the important physiological results of denervation?

Baseline tachycardia (90–110 beats/min) because of the loss of parasympathetic tone that normally inhibits the sinoatrial node Delayed myocardial response to stress because of the exclusive dependence on circulating catecholamines from distant noncardiac sites for positive chronotropic and inotropic effects

What standard cardiac therapeutic interventions are ineffective with loss of autonomic innervation?

Atropine, digoxin, carotid sinus massage, and the Valsalva maneuver

How does denervation complicate the presentation of MI?

Heart transplant recipients do not have angina because of the lack of afferent sensory fibers; several yr after transplantation, a few patients apparently have reinnervation of the donor heart and experience angina, but these are rare and unpredictable exceptions

Early Postoperative Hemodynamic Complications What is the usual etiology of early postoperative low CO?

The newly transplanted heart is noncompliant and stiff because of the injury associated with harvesting, cooling, and ischemia; fortunately, this dysfunction usually resolves during the first 3 d

What is the treatment of early low CO?

Volume (to optimize preload in noncompliant ventricles), isoproterenol (to maintain heart rate [HR] at 100–125 beats/ min), ± additional inotropic support with dobutamine

What are two additional complications and their first-line treatment?

Right ventricular failure (RVF): Isoproterenol Sinus bradycardia and junctional rhythms: Isoproterenol, not atropine


A patient moves to a chair on postoperative day 2 and promptly loses consciousness. What is the most likely etiology?

Orthostatic hypotension because of the loss of normal reflex tachycardia as well as a great dependence on preload

What is the most common cause of death in the first year?

Infection

What is the most common cause of death after the first year?

Rejection

Infectious Complications What is the most common site of infections in heart transplant recipients?

Lungs

These patients are at risk for opportunistic infections in addition to the usual bacterial pathogens encountered in surgery. When is each type of infection most prevalent?

Bacterial: Acute infections (<1 mo postoperatively) Opportunistic: Subacute infections (>1 mo, especially 1–4 mo)

What are the most common organisms in acute infections?

Gram-negative bacilli (Pseudomonas, Escherichia coli, and Klebsiella)

What are the most common organisms in subacute infections?

CMV, although some groups report Pneumocystis as the most prevalent

What are the four types of opportunistic infection?

Intracellular: Listeria, Mycobacterium, Salmonella Fungal: Candida, Aspergillus Viral: Herpes simplex, CMV Protozoal: Pneumocystis, Toxoplasma

What transplant is associated with the highest incidence of aspergillosis?

Heart transplant


What drug is given if a CMVpositive heart is transplanted into a CMV-negative recipient (CMV mismatch)?

Ganciclovir (also used to treat serious CMV infection)

What is the standard immunosuppressive maintenance regimen for heart transplantation?

Triple therapy: Calcineurin inhibitor (i.e., cyclosporine or tacrolimus), an antimetabolite (i.e., mycophenolate mofetil or azathioprine), and a steroid taper for the first year after transplantation

What is the most common type of rejection?

Acute rejection (days to months postoperatively); the highest incidence of rejection occurs in the first 3 months

What percentage of patients have a rejection episode during the first few months?

80%!

What is the classic manifestation of chronic rejection (controversial)?

Accelerated coronary artery disease (ACAD); some theorize that there are nonrejection etiologies for ACAD (e.g., CMV)

What is the most common presentation of rejection?

Usually asymptomatic, unless severe

What are the classic signs?

Fever; if severe, signs of RV and/or LV dysfunction (e.g., S3, S4, jugular venous distension [JVD], hepatomegaly, and arrhythmias)

What is the most reliable way to diagnose rejection?

Endomyocardial biopsy of the RV septum with a percutaneous bioptome

What is the most common treatment of rejection?

Corticosteroids: Short course of IV methylprednisolone (Solu-Medrol) on an outpatient basis, requiring a daily visit to the hospital, or increased dose of oral prednisone, if rejection is mild


What is the main complication of this treatment?

Increased risk of opportunistic infection; over the last several yr, the threshold for treatment of rejection has become steadily higher to avoid the more dangerous infectious complications of additional immunosuppression

What additional immunosuppressive agents may be used if steroids fail?

The monoclonal antibody OKT3 or antithymocyte globulin (ATG)

What is the most common reason for retransplantation?

Chronic rejection, which accounts for 66% of cases

What are the most common neoplasms seen in heart transplant recipients?

Carcinoma of the skin and lip (i.e., squamous cell carcinoma); non-Hodgkin’s lymphoma

What are the survival rates at 1 and 5 yr?

1 yr: 80%–90% 5 yr: 50%–60%

CARDIOPULMONARY BYPASS (CPB) What are the functions of CPB?

Perfusion of the body with blood, gas exchange (oxygen added and carbon dioxide removed from blood), alterations of core temperature (decrease in temperature during surgery to reduce metabolic rate)

Compare total CPB with partial CPB:

Total CPB: All venous blood is bypassed to the pump Partial CPB: Some venous blood passes through the lungs

What are the components of the basic CPB circuit?

Venous cannula(e) from RA (or superior and inferior vena cava); heart–lung machine with pump apparatus, heat exchanger, and oxygenator; arterial filter; arterial cannula into the ascending aorta; (The femoral artery and vein occasionally are used for cannulation sites)


How is the heart arrested so that surgery can be performed safely?

Infusion of cold, high-potassium solution (i.e., cardioplegia) into aortic root or directly into coronary arteries after crossclamping of ascending aorta; topical cold saline (4°C) helps to maintain myocardial temperature at ≅ 15°C

To what temperature is the patient usually cooled for a standard cardiac procedure?

28°–32°C (mild hypothermia)

What is deep, or profound, hypothermia?

<18°C

How low may pump rate be reduced during profound hypothermia?

Pump may be turned off (i.e., hypothermic circulatory arrest)

For what procedures is profound hypothermia indicated?

Aortic arch surgery and complex congenital cardiac surgery

What step is necessary to prevent thrombosis in the pump?

Patient must be anticoagulated with heparin (activated clotting time is monitored intraoperatively)

A patient is not weaning from CPB (i.e., as the pump rate is decreased, the patient cannot maintain blood pressure). What steps are taken to permit successful discontinuation of CPB?

1. Intravascular volume (crystalloid or blood) is increased 2. Vasopressor and inotropic support (infusions of dopamine, dobutamine, or epinephrine) is provided 3. IABP 4. Left ± right ventricular assist device (VAD) is placed 5. Very rarely, heart transplant is performed (limited resource)

Shortly after discontinuing CPB, severe pulmonary hypertension suddenly develops. What is the most likely etiology?

Protamine reaction; protamine sulfate is used to reverse the activity of heparin after completing CPB


What features of the patient history suggest the potential for protamine reaction?

Diabetes (protamine in insulin) Allergies to iodine or seafood Patient or family history of protamine reaction

What is “postperfusion syndrome” (PPS)?

End-organ effects of the “whole-body inflammatory reaction” associated with CPB, manifested as postoperative pulmonary insufficiency, renal failure, bleeding disorder, and/or myocardial dysfunction

What is the etiology of PPS?

Uncertain; current evidence suggests that contact with the synthetic surfaces of the extracorporeal circuit activates the humoral (i.e., complement) and cellular (i.e., neutrophil) cascades of the acute inflammatory response, resulting in endothelial injury

Which factor is activated at the onset of CPB and appears to initiate the various humoral cascades?

Factor XII (Hageman factor)

Which complement anaphylatoxins appear intimately involved in PPS?

C3a and C5a

What is the treatment of PPS?

Supportive therapy (e.g., ventilator, dialysis) until the patient recovers

POSTOPERATIVE INTENSIVE CARE MANAGEMENT Cardiac Output What are the physiological determinants of CO?

Preload (end-diastolic volume of the ventricle) Compliance (tendency of the ventricle to permit distension with blood) Afterload (the force opposing ventricular ejection) Contractility (intrinsic contractile performance, independent of other determinants of CO) CO = SV × HR (SV = stroke volume)


What is the cardiac index (CI)?

CO per body surface area expressed in meters squared

What are the normal values for CO and CI?

CO = 4–8 L/min CI = 2.5–4 L/min/m2

What is the Frank–Starling relation?

Relation between resting muscle length (determined by preload) and tension achieved by the contracting muscle; up to a point defined by the Frank–Starling curve of the ventricle, increases in preload augment SV and thus CO

What is the key determinant of CO in a heart with normal vs. reduced compliance?

Normal compliance: Preload Reduced compliance: Afterload

Why is blood pressure an INSENSITIVE index of myocardial performance?

Blood pressure is the product of systemic vascular resistance (SVR) and CO; if CO decreases, blood pressure is maintained initially by compensatory arterial vasoconstriction because of reflex sympathetic discharge; thus, a decrease in blood pressure is often a late sign of reduced myocardial performance

What is the equation for calculating SVR?

SVR = [(MAP – CVP)/(CO)] × 80

Low Cardiac Output Syndrome (LCOS) What is the presentation of Cool, clammy skin; slow capillary refill; LCOS? oliguria (<0.5 mL/kg/h); restlessness; depressed mental status; tachypnea, metabolic acidosis What are the etiologies of LCOS in the postoperative period?

1. Hypovolemia (third spacing, diuresis, bleeding, or relative hypovolemia because of reflex vasodilation associated with postoperative warming) 2. Elevated SVR (hypothermia, circulating catecholamines)


3. Myocardial dysfunction (ischemia, hypothermia, volume overload); pericardial tamponade; dysrhythmia; and increased intrathoracic pressure (positive end-expiratory pressure [PEEP], tension pneumothorax) In what order are these determinants of CO addressed to improve CO?

1. HR (and arrhythmias or electrical state of heart) 2. Preload 3. Afterload 4. Contractility

For each determinant, what disturbance usually causes LCOS, and what are the therapeutic options and management?

1. Bradycardia: Atropine, Isoproterenol, Temporary Pacer 2. Tachycardia: Fluids, oxygen, anxiolytics, morphine, esmolol (rarely) 3. Inadequate preload: Fluids, control of mediastinal bleeding (and rule out tamponade) 4. Elevated afterload: Warming lights or blanket, fluids, vasodilator therapy 5. Reduced contractility: Inotropic therapy, mechanical assist device (and rule out myocardial ischemia; see Postoperative Myocardial Ischemia section)

What are the first-line inotropic agents?

Epinephrine, dobutamine, and milrinone

What are the drawbacks of using these agents?

Epinephrine and dobutamine can be proarrhythmogenic, and milrinone is also a vasodilator that can cause hypotension

If LCOS persists despite multiple vasoactive agents, and all other determinants of CO are optimized, what mechanical assist modalities can be initiated?

1. Intra-aortic balloon pump (IABP) 2. Ventricular assist device (VAD)


How does the IABP augment cardiac function?

Inflates during diastole, increasing diastolic coronary perfusion; deflates during systole, reducing afterload and decreasing cardiac work

How does the VAD work?

Completely replaces the pumping function of the heart, thereby offloading the failing heart

Postoperative Myocardial Ischemia When in the postoperative period is the patient at greatest risk of myocardial ischemia?

First 6 hr

What are the sequelae of myocardial ischemia?

MI, LCOS, arrhythmias, RV failure, acute MR, acute VSD, and acute ventricular free wall rupture (± pericardial tamponade)

What are the treatment goals, and how are they achieved?

1. Alleviation of myocardial ischemia: Oxygen, nitrates, ± surgery 2. Treatment of ventricular dysfunction: According to LCOS treatment regimen 3. Prevention or treatment of arrhythmias: β-blockade if pressures tolerate, correct electrolyte disturbances, administer amiodarone or lidocaine 4. Antiplatelet therapy (immediate ASA, add second agent if STEMI) and systemic anticoagulation

When is surgery indicated for myocardial ischemia after cardiac surgery?

1. Hemodynamic or electrical instability because of significant myocardial ischemia 2. Mechanical complications of ischemia (i.e., acute MR or VSD) (See the Acquired Coronary Artery Disease section for a discussion of mechanical complications)

What is the treatment of RV failure?

Volume expansion (the foundation of treatment of RVF) Dobutamine, the overall pharmacologic agent of choice because it reduces pulmonary afterload and provides inotropic support


Postoperative Hypertension What are the etiologies of postoperative hypertension?

Pain or anxiety, hypothermia, hypoxia, hypercarbia, LCOS (with reflex vasoconstriction), and hyperdynamic myocardium syndrome, fluid overload

What are the sequelae?

Myocardial ischemia, LCOS, cerebrovascular accident, increased postoperative bleeding, and more rarely aortic dissection

What is the goal of treatment?

Reduction of blood pressure while maintaining adequate visceral perfusion, especially coronary and cerebral; the target mean arterial pressure is 60–85 mm Hg (variable depending on patient’s baseline blood pressure)

What is the first-line parenteral agent for vasodilation?

Labetalol

What are the second-line parenteral agents for vasodilation?

1. Sodium nitroprusside (contraindicated if elevated ICP or renal insufficiency) 2. Nicardipine (especially useful in coronary disease due to coronary vasodilatory effects)

Postoperative Hypotension What are the most common etiologies in the postoperative cardiac surgery patient?

Hypovolemia or bleeding, myocardial ischemia or infarction, cardiac tamponade, arrhythmias, and tension pneumothorax

What is shock?

Inadequate perfusion pressures to preserve visceral function (not hypotension per se)

What are the etiologies of cardiogenic shock?

Large MI (>30%–40% of LV), acute MR, acute VSD, RVF

What is the mortality rate associated with cardiogenic shock?

70%–90%


Hyperdynamic Myocardium Syndrome What is hyperdynamic myocardium syndrome?

Elevated CO caused by increased myocardial contractility ± tachycardia; the mechanism is uncertain, but may involve circulating catecholamines

Which patients are at greatest risk?

Patients with compensatory hypertrophy of the LV because of preoperative systemic hypertension, AS, or idiopathic subaortic stenosis

What is the indication for treatment?

Significant tachycardia with untoward effects on diastolic ventricular filling or myocardial oxygen demand

What is the pharmacologic intervention of choice?

Esmolol (parenteral β-blocker with a short half-life)

What is the correct way to administer and titrate esmolol infusion?

0.5 mg/kg IV bolus over 1 minute and immediately start infusion at 0.05 mg/kg/ min. Re-load with 0.5 mg/kg IV before titrating up the infusion rate (between 0.05–0.3 mg/kg/min)

Postoperative Hemorrhage What is the medical management?

1. Increased PEEP on the ventilator 2. Vasodilators for hypertension 3. Correct coagulopathy: protamine sulfate, fresh-frozen plasma (if prothrombin time or partial thromboplastin time is elevated), cryoprecipitate if hypofibrinogenemia (<100 mg/dL), and platelets (if platelet count <100,000) 4. Recombinant factor VII if still coagulopathic despite blood products above 5. Desmopressin acetate (DDAVP) if uremic platelet dysfunction

What are the indications for re-exploration?

Bleeding rate from chest tubes of 200 mL/h for 4–6 hr (>1,500 mL over 12 hr), sudden significant increase in chest tube output (300–500 mL), or evidence of pericardial tamponade


Pericardial Tamponade How does pericardial tamponade reduce CO?

Preload reduction: Low pressure of venous return has difficulty overcoming the intrapericardial pressure gradient formed by the tamponade

What is the usual presentation of tamponade?

Tachycardia, hypotension, distended neck veins (“Beck’s triad”), and pulsus paradoxus, often in a patient with bleeding from the chest tube that is initially heavy and suddenly stops; however, freely draining chest tubes and tamponade are not mutually exclusive

What is the classic finding on Swan–Ganz catheter readings?

Equalization of diastolic pressures in the heart (central venous pressure [CVP], RV end-diastolic pressure, pulmonary diastolic pressure, and PCWP), usually 18–22 mm Hg


Volume loading, inotropes and, until an OR is available for re-exploration of the mediastinum; if the patient becomes unstable before surgery, emergent bedside re-exploration is performed

Cardiac ICU In patient management, trends, rather than absolute numbers, are key, but these values are guidelines. What are the normal values for the following parameters: CO and CI?

CO = 4–8 L/min CI = 2.5–4 L/min/m2

CVP?

CVP = 0–4 mm Hg

PCWP?

PCWP = 12–15 mm Hg

SVR?

SVR = 900–1400 dynes/sec/cm2

PVR?

PVR = 150–250 dynes/sec/cm2


What is the general management regimen for each of the following classic clinical scenarios: Decreased CO, decreased PCWP, increased or decreased SVR?

Volume (i.e., crystalloid, blood)

Normal or increased CO, but decreased blood pressure, normal PCWP, decreased SVR?

Vasopressor (i.e., vasopressin, norepinephrine, or phenylephrine)

Decreased CO, increased PCWP, normal or decreased SVR?

Inotrope (i.e., epinephrine, dobutamine)

Decreased CO, increased PCWP, increased SVR?

Vasodilator (i.e., labetalol, sodium nitroprusside, or nicardipine) + IABP if blood pressure is too low for vasodilator therapy alone

What measurement is performed to evaluate oxygen delivery and the adequacy of tissue perfusion?

Mixed venous oxygen saturation; a sample is drawn slowly through the distal port of the Swan–Ganz catheter (the site of the most deoxygenated blood in the body, the pulmonary artery)

What is a normal value of this measurement?

65%–75% saturation

What does an increase in oxygen saturation between the proximal port of the Swan–Ganz catheter (in the RA) and the distal port (in the pulmonary artery) suggest?

Intracardiac shunt (i.e., VSD)

How do patients with cyanide toxicity present initially?

Decreased contractility and CO

What are the classic LATE findings of toxicity?

Dilated pupils, headache, absent reflexes, nausea, mental status changes ± coma, death


Intra-Aortic Balloon Pump (IABP) What are the indications for IABP?

Refractory LVF after CPB (e.g., inability to wean from bypass pump) Unstable angina refractory to medical treatment CHF in a patient awaiting surgery (i.e., acute MR or VSD, transplant candidate) Cardiogenic shock caused by MI (now rare, unless the patient is a candidate for CABG or percutaneous transluminal coronary angioplasty [PTCA])

What are the contraindications to IABP?

Aortic aneurysm or synthetic thoracic aortic graft (may rupture with balloon inflation) Moderate or severe AR (IABP may worsen regurgitation)

What is the usual route of insertion?

Femoral artery, but the pump can be placed directly into the aorta at the time of median sternotomy if severe peripheral atherosclerosis precludes a femoral approach

Where does the balloon reside in the aorta?

Between the left subclavian artery and the diaphragm

What complication occurs if the balloon migrates?

Intermittent ischemia in territories supplied by vessels that are intermittently occluded by the inflated balloon (e.g., carotid, subclavian, renal, celiac)

How does the IABP work?

Balloon inflates during diastole, increasing pressure inside the aorta, which increases coronary and visceral perfusion; balloon deflates during systole, reducing afterload, which decreases cardiac work

What is the key benefit of IABP over medical treatment of hypotension or decreased CO?

No increase in oxygen consumption or demand, unlike α- or β-agonists, which cause increased cardiac work because of increased afterload or HR/contractility, respectively


What are the complications of IABP?

Lower extremity ischemia because of occlusion of femoral artery; monitoring distal pulses is imperative Emboli caused by thrombosis around the balloon Bowel infarction, renal failure, and paraplegia caused by migration of the balloon Mechanical damage to formed components of the blood

Left Ventricular Assist Device (LVAD) What are the indications for LVAD?

Intraoperative MI to reduce left ventricular work temporarily and allow the heart to recover more quickly “Bridge” for heart transplant candidates until a donor is available

Why is LVAD not true cardiopulmonary bypass?

It is only a perfusion device, with no oxygenator in the circuit

How is the LVAD fundamentally different from the IABP?

LVAD provides “flow” and can fully replace pumping function of heart; IABP provides “pressure assistance” and only augments existing cardiac function

How is the LVAD different from extracorporeal membrane oxygenation (ECMO)?

ECMO includes a membrane lung apparatus and can also provide support for respiratory insufficiency; the inflow source is the RA

Automatic Implantable Cardioverter Defibrillator (AICD) What are the three components of the AICD?

1. Sensory leads to detect arrhythmia 2. Anode–cathode titanium patches around the heart 3. Pulse generator to terminate arrhythmia (Newer devices also have leads for pacing capability for bradycardia and asystole)

What is the indication for AICD?

Malignant ventricular arrhythmia refractory to medical therapy


What are the 1-year survival rates in treated patients and untreated historical control subjects?

AICD 95%–98% Untreated; 30%–40% These patients are at high risk for sudden death syndrome

Why is pharmacologic therapy necessary after AICD placement?

Episodes of nonsustained ventricular tachycardia and atrial fibrillation can cause discharge of the AICD

CARDIAC TUMORS What is the most common type of cardiac tumor?

Metastatic neoplasm (lung, breast, melanoma, and lymphoma) accounts for 65%–70% of all malignant cardiac tumors

What is the most common complication associated with this type of tumor?

Pericardial tamponade from bloody pericardial effusion

In which side of the heart are malignant cardiac tumors more commonly found?

Right side (as opposed to benign tumors, which are common on the left side)

What are the two most common primary malignant cardiac tumors?

Sarcoma (i.e., angiosarcoma, rhabdomyosarcoma): 15%–20% of all malignant cardiac tumors Melanoma: 5%–10%

How do these tumors differ grossly from myxoma?

Intramural rather than intraluminal; thus, almost always unresectable

What is the most common cardiac tumor in children?

Rhabdomyoma (benign)

Benign Cardiac Tumors What is the most common benign cardiac tumor?

Myxoma, which is also the most common primary cardiac tumor, accounting for 60%–80% of all primary cardiac tumors

This tumor occurs most in which chamber?

LA: 75% (>95% in atria)

What is the classic gross feature?

Pedunculated (stalk attached to atrial septal wall)


What complications are associated with this tumor?

LA outflow obstruction (“ball valve”) and embolism (from friable surface of myxoma); acute arterial insufficiency in young patients without heart disease may be due to embolism from LA myxoma

Chapter 77 Transplant Surgery MAJOR HISTOCOMPATIBILITY COMPLEX (MHC) What is MHC?

Cluster of genes on the short arm of chromosome 6

What is this cluster called in humans?

Human leukocyte antigen (HLA)

What are the three important characteristics of MHC (HLA) antigens?

1. Extreme polymorphism 2. Produced by closely linked subloci that form inheritable HLA haplotypes 3. Codominant expression of HLA (HLA antigens on the cell surface)

Where are the polymorphisms clustered?

Polymorphic amino acids are clustered in the peptide-binding site in the antigenbinding groove

What are the three basic products of the MHC and the corresponding regions involved?

1. Class I antigen: HLA-A, -B, and -C 2. Class II antigen: HLA-D region, with DR, DQ, and DP 3. Class III antigens: complement cascade

On what cell types are these MHC products expressed?

1. Class I antigens: all nucleated cells and platelets 2. Class II antigens: B lymphocytes, activated T cells, macrophages, and monocytes

What lymphocytes do not express class II antigens?

Resting T lymphocytes

Chapter 77 / Transplant Surgery 641

What causes allograft rejection?

Foreign histocompatibility antigens on the graft and tissue

What antigens are histocompatibility antigens?

Any antigen that causes tissue incompatibility between donor and recipient

What are the strongest transplantation antigens?

Antigens that express the MHC (HLA in humans)

What two tests detect HLA antigens?

1. Serologic testing with antigen-specific antisera 2. Mixed lymphocyte culture (MLC)

What does MLC detect?

Proliferative capacity of the host lymphocytes to antigens on the graft (MHC class II antigens or D antigens)

Which classes of MHC genes significantly affect transplantation?

Classes I and II

What are the structures of class I and class II molecules?

Two polypeptide chains with variable and constant regions, similar to the immunoglobulin structure

What do class I genes encode for?

Transplantation antigens that are primary targets for cytotoxic T lymphocytes (CTLs) in rejection; cell surface molecules that present certain antigens to CD8 T cells (i.e., viral antigens)

What do class II genes represent?

Immune response genes

Class I gene products are the primary target of which cells?

CTLs

Class II gene products are the primary target of which cells?

Th cells

What are the minor transplantation antigens?

Antigens that express genes on other chromosomes that are capable of weaker, slower rejection; they are presented by class I and II MHC determinants


Which antigens cause rejection of grafts between HLA-identical siblings?

Minor transplantation antigens

IMMUNOSUPPRESSIVE AGENTS What is MMF?

Mycophenolate mofetil

How does it work?

Inhibits T cells and B cells by inhibiting purine synthesis

FK-506 (Tacrolimus) What is the basic structure of FK-506?

Macrolide antibiotic

What is the source of FK-506?

Soil fungus (Streptomyces tsukubaensis)

What is the potency of FK-506 compared with that of cyclosporine A (CSA)?

FK-506 is 500× more potent than CSA

What is the typical dosing regimen for FK-506?

0.05 mg/kg PO every 12 hr

What is the therapeutic drug level?

10–15 ng/mL

What is the mechanism of immunosuppressive action?

Inhibits T-cell activation and maturation

What are the intracellular receptors for FK-506?

FK-binding proteins

What adverse side effects are associated with FK-506 administration?

1. Nephrotoxicity 2. Anorexia and weight loss 3. Neurotoxicity

Which drugs increase FK-506 levels?

1. 2. 3. 4. 5. 6.

Verapamil Ketoconazole Erythromycin Diltiazem Fluconazole Cimetidine


Which drugs decrease FK-506 levels?

1. 2. 3. 4.

Phenytoin Phenobarbital Carbamazepine Rifampin

Rapamycin (RAPA) What is the structure of RAPA?

Macrolide antibiotic

What is the mechanism of immunosuppressive action?

1. Inhibits B-cell and T-cell activation and proliferation 2. Inhibits activated T cells 3. Blocks the ability of the interleukin (IL)-2 receptor to induce signal transduction

What intracellular receptor does RAPA bind?

FK-binding proteins

What action is inhibited by RAPA, but not by CSA and FK-506?

Activated cell proliferation induced by IL-2 and IL-4

LIVER TRANSPLANTATION What factor significantly decreases morbidity and mortality rates of the anhepatic phase of the orthotopic liver transplant (OLTx) procedure (i.e., after hepatectomy and before the completion of implantation)?

Heparin-free veno-venous bypass; the cannula drains the IVC, and the centrifugal pump returns blood to the axillary vein


What standard anastomoses are used for OLTx?

1. Suprahepatic IVC and infrahepatic IVC anastomoses 2. Portal vein anastomosis 3. Hepatic (splenic) artery anastomosis 4. Anastomosis for biliary drainage

What is the veno-venous bypass during liver transplant surgery?

During the “anhepatic” phase of the transplant the blood from the portal vein and iliac vein is pumped back to the heart through the pump Suprahepatic Axillary vein Portal vein 9-mm Gott tubing Infrahepatic External iliac vein 7-mm Gott tubing

Pump


What is the most common anatomic liver arterial anomaly?

Double (or multiple) hepatic artery

What two other commonly encountered variations in hepatic artery anatomy are important during procurement and implantation of the allograft?

1. Left hepatic artery originating from left gastric artery (palpable in gastrohepatic omentum): 15% of individuals 2. Right hepatic artery originating from superior mesenteric artery (palpable posterior and to the right of portal vein in porta hepatis): 12%–17% of individuals

What is included in the differential diagnosis of abnormal coagulation parameters in a patient with OLTx?

1. 2. 3. 4. 5.

Thrombosis is most common in which vessel?

Hepatic artery

What biliary complications are associated with acute versus chronic hepatic artery thrombosis?

Acute: bile duct leak Chronic: bile duct strictures

What are the clinical signs of caval stenosis?

1. Lower extremity edema 2. Ascites 3. Renal insufficiency

Hepatic abscesses are a common presentation of what complication?

Hepatic artery thrombosis

What procedure differentiates among rejection, ischemia, viral infection, and cholangitis?

Liver biopsy

What histological findings suggest rejection?

Mixed inflammatory cell infiltrate of the portal triads, bile duct injury, and endothelialitis

What histological finding suggests cholangitis?

Polymorphonuclear neutrophil (PMN) infiltration of the portal triads

Rejection Ischemia Infection Obstruction Cholangitis


What is the most common cause of renal failure after OLTx?

Preoperative hepatorenal syndrome; other causes include hypotension, sepsis, and CSA toxicity

What paralytic agent is avoided during renal transplantation in patients undergoing dialysis, and why?

Succinylcholine; hemodialysis breaks down serum cholinesterases (i.e., prolonged action of the agent)

GASTROINTESTINAL TRACT TRANSPLANTATION What are cluster transplants?

Transplants of multiple abdominal viscera

Give two examples of cluster transplants?

1. Liver–intestine en bloc 2. Liver, duodenum, and pancreas

What are the indications for small bowel transplantation?

Patients with short gut unable to continue on TPN

What are the complications of chronic hyperalimentation?

1. Cirrhosis 2. Liver failure 3. Vascular access complications

What factor complicates rejection in small bowel transplantation?

In addition to classic allograft rejection, recipients may also experience graftversus-host disease (GVHD) from donor lymphocytes

How is the bowel pretreated to reduce the risk of GVHD?

Radiation

IMMUNOSUPPRESSION Complications What is the most common complication of immunosuppression?

Infection

What is the most common cause of death in transplant recipients?

Infection


What are the other complications of immunosuppression?

Infection What are the most common types of fungal infection in immunosuppressed patients?

1. Hypertension (HTN) 2. Cushing’s disease (steroid-induced diabetes, cataracts, myopathy, hyperlipemia, osteoporosis, and hypercholesterolemia) 3. Thrombophlebitis 4. Malignancy 5. Pancreatitis 6. Avascular necrosis (femoral head)

1. Candida albicans 2. Aspergillus

What is the most common protozoan infection in immunosuppressed patients?

Pneumocystis carinii

What drug is given prophylactically for this protozoal infection?

Trimethoprim and sulfamethoxazole (Bactrim)

What is the typical chest x-ray finding in a patient with: Aspergillus infection?

Upper-lobe cavities

Pneumocystis infection?

Alveolar infiltrates

What are the most common viral infections in transplant recipients?

Herpes group of DNA viruses in descending order: CMV > herpes simplex > herpes zoster

What is the most common viral agent thought to elicit rejection?

CMV

What is the usual clinical presentation of CMV?

Fever, neutropenia, malaise, pneumonitis myocarditis, pancreatitis, and acute cecal ulceration

Which immunosuppressant increases the risk of CMV infection?

Antilymphocyte antibody


Which immunosuppressant decreases the risk of CMV infection, and why? Malignancy Which malignancies often occur in immunosuppressed patients?

Cyclosporine, because of the sparing of sensitized T cells

1. Immunoproliferative malignancies (i.e., B-cell lymphomas) 2. Epithelial cancers 3. Malignancies with viral etiologies (i.e., cervical cancer)

What is the relative increased risk of these cancers in transplant patients?

1. Lymphoma: 350× 2. Skin cancer: 40× 3. Cervical cancer: 4×

What is the viral etiology of polyclonal B-cell lymphoproliferative disorder?

Epstein-Barr virus

What are the three explanations for the increased risk of cancer associated with immunosuppression?

1. Decreased tumor immunosurveillance 2. Use of mutagenic immunosuppressive agents (i.e., azathioprine [AZA; Imuran]) 3. Increased susceptibility to herpes and increased exposure to viral promoters

REVIEW OF MECHANISMS OF REJECTION What causes accelerated acute rejection? Describe the following mechanisms of rejection: Hyperacute?

T-cell mediated or antibody rejection

Secondary to recipient preformed antibodies to donor ABO or HLA antigen

Accelerated acute?

Humoral or cell mediated

Acute?

Cellular immunity

Chronic?

Humoral or cellular immunity (or both)

Chapter 78 / Orthopedic Surgery 649

Chapter 78 Orthopedic Surgery ORTHOPEDIC TERMS Define the following terms: Supination?

Palm up

Pronation?

Palm down

Plantar flexion?

Foot down at ankle joint

Dorsiflexion?

Foot up at ankle joint

Adduction?

Movement toward the midline of the body

Abduction?

Movement away from the midline of the body

Inversion?

Foot sole faces midline

Eversion?

Foot sole faces laterally

Autograft bone?

Bone from patient

Allograft bone?

Bone from human donor other than patient

Reduction?

Maneuver to restore proper alignment to fracture or joint

Closed reduction?

Reduction done without surgery

Open reduction?

Surgical reduction

Varus?

Extremity deformity with apex pointed away from midline

Valgus?

Extremity deformity with apex pointed toward midline

Dislocation?

Total loss of congruity between articular surfaces of a joint


Subluxation?

Partial loss of congruity between articular surfaces of a joint

Arthroplasty?

Total joint replacement

Arthrodesis?

Joint fusion

Osteotomy?

Cutting bone to help realign joint surfaces

COMMON EPONYMS Name the following fractures or injuries: Distal radial fracture with dorsal displacement?

Colles’, which usually occurs secondary to a fall on an outstretched hand

Lunate fracture?

Kienböck’s

Radial fracture at junction of middle and distal thirds, with distal radial-ulnar dislocation?

Galeazzi’s

Avulsion of the anterior glenoid labrum?

Bankart’s

Tarsal–metatarsal fracture or dislocation?

Lisfranc’s

Fifth metatarsal shaft fracture?

Jones’

Radial head subluxation in a child?

Nursemaid’s elbow

Tibial tuberosity osteochondrosis?

Osgood-Schlatter disease

Osteochondrosis of the navicular bone?

Köhler’s

Fracture of the distal fibula?

Pott’s

Fracture of the spinous process of C7?

Clay shoveler’s


Fracture of the pedicles of C2?

Hangman’s

Fracture of the metacarpal neck?

Boxer’s; classically, the fifth digit

COMMONLY MISSED ORTHOPEDIC INJURIES List eight commonly missed orthopedic injuries:

1. Carpal bone injuries, especially scaphoid 2. Radial head fractures 3. Posterior dislocation of the shoulder 4. Patellar tendon tears 5. Compartment syndrome 6. Rotational deformities of metacarpal and phalangeal fractures 7. Tendon injuries of the hand 8. Femoral neck fractures in the elderly

BASIC SCIENCE What type of bone formation results in: Long bones? Flat bones? What type of bone growth determines long bone: Length? Width?

Endochondral ossification Intramembranous ossification

Interstitial Appositional

What cell type: Produces osteoid?

Osteoblasts

Resorbs bone?

Osteoclasts

What type of collagen predominates in: Bone? Articular cartilage?

Type I Type II


What is the composition of articular cartilage?

What are the systemic effects of: Parathyroid hormone?

1. 2. 3. 4.

Water (65%) Collagen, type II (20%) Proteoglycan (10%) Chondrocytes (5%)

1. Bone: Mobilizes calcium (Ca2+) and phosphorus (PO42−) 2. Kidney: Resorbs Ca2+, excretes PO42−, and increases vitamin D level 3. Gut: Increases absorption of Ca2+ and PO42− (through vitamin D) 4. Overall effect: Increases plasma Ca2+ level

Vitamin D?

1. Bone: Mobilizes Ca2+ 2. Kidney: Resorbs PO42− 3. Gut: Promotes Ca2+ and PO42− absorption 4. Overall effect: Increases plasma Ca2+ and PO42− levels

Calcitonin?

1. Bone: Decreases mobilization of Ca2+ and PO42− 2. Kidney: Decreases resorption of Ca2+ and PO42− 3. Gut: Increases electrolyte secretion 4. Overall effect: Decreases plasma Ca2+ level

What are the two primary components of a sarcomere?

1. Thick filament: Myosin 2. Thin filament: Actin

BIOMECHANICS What is stress?

Force per unit area

What is strain?

Change in length divided by the original length

What is the Wolfe law?

Bone is formed along the lines of stress and resorbed from areas without stress


What is stress shielding?

A rigid implant removes the stress from an area of bone, and the bone weakens as a response to the Wolfe law

Which of the following common orthopedic materials most closely matches the rigidity of bone: stainless steel, titanium, polymethyl methacrylate (PMMA; cement), or polyethylene?

PMMA

What type of force does bone most strongly resist?

Compression

What type of force does ligament or tendon most strongly resist?

Tension

Gait Analysis Where is the center of gravity for the human body?

Just anterior to sacral vertebra 2

How far does the center of gravity move during gait?

Horizontal and vertical oscillation of 5 cm

What is a concentric contraction?

Muscle fires while shortening (e.g., a person is about to jump)

What is an eccentric contraction?

Muscle fires while lengthening (e.g., a person is landing from a jump)

Are most muscles of the lower extremity most active during concentric or eccentric contraction?

Eccentric

What percentage of gait is spent in stance?

60%


What is the increased energy expenditure during gait with: Unilateral below-the-knee amputation?

25%

Bilateral below-the-knee amputation?

40%

Unilateral above-the-knee amputation?

>60%

FRACTURES General Principles Describe the physical exam in a fractured extremity:

1. Observe entire extremity (open, angulation) 2. Neurological exam (sensation, motor function) 3. Vascular (pulses, capillary refill)

Which x-rays should be ordered with a fractured extremity?

Two views of the extremity Make sure to include the joint proximal and distal

How are fractures described?

Open vs. closed Location (proximal, middle, or distal) Pattern of fracture (comminuted, transverse) Degree of angulation

Define the following types of fracture: Comminuted?

Fracture with >2 fragments

Pathologic?

Fracture through a bone weakened by tumor, osteoporosis, or other bony abnormalities

Torus?

Cortex buckled, but not disrupted, because of impaction injury; seen in children

Greenstick?

Incomplete fracture with disruption of the cortex on only one side; seen in children


What are the indications for open reduction?

1. Intra-articular fractures 2. Extremity function requiring perfect reduction 3. Failed closed reduction 4. Multiple trauma; to allow mobilization at earliest possible date 5. Elderly patients in cases in which a long period without ambulation carries a risk of compromised cardiopulmonary function 6. Displaced pathologic fractures (not imminently terminal) 7. Major avulsion fractures with important muscle/ligament involvement 8. Selected physeal fractures (e.g., Salter–Harris III & IV) 9. Fractures with associated compartment syndrome

Fracture Eponyms Describe the following fractures: Smith’s fracture?

Volarly displaced distal radius fracture, usually from fall onto dorsum of hand

Jones’ fracture?

Fracture at the base of the fifth metatarsal diaphysis

Bennett’s fracture?

Fracture of the base of the first metacarpal with involvement of the carpometacarpal (CMC) joint

Monteggia’s fracture?

Fracture of the proximal third of the ulna with dislocation of radial head

Galeazzi’s fracture?

Fracture of the radial shaft with disruption of the distal radioulnar joint (DRUJ)

Pott’s fracture?

Fracture of the distal fibula


Fracture Healing What are the three stages of fracture healing?

1. Inflammation: Infiltration of hematopoietic cells and osteogenic precursors 2. Repair (2 wk): Callus, cartilage, and woven bone formation 3. Remodeling: Lamellar bone formation, development of normal shape and configuration, and repopulation of marrow

What type of bone formation occurs in fractures treated with a cast?

Endochondral ossification

What is the usual appearance on x-ray?

Fracture callus

What type of bone formation occurs in fractures treated with open reduction and internal fixation?

Primary bone formation

What is the usual appearance on x-ray?

Blurring of fracture line; no callus

Open Fractures What is an open fracture?

Fracture that communicates with the external environment

What is the primary complication associated with these fractures?

Infection

What is the Gustilo classification for open fractures?

Grade I: Wound <1 cm; minimal contamination and soft tissue injury; simple or minimal comminuted fracture Grade II: Wound 1–10 cm; moderate contamination; soft tissue injury; fracture comminution Grade III: Wound >10 cm; gross contamination; severe soft tissue injury; fracture comminution


What additional features classify an open fracture as grade III, regardless of the size of the cutaneous lesion?

1. Soil contamination 2. Vascular injury 3. Close-range shotgun injury

What are the subgroups of grade III lesions?

Grade IIIA: Soft tissue adequate for coverage of wound Grade IIIB: Soft tissue loss that mandates flap coverage of wound Grade IIIC: Concurrent vascular injury requiring repair

What is the incidence of infection for grades I, II, and III?

Grade I: 0%–2% Grade II: 2%–7% Grade III: 10%–50%

What is the treatment of an open fracture?

1. Operative irrigation and débridement within 6 hr; repeat débridement or irrigation may be needed in 24–72 hr 2. IV antibiotics 3. Tetanus inoculation 4. Open reduction and stabilization of the fracture

What is the antibiotic regimen for each grade?

Grade I: First-generation cephalosporin (i.e., cefazolin) for 48 hr Grades II and III: Add gram-negative coverage (i.e., gentamicin) for at least 72 hr For soil contamination, penicillin is provided for clostridial coverage

What are the options for stabilizing open fractures?

1. Internal fixation 2. External fixation 3. Casting, splinting, and traction generally are not used for open fractures

What are the benefits of external fixation?

1. No need for additional dissection of injured soft tissue 2. Placement of fixator out of the region of injury 3. Easy access to wound for observation and wound care


When is wound closure performed?

At 3–7 days if there is no evidence of infection

TRAUMA A patient comes to the emergency department after a motor vehicle accident. She has an obviously deformed leg. What is the first step in management? In a trauma patient, after the ABCs are established, how are the following elements of the musculoskeletal survey addressed: Observation?

Airway, breathing, and circulation: ABCs of the advanced trauma life support (ATLS) protocol

Cervical spine immobilization is maintained until cleared; the patient is examined for any obvious deformities, abrasions, or open wounds

Palpation?

All long bones, even uninjured, nontender segments

Function?

Range of all joints is determined, ligaments are stressed, an obviously fractured pelvis is not stressed, and neurologic and vascular evaluation is performed

Which x-rays are mandatory in a patient with trauma?

Anteroposterior (AP) and lateral x-rays of cervical spine, AP x-ray of chest, and AP x-ray of pelvis

For a traumatized extremity, what x-rays are obtained?

AP and lateral views of the affected long bone plus an evaluation of the joints proximal and distal to the long bone

What is the initial treatment of a traumatized extremity?

1. Splinting 2. Reduction of deformities (i.e., restoration of normal alignment of bone or joint) 3. Irrigation of any open wounds and application of a sterile dressing


What are the general indications for open (surgical) reduction?

1. Failed closed reduction 2. Intra-articular fractures 3. Extremity function requiring perfect reduction 4. Multiple trauma 5. Advanced age (long nonambulatory period increases morbidity rate)

How does orthopedic surgery help to prevent pulmonary complications in patients with multisystem trauma?

1. Early mobilization of the patient with operative fixation of fractures allows upright posture 2. Surgery reduces the incidence of adult respiratory distress syndrome secondary to fat embolism in patients with long bone fractures

Which fractured bone is most commonly associated with a fat embolism?

Femur

How does a fat embolism present?

Shortness of breath and petechiae across the chest and in the axilla 48 hr after injury

In an extremity that is deformed because of fracture or dislocation, what assessments are performed before reduction is attempted?

1. Vascular status 2. Neurologic status 3. Identification of open wounds

What treatment is performed emergently on a deformed extremity with vascular compromise?

Correction of the deformity by gentle traction in-line of the injured bone; splinting

What procedure is performed on a pulseless extremity whose pulses do not return after reduction?

Immediate operative exploration with intraoperative arteriogram to identify the level of vascular injury

What areas are incorporated into a splint?

The joints proximal and distal to the injured bone are immobilized


What is the treatment of an extremity whose neurologic function was compromised before reduction and remains compromised after reduction?

Observation

What is the treatment if the neurologic function is compromised only after reduction?

Surgical exploration

ORTHOPEDIC EMERGENCIES What are the seven classic orthopedic emergencies?

1. 2. 3. 4. 5. 6.

Unstable pelvic fracture Unstable spine fracture Open fracture Septic joint Septic osteomyelitis Displaced long bone fracture with neurovascular compromise 7. Compartment syndrome 8. Dislocation

Compartment Syndrome What injuries are particularly susceptible to compartment syndrome?

1. 2. 3. 4.

Tibial shaft fractures Extremity vascular injuries Burn injuries (thermal or electric) Supracondylar elbow fractures in children

What are the most reliable symptoms of compartment syndrome?

Pain out of proportion to the expected injury

What physical findings strongly suggest compartment syndrome?

Tense or firm compartments with pain on passive stretching of the involved compartments

What is the normal pressure of a compartment?

0–5 mm Hg

What pressure suggests compartment syndrome?

>30 mm Hg


What is the usual treatment of compartment syndrome?

Emergent open fasciotomy

Should the skin be opened for the length of the fascial incision?

Yes; skin alone can cause a compartment syndrome!

What are the muscular and neurovascular contents of the four compartments of the leg:

1. Anterior compartment?

Muscles: Anterior tibialis, extensor hallucis longus, extensor digitorum longus, and peroneus tertius; Nerve: Deep peroneal; Artery: Anterior tibial

2. Lateral compartment?

Muscles: Peroneus longus and peroneus brevis; Nerve: Superficial peroneal

3. Deep posterior compartment?

Muscles: Posterior tibialis, flexor hallucis longus, and flexor digitorum longus; Nerve: Tibial; Arteries: Posterior tibial and peroneal

4. Superficial posterior compartment?

Muscles: Gastrocnemius, soleus, and plantaris

What are the sequelae of compartment syndrome that is not decompressed within 4–6 hr?

Muscle ischemia and necrosis resulting in contracture


Clavicle Fractures What is the most common site of clavicular fracture?

Central one-third: 80% Distal one-third: 12%–15% Proximal one-third: 5%

What is the usual treatment of this fracture?

Sling or figure-of-eight shoulder harness for 6–8 wk

What clavicle fractures may require surgical fixation?

1. Concurrent vascular injury 2. Displaced distal clavicle fracture 3. Fracture end embedded in or piercing the trapezius muscle 4. Fracture end tenting the skin 5. Open fracture

What type of fixation is used for a clavicle fracture?

Plates and screws, not pins, because pins may migrate into the chest and erode into the chest cavities

What vascular structure is located directly beneath the clavicle?

Subclavian vein; vascular injuries are rare

Scapula Fractures What is the significance of scapula fracture?

Indicates significant injury; the patient must be thoroughly evaluated for lifethreatening lesions (i.e., pneumothorax, aortic injury, pelvic fracture)


Conservative management

Shoulder Trauma What is the most common direction of shoulder dislocation?

Anterior inferior


Pain and reduced shoulder mobility, with the injured arm held by the contralateral arm in slight abduction; prominent acromion


Which x-ray views are included in a shoulder trauma series?

AP, lateral Y, and axillary views

Which nerve is most commonly injured during shoulder dislocation?

Axillary nerve (almost always a neurapraxia)

What are the usual findings on physical exam if this nerve is injured?

Decreased sensation in region of lateral shoulder, decreased deltoid strength

What is the usual technique for reduction of anterior shoulder dislocation?

The patient lies prone with affected arm hanging over the side of the stretcher; a 5- to 10-lb weight is hung from the wrist; the patient is given muscle relaxant and medication for pain relief; after reduction, the arm is immobilized with a sling or swathe

What step is especially important after reduction?

Re-evaluation of neurovascular status of limb

What factor is most predictive of a recurrent shoulder dislocation?

Younger age at first dislocation increases risk of recurrence; anterior shoulder reconstruction may be required

What structure is at increased risk for injury during shoulder dislocation in the elderly?

Axillary artery

What is the usual presentation of posterior shoulder dislocation?

Arm is held adducted and internally rotated; the posterior shoulder is more prominent (until proven otherwise, if the patient cannot externally rotate the shoulder beyond the neutral position or cannot supinate the hand, a posterior dislocation is present) these dislocations are frequently missed!)

What are the common mechanisms for posterior dislocation of the shoulder?

Seizure and electrocution


Closed reduction


Humerus Fractures What are the four anatomic parts that can be displaced in a proximal humerus fracture?

Which muscle inserts on the: Greater tuberosity? Lesser tuberosity?

1. 2. 3. 4.

Head Shaft Greater tuberosity Lesser tuberosity

Supraspinatus muscle Subscapularis muscle

Which x-rays are mandatory for a proximal humerus fracture?

AP, Y, and axillary view

Which nerve is at risk for injury in a humerus shaft fracture?

Radial nerve

What is the incidence of injury to this nerve?

5%–10% of humerus shaft fractures

Which muscles are innervated by the radial nerve distal to the shaft of the humerus?

Extensors of wrist and fingers

What is the usual treatment of nondisplaced fractures of the proximal humerus?

Sling for comfort; begin gentle range of motion as soon as the proximal humerus can move as a unit

What is the usual treatment of displaced proximal humerus fractures?

Open reduction, internal fixation, or hemiarthroplasty (replacement of proximal humerus only), with repair of rotator cuff tear

Should a humerus fracture with 30∞ angulation be corrected, and why?

No; the mobility of the shoulder joint allows the extremity to remain functional

What is the usual treatment of humerus shaft fractures?

Coaptation or “U” splint and sling as long as there is bony opposition

What are the usual indications for surgical fixation of shaft fracture?

1. 2. 3. 4.

Segmental fracture Distal fracture Pathologic fracture Concurrent forearm fracture (floating elbow) 5. Radial nerve injury during reduction


Elbow Dislocations What are the five types of elbow dislocations?

1. Posterior

3. Lateral

2. Anterior

4. Medial

5. Divergent

What is the most common direction of an elbow dislocation?

Posterior (radius and ulna posterior to the humerus); others are rare

Which nerves are most commonly injured with an elbow dislocation?

Median and ulnar nerves

Which muscles does the median nerve innervate distal to the elbow?

Radial wrist flexor (flexor carpi radialis) and deep flexor of thumb, index, and long finger, and all superficial flexors

Which muscles does the ulnar nerve innervate distal to the elbow?

Ulnar wrist flexor (flexor carpi ulnaris), deep flexors to ring and small fingers, and intrinsic muscles to hand

Which artery may be injured?

Brachial artery

What is the usual treatment of elbow dislocation?

Closed reduction with splinting; splinting should last no more than 3 wk to prevent joint contractures

What are the indications for open reduction?

1. Irreducible dislocation 2. Incongruent reduction


Elbow Fractures What is a Monteggia fracture?

Proximal ulna fracture plus radial head dislocation

Which nerve may be injured with this fracture?

Posterior interosseous nerve (PIN), a continuation of the distal radial nerve

What muscles does the PIN innervate?

Extensor carpi ulnaris; finger and thumb extensors

What is a Galeazzi fracture?

Radial fracture at the junction of the middle and distal thirds plus subluxation of the radioulnar joint

Which classic x-ray finding suggests occult elbow fracture?

“Sail sign”: Fat anterior to distal humerus has a triangular appearance because of joint capsule distension

What is the usual treatment of elbow fracture?

Open reduction and internal fixation; precise alignment is needed for upper extremity function

What are the four types of intercondylar fractures?

Which intercondylar fractures types are treated with open technique?

I

II

III

IV

II, III, ± IV (depends on age and bone quality)


What are the three types of coronoid fractures?

I II III

What is a “night stick” fracture?

Ulna fracture

What is Kienböck’s disease?

Avascular necrosis of the lunate

Forearm Fractures What is a Colles’ fracture?

Fracture of the distal radius with dorsal carpal displacement

What is a Smith fracture?

Fracture of the distal radius with volar carpal displacement

What is the usual treatment of displaced midshaft radius fractures?

Open reduction with internal fixation

What is the usual treatment of displaced distal radius fractures?

Closed reduction with splinting

Why are distal radius fractures splinted initially?

Casts do not allow for swelling

Which joints are immobilized when a distal radius fracture is splinted?

Elbow and wrist

What postreduction parameters determine whether surgical intervention is warranted for a distal radius fracture?

1. Articular congruency 2. Radial length 3. Lack of volar tilt (in the AP plane)


What injury to the carpus is commonly missed with a distal radius fracture?

Scapholunate dissociation

What does “snuff-box” tenderness usually indicate?

Scaphoid (or navicular) bone fracture

PELVIC AND ACETABULAR TRAUMA Pelvic Fractures Which bones are included in the pelvic ring? Which ligaments connect the: Sacrum to the ilium?

Sacrum to the ischium?

Ilium, ischium, and pubis

Anterior and posterior sacroiliac ligaments and interosseous ligaments Sacrotuberous ligament and sacrospinous ligament

Which ligament joins the ring anteriorly?

Pubic symphysis

Which x-rays are necessary to evaluate a pelvic fracture or pelvic ring injury?

1. AP, inlet, and outlet 2. CT scan if the patient is hemodynamically stable

What aspect of a physical exam is mandatory before a Foley catheter is inserted?

Rectal exam (for high-riding prostate) and inspection for blood at the urethral meatus because of the risk of urethral disruption with pelvic fracture


What percentage of patients with a major pelvic fracture: Have concurrent intra-abdominal injury?

10%–20%

Require blood transfusion?

40%

Have injury to a major pelvic arterial vessel?

2%

What are the usual applications for CT scan?

1. Evaluation of the posterior ligaments 2. Evaluation of the acetabulum 3. Identification of a pelvic hematoma or intraperitoneal injury

What is the quickest form of surgical treatment of a hemodynamically unstable patient with an unstable pelvic fracture?

External fixation, with pins placed through the skin and into the iliac wings and connected to a bar externally

What vessel is at risk for injury with a pelvic fracture through the greater sciatic notch?

Superior gluteal artery, a branch of the internal iliac artery

Describe the pelvis fracture classification by mechanism, including the feature that classifies each type as unstable:


1. Type I

1. Lateral compression: Unstable when the posterior ligamentous or bony structure is disrupted

2. Type II

2. AP compression: Unstable when the pubic diastasis is >2.5 cm, which indicates that the posterior ligamentous or bony structure is disrupted

3. Type III

3. Vertical shear: Unstable by definition

Acetabular Fractures What is the basic anatomy of the acetabulum?

Rounded cavity whose walls contain anterior and posterior columns of bone that join at its dome

Which x-rays are necessary to evaluate an acetabular fracture?

AP Judet views CT scan if the patient is hemodynamically stable

Which fractures do not require surgical treatment?

<2 mm displacement Satisfactory joint congruity

If surgery is necessary, when are these fractures usually repaired?

3–10 days after trauma, to reduce the risk of hemorrhage

What three complications are associated with acetabular fractures?

1. Sciatic nerve palsy 2. Post traumatic arthritis 3. Heterotopic ossification that may limit hip motion

What are the four types of hip femur fractures?

1. 2.

3. 4.


1. 2. 3. 4.

Femoral head (intracapsular) Femoral neck (intracapsular) Intertrochanteric (extracapsular) Subtrochanteric (extracapsular)

HIP TRAUMA Hip Dislocation What is Shenton’s line?

Shenton’s line

What is the most common mechanism of injury?

Motor vehicle accident (75%)

What is the most common type of hip dislocation?

Posterior


What is the usual presentation of an anterior hip dislocation?

Externally rotated extremity with anterior hip fullness; think A for Anterior

What vascular structure can be injured with anterior dislocation?

Femoral artery


What is the usual presentation of posterior hip dislocation?

Internally rotated extremity with posterior fullness

What neurologic structure can be injured with posterior dislocation?

Sciatic nerve

What is the usual incidence of this injury?

10%

What is the usual treatment of hip dislocation?

Attempted closed reduction, followed by open reduction if dislocation is irreducible; hip dislocation is an orthopedic emergency!


What is the Allis technique for closed reduction of a posterior hip dislocation?

What is the Stimson technique for closed reduction of a posterior hip dislocation?

How is the stability of reduction assessed?

Hip is flexed to 90° in neutral rotation; if the hip redislocates, it is considered unstable

What are the usual indications for open reduction?

1. 2. 3. 4.

What intervention is sometimes needed to prevent acute redislocation?

Traction

What follow-up study is necessary after reduction, and why?

X-ray (or, ideally, CT scan) to evaluate for: 1. Congruency of reduction 2. Presence of intra-articular bodies, which must be surgically removed

Failed closed reduction Incongruent reduction Intra-articular debris Unstable reduction


What are the usual late complications after hip dislocation?

1. Avascular necrosis (AVN; osteonecrosis) of the femoral head 2. Post traumatic arthritis

What is the usual incidence of each complication?

1. AVN: 15%–20% in posterior dislocation; 5%–10% in anterior dislocation 2. Arthritis: 25%–60% in both

Hip Fracture Describe a hip fracture classification by location:

1. Femoral neck fracture 2. Intertrochanteric fracture—fracture traverses the metaphyseal region from greater to lesser trochanter 3. Subtrochanteric fracture—fracture extends in shaft of femur below lesser trochanter

What is the usual position of the lower extremity of a fractured hip?

Shortened and externally rotated


Closed reduction with internal fixation; in the elderly, traction is often the first line of therapy

What are the Garden classification Types I–IV of femoral neck fractures?

Type I: Incomplete; valgus impaction Type II: Complete; undisplaced Type III: Complete; partially displaced Type IV: Complete; totally displaced

What is the usual treatment of Garden type I and type II fractures?

Closed reduction with internal fixation

What is the usual treatment of Garden type III and type IV fractures?

Hip replacement (hemiarthroplasty vs. total hip replacement)

What is a common complication of femoral neck fractures?

AVN of the femoral head


Why this is a common complication?

Blood supply is disrupted as it travels distally to proximally

What factors correlate most closely with the risk of AVN in femoral neck fractures?

Closeness of the fracture to the femoral head Degree of displacement at the time of injury

What is the usual mortality rate after hip fractures: In hospital? At 1 yr?

10% 35%

FEMORAL SHAFT FRACTURES What fracture commonly occurs at the same time as a femoral shaft fracture?

Ipsilateral femoral neck fracture

What is the usual treatment of adult femoral shaft fractures?

Closed intramedullary nailing (with locking screws)

What is the usual treatment of pediatric femoral shaft fractures?

Hip spica cast

TRAUMATIC KNEE INJURIES Name the labeled structures (patella and patella tendon removed):

1. 2. 3. 4. 5. 6.

Medial collateral ligament Lateral collateral ligament Anterior cruciate ligament Posterior cruciate ligament Medial meniscus Lateral meniscus


Knee Dislocations Which neurovascular structures are most commonly injured during knee dislocations?

1. Popliteal artery 2. Peroneal nerve

What is the usual incidence of injury of each structure?

Popliteal artery: 20%–40% Peroneal nerve: 15%


Closed reduction is attempted; however, open reduction may be necessary

What study is performed after reduction?

Arteriogram to evaluate the popliteal artery

What may result from knee dislocations?

Multiligament disruptions, which require surgical reconstruction; if peroneal nerve palsy exists, decompression of the nerve should be performed urgently

In which direction does the patella most commonly dislocate?

Laterally


Closed reduction by knee extension and manipulation; the dislocation often reduces spontaneously

Why is a postreduction x-ray necessary?

To identify osteochondral fractures that require surgical repair

Patellar Fractures What is a bipartite patella?

Patella with a well-defined superior-lateral secondary ossification center that is often mistaken for a fracture

What is the usual treatment of nondisplaced patellar fracture?

Cylinder cast

What is the usual indication for surgical repair of a patellar fracture?

>3 mm of displacement or loss of the extensor mechanism


TIBIAL SHAFT FRACTURES What complications often affect patients with tibial fractures?

1. Open fracture 2. Compartment syndrome

Why are tibial fractures prone to open wounds?

Subcutaneous location of the tibia

What flap can be used for coverage of an open fracture wound in the: Proximal one-third of the tibia?

Gastrocnemius muscle

Middle one-third of the tibia?

Soleus muscle

Distal one-third of the tibia?

Soleus muscle

Which fracture configuration is most amenable to: Intramedullary rod fixation?

Transverse

External fixation?

Open, comminuted

Casting?

Spiral, nondisplaced

TRAUMATIC ANKLE AND FOOT INJURIES Which x-rays are mandatory in evaluating an ankle fracture?

AP, lateral, and mortise views

What does the mortise view evaluate?

Articular congruency (medially, superiorly, and laterally) and competency of the tibiofibular interosseous membrane

Which ligament is most commonly injured in an ankle sprain?

Anterior talofibular ligament

What is the most common mechanism of ankle fracture?

Externally rotated leg on a supinated foot


What are the indications for surgery for ankle fractures?

1. Unstable ankle fractures (lateral and medial malleolus fracture or ligamentous disruption) 2. Incongruent joint after closed reduction 3. Syndesmotic rupture (disruption of distal tibiofibular ligamentous complex)

Where does the talus usually fracture?

Talar neck

What are the complications of talus fractures?

AVN of the body or dome; severe soft tissue injury

What is the usual mechanism of injury for calcaneus fractures?

Axial load (fall from a height)

What other fracture is common with a calcaneus fracture?

Lumbar spine fracture (10%)

What is the goal of treatment of a calcaneus fracture?

1. Prevent widened heel so that the foot can fit into a shoe 2. Maintain subtalar joint congruency to minimize risk of post traumatic arthritis

What is a Lisfranc fracture or dislocation?

Fracture or dislocation of the base of the second metatarsal-cuneiform joint

Homolateral

Divergent



Displaced injuries require anatomic reduction (open or closed) and fixation (percutaneous pin or screw)

Which tendon is responsible for avulsion injuries to the base of the fifth metatarsal?

Peroneus brevis


Hard-soled shoe or cast for 2–3 wk

PERIPHERAL NERVE INJURY For each listed nerve, identify the contributing spinal levels and the motor test used to evaluate motor function: Axillary nerve?

C5 to C6; abduction of the shoulder

Musculocutaneous nerve?

C5 to C6; flexion of the elbow

Radial nerve?

C6 to C8; extension of the thumb

Median nerve?

C6 to T1; flexion of the thumb interphalangeal joint

Ulnar nerve?

C7 to T1; abduction of the index finger

Femoral nerve?

L2 to L4; extension of the knee

Obturator nerve?

L2 to L4; adduction of the hip

Superior gluteal nerve?

L5; abduction of the hip

Inferior gluteal nerve?

S1; extension of the hip

Tibial nerve (sciatic nerve)?

L4 to S3; plantar flexion of the toe and ankle

Deep peroneal nerve (sciatic nerve)?

L4 to S2; dorsiflexion of the toe


SPORTS MEDICINE Sprains and Strains What is a sprain?

Ligament tear


Swelling and tenderness over the ligament; increased pain on stretching of the ligament

How are sprains graded?

Grade I: Minor incomplete tear; no laxity compared with the contralateral ligament Grade II: Significant incomplete tear; increased laxity; significant swelling and ecchymosis Grade III: Complete tear; no end point felt when stress is applied to the ligament; diagnosis may be missed because of muscle spasm and pain that prevent adequate examination of the ligament

What is a strain?

Partial tear of the musculotendinous unit

Shoulder Separation What is the most common shoulder dislocation?

Anterior

Which shoulder joint is most commonly sprained?

Acromioclavicular (AC) joint

Which ligaments stabilize the AC joint?

1. AC ligaments 2. Coracoclavicular (CC) ligaments (conoid and trapezoid)


What is the usual mechanism of ligament injury?

Fall on the side of the shoulder

How are these injuries evaluated?

AP x-ray taken with weight (10 lb) hanging from the arm, and compared with contralateral side

How are AC sprains graded?

Grade I: Ligament continuity; no joint opening Grade II: Ligament continuity; joint opening Grade III: No ligament continuity; complete tear of AC and CC ligaments


Sling for comfort for all grades with early range of motion; orthopedic referral in 3–5 days for grades I and II and immediately for grade III because surgery may be indicated

Rotator Cuff Pathology How does rotator cuff usually present?

Middle-aged man (40s) with gradually increasing pain in the shoulder and difficulty raising the arms above the head

What clinical findings support the diagnosis of rotator cuff tendinitis?

Passive internal rotation, flexion, and abduction of the shoulder causing severe pain

What are the four muscles of the rotator cuff?

Think SITS: 1. Supraspinatus muscle 2. Infraspinatus muscle 3. Teres minor muscle 4. Subscapularis muscle

Which muscle tendon is usually affected by tendinitis?

Supraspinatus muscle

What three factors contribute to rotator cuff tendinitis?

1. Impingement from bone spur of the acromion or AC joint 2. Vascular watershed of the tendon 3. Repetitive trauma from overhead activities


What is the end-stage condition of rotator cuff impingement?

Rotator cuff tear with eventual proximal migration of the humerus; severe pain

What is the usual presentation of acute tear of the rotator cuff?

Acute onset of pain and inability to raise the arm over the head after a traumatic event

What radiographic studies are used to diagnose rotator cuff tears?

MRI or arthrogram

What is the usual medical treatment?

1. Physical therapy 2. Nonsteroidal anti-inflammatory drug (NSAID) 3. Steroid injection

What is the usual surgical treatment of severe impingement or rotator cuff tear?

1. Removal of bony spurs (acromioplasty) 2. Repair of rotator cuff

Knee Injuries What is a common mechanism for rupturing the anterior cruciate ligament (ACL)?

Changing direction at high speed on a planted foot

What is the most common finding on knee aspiration after an ACL rupture?

Hemarthrosis (blood); 70% of patients with hemarthrosis and stable ligamentous findings actually have an ACL injury

What physical findings are consistent with ACL injury?

1. Increased anterior translation of the tibia on the femur with the knee in 90° flexion (anterior drawer test) 2. Increased translation of the tibia on the femur with the knee in 20–30° flexion (Lachman test)

Which study best evaluates intra-articular abnormalities of the knee?

MRI

Which intra-articular structure is most commonly injured with a traumatic ACL rupture?

Lateral meniscus


What physical finding is consistent with a medial collateral ligament rupture?

Increased pain and medial joint opening with the knee in slight flexion and valgus stress applied

What physical finding is consistent with a lateral collateral ligament rupture?

Lateral joint opening with the knee in slight flexion and valgus stress applied

What is the most sensitive physical finding that suggests an acute posterior cruciate ligament rupture?

Quadriceps active test: Increased anterior translation of the tibia on the femur from a posteriorly displaced position when the knee is actively extended against gravity from a position of flexion

What is the usual conservative therapy?

Ice, elevation, compression, immobilization, nonweight-bearing with crutches, and physical therapy (think NICE: Nonweight-bearing, Ice, Compression, Elevation)

What is the usual surgical therapy?

Reconstruction of the ligament with arthroscopic assistance, using the patella tendon or a hamstring autograft

What is the “unhappy triad”?

Knee injury that includes the ACL, medial collateral ligament (MCL), and the medial meniscus

Foot and Ankle Sports Injuries What are the signs of an Achilles tendon rupture?

Calf pain, palpable disrupted tendon, unable to plantar flex ankle

What physical exam finding is indicative of an Achilles tendon tear?

Positive Thompson test: Squeezing the gastrocnemius muscle does not result in plantar flexion of the foot

What is turf toe?

Hyperextension injury of the first metatarsophalangeal (MTP) joint resulting in a strain or avulsion of volar plate from the metatarsal head; often occurs on artificial turf


ORTHOPEDIC INFECTIONS Septic Arthritis What is the most common route of infection that causes a septic joint?

Hematogenous

What is the usual presentation of bacterial septic arthritis?

Localized joint pain, erythema, warmth, swelling with pain on active and passive range of motion, inability to bear weight, ± fever

What are the components of the diagnostic evaluation?

X-ray (to rule out osteomyelitis), erythrocyte sedimentation rate, WBC count, blood cultures, and aspirate

What findings on aspirate are diagnostic of infection?

1. WBC > 80,000; >90% neutrophils 2. Protein level >4.4 g/dL 3. Glucose level significantly < blood glucose level 4. No crystals 5. Positive Gram stain results

What is the most common organism that causes septic arthritis?

Staphylococcus aureus

What other organism must be considered in a sexually active patient?

Neisseria gonorrhoeae

What is the usual treatment of septic arthritis?

1. Hip joint is emergently decompressed and drained surgically; other joints may be serially aspirated 2. IV antibiotics

Osteomyelitis What is the usual presentation of osteomyelitis?

Localized extremity pain, ± fever, 1–2 wk after respiratory infection or infection at another nonbony site


What is the most common organism in the bacteriology of osteomyelitis?

S. aureus

Which patients are susceptible to gram-negative organisms?

Neonates and immunocompromised patients

Which additional organism is common in patients with sickle cell disease?

Salmonella

What classic radiographic findings are associated with osteomyelitis?

Lytic, eccentrically located serpiginous lesion involving the cortex

What other studies confirm the diagnosis?

Blood cultures, aspirate cultures, erythrocyte sedimentation rate, leukocytosis, and increased uptake on bone scan

What other organism must be considered when osteomyelitis occurs in a child <5 yr old?

Haemophilus influenzae

What organisms must be considered in the IV drug abuser?

Gram-negative organisms and Pseudomonas aeruginosa

What organism must be considered in the patient with sickle cell disease?

Salmonella typhi

What organism must be considered in patients with foot puncture wounds?

Pseudomonas

What is the usual treatment of osteomyelitis?

Surgical decortication and drainage; IV antibiotics


PEDIATRIC ORTHOPEDIC SURGERY Name and describe the classification used for pediatric fractures:

Salter classification of fractures involving the physis (growth plate): I. Through the growth plate only II. Through the metaphysis and growth plate III. Through the epiphysis and growth plate IV. Through the epiphysis, growth plate, and metaphysis V. Crushed growth plate (Note: Most “ligamentous” injuries in children are actually fractures involving the physis) What possibility should be investigated in children with spiral or oblique fractures?

Child abuse

What is the most commonly fractured bone in childhood?

Clavicle

Leg Length Discrepancy What leg length discrepancy goes unnoticed by patients?

1 cm

What leg length discrepancy can be treated with a shoe lift?

2.5 cm


What leg length discrepancy is generally treated by epiphysiodesis (i.e., limb shortening)?

2.5–5 cm (discrepancy >5 cm is generally treated with limb lengthening)

Hip Disorders How do hip abnormalities commonly present in children?

Knee pain referred from the hip

What nerve is responsible for this referred hip pain?

Obturator nerve

What is the differential diagnosis for a child with hip or knee pain and a waddling gait?

1. Late developmentally dysplastic hip 2. Perthes disease 3. Slipped capital femoral epiphysis

What is the usual presentation of developmentally dysplastic hips?

1. Hip “click” detected by newborn screening 2. Asymmetric skin folds and thigh lengths in newborns Most common in girls, firstborns, and infants presenting in breech position

What physical maneuvers are is used to screen a newborn’s hips?

Barlow test: Hip is dislocated by adducting the leg while driving the hip posteriorly Ortolani test: Hip is reduced by abducting the leg while pulling the hip anteriorly

What is the usual treatment in a child 0–6 mo old?

Pavlik harness (straps that hold the hips flexed and slightly abducted)

What is the usual treatment in a child >6 mo old?

Traction or surgery

Legg-Calvé-Perthes Disease What is Legg–Calvé–Perthes disease?

Osteochondritis of the capital femoral epiphysis


Painless limp in a child 4–8 yr old; knee pain


Hypothyroidism, infection, and epiphyseal dysplasia


What are the principles of treatment for Perthes disease?

1. Maintain hip range of motion 2. Contain the softened revascularizing femoral head in the acetabulum during remodeling

How are these goals achieved?

Bilateral walking long leg casts fixed together with transverse bars until x-rays show that mature bone has replaced the avascular epiphysis (usually 18 mo)

Slipped Capital Femoral Epiphysis (SCFE) What is the usual presentation of SCFE?

Painful, waddling gait in an adolescent; most common in African American obese males

What is the classic physical finding?

Obligator external rotation with hip flexion

How is SCFE quantified?

Degree or percentage of translation of the capital femoral epiphysis in relation to the femoral neck as seen on a lateral (frog leg) hip x-ray

What steps are mandatory in the evaluation of a patient diagnosed with SCFE?

1. Evaluation of the contralateral hip (≈25% are bilateral) 2. Endocrine evaluation to rule out hypothyroidism


Mandatory admission with strict nonweight-bearing until operative pinning is performed; some deformities require an osteotomy

What maneuver is avoided during the treatment of SCFE?

Forceful reduction of the hip

Scoliosis What is scoliosis?

Lateral curvature of a segment of the spine


1. Idiopathic (most common) 2. Neuromuscular (neuropathic and myopathic) 3. Congenital defect in formation, segmentation, or both


4. Neurofibromatosis 5. Connective tissue disorders (Marfan’s, Ehlers–Danlos) 6. Osteochondrodystrophy 7. Metabolic 8. Nonstructural (painful lesion) 9. Trauma (thoracic surgery) What are the two general types?

1. Structural: Does not correct with positional changes 2. Nonstructural: Corrects with positional changes

What is the most common form of scoliosis?

Adolescent idiopathic scoliosis


Adolescent girl with painless curvature or asymmetric shoulders, pelvis, or rib hump (seen with forward bending)


Congenital vertebral malformation, neuromuscular disorders, tumors, or spinal dysraphism

What is the most common direction and location of adolescent idiopathic scoliosis?

Convexity to the right in the thoracic spine; look for chest rotation and rib hump

What findings require further evaluation with MRI or bone scan?

1. Pain 2. Left thoracic curve 3. Neurologic compromise

Which adolescent idiopathic scoliotic curves require treatment?

Curves that are likely to progress or those that show progression; others need serial observation until the patient reaches maturity

How is adolescent idiopathic scoliosis treated in skeletally immature patients?

1. Bracing for curves that are 25–30° and show progression of 5–10° 2. Bracing for any curve that is 30–40° 3. Surgical fusion for curves >40°

What degree of scoliosis is likely to progress in skeletally mature patients?

>50°


What degree of curvature is associated with cardiopulmonary compromise?

>90°

Cerebral Palsy (CP) What is CP?

Nonprogressive, neuromuscular disease secondary to injury of the immature brain

What types of movement characterize CP?

Spasticity, athetosis, ataxic, and mixed

What are the patterns of movement of the extremities?

Hemiplegic (upper and lower extremities on the same side), diplegic (both lower extremities), and totally involved

What is the most common type of CP?

Spastic and diplegic

Which type has the worst prognosis for ambulation?

Totally involved

Which type has the best prognosis for ambulation?

Hemiplegic


Physical therapy and orthotics; surgery is not commonly used, but may be necessary for lengthening or transplantation of the tendons, arthrodesis of the joints, or correction of limb length inequality

Myelodysplasia (Spinal Dysraphism) What is myelodysplasia?

Defect of spinal cord closure ranging from only the posterior vertebral arch (spina bifida occulta) to exposed neural elements (rachischisis)

Compare meningocele and myelomeningocele:

Meningocele: Exposed sac protruding into the defect without neural elements Myelomeningocele: Protruding sac containing neural elements

What factors determine the functional prognosis in myelodysplasia?

Level of defect and extent of neurologic injury


What is the highest level of myelodysplasia that allows ambulation?

Fourth lumbar

Which muscle group is innervated by the fourth lumbar nerve roots?

Quadriceps by L2, L3, and L4

What are the usual orthopedic manifestations of myelodysplasia?

Scoliosis, dislocated hips (from unopposed flexion and adduction at the level of L3 to L4), lower extremity contraction and fractures

Duchenne Muscular Dystrophy (DMD) What is DMD?

X-linked recessive, noninflammatory disorder of progressive muscle weakness affecting young males


Young male with clumsiness, lumbar lordosis, and calf pseudohypertrophy

What is the Gowers’ sign?

Child stands from the recumbent position by walking his hands up his legs

What laboratory value supports the diagnosis of DMD?

Highly elevated creatinine phosphokinase level

What are the orthopedic manifestations of DMD?

Flexion contractures of the joints and neuromuscular scoliosis

What is the usual prognosis?

Most patients die by 20 yr of age as a result of cardiopulmonary complications

Toeing-In What is the differential diagnosis for pigeon toe (toeing-in gait) in a child?

1. Metatarsus adductus 2. Tibial torsion 3. Excessive femoral anteversion

Which type is the most common?

Tibial torsion

What is metatarsus adductus?

Adducted forefoot


What is the most commonly affected age group?

First year of life


If flexible, stretching; if inflexible, osteotomy

What is tibial torsion?

Rotational deformity of the tibia proximally to distally


2 yr of age


None; spontaneous resolution is the norm

What is femoral anteversion?

Increased internal rotation of the femur in relation to the femoral neck and head


3–6 yr of age


Spontaneous resolution by 10 yr of age is the norm

Nursemaid’s Elbow What is it?

Subluxation of the radial head because of a sudden tug on a child’s pronated, extended arm


Local tenderness, limited use of the arm, but no swelling or x-ray abnormalities


Closed reduction by supinating the arm; no immobilization is necessary

JOINT RECONSTRUCTION What three forms of arthritis commonly require joint replacement?

1. Osteoarthritis 2. Rheumatoid arthritis 3. AVN

What are the radiographic hallmarks of osteoarthritis?

Loss of joint space, periarticular osteophytes, subchondral sclerosis, and subchondral cyst formation


What are the radiographic hallmarks of rheumatoid arthritis?

Periarticular erosions and osteopenia

What are the radiographic hallmarks of AVN of the femoral head?

Stage I: Normal x-ray findings; decreased signal by MRI Stage II: Femoral head that has subchondral radiodensity or radiolucency, but no collapse Stage III: Femoral head that has collapse, with a “crescent sign” and no acetabular involvement Stage IV: Femoral head involvement with acetabular involvement

Who is the ideal candidate for joint replacement surgery?

Elderly patient with debilitating pain localized to a joint and radiographic evidence of arthritis; failed nonoperative treatment

What are the classic nonoperative treatment modalities?

Unloading of joints through weight loss or a cane; support of joints through muscle strengthening or bracing; and relief of symptoms with an NSAID or joint injections with anesthetics and steroids

What are the contraindications to joint replacement surgery?

1. Active infection 2. Neurologic compromise 3. Young, active patient

What surgical options are available for the young patient with debilitating arthritis?

1. Osteotomy: Controlled fracture of the bone and fixation to correct the alignment 2. Arthrodesis: Joint fusion

What are the major complications after total hip arthroplasty (replacement) and the incidence of each?

1. DVT: 70% (by venogram) 2. Infection: 1% 3. Dislocation: 1%–5%

What structures are at risk because of screw penetration of the inner wall of the acetabulum during total hip arthroplasty?

1. External iliac artery and vein in the anterior superior quadrant 2. Obturator nerve artery and vein in the anterior inferior quadrant


FOOT AND ANKLE Diabetic Foot What two entities in patients with diabetes cause deformity and radiographic obliteration of the affected joints?

1. Infection 2. Neuropathic joint (Charcot’s joint)

How do these two entities differ?

Charcot’s joint presents with a swollen, warm, relatively painless deformed foot with no systemic fever and a low WBC count

What is the usual treatment of Charcot’s joint?

Immobilization in a cast until the inflammation resolves

Flatfoot What is the differential diagnosis for flatfoot in adulthood?

1. Posterior tibial tendon rupture 2. Talonavicular arthritis 3. Neuropathic arthritis

What is the differential diagnosis for rigid flatfoot in childhood?

1. Tarsal coalition 2. Congenital vertical talus

When is treatment of flatfoot indicated?

When it becomes painful


Flexible flatfoot is generally treated with orthotics (arch supports); rigid flatfoot requires surgical correction

Toe Abnormalities What is a claw toe?

Extended MTP joint and flexed proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints

What is a hammer toe?

Flexed PIP joint ± extended MTP joint

What is a mallet toe?

Flexed DIP joint

What is the most common cause of deformed toes?

Narrow toe box of shoes


SPINE Low Back Pain What is the most common cause of low back pain in children?

Spondylolysis

What are the common intrinsic spine disorders of children with back pain?

Congenital, developmental, and infectious disorders; tumors

What are the common intrinsic spine disorders of young adults with back pain?

Disc disease, spondylolisthesis, and acute fracture

What are the common intrinsic spine disorders of older adults with back pain?

Spinal stenosis, metastatic disease, and osteoporotic compression fractures

What percentage of the population shows evidence of herniated nucleus pulposus by MRI?

≈30%; most are asymptomatic

Spondylolysis What is spondylolysis?

Bony defect in the pars interarticularis, usually caused by a fatigue fracture

Which x-ray views best show spondylolysis?

Oblique lumbar spine views, which show a break in the neck of the “Scottie dog”

What is the usual treatment of spondylolysis?

Asymptomatic spondylolysis is not treated; symptomatic cases are treated with activity restrictions and, rarely, fusion

Spondylolisthesis What is spondylolisthesis?

Slippage of one vertebra on another

What are the causes of spondylolisthesis?

Congenital, elongation of the pars interarticularis, degenerative, traumatic, pathologic, and postsurgical


What is the usual presentation of childhood spondylolisthesis?

Tight hamstrings, low back pain

At what level does childhood spondylolisthesis typically occur?

L5 to S1

At what level does adult degenerative spondylolisthesis usually occur?

L4 to L5

What is the usual treatment of spondylolisthesis?

Mild slips are treated with activity restriction until symptoms disappear; severe slips are treated with fusion

Spinal Infections What is Pott’s disease?

Tuberculosis infection of the spine


Back pain, ± fever and weight loss, in an exposed or immunocompromised patient


Immobilization and IV antibiotics; if this treatment fails, then surgical débridement and stabilization

How is pyogenic vertebral osteomyelitis differentiated radiographically from tumor?

Infection often involves the disc space; tumor commonly spares the disc space

MUSCULOSKELETAL ONCOLOGY What is the usual treatment for extremity tumors?

Wide excision or amputation; adjunctive chemotherapy or radiation therapy

Soft Tissue Tumors What is the most common soft tissue sarcoma of late adulthood?

Malignant fibrous histiocytoma

What is the most common soft tissue mesenchymal tumor?

Lipoma


What is the most common soft tissue sarcoma of childhood?

Rhabdomyosarcoma

What is the most common sarcoma of the hand?

Epithelioid sarcoma

Bone Tumors What is the most common malignancy of bone?

Metastatic disease

What is the most common tumor of the spine?

Metastatic disease

What primary malignancies commonly metastasize to bone in adults?

Breast, lung, prostate, kidney, and thyroid carcinoma

What primary malignancies commonly metastasize to bone in children?

Neuroblastoma and Wilms’ tumor

What is the usual treatment of metastatic disease to the bone?

Radiation therapy and, in some cases, prophylactic fixation

What is the most common benign primary bone tumor?

Nonossifying fibroma

Primary Bone Malignancies What is the most common primary bone malignancy in adults?

Multiple myeloma

What are the most common primary bone malignancies in children and adolescents?

1. Osteosarcoma 2. Ewing’s sarcoma

What is the most common location for each type?

Both are usually found in the knee region (distal knee, proximal tibia)

What are the classic radiographic findings for each type?

1. Osteosarcoma: Sunburst pattern 2. Ewing’s sarcoma: “Onion skinning” pattern

Chapter 79 / Neurosurgery 699


1. Osteosarcoma: Wide or radical excision with multiagent chemotherapy 2. Ewing’s sarcoma: Chemotherapy with wide excision or radiation therapy

Unicameral Bone Cyst What is it?

Benign fluid-filled cyst found in bone


Proximal humerus

What is the most common age group?

5–15 yr


Pain or pathologic fracture


Steroid injections

Chapter 79 Neurosurgery ADVANCED NEUROANATOMY What is the pterion?

The H-shaped junction of the frontal, parietal, temporal, and greater wing of the sphenoid bones; its location is roughly 2.5 cm above the zygomatic arch and 1.5 cm behind the zygomatic process of the frontal bone

Why is the pterion important?

Its position represents the central focus of one of the more common craniotomies in neurosurgery

What is the largest foramen of the skull?

Foramen magnum


What does each foramen in the skull contain: Foramen magnum?

Spinal cord and medulla, the anterior and posterior spinal arteries, the spinal accessory nerve (cranial nerve 11), and the vertebral arteries

Foramen ovale?

Mandibular branch of cranial nerve 5 and the motor branches to the jaw musculature

Jugular foramen?

Internal jugular vein and cranial nerves 9, 10, and 11

Foramen lacerum?

Although the foramen lacerum appears large when viewing the base of the skull, usually no structures enter or exit from this foramen

What constitutes the base of the skull?

1. 2. 3. 4.

Orbital roofs of frontal bones Cribriform plate of ethmoid bones Sphenoid bone Squamous and petrous portions of temporal bones 5. Occipital bones

What are the major anatomic divisions of the brain?

1. Two cerebral hemispheres 2. Brain stem 3. Cerebellum

What are the lobes of the cerebral hemispheres?

1. 2. 3. 4.

What are the three divisions of the brain stem?

1. Midbrain 2. Pons 3. Medulla

What are the functions of the frontal lobes?

Planning and sequencing of movement, voluntary eye movements, and emotional affect

Frontal lobes Parietal lobes Temporal lobes Occipital lobes


What are the functions of the parietal lobes?

Subserve motor control and cortical sensation; the dominant parietal lobe governs motor programs, whereas the nondominant lobe governs spatial orientation

What are the functions of the occipital lobes?

Visual perception and involuntary eye movements

What are the functions of the temporal lobes?

Subserve olfaction, memory, and certain components of auditory and visual perception

What region of the brain governs the comprehension of speech, and in which lobe is it located?

Wernicke’s area; located in the dominant temporal lobe of the brain

What region of the brain governs the motor component of speech, and in which lobe is it located?

Broca’s area; within the posterior portion of the dominant frontal lobe

What are the major vessels supplying blood to the brain and their branches?

1. The anterior circulation of the brain consists of the internal carotid arteries, which further divide into the anterior cerebral artery and the middle cerebral artery 2. The posterior circulation consists of the vertebral arteries, which join to form the basilar artery, which divides into the two posterior cerebral arteries; the vertebral arteries also give off the anterior spinal artery of the spinal cord and the posterior inferior cerebellar artery (PICA), whereas the basilar artery gives off the anterior inferior cerebellar artery (AICA) and the superior cerebellar artery (SCA)


What is the “circle of Willis”?

An arterial anastomosis of vessels that enables the entire brain to be reliably vascularized from one main feeding vessel; the anterior communicating artery between the two anterior cerebral arteries, and the two posterior communicating arteries between the internal carotid artery and the posterior cerebral arteries serve as the main conduits between the anterior and posterior circulatory systems as well as the right- and left-sided circulatory systems Anterior communicating artery Anterior cerebral artery

Internal carotid artery Posterior cerebral artery

Middle cerebral artery Posterior communicating artery Basilar artery

Vertebral artery

Circle of Willis

What are the main draining vessels of the brain?

The venous drainage systems of the brain are divided into superficial and deep systems: 1. In the superficial system, the superior sagittal sinus joins the straight sinus at the confluence of the sinuses, known as the torcular; blood then drains from the cranial vault via the transverse and sigmoid sinuses to exit the skull via the internal jugular veins 2. The deep system starts with the internal cerebral veins and inferior sagittal sinus draining into the straight sinus


What is the cavernous sinus?

The cavernous sinus is a plexus of veins located on both sides of the bony sella turcica; a number of veins, including orbital and cortical vessels, contribute to its flow

Which nerves travel within the lateral walls of the cavernous sinus?

Cranial nerves III, IV, and the ophthalmic and maxillary divisions of cranial nerve V

Which nerve and artery travel within the sinus itself?

Cranial nerve VI and the carotid artery

What is a carotid cavernous fistula?

Carotid cavernous fistulas are the general arterialization of the cavernous sinus. The fistulas are of two types: traumatic and spontaneous.

What symptoms are associated with carotid cavernous fistulas?

Headache, orbital pain, and diplopia

What signs are associated with carotid cavernous fistulas?

Ophthalmoplegia, arterialization of the conjunctiva (chemosis), and ocular or cranial bruit

What is the treatment of carotid cavernous fistulas?

Although some low-flow lesions may spontaneously thrombose, high-flow lesions often require balloon embolization

Where is cerebrospinal fluid (CSF) produced?

The bulk of CSF is produced by the choroid plexus, which is located in the lateral and fourth ventricles; small amounts are also produced in the interstitial spaces, the ependymal linings of the ventricles, and the dural root sleeves

How much CSF is produced daily in the adult?

Typically, 500–750 mL (0.35 mL/min)


What is the pathway for CSF egress from the lateral ventricles to the surface of the brain?

CSF produced in the choroid plexus of the lateral ventricles travels first through the foramen of Monro of the lateral ventricles into the midline third ventricle; from the third ventricle, CSF travels through the narrow aqueduct of Sylvius to the fourth ventricle; CSF then exits the brain via the midline foramen of Magendie or the lateral foramina of Luschka; once over the surface of the brain, CSF is primarily absorbed by the arachnoid granulations located in continuity with the superior sagittal sinus

What are the principles of the Monro–Kellie doctrine?

For intracranial pressure to remain constant, the sum of the volumes of the intracranial contents (brain, blood, CSF) must remain constant

What is the normal cerebral perfusion pressure (CPP) and how is it maintained?

The brain, through autoregulation, maintains CPP at ≥50 mm Hg

What is normal cerebral blood flow (CBF)?

CBF in the normal resting brain is 50 mL/100 mg brain/min

At what CBF does the electroencephalogram become flatline?

At 25 mL/100 mg brain/min

At what CBF does neuronal cell death ensue?

At 10 mL/100 mg brain/min

What is Kernohan’s phenomenon?

Contralateral cerebral peduncle compression against the tentorial notch, resulting in contralateral dilated pupil and ipsilateral hemiparesis, is seen in 10%–20% of epidural hematomas

What is a subdural hygroma?

A subdural fluid collection due to a tear in the arachnoid membrane

What is the radiographic appearance of subdural hygroma?

A hypodense crescent of fluid displacing brain tissue


PITUITARY TUMORS Identify the hormones from the pituitary?

Where are hormones in the posterior pituitary produced?

Hypothalamus (vasopressin and oxytocin); think: VOX = Vasopressin and OXytocin

Where are the anterior pituitary hormones produced?

Anterior pituitary

Most common pituitary tumor?

Prolactinomas

Difference between male and female pituitary tumor histology?

Prolactinomas: Macroadenomas = male Microadenomas = women Think = Men (macro) on average are heavier than women (micro)

What are symptoms of a pituitary tumor?

Headache, cranial nerve dysfunction, amenorrhea, galactorrhea, sexual dysfunction, gynecomastia, visual disturbance

What is common cranial nerve dysfunction?

Extraocular movements (CN III, IV, VI)


What is the most common visual finding with a pituitary tumor?

Bitemporal hemianopsia

What is a laboratory test for prolactinoma?

Prolactin >300 diagnostic >100 highly suggestive

What are treatment options?

Medication, radiation, surgery

What is a drug treatment for prolactinoma?

Bromocriptine (or cabergoline)

SPINAL INJURIES AND INTERVERTEBRAL DISC DISEASE Are neurologic deficits more common with cervical or thoracolumbar vertebral fractures, and why?

Thoracolumbar fractures; spinal canal is smaller at more caudal levels

How is motor strength graded on physical examination?

Grade 0: No contraction Grade 1: Muscle contracts Grade 2: Movement without gravity Grade 3: Movement against gravity Grade 4: Movement against resistance Grade 5: Normal strength


Which sensory levels correspond to the following: Shoulders?

C4

Nipples?

T4

Umbilicus?

T10

Knees?

L3

Perianal region?

S5

Cervical Spine What are the three functional columns of the cervical spine and the ligamentous complexes of each column: Anterior column? 1. Anterior half of vertebral body and disc 2. Anterior longitudinal ligament and anulus fibrosus Middle column?

1. Posterior half of vertebral body and disc 2. Posterior longitudinal ligament and anulus fibrosus

Posterior column?

1. Lamina, pedicles, spinous processes, and facet joints 2. Interspinous ligaments and facet capsules


When is a cervical spine generally considered unstable?

When two or more of these functional columns are damaged

What are the names given to the first two cervical vertebrae (C1 and C2)?

C1: Atlas C2: Axis (has an anterior protuberance called the odontoid)

What is the usual mechanism of C1 vs. C2 fracture?

C1: Axial loading C2 (including odontoid): Hyperextension

What is a Hangman’s fracture?

Fracture through pedicles of C2 at the pars interarticularis

What is a Jefferson fracture?

A fracture of the ring of C1 at more than one site

What is the radiographic criterion for a Jefferson fracture?

The “rule of Spence” provides that if the sum of the overhang of both lateral masses is ≥7 mm (on AP view), an abnormality exists at the level of C1

Are neurologic deficits common with this injury, and why?

Given the large size of the spinal canal at this level, neurologic deficits are rare if this lesion occurs in isolation

What is the treatment of a Jefferson fracture?

External fixation in a halo device

What are the three types of odontoid fractures?

Type I: Fracture of the apical portion of the dens Type II: Fracture of the dens at its base Type III: Fracture of the dens extending into the body of C2


What is the treatment of odontoid fractures?

Type I: Stable fracture; treatment rarely necessary Type II: Unstable fracture; surgical fusion Type III: Stable fracture; immobilization with halo device

What surgical procedures are used for fixation of odontoid fracture?

1. Posterior approach: C1 can be plated or wired to C2 2. Anterior approach: A screw can be placed into the body of C2 through the axis of the dens

Which of these approaches preserves rotation of the head?

The anterior approach preserves rotation, which at C1 to C2 represents 50% of all rotation of the head at the neck; this technique is generally reserved for younger individuals

How many cervical nerve roots are there?

There are 8 cervical nerve roots (C1 to C8), but only 7 cervical vertebrae

What nerve root exits between vertebrae C3 and C4?

Nerve root C4

What are the clinical components of a radiculopathy?

Weakness, reflex changes, and dermatomal sensory changes ascribed to a particular nerve root

What is the most common cervical disc herniation and its associated radiculopathy?

Disc herniations at the C6 to C7 interval represent roughly two-thirds of all disc herniations; a C7 radiculopathy develops in these cases


What are the clinical correlates of a C5 radiculopathy?

1. Deltoid weakness 2. Diminished sensation over the shoulder


1. Diminished biceps reflex 2. Biceps weakness 3. Decreased sensation over the upper arm, radial forearm, and thumb


1. Diminished triceps reflex 2. Triceps muscle weakness

What is the usual treatment of cervical disc herniation?

Over 95% of cervical disc herniation radiculopathies heal spontaneously

What are the surgical approaches for those that fail to heal?

1. Anterior cervical discectomy (ACDF), with or without fusion 2. Posterior foraminotomy and disc excision

What is cervical spondylosis?

A degenerative disease of the spine associated with osteophytic spurs, hardening of the intervertebral discs, and hypertrophy of the vertebral ligaments, particularly the posterior longitudinal ligament

How does cervical spondylosis present?

Neck pain and the physical findings associated with cervical spondylitic myelopathy (CSM)

What is CSM?

A syndrome commonly associated with clinical findings including hyperreflexia, spasticity, weakness of the hands, proximal lower extremity weakness, and a paucity of sensory changes

What is the physiologic basis for CSM?

Repetitive trauma to the spinal cord by a narrowed canal and associated with normal movement, ischemia of the cord associated with vascular compression with a narrow canal, or direct cord compression


What is the treatment of CSM?

Physiologic decompression of the cord, which may be achieved by cervical laminectomy; despite the sound theory, some patients have progression of disease and confinement to a wheelchair

Lumbar Spine How many lumbar nerve roots are there?

5 lumbar nerve roots (and 5 lumbar vertebrae)

What is the relationship of a nerve root to a vertebra of the same number?

The root exits between the vertebral bodies of its own number and the one below; thus, the L4 root exits between L4 and L5

A herniated disc between L4 and L5 generally affects which nerve root?

Counterintuitive: A herniated disc between vertebrae L4 and L5 impinges the L5 nerve root; anatomically, the L4 nerve root has exited the spinal canal before the disc herniation; the shoulder of the L5 root, however, is readily impinged

Can an L4 disc ever impinge on an L4 nerve root?

Yes; this is known as a far lateral disc herniation

What is pain traveling down the lower extremity associated with nerve root impingement called?

Sciatica

What are the three main components of an L4 radiculopathy?

1. Diminished knee jerk 2. Weakness of knee extension 3. Decreased sensation over the medial malleolus

What are the two main components of an L5 radiculopathy?

1. Weakness in dorsiflexion of the great toe and foot 2. Decreased sensation at the web space of the great and second toes

What are the three main components of an S1 radiculopathy?

1. Diminished ankle jerk 2. Plantar flexion weakness at the foot 3. Decreased sensation over the lateral foot


What is the treatment for acute disc herniation?

More than 85% of patients with acute lumbar disc herniation improve without surgical intervention; hence, conservative care

What are the indications for emergent surgery in the setting of acute disc herniation?

1. Acute or progressive development of motor weakness 2. Cauda equina syndrome

NEURO-ONCOLOGY Define benign vs. malignant in the setting of CNS tumors:

Malignant tumors: Highly aggressive/ proliferative tumors of poorly differentiated cells; benign: Less aggressive, more differentiated cell line; a benign tumor can be as lethal as a malignant variety, however, because of the continued ability to grow within the confines of the skull

What are the most common presentations of brain tumors?

1. Progressive neurologic deficit 2. Headache 3. Seizure

What is the difference between an intra-axial and an extra-axial mass?

An intra-axial mass is within the substance of the brain itself, whereas an extra-axial mass impinges on the brain

What is the most common location of brain tumors in adults vs. children?

Adults: Supratentorial (anterior or middle fossa), Children: Infratentorial (posterior fossa)

Which group has the higher incidence of seizures?

Supratentorial tumors (adults)

What is the most common intra-axial primary brain tumor in adults?

1. Astrocytoma (#1) 2. Meningioma

What is the most common intra-axial primary tumor in children?

1. Astrocytoma (#1) 2. Medulloblastoma


Astrocytoma How are astrocytomas graded?

There are several astrocytoma grading systems, but the most commonly used is a three-tiered system with: Grade 1: Low-grade astrocytoma Grade 2: Anaplastic astrocytoma Grade 3: Glioblastoma multiforme (GBM)

Which grade of primary brain tumor is most common in adults vs. children?

Grade 3 (GBM) is by far the most common in adults Grade 1 is most common in children

What MRI findings are typical in low-grade glioma?

Low-grade gliomas typically do not enhance with contrast; high signal on the T2 or proton density images is always present; high-grade gliomas typically enhance on T1-weighted images; GBMs often have cysts or obvious areas of necrosis

How do primary gliomas spread?

Primarily through the white matter tracts of the brain and through the CSF pathways

What is the cure rate for GBM?

There is no cure

What is the treatment of GBM?

Chemotherapy and external beam radiation ± debulking surgery

What are the 1- and 2-year survival rates?

The 1-year survival rate is approximately 33%, whereas the 2-year survival rate is approximately 10%

Meningioma What are the most common locations for a meningioma?

Parasagittal region and sphenoid bone

Is this tumor usually benign or malignant?

Benign

How does it cause focal neurologic deficits?

Compression (rather than invasion) of adjacent neural structures (an extraaxial tumor); examples include unilateral exophthalmos and optic nerve compression


What is the peak age of incidence for meningioma?

Age 45

What is the treatment of meningioma?

Surgical removal

What anesthetic decreases the seizure threshold?

Enflurane, so isoflurane is preferred in neurosurgical cases

What is the 5-year survival rate?

90%; however, recurrences are common and often necessitate additional surgical interventions

Acoustic Neuroma What histological type are the cells of an acoustic neuroma?

The term acoustic neuroma is actually a misnomer; the tumor cells are actually Schwann cells which typically arise from the vestibular portion, not the cochlear portion of cranial nerve 8

What are the most common symptoms associated with acoustic neuroma?

1. Hearing loss (virtually all patients) 2. Tinnitus 3. Disequilibrium

Other than hearing loss, what is the most common physical finding?

≈33% of patients lose the corneal reflex

What is the treatment of acoustic neuroma?

Surgical removal (via craniotomy and/or translabyrinthine approach)

Pituitary Tumors What are the two general presentations of pituitary tumors?

1. Endocrine disturbance (excess adrenocorticotropic hormone [ACTH], growth hormone, or prolactin) 2. Neurologic deficits due to mass effect

Do pituitary tumors most commonly arise in the anterior or posterior pituitary?

Anterior pituitary

Pituitary tumors are associated with what endocrine syndrome?

Multiple endocrine neoplasia I (MEN I)


What are the three components of this syndrome?

1. Pancreatic islet-cell tumors 2. Nonsecretory pituitary adenomas 3. Parathyroid tumors

What is the common visual field defect associated with pituitary adenomas?

Bitemporal hemianopsia (due to compression of the medial retinal fibers at the chiasm)

What is the difference between Cushing’s syndrome and Cushing’s disease?

1. Cushing’s syndrome is the result of hypercortisolism 2. Cushing’s disease is caused by overproduction of ACTH by a pituitary adenoma

What are the treatments for pituitary tumors?

1. For tumors that secrete prolactin, medical treatment with bromocriptine (or cabergoline) (dopamine agonist) is often helpful 2. Otherwise, transsphenoidal surgery or open craniotomy, with or without adjuvant external beam irradiation

Neurocutaneous Disorders What are the four principal neurocutaneous disorders?

1. 2. 3. 4.

Neurofibromatosis (NF) Tuberous sclerosis Von Hippel–Lindau disease Sturge–Weber syndrome

Which of these disorders usually initially present with seizures?

Tuberous sclerosis, von Hippel–Lindau disease, and Sturge–Weber syndrome

Which is the most common NF?

NF-1, also called von Recklinghausen’s disease, represents 90% of cases of NF

What is the inheritance pattern of this syndrome?

NF-1 has an autosomal dominant inheritance with nearly 100% penetrance

What are the clinical features of this syndrome?

Café au lait spots, optic gliomas, cutaneous neurofibromas, and Schwann-cell tumors on any nerve

What is the hallmark of NF-2?

Bilateral acoustic neuromas, which are virtually never seen in NF-1 patients


What is the most common cutaneous lesion in tuberous sclerosis?

Adenoma sebaceum (reddened nodules on face)

Where are the vascular malformations located in von Hippel–Lindau disease?

1. Retina (results in progressive vision loss) 2. Cerebellum (results in progressive ataxia)

What are the clinical features of Sturge–Weber syndrome?

1. Unilateral, cutaneous capillary angioma (nevus flammeus or port-wine stain of upper face) 2. Leptomeningeal venous hemangiomas with intracranial calcification (classic “railroad track” appearance on x-ray)

Assorted Neuro-Oncology Topics Where do chordomas commonly arise?

Chordomas are tumors of the notochord remnant; they typically arise at either end of the notochord (i.e., at the clivus and at the sacrum/coccyx)

What is a PNET, and what is the most common type?

PNET stands for Primitive NeuroEctodermal Tumor; the most common type is the medulloblastoma, which accounts for about 20% of all intracranial tumors in children

What are the most common metastases to the brain?

In descending order of frequency: 1. Lung 2. Breast 3. Renal 4. Gastrointestinal 5. Melanoma

Which primary brain tumors have potential to spread systemically?

Although brain tumors rarely spread systemically, medulloblastoma, meningioma, pineoblastomas, and choroid plexus tumors have the potential for systemic spread

Which tumor generally arises from the roof of the fourth ventricle?

Medulloblastoma


Which tumor arises from the remnants of Rathke’s pouch above the sella?

Craniopharyngioma (results in bitemporal field defects)

What are false lateralizing signs?

Clinical findings that are due to tumors but are not due to direct infiltration or compression of tumor; this situation may result in false localization of the primary tumor

What are the two examples of false lateralizing signs?

1. CN III or CN VI palsy secondary to herniation syndromes 2. Ipsilateral hemiparesis secondary to compression of the contralateral cerebral peduncle against the tentorial ridge

NEUROVASCULAR MALFORMATIONS What are the basic types of vascular malformations?

1. 2. 3. 4.

Venous angioma Capillary telangiectasias Cavernous angioma Arteriovenous malformations (AVM)

What is the histologic appearance of AVMs?

A tangle of abnormal vessels that do not have normal brain tissue between the vessels

What is the common presentation of AVMs?

Hemorrhage (peak age 15–20) and seizure are the most common features Headache is rare

What are the treatment options for AVMs?

1. Surgical excision 2. Intra-arterial embolization for AVMs that are not surgically accessible 3. Gamma knife

HYDROCEPHALUS What is hydrocephalus?

Enlargement of CSF compartments of the brain; generally results from obstruction of CSF reabsorption


What are the examples of congenital and acquired etiologies of hydrocephalus?

Congenital: Aqueductal stenosis, myelomeningocele, and Dandy–Walker malformation Acquired: Meningitis, intraventricular hemorrhage, and obstruction of CSF passage by tumor

How often is hydrocephalus due to overproduction of CSF?

Very rarely (e.g., choroid plexus papilloma)

What are the signs and symptoms of hydrocephalus?

Presentation of increasing ICP with headache, nausea, vomiting, and papilledema; late signs of impending herniation include lethargy and diplopia

What is the level of obstruction in communicating vs. noncommunicating hydrocephalus?

Communicating: At the level of the arachnoid granulations Noncommunicating: Proximal to the level of the arachnoid granulations

Why is it important to distinguish communicating from noncommunicating hydrocephalus?

Pressure engendered by an obstruction can be relieved by lumbar puncture in the case of communicating hydrocephalus, whereas noncommunicating hydrocephalus generally requires ventricular drainage

How is persistent hydrocephalus treated?

Ventriculoperitoneal shunting (or, alternatively, ventriculopleural, ventriculoatrial, or ventriculoureteral shunting)

CONGENITAL NEUROMALFORMATIONS What is the most common congenital neuromalformation?

Spina bifida occulta

What is the most common form of neural tube defect?

Myelomeningocele (due to failure of closure of posterior neuropore)

What is spina bifida?

Congenital absence of posterior elements of spinal vertebra (e.g., spinous processes and lamina)


What differentiates spina bifida occulta from spina bifida aperta?

Occulta form has skin overlying the spinous defect

What is an encephalocele?

Protrusion of neural tissue through a cranial defect (due to failure of closure of anterior neuropore)

What is the most common site of encephalocele?

Occipital region

What is a meningocele?

A membrane- or skin-covered, cystic, posterior midline mass containing CSF and meninges (no neural elements)

What is the most common site of meningocele?

Lumbosacral region

INFECTIONS Brain Abscess What are the five predisposing factors for brain abscess?

1. 2. 3. 4. 5.

Systemic infection Immunosuppression (e.g., AIDS) Localized sinus infection Cranial trauma Pulmonary arteriovenous fistulae

What is the most common systemic source?

Pulmonary infections; but in 25% of cases, no source is identified

What is the most common bacterial organism?

1. In adults, Streptococcus species predominate, but in 80% of cases; multiple organisms (often anaerobes, like Bacteroides) are cultured 2. In trauma, Staphylococcus is the most common pathogen 3. In infants, gram-negative organisms predominate

What is the most common organism in patients with AIDS?

Toxoplasmosis


What is the usual treatment of brain abscess?

Medical management with a 6- to 8-week course of intravenous antibiotics is effective in many cases

When is surgical intervention for abscess indicated?

1. If abscess exhibits significant mass effect (evidence of increased ICP or neurologic deficit) 2. If abscess approaches the ventricles (ventricular rupture carries high mortality)

Subdural Empyema What are the most common sources?

1. Paranasal sinus infection 2. Otitis infection

With what dangerous vascular complication is subdural empyema associated?

Thrombophlebitis of the cerebral veins


Intravenous antibiotics and emergent surgical evacuation

PAIN SYNDROMES What are the symptoms associated with trigeminal neuralgia (TN)?

The symptoms of TN (tic douloureux) are episodes of severe lancinating pain lasting only a few minutes; it is often triggered by facial or oral sensory stimuli

Which divisions of the trigeminal nerve (CN V) are most commonly involved in TN?

V2 and V3 combined are most commonly involved, followed by V2 alone and V3 alone

What are the major treatment modalities of TN?

1. Medical: Carbamazepine 2. Lesioning of TNs with radio frequency, glycerol, or balloon inflation has proved reliable 3. Posterior microvascular decompression of the nerve from associated arteries and veins has also proved reliable


What is cordotomy?

Interruption of the lateral spinothalamic tracts; it may be performed as an open procedure anywhere along the spinal cord or percutaneously at the level of C1–C2

When is cordotomy most useful?

For unilateral pain below the nipple

What nerve is trapped in carpal tunnel syndrome?

The median nerve

Under what structure is the nerve trapped?

The transverse carpal ligament

Which fingers typically experience decreased pinprick sensation in carpal tunnel syndrome?

The thumb and first and second fingers

What is Tinel’s sign?

Production of pain or paresthesia in the thumb and first and second fingers by gentle tapping over the transverse carpal ligament

What is meralgia paresthetica?

Pain over the anterior lateral aspect of the thigh associated with entrapment of the lateral femoral cutaneous sensory nerve

Which patients are at risk of meralgia paresthetica?

1. Obese patients 2. Patients undergoing iliac bone graft harvesting or abdominal surgery near the iliac crest

EPILEPSY SURGERY What are the indications for surgery?

Poorly controlled severe epilepsy lasting >1 yr

What is the goal of surgery?

Resect seizure focus

How is seizure focus located?

CT, MRI, with or without surface electrodes (subdural grids)


SYRINGOMYELIA What is syringomyelia?

Central pathologic cavitation of the spinal cord


Unknown, but associated with cranial base malformations, intramedullary tumors, or traumatic necrosis of the cord

What is the anatomic location?

Most are in the cervical/upper thoracic region; they can extend either way (syringobulbia = extension into medulla)


First, bilateral loss of pain and temperature sensation in “cape-like” distribution (lateral spinothalamic tract involvement); enlargement of syrinx will cause further motor and sensory loss


MRI will show defect in cord


Surgical (syringosubarachnoid shunt)

Chapter 80 Urology SCROTUM AND SPERMATIC CORD Anatomy What are the six major layers of the scrotal sac and the corresponding layers of the abdominal wall?

1. Skin 2. Dartos muscle 3. External spermatic fascia: derived from external oblique 4. Cremaster muscle: derived from internal oblique and transversus abdominis 5. Internal spermatic fascia: derived from transversalis fascia 6. Tunica vaginalis: derived from peritoneum

Chapter 80 / Urology 723

Which nerves receive sensory information from the scrotum?

Anterior scrotum Ilioinguinal nerve Genitofemoral nerve Posterior scrotum Perineal division of the pudendal nerve Posterior femoral cutaneous nerve

What common surgical procedure can result in anesthesia of the scrotum and why?

Inguinal hernia repair complicated by injury to the ilioinguinal nerve

What is an appendix testis?

Appendix testis

What nervous systems are responsible for erection and ejaculation in the male?

Erection = parasympathetic Ejaculation = sympathetic Memory aid: “Point” (erection) = Parasympathetic “Shoot” (ejaculation) = Sympathetic

Infectious Disorders Fournier’s Gangrene What is Fournier’s gangrene?

Rapidly progressive gangrenous infection that usually involves scrotum, penis, and perineum (may extend up the abdominal wall)

What is the bacteriology?

Usually mixed infection of gram negatives and anaerobes

What is the most common origin of the infection?

Urinary tract (usually the urethra)


What are other origins?

Perianal, external genitalia, intraabdominal process, and retroperitoneum


Abrupt onset of severe pain and erythema of scrotum, penis, and perineum; the patient often declines rapidly into florid sepsis

What are the classic physical findings?

Erythema, induration, necrosis, and crepitance of involved regions; grayish discharge with foul odor

What is the mortality rate?

50%

What are the predisposing conditions?

1. 2. 3. 4. 5. 6.


IVF, IV antibiotics (triples), immediate surgical debridement

Diabetes mellitus Corticosteroid usage Immune compromise Alcohol abuse Obesity Trauma or surgery

Tumors of the Spermatic Cord What is the most common benign tumor of the spermatic cord?

Lipoma

What is the most common malignant tumor of the spermatic cord?

Rhabdomyosarcoma

What is the usual pathological cell type of paratesticular rhabdomyosarcoma?

Embryonal

What is a common site of early metastasis?

Retroperitoneal lymph node (LN)

What is the treatment for paratesticular rhabdomyosarcoma?

Inguinal orchiectomy and radiologic evaluation of retroperitoneal LN status: 1. If LN negative: chemotherapy only (with vincristine and dactinomycin); no radiation


2. If LN positive: unilateral retroperitoneal lymph node dissection (RPLND); chemotherapy with vincristine, dactinomycin, and cyclophosphamide; radiation therapy depends on the amount of residual local or nodal disease

PENIS AND MALE URETHRA Anatomy What are the three erectile bodies of the penis and where does each originate?

Paired (two) corpora cavernosa: just anterior to the ischial tuberosities Corpora spongiosum: at the urogenital diaphragm, and expands distally to form the glans penis

Within which corporal body does the urethra run?

Corpora spongiosum

What are the four covering layers of the penis?

1. Tunica albuginea: surrounds each corpora 2. Buck’s fascia: envelops all three corpora 3. Colles’ fascia: lies beneath the skin of the penis from the base of the glans to the urogenital diaphragm; continuous with Scarpa’s fascia of the abdominal wall 4. Skin

Identify the labeled structures or layers in the cross section of the penis?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Cutaneous dorsal vein Deep dorsal vein, artery, and nerve Colles’ fascia Buck’s fascia Tunica albuginea Corpora cavernosa Corpus spongiosum Urethra Cavernosal artery and vein Bulbourethral artery and vein


What are the three regional segments of the male urethra?

1. Prostatic urethra: begins at bladder neck, traverses prostate, and ends at urogenital (UG) diaphragm; ≈3 cm long 2. Membranous urethra: traverses UG diaphragm; these encircling muscles function as the external (voluntary) urethral sphincter; ≈2–2.5 cm long 3. Penile urethra: begins after UG diaphragm and extends to external meatus; often subdivided into bulbous and pendulous portions; ≈15 cm long

Which branch of the hypogastric artery supplies the majority of blood to the penis?

Internal pudendal artery

What are the four main branches of the previously mentioned artery that supply the penis?

1. 2. 3. 4.

Deep cavernosal artery of the penis Deep dorsal artery of the penis Bulbar artery Urethral artery

Infectious Disorders Urethritis What is the classic presentation of gonococcal urethritis?

Thick, yellow urethral discharge with dysuria

How long is the incubation period?

Usually 1–5 d

What is the causative organism?

Neisseria gonorrhoeae

How is gonorrhea diagnosed?

1. Positive Gram stain (urethral swab showing gram-negative diplococci within PMNs), and/or 2. Positive culture growth on a modified Thayer-Martin culture plate 3. Positive nucleic acid amplification test

What are the treatment options for gonococcal urethritis?

1. Ceftriaxone 250 mg IM, plus 2. Doxycycline 100 mg PO bid for treatment of chlamydia


What is the classic presentation of nongonococcal urethritis?

Thin, white, mucoid discharge with or without dysuria


1–3 wk


1. 2. 3. 4.

How is nongonococcal urethritis diagnosed?

1. More than four PMNs per high-power field (hpf) in a urethral swab, and 2. Exclusion of gonococcal urethritis by Gram stain and culture

How can the presence of chlamydia be confirmed?

Conjugated monoclonal antibody test (sensitivity 93%, specificity 96%)

What are the complications of urethritis?

1. 2. 3. 4.

Genital Herpes What is the classic presentation?

Chlamydia trachomatis (most common) Ureaplasma urealyticum Mycoplasma hominis Trichomonas vaginalis

Urethral stricture Epididymitis Prostatitis Impaired fertility

1. Primary infection: grouped vesicles followed by painful shallow erosion lasting 4 d to 2 wk; often associated fever, myalgias, and/or lymphadenopathy; urinary retention can occur because of local pain 2. Secondary infection: usually constitutional, and local symptoms less severe; reappearance of classic painful vesicles and ulcerations


Herpes simplex virus (HSV) type I or II

What is the regional predilection of each type?

In general, type II infects the genital region and type I infects the oral mucosal surface, but either organism can infect the external genitalia


Where does the virus establish its latent infection?

Dorsal root ganglion

When does viral shedding occur?

When vesicles rupture; it can also occur when the patient is asymptomatic

Which diagnostic test is used?

1. PCR 2. Rare: Tzanck prep of a skin lesion may reveal the virus 3. If Tzanck is negative, obtain a viral culture


7-day course of acyclovir can be used to decrease severity and duration of primary and secondary infections

Syphilis What is the causative organism?

The spirochete Treponema pallidum

What is the incubation period?

Usually 2–4 wk


1. Primary syphilis: shallow painless ulcer with rolled borders (chancre) lasting 1–5 wk; nontender unilateral or bilateral inguinal adenopathy 2. Secondary syphilis: copper-colored maculopapular lesions on palms, soles, oral and anogenital region; generalized lymphadenopathy 3. Tertiary (latent) syphilis: no outward signs of disease; all organs of body now infected; late manifestations in CNS, peripheral nerves (tabes dorsalis), and/ or aortic arch (aortitis)

How is syphilis diagnosed?

1. Rapid plasma reagin (RPR) serology test for syphilis may be negative for up to 3 wk after appearance of chancre 2. Fluorescent treponema antibodyabsorption (FTA-ABS) test 3. Rare: demonstration of spirochetes on dark-field exam of chancre scrapings

What is the treatment of primary syphilis?

Benzathine penicillin G 2.4 × 106 U IM (1 dose)


Chancroid What is the clinical presentation?

Deep, ragged, painful ulcer or ulcers; foul smelling with unilateral or bilateral adenopathy


Haemophilus ducreyi


1–5 d following exposure (usually intercourse)

How is chancroid diagnosed?

Usually clinical; occasionally the organism grows from cultures of the ulcer


Ceftriaxone 250 mg IM × 1 dose

Lymphogranuloma Venereum What is the classic presentation?

Painless primary papule or vesicles that ulcerate, then heal; fixed matted unilateral adenopathy develops and can form multiple draining fistulae

What is the causative agent?

C. trachomatis (an obligate intracellular organism)


From 1 wk to 3 mo following exposure (usually intercourse)

How is lymphogranuloma venereum diagnosed?

Immunofluorescent serological testing


Doxycycline 100 mg PO bid × 7 d

Congenital and Acquired Disorders Paraphimosis What is paraphimosis?

What is the primary sequela?

A foreskin with a narrowed opening that forms a tight band behind the coronal ridge when retracted, leading to inflammation and inability to pull the foreskin back over the glans Further painful swelling of the glans and foreskin, which can lead to decreased arterial flow and necrosis of the glans



Priapism What is priapism?

1. Manual compression of the glans for 5–10 min after a penile block with 1% lidocaine may reduce its size enough to allow the foreskin to be pulled back into place 2. If this fails, a dorsal slit is made in the constricting foreskin, followed by a formal circumcision when inflammation has resolved; antibiotics should also be administered

Prolonged, often painful, erection not associated with sexual desire and lasting 4 or more hr

What are the etiological classifications?

1. Primary (idiopathic) 2. Secondary Intracavernous injections for impotence (PGE, phentolamine, papaverine) Hematologic (sickle cell disease, leukemia, hypercoagulable states) Oral agents (alcohol, psychotropics, antihypertensives) Neurogenic (anesthesia and spinal cord injury) Traumatic injury of cavernosal artery within corporal tissue causing traumatic arteriovenous (A-V) fistula (pelvic fracture or laceration from injection therapy) Malignant metastasis to the corpora

What are the two most common causes?

1. Primary (>50%) 2. Intracavernous injections for impotence

What are the differences between classic low-flow priapism and the high-flow priapism associated with pelvic trauma: Low-flow priapism?

1. Usually painful 2. Dark, poorly oxygenated blood obtained on corporal aspiration 3. Associated with sludging, thrombosis, and fibrosis if not treated within 24 hr


High-flow priapism?

1. Usually painless 2. Red, well-oxygenated blood obtained on corporal aspiration 3. An A-V fistula exists between the injured cavernosal artery and the corpora, resulting in a persistent erection without associated sludging and thrombosis

What are the classic treatment approaches to priapism associated with sickle cell disease?

1. 2. 3. 4.

What are the general treatment approaches to the other types of low-flow priapism?

1. Aspiration of 10–20 mL of corporal blood followed by injection of dilute α-adrenergic compound every 5 min up to 10 doses (Note: monitor blood pressure and heart rate; use caution in patients with cardiac or cerebrovascular disease) 2. Surgical shunting (multiple procedures have been described to shunt blood from the corpora cavernosa to the spongiosum or directly to the venous system)

What is a simple, effective shunting procedure?

Winter’s shunt: shunt generated by passing a 16-gauge IV or Tru-Cut needle several times through the glans into the cavernosal bodies

Peyronie’s Disease What is Peyronie’s disease?

What are the common etiologic theories?

Oxygenation Hydration Alkalinization Needle corporal aspiration followed by intracavernous injection of a dilute α-adrenergic compound (e.g., phenylephrine or epinephrine)

Fibrosis and plaque formation in the tunica albuginea of the corpora cavernosa, often associated with pain and a bending deformity with erection 1. Vasculitic immune-mediated process 2. Repeated microtrauma to the tunica during intercourse


What percentage of these conditions will resolve spontaneously?

≈50%

What is the medical treatment if no resolution?

1. Vitamin E 2. Potassium para-aminobenzoate (Potaba) 3. Dimethyl sulfoxide (DMSO) 4. Intralesional steroids (triamcinolone 40 mg)


Excision of plaque and placement of a dermal patch graft with or without a penile prosthesis (Note: this treatment is usually reserved for patients with angulation too severe for successful intercourse)

Tumors Urethral Cancer What is the most common histological type?

Squamous cell carcinoma


1. Stricture disease 2. Chronic irritation and infection

What is included in the evaluation?

1. Urethroscopy with transurethral biopsy or brushings 2. Pelvic CT to evaluate lymph node status 3. CXR

What is the difference in pattern of nodal drainage between anterior and posterior tumors?

Anterior (distal) tumors: drain to the inguinal chain Posterior tumors: drain to the pelvic nodes (e.g., external iliac, obturator, and hypogastric)


1. Transurethral resection: for superficial, low-grade lesions of the proximal penile or prostatic urethra 2. Segmental urethrectomy and reanastomosis: for superficial, low-grade cancers of the penile urethra


3. Partial penectomy: for invasive lesions of the distal urethra 4. Extended en bloc cystectomy including proximal urethrectomy with excision of the pubic symphysis and subsymphyseal soft tissue: for proximal invasive bulbous or membranous urethral lesions Is therapeutic lymph node dissection effective?

Penile Cancer What is the incidence of penile cancer in US males?

Occasional long-term survivors with inguinal or pelvic lymph node metastases have been reported following lymphadenectomy

<1% of all malignancies

What is another name for squamous cell carcinoma in situ?

Bowen’s disease

What is its appearance?

Red plaque with encrustations

What is the incidence of visceral malignancy in association with this condition?

≈25%

What is the most common location of invasive penile squamous cell carcinoma?

Glans

What is the primary route of dissemination?

Lymphatic

How does location of the primary tumor affect its pattern of spread?

1. Prepuce and shaft: superficial inguinal nodes 2. Glans and corporal bodies: superficial and deep inguinal nodes (Note: due to extensive cross communications, penile lymphatic drainage is bilateral)

What percentage of patients present with palpable nodes?

>50%


What percentage of this enlargement is secondary to inflammation?

≈50%

What is the classic Jackson staging system for penile cancer?

Stage I: tumor involving glans or prepuce only Stage II: tumor involving penile shaft Stage III: operable nodal involvement Stage IV: inoperable local, nodal, or distant metastasis

What does the metastatic workup include?

1. CXR 2. Bone scan 3. Abdominal pelvic CT scan

What is the treatment of: Carcinoma in situ (CIS)?

Conservative treatment with fluorouracil cream or neodymium/YAG laser

Carcinoma of prepuce?

Circumcision only, provided the margin is adequate

Carcinoma of glans or distal penile shaft?

Distal penectomy with 2-cm margin

Proximal lesions?

If unable to maintain enough length for direction of urinary stream or sexual function, then total penectomy with perineal urethrostomy

TESTIS AND EPIDIDYMIS Anatomy From the epithelial lining of what structures within the testis do spermatozoa develop?

Seminiferous tubules

What is the arterial blood supply to the testis?

1. Internal spermatic artery 2. Cremasteric artery 3. Artery of the vas


What is the clinical significance of this collateral blood supply?

What are the primary lymphatic drainage sites of the: Right testicle?

Left testicle?

Where is the epididymis located in relation to the normal testicle?

Blood flow via the collaterals is often sufficient to allow ligation and division of the internal spermatic artery to gain extra length during orchiopexy (Fowler-Stephens orchiopexy)

Interaortocaval LNs followed by precaval, preaortic, and paracaval LNs Left paraaortic LNs followed by the preaortic LNs Along the posterolateral surface of the testis

Acquired and Congenital Disorders Ectopic Testis What is the difference between an ectopic testis and a cryptorchid testis?

What are some observed ectopic positions and which is most common?

An ectopic testis has descended along an abnormal path, whereas a cryptorchid testis has descended along the normal course but has not made it out of the inguinal canal 1. Superficial inguinal (most common): migrates cephalad and lateral to the external ring 2. Femoral: lies in the superficial femoral triangle 3. Perineal: lies in the perineum anterior and lateral to the anus 4. Penile: lies subcutaneously at the base of the penis 5. Crossed descent: both testicles descending through the same inguinal canal


Cryptorchid Testis What are the etiological theories?

Why is it important for the testicles to descend?

1. Deficient maternal gonadotropin stimulation 2. Intrinsic gonadal defect, making the testicle nonresponsive to gonadotropin stimulation 3. Abnormal gubernaculum formation The scrotal location is 1–2 degrees cooler than the rest of the body, a condition that is necessary for normal spermatogenesis

What is the incidence of cryptorchidism in: Preterm infant?

30%

Full-term infant?

3.5%

1 yr?

0.8%

Adulthood?

0.8%

What is the single most common factor that causes a misdiagnosis of a cryptorchid testis?

A retractile testis from cremasteric contraction

If a testis is not retractile or ectopic and it cannot be palpated, what are the possible locations?

1. Canalicular: located between the internal and external rings 2. Intra-abdominal: located proximal to the internal ring 3. Absent

How is bilateral cryptorchidism distinguished from bilateral anorchia?

Baseline testosterone levels are obtained; then human chorionic gonadotropin (hCG) is given for 3 d; if testicular tissue is present, an elevation in serum testosterone will be seen

By what age should intervention for a cryptorchid testis be initiated, and why?

By 1 yr of age; after this: 1. Spontaneous descent is extremely unlikely 2. Significant histologic changes (fibrosis) occur, greatly increasing the risk of diminished fertility of the involved testis


What is the incidence of neoplasm formation in a cryptorchid testis versus a normally descended testis?

35–50 × greater in a cryptorchid testis

Does the timing of orchiopexy affect the risk of neoplasm formation in a cryptorchid testis?

No (however, it improves the ability to examine the testis)

Due to its abnormal position and lie, what other complication can be seen in association with an undescended testis?

Torsion (especially in the enlarged postpubertal testis)

What is the medical treatment of cryptorchid testes?

1. hCG stimulation: increasing testicular testosterone production (success rate 15%–50%) 2. Gonadotropin-releasing hormone (Gn-RH) (specifically luteinizing hormone-releasing hormone [LH-RH])

What are the surgical treatment options for cryptorchid testes?

Standard orchiopexy, Fowler-Stephens orchiopexy, laparoscopic orchiopexy, and testicular autotransplantation

What is a standard orchiopexy?

Incision is made in the groin, the external oblique muscle is split, and the testicle is delivered to the base of the scrotum through a separate skin incision

What is the Prentiss maneuver?

The Prentiss maneuver is performed by opening the floor of the inguinal canal and dividing the inferior epigastric vessels to gain additional length

What is a Fowler-Stephens orchiopexy?

In cases with insufficient length to bring the testicle into the scrotum, the internal spermatic artery is clamped, and if adequate testicular collateral blood supply is demonstrated, the artery is divided and the testis is brought into the scrotum


What is testicular autotransplantation?

The testicular artery is anastomosed to the inferior epigastric artery and the testicle is transplanted into the scrotum. (Note: this technically difficult procedure has relatively poor success rates)

Tumors Epididymal Adenomatoid Tumors At what age do these tumors Third and fourth decades usually present? What is the classic presentation?

Round, discrete, usually painless mass that can be found in any region of the epididymis

In what other regions are these lesions found?

1. Tunica albuginea of the testicle 2. Spermatic cord

What is the histological appearance?

Acidophilic epithelial-like cells in a collagenized stroma

What are the theories of etiology?

1. Reaction to injury 2. Some ultrastructural similarities to mesotheliomas

KIDNEYS Anatomy What are the dimensions of a normal adult kidney?

Vertical: 10–12 cm Transverse: 5–7 cm Anteroposterior: 3–4 cm

Which intra-abdominal organs are in contact with the labeled regions of anterior surface of the kidneys?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Adrenal gland Liver Colon Ileum Adrenal gland Stomach Pancreas Ileum Spleen Colon


What is the normal location of the upper pole of each kidney relative to the: Vertebral bodies? Ribs? What is the clinical significance of the location of the upper pole with regard to: Penetrating chest trauma?

Surgical incision?

Left: T12; Right: top of L1 Left: to 11th rib; Right: to 11th interspace

Stab wounds to the lower chest may injure the kidneys Inadvertent entry into the pleural space can occur during a standard flank incision (obtain a postoperative CXR) Access to large renal tumors can be facilitated by a thoracoabdominal incision that enters the chest and splits the diaphragm to expose the upper pole

Which structures are contained within Gerota’s fascia?

1. 2. 3. 4. 5.

What is the order of structures in the renal hilum (anterior to posterior)?

Renal vein > Renal artery > Renal pelvis

The main renal artery: Arises at which vertebral level?

Perirenal fat Kidney Adrenal gland Ureter Gonadal vessels

L2, below the superior mesenteric artery (SMA)


Divides into what five segmental branches?

Anterior division: apical, upper, middle, and lower Posterior division: posterior (segmental divisions are named after the region of parenchyma they supply)

Which segmental branch is the first and most constant branch?

Posterior

What collateral drainage exists to the left renal vein?

1. 2. 3. 4.

What is the clinical significance of collaterals?

Surgical ligation or occlusion of the left renal vein is tolerated in most cases

What are the components of the intrarenal collecting system?

1. Minor (tertiary) calyx: 7–9 cup-shaped structures surrounding the papilla of each renal pyramid 2. Infundibula: narrowing of each minor calyx, which coalesces to form a major calyx 3. Major calyx: coalescence of several infundibula to form these two or three larger drainage channels

Left inferior phrenic vein Left adrenal vein Left ascending lumbar vein Left gonadal vein


4. Renal pelvis: main collection chamber, which can be completely contained within the substance of the kidney or can be a large saccular extrarenal structure

What is the fornix?

The delicate rim of each calyx or “edge of the wineglass”

Renal Physiology What are the four major functions of the kidney?

1. 2. 3. 4.

Excretion of metabolic waste products Reabsorption of necessary solutes Secretion of unnecessary solutes Endocrine function (e.g., erythropoietin, renin, and vitamin D)

What percentage of normal cardiac output do the kidneys receive?

20%–25%

What is renal clearance?

Rate at which the kidney excretes a substance in relation to its plasma concentration (mL/min)

What does clearance indirectly measure?

Glomerular filtration


How is clearance calculated?

C = (U × V)/P C = clearance (mL/min) U = urine concentration of creatinine (Cr) P = plasma concentration of Cr V = volume of urine flow in 1 min (Note: to compare values for persons of different size, glomerular filtration rate is standardized per unit of body surface [1.73 m2])

Which formula allows a quick calculation of Cr clearance based on serum Cr (SCr)?

([140 – age] × [weight])/(72 × SCr)

How is the calculation altered for women?

Multiply by 0.85

What is the normal adult value for Cr clearance?

75–120 mL/min

Where is most filtered sodium reabsorbed in the nephron?

Proximal tubule (70%–80% of the filtered load)

Is this an active or passive process?

Active: the energy for the function of the Na− K+ = pump comes from aerobic metabolism

Where is renin produced, and what stimulates its release?

The myoepithelial (juxtaglomerular) cells of the afferent arteriole; release is stimulated by: 1. Decreased renal perfusion 2. β-adrenergic stimulation 3. Decreased salt delivery to the distal tubule

What is the major effect of renin?

Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II in the lung; angiotensin II is a potent vasoconstrictor and also stimulates the release of aldosterone

Where is aldosterone produced, and what are its major effects?

Zona glomerulosa of the adrenal cortex; it acts upon the collecting tubule, causing: 1. Increased Na+ reabsorption 2. Increased H+ secretion 3. Increased K+ secretion


How much acid must the kidney excrete per day to maintain acid–base balance?

0.3–1.0 mEq/kg/d

How does the kidney accomplish this task, and in what part of the nephron do these mechanisms occur?

1. Reclamation of filtered HCO3−: primarily in the proximal tubule 2. Generation of new HCO3−: via net acid excretion (collecting tubule secretes H+ ions, which are then bound to titratable buffers, e.g., PO4 and NH4+)

Infectious Diseases Pyonephrosis What is pyonephrosis?

An obstructed, infected, hydronephrotic kidney filled with purulent debris


Flank pain, fever, and chills; patients are often floridly septic


1. Emergent drainage via percutaneous nephrostomy 2. Triple IV antibiotic coverage (e.g., ampicillin, aminoglycoside, and Flagyl)

Xanthogranulomatous Pyelonephritis What is xanthogranulomatous A chronic bacterial infection of the kidney pyelonephritis? associated with calculi and often partial obstruction/dilation of the collecting system What is the classic histology?

Localized yellow nodules composed of inflammatory infiltrate and foamy macrophages

What is the target population?

Middle-aged or older women


Fever, flank tenderness, anorexia, or malaise


What are the common laboratory findings?

1. 2. 3. 4. 5.

Anemia: 65% Leukocytosis: 50% Pyuria Microhematuria Positive urine culture (Proteus mirabilis and Escherichia coli are the most often isolated organisms)

Congenital and Acquired Disorders Renal Tubular Acidosis (RTA) From what defect does type I RTA result?

Distal tubule is unable to secrete H+ ions across a large gradient (Note: proximal tubule’s ability to absorb HCO3− is not affected)

What are the clinical features?

1. 2. 3. 4.


1. Increased fluid intake 2. Sodium bicarbonate or potassium citrate to alkalinize the urine (Note: effect can be monitored by measuring urinary citrate)

From what defect does type II RTA result?

Proximal tubule decreased HCO3− reabsorptive ability, which causes extracellular fluid contraction, Cl− reabsorption, and acidosis

What is the treatment of type II RTA?

Sodium bicarbonate or potassium citrate to correct HCO3− loss

Pelvic Kidney What is the incidence of pelvic kidney?

1:500 to 1:1,000 (the most common location of ectopic kidney)

In which sex and on which side is this condition found most commonly?

Systemic acidosis Inappropriately alkaline urine Hypokalemia/hyperchloremia Calcium phosphate stone formation (70%) due to hypercalciuria in the setting of low urinary citrate levels

Boys; left side


Are these kidneys normal?

≈50% are pathological with poor function; reflux is common


Correction of reflux, if possible; most remain asymptomatic

Adult Polycystic Kidney Disease What is the pattern of inheritance?

Autosomal dominant—100% penetrance

What are the classic clinical findings?

1. Bilateral flank masses: large cystic enlargement of both kidneys 2. Hypertension (65%) 3. Renal failure 4. Lumbar pain 5. Recurrent pyelonephritis: infection of cysts is also common

What are the two associated nonrenal lesions, and what is the incidence of each?

1. Hepatic cysts (33%) 2. Aneurysm of the circle of Willis (10%–40%)


1. General conservative measures (e.g., low protein diet, 0.5–0.75 g/kg/d) 2. Cyst decompression or drainage: indicated for infection, obstruction, or severe distension and compression of the diaphragm 3. Nephrectomy: indicated in a few patients with severe hemorrhage, complicated infections, or obstruction 4. Dialysis versus renal transplant (progression to renal failure common)

Multicystic Dysplastic Kidney Disease (MCDK) What is the typical renal Grape-like cystic structures replace the appearance in this disorder? kidney, which has little true stroma and no calyceal system What are the etiologic theories?

1. Severe hydronephrosis secondary to atresia of the ureter or pelvis 2. Failure of union between the ureteric bud and metanephric blastema


On which side is this disorder more typically seen?

Left

What is the presentation of MCDK?

Diagnosis may be via prenatal ultrasound, or later in life on evaluation of abdominal pain, hematuria, or hypertension

What abnormalities of the contralateral kidney are associated with MCDK?

1. Ureteropelvic junction obstruction 2. Obstructive megaureter

What name is given to the syndrome of bilateral MCDK?

Potter’s syndrome

What are the clinical features of this syndrome?

1. Classic facial appearance (blunted nose, prominent skinfold beneath each eye, depression between lower lip and chin, and broad ear lobes) 2. Bilateral multicystic dysplastic kidneys 3. Oligohydramnios

What is the prognosis of this syndrome?

Incompatible with life

What test is most useful in differentiating MCDK from severe hydronephrosis?

Dimercaptosuccinic acid (DMSA) renal scan: function (i.e., radioisotope clearance) is usually present with hydronephrosis and not with MCDK


Controversial; most advocate conservative management unless severe flank pain is present; then, the best management is with simple nephrectomy

Tumors Oncocytoma What is the distinguishing histological feature?

Are the cells benign or malignant?

Uniform cells with eosinophilic granular cytoplasm due to increased number of mitochondria Benign


Which characteristic angiographic feature is often noted?

“Spoke wheel” configuration of arterioles (Note: this appearance can also be seen in renal cell cancers)


Due to the similar radiographic and clinical appearance with renal cell cancer, these lesions are usually treated with nephrectomy

PROSTATE Anatomy What percentage of the prostate gland is: Fibromuscular stroma? Glandular epithelial tissue?

40% 60%

From what embryonic structures does the prostate originate?

Urogenital sinus (with the exception of the central zone and ejaculatory ducts, which are of wolffian origin)

What are the major zones of the prostate?

1. Peripheral zone: together with the central zone, it makes up 95% of the gland 2. Central zone: surrounds the ejaculatory ducts and is found in the posterior portion of the gland 3. Transition zone: surrounds the urethra and verumontanum 4. Anterior fibromuscular area: forms a cap over the anterior surface of the prostate and has some sphincteric action

In which zone does benign hyperplasia arise?

Transition zone

In which zones do adenocarcinomas arise?

Peripheral (60%–70%), transition (10%–20%), and central (5%–10%) zones


Which vessel supplies the majority of blood to the prostate?

Inferior vesical artery; branches supply the seminal vesicle, and then the artery divides into the urethral group (supplying bladder neck and periurethral gland) and the capsular group (supplying the outer prostate)

Which nerve roots contribute autonomic innervation to the prostate and seminal vesicles?

Parasympathetic visceral efferents from S2 to S4 and sympathetics from T11 through L2

Which structures mark the macroscopic location of the nerves supplying innervation to the cavernosal bodies?

The lateral pedicle of the inferior vesical artery marks the location of the “neurovascular bundle,” which runs dorsolaterally (outside Denonvilliers fascia) in the lateral pelvic fascia

Infectious Disorders Acute Bacterial Prostatitis What are the causative organisms?

1. E. coli 2. Pseudomonas species 3. Streptococcus faecalis

What are the routes of infectious spread?

1. Retrograde ascent up the urethra 2. Reflux of infected urine into the prostatic ducts 3. Direct lymphatic spread from the rectum 4. Blood-borne infection

What are the usual presenting symptoms?

Perineal or low sacral pain, fever, chills, irritative voiding symptoms, and varying degrees of obstruction

What is found on digital rectal exam?

Swollen, firm, indurated, and extremely tender prostate

Should a prostatic massage be performed to express the infecting pathogen, and why?

No; vigorous prostatic manipulation can result in significant bacteremia, and urine cultures alone are often positive


If the patient cannot empty his bladder completely, should a Foley catheter be inserted?

No, for the reason mentioned previously; if significant residual urine exists, a percutaneous suprapubic tube should be placed

What are the complications of prostatitis?

1. 2. 3. 4.

What is the treatment for acute prostatitis in an uncompromised patient?

Trimethoprim-sulfamethoxazole (TMP/ SMX) PO for 14 d

What is the treatment for chronic prostatitis?

TMP/SMX for 3 mo or quinolones × 1 mo

What is the treatment of prostatitis in a septic or otherwise compromised patient?

1. Gentamicin IV or IM and ampicillin IV for 1 wk 2. Thereafter, oral agents for 30 d

Prostatic Abscess What is the causative organism seen today?

Septic shock Pyelonephritis Epididymitis Prostatic abscess

E. coli


Usually a complication of acute bacterial prostatitis

What are the clinical symptoms?

Identical to those of acute prostatitis

What are the findings on digital rectal exam?

Tender, fluctuant prostate with asymmetric enlargement

What is the best imaging modality for confirming the diagnosis?

Transrectal ultrasound

Which patient group has a much higher incidence of abscess formation?

AIDS patients


What is the treatment of prostatic abscess?

1. Surgical drainage via transurethral unroofing or transperineal drainage 2. Antibiotic coverage: similar to that for acute prostatitis

BLADDER Anatomy What is the capacity of the normal adult bladder?

350–450 mL

What is the urachus?

The fibrous remnant of the allantois, which joins the dome of the bladder with the umbilicus

What is the clinical significance?

1. Varying degrees of patency can result in urachal cysts, diverticula, or sinuses 2. Often the site of origin of bladder adenocarcinoma

What is the main muscle of the bladder, and how are its fibers arranged?

Detrusor muscle: 1. Inner: longitudinal 2. Middle: circular 3. Outer: longitudinal

In the male bladder, from which vessels does the major arterial blood supply come?

The superior, middle, and inferior vesical arteries, which arise from the anterior division of the hypogastric artery (minor branches arise from the obturator and inferior gluteal artery)

Where is the major lymphatic drainage of the bladder?

External iliac, common iliac, and hypogastric LNs

Which nerve fibers supply the contractile innervation of the detrusor muscle?

Parasympathetic fibers via S2 to S4

What supplies the motor innervation of the trigone and bladder neck sphincter?

Sympathetic fibers from T11 to T12 and L1 to L2


Infectious Disorders Acute Cystitis What are the most common causative organisms?

1. Coliform bacteria (E. coli most common) 2. Gram-positive organisms are also occasionally found (e.g., Enterococci and Staphylococcus saprophyticus)

How do these organisms gain access to the bladder?

Ascending infections from the urethra

What viral infection is reported to cause hemorrhagic cystitis in children?

Adenoviral infection

Are men or women more commonly affected?

Women


1. Irritative voiding symptoms (e.g., frequency, urgency, and dysuria) 2. Suprapubic discomfort 3. Hematuria or foul-smelling urine

What are the laboratory findings?

1. CBC may show mild WBC elevation with a left shift 2. UA shows WBCs, RBCs, and bacteria


1. Ascending pyelonephritis 2. Epididymitis 3. Prostatitis


1. Hydration 2. In uncomplicated patients, oral antibiotic therapy for 1–3 d is usually adequate (e.g., ampicillin, nitrofurantoin, or TMP/SMX) 3. In complicated patients (e.g., associated calculi, diabetes, or immunocompromise), intravenous therapy may be necessary


Congenital and Acquired Disorders Interstitial Cystitis What is interstitial cystitis?

Chronic irritative process of the bladder wall leads to fibrosis, pelvic pain, and irritative voiding symptoms

Which group of patients does it tend to affect?

Middle-aged women

What are the etiological theories?

1. Autoimmune collagen disease 2. Hypersensitivity response to food allergens 3. Obstruction of the pelvic lymphatics secondary to surgery causing fibrosis 4. Fibrosis secondary to thrombophlebitis from recurrent bladder infections 5. Arteriolar spasm secondary to vasculitic or psychogenic impulses


1. Worsening irritative voiding symptoms (e.g., frequency, urgency, and nocturia) 2. Suprapubic pain made worse by bladder distention and relieved with voiding 3. Microscopic hematuria, which may progress to gross hematuria with bladder overdistention

What are the classic cystoscopic findings?

Areas of punctate hemorrhage (i.e., glomerulations), stellate splitting of the dome, and occasional areas of ulceration (i.e., Hunner’s ulcer)


No definitive treatment; the goal is symptomatic pain relief; the following methods have been tried with varying degrees of success: 1. Hydraulic distension under anesthesia 2. Instillations of dimethyl sulfoxide (DMSO) every 2 wk 3. Irrigations with 0.4% oxychlorosene sodium (Clorpactin) 4. Corticosteroids (unpredictable results) 5. Surgical therapies such as augmentation and loop diversion (unpredictable results)


Hemorrhagic Cystitis What chemotherapeutic agent is most often associated with this condition?

Cyclophosphamide (the urotoxic metabolite acrolein is the etiologic agent)

Tumors Adenocarcinoma of the Bladder What percentage of bladder cancer does adenocarcinoma represent?

2%

What are the three possible sites of origin?

1. Primary bladder adenocarcinoma arising from the base of the bladder 2. Urachal remnant 3. Metastatic adenocarcinoma from the gastrointestinal or the female gynecological tract

What developmental abnormality is associated with increased risk of this condition?

Classic bladder exstrophy


Preoperative radiotherapy with 3,000 cGy followed by radical cystectomy

Squamous Cell Carcinoma (SCCa) of the Bladder What percentage of bladder <8% lesions does SCCa represent? What are the risk factors?

1. Chronic indwelling catheter or other foreign body irritation 2. Vesical calculi 3. Stricture disease 4. Infection with Schistosoma haematobium


1. Superficial well-differentiated tumors can be treated with transurethral resection or partial cystectomy 2. Locally invasive lesions should receive preoperative radiotherapy with 3,000 cGy and radical cystectomy 3. There is no effective chemotherapy for metastatic squamous cancers


Transitional Cell Carcinoma (TCCa) of the Bladder What are the classic 1. Mean age 65 yr demographics in terms of age, 2. Male-to-female ratio of 2.7:1 sex, and race? 3. White to African American ratio of 4:1 What are the known occupational risk factors?

Exposure to the aromatic amines: 1. Benzidine 2. β-naphthylamine 3. 4-aminobiphenyl (Note: these substances are most commonly encountered in the manufacturing of dyes, rubber, textiles, and plastics)

What are the known nonoccupational risk factors?

1. Cigarette smoking: this risk factor is present in 50% of men and 30% of women 2. Dietary nitrosamines 3. Cytoxan exposure

What are the TMN stage groupings of TCCa of the bladder?

T0—papillary lesion confined to the mucosa TIS—carcinoma in situ (CIS) T1—tumor invading submucosa or lamina propria T2—tumor invading superficial muscle T3—tumor invading deep muscle or perivesical fat; LN negative T4—tumor extending into adjacent organs, LN involvement, or distant metastasis

Which histological features determine the grade of a lesion, and how does this correlate with tumor invasiveness?

Grade is determined by: 1. Cellular atypia 2. Nuclear abnormalities 3. Number of mitotic figures Grade 1: well differentiated (10% are invasive) Grade 2: moderately differentiated (50% are invasive) Grade 3: poorly differentiated (>80% are invasive)

What is the most common presenting sign of bladder cancer?

Hematuria, either gross or microscopic (present in 85%–90%)


What is another common presenting complaint more often seen in association with diffuse CIS?

Irritative voiding symptoms such as dysuria, frequency, and urgency

What is the evaluation?

1. UA, culture, and bladder washings for cytology 2. Bimanual exam (usually performed under anesthesia at the time of cystoscopy and deep bladder biopsy) 3. Intravenous pyelogram to rule out concomitant upper tract disease 4. Cystoscopy with directed deep biopsy of any suspicious lesions and random cold-cup biopsies of the four walls, trigone, and prostatic urethra 5. CT scan to determine presence of intra-abdominal metastases and nodal involvement >1.5 cm

What is the treatment of CIS?

1. Due to the high risk of progression to invasive disease (50%–75%), these lesions are treated with intravesical Bacillus Calmette-Guérin (BCG; an attenuated strain of Mycobacterium bovis) 2. Recurrences can be treated by a repeat course of BCG or radical cystectomy

What is the treatment of stage T0 and T1?

1. Transurethral resection of the bladder tumor (TURBt) 2. Recurrences can be treated with repeat TURBt with or without intravesical chemotherapy

What are the indications for intravesical chemotherapy in superficial bladder TCCa?

1. 2. 3. 4.

CIS Multicentricity Rapid recurrence Progression to higher grade

What are the most common intravesical agents?

1. 2. 3. 4.

Thiotepa Mitomycin C Doxorubicin BCG


How often should superficial lesions be followed with repeat cystoscopy and cytology?

Every 3 mo

What is the treatment of stage T2 and T3 (muscle-invasive) TCCa?

1. Radical cystectomy with bilateral pelvic LN dissection and urinary diversion 2. Preoperative radiotherapy (3,000 cGy) is controversial; some studies have shown a decrease in the incidence of recurrence in patients with full-thickness muscle invasion 3. Partial cystectomy may be performed for isolated lesions of the posterior wall, lateral wall, dome, or within a diverticulum in the absence of CIS

What is the treatment of stage T4?

1. Combination methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) 2. A cystectomy may be performed for uncontrolled bleeding, but does not improve overall survival rate

COLLECTING SYSTEM AND URETERS Anatomy From what major vessels does the ureter receive its arterial blood supply?

1. Upper and middle ureter: renal, gonadal, aorta, and common iliac arteries 2. Distal ureter: internal iliac, superior vesical, uterine and vaginal (in females), middle rectal, and inferior vesical arteries

What are the three anatomic narrowings of the ureter and their usual calibers?

1. Ureteropelvic junction: 2 mm 2. Iliac vessel crossing: 4 mm 3. Ureterovesical junction: 3–4 mm

What is the significance of these narrowings?

They are the most common sites of stone obstruction


CONGENITAL AND ACQUIRED DISORDERS Ureteropelvic Junction Obstruction What are the etiologies? 1. Intrinsic circular smooth muscle disorder 2. Compression due to a crossing vessel from the lower pole of the kidney 3. High insertion of the ureter on the renal pelvis 4. Valvular fold of mucosa (rare) What is the male to female ratio?

2.5:1

What are the usual presenting symptoms?

1. Infants usually present with an asymptomatic flank mass, evaluation of hydronephrosis detected on prenatal U/S, or urosepsis 2. Children and adults usually present with episodic flank pain with or without associated vomiting

What percentage present during the first year of life?

25%

Which studies are included in the evaluation?

1. Intravenous pyelogram (IVF) can usually establish the diagnosis 2. Diuretic DTPA renogram is useful in equivocal cases 3. Retrograde pyelogram is often attempted to further define the region of obstruction


1. Open pyeloplasty (gold standard therapy) 2. Laparoscopic pyeloplasty 3. Antegrade or retrograde pyelotomy

Vesicoureteral Reflux (VUR) What is VUR?


Abnormal backward flow of urine from the bladder up the ureter (and possibly into the intrarenal collecting system) 1. Recurrent infections 2. Renal parenchymal scarring 3. Renal damage (reflux nephropathy)


Which factors contribute to the occurrence of reflux?

1. Shortened intramural segment of ureter (less than a 4:1 ratio of intramural segment to ureteral diameter) 2. Abnormal ureteral orifice due to varying degrees of diminished supporting musculature (i.e., stadium orifice or golf hole) 3. Ectopic lateral displacement of the ureter 4. Edema secondary to infection or inflammation 5. Displacement from a diverticulum or from the ureterocele of a duplicated ureter

What is the gold standard diagnostic test for VUR?

Voiding cystourethrogram

What is the radiographic grading system for VUR?

Grade I: ureter only Grade II: into the intrarenal collecting system without dilation Grade III: reflux into the calyceal system with loss of the fornices Grade IV: moderate dilation of renal pelvis, calyces, and ureter with or without ureteral tortuosity Grade V: severe dilation of the ureter, renal pelvis, and calyces with a markedly tortuous ureter


What is a “Boari flap”?

Provides length to a shortened ureter

What is a “Psoas hitch”?

Provides length to a shortened ureter

What is the medical treatment of VUR?

Low-dose suppressive antibiotics, frequent urine culture, yearly nuclear or voiding cystourethrogram, and an IVP every 2 yr

What are the indications for medical treatment?

Young patients without evidence of progressive renal damage and a normal appearing ureteral orifice

What is the surgical treatment of VUR?

Ureteral reimplantation (of the many techniques, the primary principle of each is to increase the length of the intravesical ureter)



1. Progressive scarring or pyelonephritis despite medical therapy 2. Poor compliance with medical therapy 3. Reflux in association with a significant anatomic abnormality such as a diverticulum, duplication, ureterocele, or ectopic location

What is VUR’s claim to fame?

Most common anomaly of the urinary tract

What is the female-to-male ratio?

2:1

What is the Meyer-Weigert rule?

In a duplicated system, the ureteral orifice draining the upper pole is located inferiorly and medial to the lower pole ureter

Which of the duplicated ureteral orifices most commonly refluxes?

The lower pole ureter

Ectopic Ureter What is ectopic ureter?

The ureteral orifice opens into the urinary tract in a position other than its normal location on the trigone

With what other condition is this anomaly often associated?

Ureteral duplication

What are the most common extravesical ectopic sites in men?

1. Posterior urethra 2. Seminal vesicle

What are the most common extravesical ectopic sites in women?

1. Urethra 2. Vestibule 3. Vagina


1. Partial nephroureterectomy if the ectopic ureter drains a nonfunctioning renal segment 2. Pyeloplasty and distal ureterectomy if the renal moiety is functioning 3. A primary reimplantation if a single ureter is ectopic


Idiopathic Retroperitoneal Fibrosis What is idiopathic A chronic inflammatory process in the retroperitoneal fibrosis? retroperitoneum, which can encompass the ureters What is the primary complication?

Ureteral obstruction and hydroureteronephrosis


1. Primary: idiopathic 2. Secondary: cancer (e.g., breast, ovarian, prostate) Several drugs/medications (e.g., methysergide, hydralazine, β-blocker) Infections (e.g., tuberculosis, syphilis) Radiation exposure Inflammatory processes (e.g., leaking aortic aneurysm, inflammatory bowel disease)


Flank or abdominal pain

What is the most useful diagnostic modality for evaluating this condition?

Abdominal and pelvic CT scan with contrast to define extent of involvement and to evaluate for underlying malignancy


Diagnostic biopsy of the retroperitoneal process followed by intraperitonealization of the ureters (Note: some surgeons advocate wrapping the ureters with segments of omentum to keep them from becoming reincorporated in the process)

Tumors Transitional Cell Carcinoma (TCCa) of the Renal Pelvis or Ureter What percentage of TCCa ≈4% tumors are located in either the renal pelvis or ureter? What percentage of patients with an upper tract tumor will develop a lesion in the lower tract?

33%


What are the most common presenting complaints?

1. Hematuria: most common (70%–80%) 2. Flank pain: due to obstruction from clot or tumor

What studies and procedures are included in the evaluation?

1. UA with cytology 2. IVP: Often the initial study; also to evaluate the contralateral collecting system 3. Cystoscopy with retrograde pyelogram and selective ureteral washings: to further define the lesion and to gain a pathologic diagnosis; cystoscopy is necessary to rule out concomitant disease in the bladder 4. Ureteropyeloscopy with brush biopsies (occasionally necessary) 5. Abdominal and pelvic CT scan; to evaluate for obvious metastases 6. Chest x-ray

What is the staging system?

Stage 0: CIS or superficial papillary cancer Stage I: invasion of the lamina propria Stage II: invasion of the underlying smooth muscle Stage III: invasion of the peripelvic fat, periureteral fat, or renal parenchyma Stage IV: invasion through the renal capsule, into adjacent organs or metastases to LN or distant organs

What is the treatment of: Low-stage, low-grade distal ureteral tumor?

Distal ureterectomy, excision of a cuff of bladder and ureteral reimplantation

Stage I to III tumors?

Nephroureterectomy (Note: in patients with a solitary renal unit, more conservative therapy such as segmental ureteral resection or endoscopic pelvic resections followed by chemotherapeutic instillations have all been tried, with variable results)

Stage IV tumors?

Combination chemotherapy using MVAC


MISCELLANEOUS On which side is testicular cancer more common?

Right

What is a “Goldblatt kidney”?

A small shrunken kidney due to renal artery stenosis

What is a varicocele?

Dilation of spermatic cord veins (no valves), pampiniform plexus, and spermatic veins

Varicocele

On which side is a varicocele more common?

Left

What is the “BCG” intravesical agent, and how does it work?

Bacillus Calmette-Guérin (BCG) tuberculin agent: works by increasing patient’s own immune response against the tumor

What is the recurrence rate of TURB (transurethral resection of the bladder)?

Increased risk because of “field effect” (i.e., the uniform exposure of the urothelium as it is bathed in urinary carcinogens); therefore, surveillance with repeat cystoscopy and urinary cytology every 3–4 mo is required

What is the most likely outcome with TURP (transurethral resection of the prostate)?

>66% of patients have improvement in urinary symptoms

What is a complication from forceful digital rectal exam with patient with severe prostatitis?

Bacteremia and septic shock


Chapter 81 Ophthalmology Define the following terms: Amblyopia?

Partial/complete loss of vision in eye (a.k.a. “lazy eye”)

Astigmatism?

Asymmetric cornea

Esotropia?

Eyes inward

Exotropia?

Eyes outward

Hypertropia?

Eyes upward

Hypotropia?

Eyes downward

Hyperopia?

Farsightedness

Diplopia?

Double vision

Strabismus?

Eye malalignment

Hyphema?

Blood in anterior chamber of eye

Chemosis?

Edema of the conjunctiva

Endophthalmitis?

Intraocular infection

Ptosis?

Eyelid droop

Anisocoria?

Asymmetric pupil diameter

Nystagmus?

Back and forth jerky movement of the eyes

Dacryocystitis?

Lacrimal sac infection

Mydriasis?

Pupil dilation (Think: myDriasis = Dilation)

Miosis?

Pupil constriction

Chapter 81 / Ophthalmology 765

Myopia?

Nearsightedness

PHACO?

PHACOemulsification

PRK?

PhotoRefractive Keratectomy

LASIK?

LASer In situ Keratomileusis

AK?

Astigmatic Keratotomy

ANATOMY What are the labeled ocular structures?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Cornea Anterior chamber Iris Posterior chamber Conjunctiva Lens Zonular fibers Ciliary body Vitreous humor Retina Choroid Sclera Macula Optic disc Retinal artery and vein Optic nerve


What are the labeled structures in this anterior view of the dissected orbital cavity?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Zygomatic bone Lateral rectus muscle Lacrimal gland Frontal bone Superior rectus muscle Superior oblique tendon Supraorbital nerve Trochlea of superior oblique muscle Lacrimal canaliculi (duct) Lacrimal sac Nasolacrimal duct Maxilla Inferior rectus muscle Infraorbital nerve Inferior oblique muscle

OPHTHALMOLOGICAL EXAMINATION What are the basic components of the bedside ophthalmological examination?

Systematically evaluate structures from anterior to posterior: Orbital rim—palpate for crepitus, step-off deformities; test for periorbital hypesthesia Eyelid—inspect lid for lacerations/ foreign bodies (examination should include careful lid eversion) Visual acuity—test with counting of fingers (or reading of card eye chart) Globe—test extraocular muscles; inspect for laceration or rupture Conjunctiva—inspect for subconjunctival hemorrhage, laceration, emphysema, or foreign body Anterior chamber—inspect for hyphema and chamber depth (tangential lighting) Iris—inspect for shape and reactiveness Lens—inspect for transparency and position (dislocated?); red reflex? Vitreous humor—inspect for transparency Retina—inspect for hemorrhage and detachment


What may absence of red reflex suggest?

Cataract, vitreous hemorrhage, retinal detachment, retinoblastoma

What may lid ptosis suggest?

Injury to levator palpebrae or its innervation (CN III)

OCULAR TRAUMA What are the signs/symptoms of corneal abrasions?

Pain!

History of Ocular Trauma How are corneal abrasions diagnosed?

Fluorescein test

With a laceration of the eyebrow, should the eyebrow be shaved prior to suturing closed?

NO; 20% of (Do NOT ever shave eyebrows!!) the time the eyebrow will not grow back!

What is a retinal detachment?

A separation of the neurosensory retina from the pigment epithelium and its supportive choroid, resulting in retinal infarction

What causes retinal detachment?

Trauma, ocular surgery, diabetes, spontaneous—small rent in retina allows fluid to insinuate itself in the subretinal space, causing a retinal detachment

What are the signs/symptoms of a retinal detachment?

Floaters, blind spots, flashing lights

What is the treatment for a retinal detachment?

Surgery—sclera buckling therapy

What is the major symptom of a lens detachment?

Blurred vision

What is the common ocular physical finding after a sinus fracture?

Conjunctivae emphysema

How are acid and alkali chemical eye burns treated?

Copious eye irrigation for both


What is sympathetic ophthalmia?

Autoimmune destruction of the contralateral good eye after penetrating injury causing blindness to ipsilateral eye; remove blind eye within 2 wk following penetrating injury to avoid this condition

Should a penetrating eye object be removed?

NO! Call the ophthalmologist and do not remove

What are the symptoms of BLOWOUT fracture?

Double vision

What is a concern if posttraumatic PROPTOSIS develops?

Retrobulbar hematoma (if severe, treat with lateral canthotomy)

Lateral canthal ligament

Lateral corner of skin cut 1-2 cm

What is an eye finding with electrocution?

Inferior crura of lateral canthal tendon cut

Cataracts

NONTRAUMATIC OCULAR EMERGENCIES Orbital Cellulitis What are the most common microbial etiologies?

Gram-positive cocci (Streptococcus, Staphylococcus); Haemophilus influenzae (in children <5 yr of age)


What are the routes to orbit?

Direct extension via paranasal sinuses, vascular drainage from periorbital soft tissue, and occasionally hematogenous spread from distant site


Acute onset of severe orbital pain, reduced mobility of eye, conjunctival chemosis (edema), reduced vision, malaise, fever, and in some cases, marked periorbital erythema and edema

What are the sequelae?

Cavernous sinus thrombosis due to thrombophlebitis of the orbital veins, blindness due to optic neuritis, spread of infection to brain or meninges


Hospitalization, systemic antibiotics, warm packs, bed rest; occasionally, surgical drainage indicated (Note: most experts recommend CT scan of orbit to exclude abscess)

GLAUCOMA What is it?

An ocular disease complex primarily characterized by an increased intraocular pressure

What are the three different types?

1. Chronic open angle: bilateral, insidious, slowly progressive; most common type (90%) 2. Narrow angle: acute obstruction of aqueous outflow; painful, acute visual loss, cloudy cornea 3. Congenital: genetically transmitted; often appearing in first year of life


Increased ocular pressure related to increased intraocular aqueous humor production, decreased outflow of aqueous humor from the eye, or both, leading to optic nerve degeneration



1. Increased intraocular pressure 2. Retinoscopy (optic disc cupping) 3. Peripheral visual field testing


Decrease intraocular pressure through topical eyedrops, surgery, or both

What are the surgical treatment options?

Laser iridotomy (Note: the contralateral eye is also prophylactically treated)

Hyphema What is hyphema?

Hemorrhage into anterior chamber of the eye; seen as meniscus or layering of blood anterior to iris

What percentage of patients rebleed?

Between 10% and 30% rebleed in the first wk posttrauma

What is the medical management of hyphema?

Controversial; the most conservative treatment involves elevation of head for 5 to 7 d (± admission to hospital), bed rest, daily examination, and tonometry (to ensure absorption of blood without development of glaucoma)

What are the indications for surgical washout of hyphema?

Blood staining of cornea, secondary glaucoma

Conjunctival Emphysema What is the usual etiology of conjunctival emphysema?

Fracture of sinus (often the lamina papyracea of the ethmoid bone) permitting air to dissect under the conjunctiva

What special instructions should be given to the patient?

Patient should not blow nose, because acute increases in sinus pressure result in further dissection

Lens Dislocation What is the mechanism of lens dislocation?

Disruption of >25% of zonular fibers (anchored to ciliary body), which hold lens to posterior surface of iris



Blurred vision (often subtle)

Which general type of lens dislocation is a surgical emergency, and why?

Anterior; can cause acute glaucoma (Note: posterior dislocation into vitreous humor is treated electively after resolution of inflammation)

What is the classic LATE complication of blunt trauma?

Retinal detachment (due to retinal tear)


Decreased visual acuity (due to slowly progressive and painless dissection of retina from choroid)


Cryosurgery and/or scleral buckling (performed emergently if the macula is threatened because it can prevent permanent loss of central vision)

CORNEA What is keratitis?

Inflammation of the cornea secondary to an infectious or mechanical etiology

What infectious agents are frequently involved?

Staphylococcus, Streptococcus, Pseudomonas, herpes, Chlamydia

What predisposes the cornea to infection?

Exposure, trauma

What is the treatment of corneal opacities secondary to scarring?

Corneal transplant

REFRACTIVE SURGERY What is it?

Surgery to correct vision by reshaping the cornea

What are the types?

PRK, AK, LASIK

What is PRK?

Photorefractive keratotomy—shaping of the cornea with a laser only


What is AK?

Astigmatic keratotomy—curved incisions are made into the cornea to smooth the asymmetric areas

What is LASIK?

Laser in situ keratotomy—the cutting of the cornea with a scalpel blade and then using a laser to modify the shape of the cornea

MISCELLANEOUS What are the terms used to describe the constriction and dilatation of the iris?

Miosis-parasympathetic-mediated constriction Mydriasis-sympathetic-mediated dilatation

What type of ophthalmological medication should not be given to the patient for outpatient use, and why?

Local anesthetics; patient may further injure eye without realizing it, and these agents often delay healing

What drugs are used to reduce the spasm of the ciliary muscle frequently seen with ocular injuries?

Cycloplegic-anticholinergic agents (e.g., atropine drops)

What are the untoward sequelae of topical corticosteroids?

Herpes simplex keratitis, cataract formation, fungal infection, and acute-angle glaucoma

Which injuries to the eye classically first present with symptoms 4 to 12 hr after injury?

Ultraviolet burns of cornea (e.g., welding arc, “snow blindness”)

What is the associated finding on examination?

Diffuse punctate fluorescein staining of corneas


Topical corticosteroids, oral analgesia (Note: resolution of symptoms in 1–2 d without sequela)


Which lacerations to the eyelid should be repaired by an ophthalmologist or plastic surgeon?

Lacerations involving: 1. Medial canthal region 2. Deep or through-and-through laceration involving the tarsal plate 3. Edge of lid (risk of obvious lid notching)

What is a cataract?

Opacification of the lens

What is strabismus?

Misalignment of the eyes

Why is it important to correct strabismus?

To allow proper development of visual acuity and binocular vision

What is a pterygium?

A plaque-like extension of fibrovascular tissue onto the cornea

In what cases should a blind eye be removed?

Blind and painful, malignancy, blind traumatized eye, diagnostic purposes

What is Horner’s syndrome?

Sympathetic nerve lesion of the neck resulting in “MAP”: Miotic pupil Anhydrosis (face) Ptosis

What is a PHACO?

Phacoemulsification: cataract is removed with ultrasonic dissector/aspirator

What prophylactic antibiotics are given for eye surgery?

Gentamicin or tobramycin eye drops

What is the most common eye malignancy in adults?

Metastatic disease

What is the most common primary eye malignancy in adults?

Melanoma

What is the most common primary eye malignancy in children?

Retinoblastoma

What is dacrocystitis?

Infection of the lacrimal sac


What is the usual etiology?

Obstruction of nasolacrimal duct with resultant Streptococcus pneumoniae infection (in infants, H. influenzae is the responsible organism)

THE RED EYE What are the eight signs of serious ocular pathology in a red eye?

Give the classic signs/ symptoms of the following conditions: Bacterial conjunctivitis?

1. 2. 3. 4. 5. 6. 7. 8.

Visual loss Pain Opacities Pupil irregularities Perilimbal erythema Increased pressure History of eye disease Refractory to treatment

Conjunctival redness with purulent discharge

Viral conjunctivitis?

Conjunctival redness with serous discharge

Allergic conjunctivitis?

Clear conjunctival discharge

Acute narrow angle glaucoma (congenital glaucoma)?

Acute pain, cloudy cornea, perilimbal redness, blurred vision

Iritis?

Perilimbal redness, irregular pupil, pain, decreased vision

Corneal ulcer?

Epithelial defect with infiltrate, pain

Corneal abrasion?

Epithelial defect, no infiltrate, pain

Orbital cellulitis?

Periocular swelling, erythematous ocular surface, decreased vision

Chapter 82 / Obstetrics and Gynecology 775

Chapter 82 Obstetrics and Gynecology ANATOMY Identify:

1. Common iliac artery 2. Iliolumbar artery 3. Internal iliac artery 4. Lateral sacral artery 5. Superior gluteal artery 6. Inferior gluteal artery 7. Pudendal nerve 8. Middle rectal artery 9. Perineal artery 10. Internal pudendal artery 11. Superior vesical artery 12 Uterine artery 13. Obturator artery and nerve 14. Inferior epigastric artery 15. External iliac artery

Uterus What is the normal shape and position of the uterus?

Anteflexion (concave forward) and anteversion (forward at a right angle to the vagina)


Identify the labeled structures:

1. 2. 3. 4. 5. 6. 7. 8.

Round ligament of uterus Internal iliac artery Ovarian artery Uterine artery Ureter Vaginal artery Internal pudendal artery Perineal branch of internal pudendal artery

What is the round ligament?

Fibrous tissue and smooth muscle remnant of the gubernaculum, which runs in the anterior leaf of the broad ligament, from the cornua of the uterus through the inguinal canal to the labium majora and holds the uterus in anteversion

Identify the labeled structures:

1. 2. 3. 4. 5. 6. 7.

Oviduct Mesosalpinx Mesovarium Round ligament Broad ligament Uterine artery Ureter


Ovary Is the ovary covered by serosa?

The ovary is not invested with a peritoneal covering, although the surface is covered by low columnar epithelium

Why is ovarian pain often referred down the inner side of the thigh?

The ovary lies on the sidewall of the pelvis, on the obturator nerve; the parietal peritoneum here is supplied by the obturator nerve, and its cutaneous distribution is the inner side of the thigh down to the knee

What is the relationship of the ovarian artery to the ureter?

Arising from the aorta, just below the renal artery, the ovarian artery crosses the ureter on the psoas muscle above the pelvic brim

CARCINOMA OF THE CERVIX What is the peak age of incidence?

Between 48 and 55 yr for invasive cervical carcinoma; between 25 and 40 yr for carcinoma in situ


1. 2. 3. 4. 5. 6.

Is an infectious etiology present?

Yes, human papillomavirus (HPV) types 16 and 18 are implicated; herpesvirus type 2 (HSV-2) and other sexually transmitted disease such as chlamydia are not

What are the pathological types?

1. Squamous cell carcinomas (arising from the squamocolumnar junction of the cervix)—80% 2. Adenocarcinomas—15%

What are the precursor lesions?

Cervical intraepithelial neoplasia (CIN), which are divided into high- and low-grade squamous intraepithelial lesions

Low socioeconomic status First intercourse at an early age Promiscuity, prostitution Early parity Increasing parity HPV infection


Over what period of time do these lesions progress to invasive carcinoma?

From 10 to 20 yr, although it can progress more quickly

Are metastases more commonly hematogenous or lymphatic?

Lymphatic

Which are the sentinel nodes?

The obturator nodes

What is the treatment of microinvasive carcinoma (stage IA)?

Confirm the depth of invasion with a cone biopsy: 1. If invasion is <3 mm, total abdominal or vaginal hysterectomy is performed when preservation of fertility is not a consideration 2. If the patient wants to have children, close follow-up may be adequate in selected patients if the margins of resection are negative

What is the Wertheim operation?

Radical abdominal hysterectomy with bilateral pelvic lymphadenectomy; the parametrial, paracervical, and upper paravaginal tissues are completely removed along with the upper third of the vagina

What are the indications for radiation therapy (XRT)?

1. Any stage of cervical cancer 2. Stage IIB–IV cancer (treatment of choice) 3. An alternative to radical hysterectomy for stages IB/IIA (both modalities have the same cure rate)

ENDOMETRIAL CANCER What are its claims to fame?

1. Most common malignancy of the female genital tract 2. Fourth most common malignancy in women

Is it more common before or after menopause?

Mainly occurs after menopause, with peak incidence in the sixth decade; it is very uncommon before 40 yr of age



Multiple! Obesity, late first pregnancy, nulliparity, late menopause, polycystic ovary disease, estrogen-secreting ovarian tumors, exogenous estrogen use, diabetes, hypertension, hypothyroidism, and chronic anovulatory states

Do combination estrogen and progesterone contraceptive pills increase risk?

No, the concomitant use of progestins negates the effect of the estrogens, and the risk of endometrial cancer is actually lowered

What is the typical presentation?

Vaginal bleeding in a postmenopausal woman

What are the diagnostic procedures?

1. Fractional dilatation and curettage 2. Endometrial biopsy

What is a good screening procedure?

None; the Pap smear is not reliable

Is there a specific tumor marker?

No; CA 125 is not specific for endometrial carcinoma, but it may be elevated, and thus useful for follow-up after therapy

What is the usual treatment modality?

Surgery; total abdominal hysterectomy and bilateral salpingo-oophorectomy with appropriate evaluations for surgical staging, which usually involves sampling of the pelvic and paraaortic nodes

OVARIAN CANCER How common is ovarian cancer?

1. Second most common gynecological malignancy, accounting for 25% 2. Accounts for only 4% of all visceral malignancies in women

What is its claim to fame?

Leading cause of gynecologic cancer death (responsible for 50%); almost 14,000 women in 1994


What is the lifetime risk for a woman to develop ovarian cancer? If no family members have ovarian cancer? If one first-degree relative has ovarian cancer? What ovarian tumors are associated with: Long-term anticonvulsant therapy?

Between 1% and 2% ≈5%

Ovarian thecomas

Peutz-Jeghers syndrome?

Granulosa cell tumors

Inherited basal cell nevus syndrome?

Benign fibromas

Gonadal dysgenesis (46XY)?

Gonadoblastomas

Turner syndrome (45XO)?

None

What are Krukenberg tumors?

They are ovarian metastases from gastric, colorectal, and breast cancers; ovaries are usually involved bilaterally

What is the most common ovarian tumor overall?

Epithelial tumors (70%)

What is the most common malignant ovarian tumor?

Serous cystadenocarcinomas (42%)

What is the most common type of tumor in patients under 20 yr of age?

Germ cell tumors (epithelial tumors account for less than one-fifth of tumors in this age group)

Which type is associated with pseudomyxoma peritonei?

Malignant mucinous cystadenocarcinoma

Which type has pathognomonic “hobnail” cells?

Clear cell carcinoma


Which tumor is associated with: Call-Exner bodies?

Granulosa cell tumors may contain these folliculoid structures

Schiller-Duval bodies?

Endodermal sinus tumors often contain these papillary formations

Hyperthyroidism?

Struma ovarii: a dermoid cyst with thyroid tissue as a component

Coombs’ positive hemolytic anemia?

Mature cystic teratoma (dermoid cyst)

Masculinization?

Sertoli–Leydig cell tumors

Precocious puberty?

Granulosa and theca cell tumors

Bilaterality?

Dysgerminomas (10%) and dermoid cysts (15%)

Exquisite radiosensitivity?

Dysgerminomas

Elevated hCG?

Choriocarcinoma

Elevated AFP?

Endodermal sinus tumor

What is the management of an adnexal mass in a: Premenarchal girl?

Premenopausal woman?

Ultrasound (U/S), usually followed by exploratory laparoscopic surgery These masses are usually benign; ultrasonographic assessment should be followed by surgical exploration if any of the following features are present: >8 cm, complex structure on U/S, irregular, solid, bilateral, or associated ascites; close follow-up with repeat pelvic exam and U/S if none of these features are present; if no regression in three menstrual cycles on follow-up, perform exploratory laparotomy


Postmenopausal woman?

Ovarian tumors have a very high suspicion for malignancy; ultrasonography and CA-125 level for assessment; a simple cystic structure <5 cm in size, and CA-125 level <35 U/mL may be followed serially (risk of malignancy is 1%); all other masses, and CA-125 >35 U/mL, require surgical exploration

What tumor markers are useful?

1. CEA 2. CA-125

Which tumors show elevated CEA?

1. >50% of stage III epithelial cancers 2. Mucinous tumors most frequently

Is CA-125 useful as a screening test?

No, because of two problems: 1. Large number of false positives mean low predictive value 2. Only 50% of patients with stage I ovarian cancer have elevated CA-125

Is CA-125 useful for follow-up after therapy?

It is of some benefit; if elevated, it definitely indicates residual disease or a recurrence; however, it may fall within the normal range in the presence of disease

COMPLETE HYDATIDIFORM MOLE What are the pathological characteristics?

Clusters of hydropic villi, absent fetal vessels, and trophoblastic proliferation; no evidence of fetus or amniotic tissues

What are the cytogenetics?

Diploid, 46 XX, with both X-chromosomes paternal in origin

What are the clinical features?

1. Vaginal bleeding 2. Large for date uterus 3. hCG titers high for the duration of gestation 4. Absence of fetal heart sounds and other evidence of fetus 5. Theca lutein ovarian cysts 6. Occasionally, early toxemia of pregnancy or expulsion of grape-like villi


What are the sonographic features?

Large for date uterus filled with grape-like structures

What follow-up is necessary after evacuation?

1. Weekly hCG levels, until they are normal 2. Regular physical examination 3. Evaluation of any clinical symptoms 4. CXR every 1 to 2 mo until hCG levels normalize

What percentage of patients develop postmolar gestational trophoblastic tumors?

40% with high-risk moles, 4% with lowrisk moles High-risk features are: large for date uterine size, high hCG levels, large ovarian theca lutein cysts, toxemia, coagulopathy, trophoblastic embolization, and hyperthyroidism

PARTIAL HYDATIDIFORM MOLE How is this mole different from the complete form?

1. Fetal and amniotic tissues are present; focal distribution of hydropic villi and trophoblastic proliferation 2. Cytogenetic analysis: triploid, generally 69 XXY or 69 XYY 3. Uterus generally not enlarged 4. Malignant sequelae rare, though possible Partial hydatidiform moles are most frequently diagnosed as incomplete abortion with hydropic degeneration

What follow-up is necessary after evacuation?

Same follow-up as required for the complete molar pregnancy

THE PREGNANT SURGICAL PATIENT Can you use Coumadin or heparin in pregnant patients?

Heparin only—Coumadin is a teratogen!

What is the incidence of fetal demise with a nonruptured appendicitis?

10%


What is the incidence of fetal demise with a ruptured appendicitis?

33%

When, during a pregnancy, does the uterus reach out of the pelvis?

12 wk

When, during a pregnancy, does the uterus reach the umbilicus?

20 wk

When, during a pregnancy, does the uterus reach the costal margin?

34 wk

Where is the uterus during pregnancy by weeks? 36 40 32 28 24 20 16 12

What findings are present on a pelvis x-ray in a near-term pregnant patient?

1. Pubic symphysis up to 8 mm separation at 7 mo 2. Increase in the SI joint space

What fetal injury is associated with a maternal traumatic pelvic fracture?

Fetal skull fracture

What should you consider if a pregnant woman develops DIC?

Amniotic embolus

A pregnant patient can lose how much blood before any change in vital signs?

Up to 1,500 cc before any change in vital signs!


What is often the first sign of hypovolemic shock in a pregnant patient?

Fetal distress

What is the mortality rate of amnionic fluid embolus?

80%

What is preeclampsia?

Remember: HEP triad: 1. Hypertension 2. Edema 3. Proteinuria

What are the signs of eclampsia?

Seizures, hypertension, edema, proteinuria, hyperreflexes

What medication is used during labor as an anticonvulsant in patients with preeclampsia?

IV magnesium sulfate

What medication is used for actual seizures?

Dilantin (phenytoin) or Valium (diazepam)

Describe the pathophysiology of fatty liver of pregnancy?

Fat accumulation in hepatocytes causing liver failure during pregnancy

What is placental abruption?

Premature separation of the placenta

What are the signs of placental abruption?

Vaginal bleeding, uterine contractions, DIC

What are the most common signs of placental abruption?

Vaginal bleeding and pain

What is a pulmonary side effect of tocolytics?

Pulmonary edema

Is maternal mortality high with penetrating injury to the near-term uterus?

Actually no, the uterus is protective to a large degree

When can you hear a fetal heart tone?

>10 wk by Doppler

What is the normal fetal heart rate?

120–160/min


Fetal distress is seen with what fetal heart tones?

1. DECELS (decreased heart rate) 2. No accelerations 3. Beat-to-beat variability decreases

How much Rh+ fetal blood does it take to sensitize 70% of Rh- pregnant women?

Only 0.01 cc!

How long after maternal death must you perform a “perimortem” cesarean section for any chance of success?

5 min

What is the normal HCT in pregnant women?

30%–35%

What hormone is responsible for the respiratory alkalosis of pregnancy:

Progesterone (respiratory stimulant)

Which inotrope/vasopressor will increase maternal blood pressure and increase uterine blood flow?

Ephedrine

What is the name of the test that checks for the presence of fetal RBCs in maternal blood?

Kleihauer-Betke test

What is the pH of vaginal amnionic fluid?

pH 7.0–7.5

What is the status of the following during pregnancy: Heart rate?

Increased (10–15 beats/min increase)

Cardiac output?

Increased (1–1.5 L/min increase)

Blood pressure?

Decreased SBP and DBP

Hematocrit?

Decreased

Intravascular volume?

Increased (but hematocrit decreased)

Tidal volume?

Increased


Minute ventilation?

Increased

Serum creatinine?

Decreased

Serum BUN?

Decreased

Gastric emptying?

Decreased (delayed)

PaCO2?

Decreased (minute ventilation increased)

GFR?

Increased

WBC?

Increased (up to 15,000)

Clotting factors?

Decreased

Fibrinogen?

Decreased

Pituitary gland size?

Increased up to 50%

Albumin level?

Decreased

SECTION IV Rapid Fire Power Review

Chapter 83 Rapid Fire Review for the American Board of Surgery In-Training Examination (ABSITE) What cells produce tissue necrosis factor (TNF)?

Macrophages; it activates neutrophils

What is the source of fever in atelectasis?

IL-1 production from alveolar macrophages

What is the defect in familial hypercholesterolemia?

LDL receptor

What is the order of cell arrival to a wound?

Platelets→PMN→Macs→fibroblast→ lymphocytes

What is the function of TGF-b?

Stimulates fibroblasts; most important cytokine in wound healing

What is the function of VEGF?

Angiogenesis growth factor

Most important cell in healing by secondary intention?

Myofibroblast causes wound contraction

Where do steroid hormones bind cell receptors?

Cytoplasm and then act as transcription factor

Where do thyroid hormones bind cell receptors?

Nucleus and then act as transcription factor

Definition of respiratory quotient?

Amount of CO2 produced/amount of O2 consumed

What is the respiratory quotient of carbohydrates, fat, protein, brain, and stomach?

Carbohydrates 1, fat 0.7, protein 0.8, brain 1, and stomach = negative

789

790 Section IV / Rapid Fire Power Review

What are the kilocalories per gram of carbohydrates, fat, and protein?

Carbohydrates 3.4, fat 9, and protein 4

How many grams of nitrogen are in 1 g of protein?

6.25 g

Calculate the amount of nitrogen in 200 g of protein:

RC: 200/6.25 = 32 g of nitrogen

What are the main components of TPN?

50% glucose, 30% lipids, 20% protein

How many calories are in 1 L of D20W and 250 cc of 20% lipids?

D20W has 20 g of glucose in 100 cc so this is 200 g of glucose which is 3.4 kcal/g if given exogenously; 200 × 3.4 = 640; 20% lipids are 20 g in 100 cc; so there is 50 g in 250 cc at 9 kcal/g; 50 × 9 = 450; 450 + 640 = 1,050 calories

How many calories/kg/d does a neonate need?

90–120

What vitamin is needed other than vitamin D for bone growth?

Vitamin C

What is the protein requirement for average adult?

1g/kg/d

What is the primary fuel of cancer cells?

Glutamine

What is the greatest risk factor for postoperative morbidity?

Low albumin

What induces cachexia?

TNF-α

What is the absorption of fatty acids (FA)?

Long-chain FA enters the lymphatic circulation with chylomicrons; medium-chain FA and short-chain FA enter the portal system along with amino acids

What is the function of P-selectin?

P-selectin is found on all platelets (Think, P = platelet); selectins are responsible for “rolling”

Chapter 83 / Rapid Fire Review for the ABSITE 791

What are integrins?

Integrins are transmembrane proteins found on neutrophils at all times; they bind to ICAM on the endothelial surface; integrins are responsible for firm adhesion

What is an ICAM?

ICAM is found on all endothelial surfaces and are produced in response to cytokines from neutrophils; they bind integrins found on neutrophils for firm adhesion

What is the function of fibronectins?

Help attach fibroblast to the wound matrix

What is the genetic inheritance of protein C deficiency?

Autosomal dominant; it causes skin necrosis if Coumadin is not bridged with heparin

What lab value is abnormal in vWB disease?

Increased bleeding time; the PT and PTT are unchanged

What is the treatment for vWB’s?

Cryoprecipitate, DDAVP

What does the 1b receptor do?

It binds the platelet to vWB factor

Where is vWB factor made?

Endothelial cells

What is the common side effect of protamine?

Hypotension; give 1 mg of protamine for every 100 units of heparin

What is HITT and how is it treated?

Stop heparin and start argatroban (direct thrombin inhibitor)

Type of clot formed in HITT?

White clot

What is the Antibody responsible for HITT?

IgG to PF-4

How do you treat hemophilia prior to surgery?

Hemophilia A—infusion to FVIII levels 100% preoperatively and 30% postoperatively Hemophilia B—infusion to FIX levels 50%

Where is prostacyclin produced?

Endothelium


PT measures which factors?

Factors II, VII, IX, X

What is the best test of liver function?

PT

What do you see on renal biopsy of acute rejection following renal transplant?

Infiltrating neutrophils; the treatment is pulse steroids

What is the diagnosis of a mesenteric mass 2 yr after kidney transplant?

Lymphoma from Epstein–Barr virus (EBV)

What is the most common cause of a liver transplant?

Hepatitis C

What is the cause of pneumonia after transplant? Treatment?

CMV; treatment is ganciclovir

MHC II is compatible with which HLA?

D

Most important HLA crossmatch overall?

HLA-DR

Which Ig is made in the Peyer’s patches?

IgA

What is the common complication after pancreas transplant?

If the exocrine pancreas is drained via the urinary bladder, 80% can have nongap metabolic acidosis from bicarbonate wasting in the urine; treatment is chronic bicarbonate replacement

Blood cross-match test for what?

Preformed recipient AB’s

What is the cause of hyperacute rejection and treatment?

Caused by preformed recipient AB’s which leads to activation of the complement cascade and thrombosis; treatment is emergent retransplant

What is the most common cause of post transplant diabetes?

Steroids


What is the cause of clear slime after vascular operation?

Staphylococcus aureus

What antibiotic should be given for colon perforation?

Cefoxitin (Mefoxin) has been shown to be as good as combination antibiotics

How many bacteria are needed in a wound to be classified a wound infection?

105

What is the cause of gram-negative sepsis?

Endotoxin release from the lipopolysaccharide A which triggers the release of TNF from macrophages

What are the different types of surgery and wound infection rates associated with them?

Clean (breast biopsy) 2% Clean contaminated (lap chole) 3–5% Contaminated (colon perforation) 5–10% Grossly contaminated (abscess) 30%

Most common nonsurgical nosocomial infection?

UTI

When should perioperative Abx be given?

Within 1 hr of incision

Name the phases and duration of wound healing?

Hemostasis (immediate) Inflammation (1–10 d) Proliferation (5–21 d) Remodeling (3 wk–1 yr)

What is the predominant mechanism of the remodeling phase?

Type III collagen is replaced by type I collagen

What is the predominant cell type of the proliferation phase?

Fibroblast

What is the most important factor for healing of open wounds?

Epithelial integrity

What is the most important factor for the healing of closed wounds?

Tensile strength


What is growth rate of nerves?

1 mm/d

What is the strength layer of bowel?

Submucosa

What is the weakest time for a bowel anastomosis?

3–5 d

What is the defect associated with Marfan’s syndrome?

Fibrillin (collagen) defect

What is the difference between keloids and hypertrophic scars?

Keloids contain excess collagen that actually extends beyond the scar; hypertrophic scar tissue is confined to the scar

Explain the relationship between induction agents and lipid solubility?

The speed of induction is inversely proportional to the lipid solubility; the potency of the induction agent is proportional to its lipid solubility

What are the four characteristics of anesthesia?

Amnesia, hypnosis, analgesia, paralysis

What is the side effect of pancuronium?

Tachycardia

What is a common side effect of meperidine (Demerol)?

Seizures (in renal failure)

Which anesthetic is contraindicated in patients with head injury?

Ketamine

Which sedative has the fewest effects on hemodynamic stability?

Etomidate

Which is the only depolarizing paralytic drug?

Succinylcholine

Succinylcholine is contraindicated in which patients?

Burn victims, head and spinal cord injury, neuromuscular disorders, any patient with hyperkalemia


What is the mechanism of malignant hyperthermia?

Defect in the calcium channel of sarcoplasmic reticulum

What is the first sign of malignant hyperthermia (MH)?

Increase in the ETCO2

Treatment of MH?

Stop the agent, fluids, O2, and give dantrolene 10 mg/kg

What is the metabolism of cisatracurium?

Hoffman degradation—can be used in renal and liver failure

Neostigmine and edrophonium act how?

Block acetylcholinesterase

Narcotics relieve pain by acting on which receptors?

Mu-2

What is the initial EKG finding with hyperkalemia?

Peaked T waves

What is the immediate treatment?

Calcium gluconate to stabilize the myocardium

What are the most common causes of hypercalcemia?

Inpatient—malignancy (breast cancer #1) Outpatient—Primary hyperparathyroidism

What is the initial treatment of hypercalcemia?

Normal saline bolus

What lab abnormalities are acquired with NGT suction or pyloric stenosis?

Hypochloremic, hypokalemic, metabolic alkalosis

What is the most sensitive test for prerenal renal failure?

FENa <1%

How do you calculate FENa?

[Urine Na/Urine Cr]/[Plasma Na/Plasma Cr]

What is the most common cause of postoperative renal failure?

Intraoperative hypotension


What is the best way to prevent ARF associated with contrast dyes?

Volume expansion

What is the treatment of myoglobinuremia?

Alkalinization of the urine with HCO3 and maintain UOP >100 cc/hr

What are the steps in vitamin D synthesis?

Hydroxylation by liver first (25-OH) and then kidney (1-OH)

If a study has a P value less than 0.05, what does this mean?

95% chance the difference seen is true

What is the definition of null hypothesis?

There is NO difference between groups; the P value is the chance that the null hypothesis is true

What is a type I error?

Reject null incorrectly

What is a type II error?

Accept null incorrectly

What is prevalence?

Number of people with a disease in the population

What is incidence?

Number of people newly diagnosed over period of time

What is sensitivity?

Ability to detect presence of disease – true positives/(true positives + false negatives)

What is specificity?

Ability to detect absence of disease – true negatives/(true negatives + false positives)

What is PPV (positive predictive value)?

Positive test means patient has disease – true positives/(true positives + false positives)

What is NPV (negative predictive value)?

Negative test means pt does not have disease – true negatives/(true negatives + false negatives)

What is Parkland formula for estimation of burn resuscitation?

4 mL/Kg/% burned; this only includes second- and third-degree burns


What is the correct treatment of traumatic injury to the pancreatic neck?

Distal pancreatectomy

What is the treatment of a pelvic fracture with lateral contrast contained from the bladder rupture?

The treatment of extraperitoneal bladder rupture is a Foley catheter; in this case, external fixation of the pelvis is also indicated

What is an indication for intracranial pressure (ICP) monitoring?

GCS <8

What are the findings with a Brown-Séquard lesion?

Loss of ipsilateral sensation and contralateral pain and temperature

Which vaccinations are appropriate after splenectomy?

Streptococcus pneumoniae, Haemophilus fluenza, and Neisseria meningitidis; should give 2 wk preop if possible; highest risks for OPSI is in less than 5 yr old; should also give prophylactic PCN if less than 15 yr of age

A trauma patient with pulse of 130 and BP of 120/80. What class of hemorrhage is present?

Class II hemorrhage; the treatment is crystalloid bolus; class III hemorrhage presents with a low blood pressure and treated with blood products

Which pelvic fractures are unstable?

Type 1 and 2 are unstable; a fracture of the sacroiliac and superior/inferior ramus must be all fractured on the same side to cause instability of the pelvis

Where are the three most common sites of aortic rupture following blunt trauma?

Adjacent to the origin of the aortic valve, ligamentum arteriosum (most common), and diaphragm hiatus

What is a common physical finding with temporal bone fracture?

Blood in ear

What is an important lab after electrocution?

CK and myoglobinuria


What is the treatment for a retained hemothorax?

Place another chest tube

What are the components of the formula for oxygen delivery (DO2)?

Hemoglobin, oxygen saturation, and cardiac output

What are the causes of a decrease in SVO2?

Any decrease in DO2 such as cardiac output, Hbg, or oxygen saturation

What are the causes of increase in SVO2?

Sepsis, right-to-left shunt, hypothermia, cyanide, over wedge

What is the appropriate lung zone for Swan–Ganz catheter placement?

Zone 3 (Pa>Pv>Alv)

Which lung zone has a VQ match?

Zone 2; Pa>Alv>PV

Most effective way to maintain core body temperature in the operating room?

Baer Hugger

What are the main effects of PEEP?

Increases FRC and compliance

What is the first ventilator setting to decrease upon initiation of the weaning process?

Decrease FiO2 first then PEEP

What is the formula for Rapid Shallow Breathing Index?

Respiratory rate divided by the tidal volume in liters = 105

What is the best measurement to determine Alveolar Ventilation?

CO2

What molecule does a PET scan detect?

Fluorodeoxyglucose

What interferes with PET scan?

Diabetes (glucose >100)


Which chemotherapeutic agent causes pulmonary fibrosis?

Bleomycin

Which causes heart toxicity?

Doxorubicin (Adriamycin)

What tumor suppressor gene regulates apoptosis?

p53 (chromosome 17)

The following proto-oncogenes are defects in which molecules: ras

G protein

src

tyrosine kinase

sis

PDGF receptor

erb B

epidermal growth factor receptor

myc

transcription factors

What margins are needed for basal cell carcinoma?

4 mm

When is a sentinel Node biopsy indicated in melanoma?

If depth is greater than 1.5 mm (stage 2) and no palpable nodes; must do a node dissection if node are palpable or positive sentinel node

What is the chemotherapy agent given for Melanoma?

Interferon α

What is the margin for 4-cm melanoma?

Margins are based on depth of lesion 1 mm = 1 cm 2 mm = 2 cm >2-mm depth needs a 3-cm margin

Most important cell in wound healing?

Macrophages

Where is the most common site of distant metastasis for laryngeal cancer?

Lung

Where to make the tracheotomy for tracheostomy placement?

Rings 2 and 3


What is the likely cause of hoarseness in a patient with lung cancer?

Squamous cell carcinoma of the larynx; remember, both are caused by smoking!

What drug causes tinnitus?

Lasix and Aspirin

Which nerve innervates the cricothyroid muscles?

Superior laryngeal nerve

Which nerve innervates all other muscles of the larynx?

Recurrent laryngeal nerve

What is the most common malignant parotid tumor?

Mucoepidermoid cancer

What is the most common parotid tumor in the child?

Hemangioma

Treatment for the above?

Total parotidectomy (with MRND and XRT if high grade)

What is the test of choice for workup of neck mass?

FNA (never excisional biopsy)

Which hormones are secreted from the posterior pituitary?

ADH, oxytocin

Which pituitary adenoma is most common?

Prolactinoma—treatment is bromocriptine

What is the first branch of the external carotid artery?

Superior thyroid artery

What is the blood supply of the inferior parathyroid glands?

Inferior thyroid artery

Blood supply of the superior parathyroid glands?

Same! inferior thyroid artery

What voice alteration results from injury to superior laryngeal nerve?

Loss of projection

Recurrent laryngeal nerve?

Hoarseness


What is the next step if FNA of a thyroid nodule shows follicular cells?

Thyroid lobectomy (10% are malignant)

Where is calcitonin produced?

Parafollicular C cells of thyroid

What is the effect of PTH on calcium and phosphorus?

↑calcium, ↓phosphorus

What is the most common cause of primary hyperparathyroidism (PHP)?

Parathyroid adenoma

What is Cl- to PO4 ratio in PHP?

>33

What is the cause of PHP in MEN-I?

Hyperplasia

Treatment?

Four-gland resection with autotransplantation

What is the most common pancreatic islet cell tumor?

Gastrinoma; 50% of these are multiple

MEN-I is associated with what gene on what chromosome?

Menin, chrom 10

MEN-II is associated with what gene on what chromosome?

RET, chrom 11

What do you do for a leiomyoma of esophagus after negative biopsy?

Enucleation; it is benign

Where is the upper esophageal sphincter in relation to the incisors?

15 cm

What is the normal pressure of the UES at rest?

50–70 mm Hg

What is the normal pressure of the UES when swallowing?

12–14 mm Hg


What is the most common site of esophageal perforation?

Cricopharyngeus muscle

Where is the lower esophageal sphincter in relation to the incisors?

40 cm

What is the normal pressure of the LES at rest?

10–20 mm Hg

What is the normal pressure of the LES when swallowing?

0–6 mm Hg

What is the diagnostic test of choice for dysphagia?

Barium swallow (esophagram)

What is the diagnostic test of choice for refractory heartburn?

Endoscopy with biopsy

What is the effect of scleroderma on the esophagus?

Loss of LES tone and peristalsis

Where does Zenker’s diverticulum occur?

Killian’s triangle (between the cricopharyngeus muscle and posterior constrictors)

Treatment of Zenker’s?

Cricopharyngeal myotomy

What is the pathogenesis of achalasia?

Failure of LES to relax

What findings are present on esophageal manometry?

Increased LES tone, failure of LES relaxation, no peristalsis

Treatment of achalasia if medical management fails?

Heller myotomy with partial fundoplication

What findings are present on manometry for diffuse esophageal spasm?

Normal LES tone, normal relaxation, strong uncoordinated contractions

What are the surgical indications for GERD?

Failure of medical therapy, aspiration, esophagitis, low-grade dysplasia


Which operation would be performed?

Laparotomy Nissen

Define Barrett’s esophagus

Squamous metaplasia -> intestinal columnar epithelium

What is the relative risk of esophageal cancer in Barrett’s?

50×

Treatment of high-grade dysplasia?

Esophagectomy

What is the most common type of esophageal cancer?

Adenocarcinoma

What is the test of choice to determine local invasion?

EUS

What is the blood supply to the stomach after esophagectomy?

Right gastric (Ivor Lewis)

What is the result of alkali ingestion?

Liquefactive necrosis

What is the result of acid ingestion?

Coagulation necrosis

What is the test of choice for suspected esophageal perforation?

Gastrografin swallow then barium

What is the treatment for contained perforation?

NPO, IVF, ABx (nonoperative)

Perforation not contained, time <24 hr?

Primary repair, drainage

Not contained, hemodynamically unstable?

Esophagostomy, chest tubes

What is the first branch from the subclavian artery?

Internal thoracic artery

What is the treatment of SVC syndrome?

Radiation


What PFT values are necessary for lung resection?

FEV1, DLCO >50% predicted value, pCO2 <45, pO2 >50 at rest

What is the number one cause of cancer death in US?

Lung cancer

What is the number one site of lung cancer metastasis?

Brain

What is the most common type of lung cancer?

Nonsmall cell (80%)

Most common paraneoplastic syndrome?

Small-cell ACTH

Squamous cell paraneoplastic syndrome?

PTH-related peptide

Where is a Pancoast tumor located?

Apex of lung

What is invaded that causes Horner syndrome?

Sympathetic chain

Describe Horner syndrome

Ptosis, miosis, anhidrosis

What peripheral nerve can be affected?

Ulnar

Treatment of lymphoma of the breast?

Excision with node dissection; chemo for recurrence

Does atypical hyperplasia increase the risk of breast cancer after bx?

YES

Where are level 1 axillary nodes located?

Lateral to pectoralis minor muscle


Beneath pectoralis minor muscle


Medial to pectoralis minor muscle


Which muscle does the long thoracic nerve innervate?

Serratus anterior

Injury to this nerve causes what deformity?

Winged scapula

Which muscle does the thoracodorsal nerve innervate?

Latissimus dorsi

Injury to this nerve causes what deformity?

Weak arm adduction

What is the most common bacteria found in breast abscess?

MRSA

What is the most common cause of bloody nipple discharge?

Intraductal papilloma

What is the most common cause of breast mass in adolescent?

Fibroadenoma

What is the test of choice for working up a palpable breast mass?

Ultrasound-guided biopsy

Describe BIRADS:

1. 2. 3. 4. 5. 6. 7.

Inconclusive Negative Benign Probably benign Suspicious Highly suspicious Known malignancy

What is the most important prognostic staging factor?

Nodal status

What gene is associated with male breast cancer?

BRCA2

What is the likelihood of breast malignancy by age 70 if BRCA positive?

80%–90%; consider prophylactic mastectomy


State, in order of best to poorest prognosis, the possible receptor status of breast cancers: Best?

ER/PR+, Her2Neu– ER/PR+, Her2Neu+ ER/PR–, Her2Neu–

Worst?

ER/PR–, Her2Neu+

Name the contraindications to breast conservation therapy:

Two or more primary tumors, persistent positive margins, pregnancy, diffuse disease, unacceptable cosmetic results

What is the next step if sentinel node biopsy is positive?

Full axillary dissection (levels 1 and 2)

What is the treatment of cystosarcoma?

Wide local excision

Does lobular carcinoma in situ require negative margins?

No

What is the role of radiation in breast conservation therapy?

Reduce local recurrence

What do the epidermal cells in the stomach produce?

Mucous and bicarbonate

What is the initial treatment of gastric MALT?

Treat Helicobacter pylori first

What artery is preserved for an Ivor Lewis?

Right gastroepiploic

What is the origin of the right gastric artery?

Common hepatic artery

What is the origin of the right gastroepiploic artery?

Gastroduodenal artery

What is the origin of the left gastric artery?

Celiac trunk

What do chief cells produce?

Pepsinogen (“peppy chief ”)


What do parietal cells produce?

HCl and intrinsic factor

What three molecules stimulate HCl production?

Ach, gastrin, histamine

What is the function of intrinsic factor?

Absorption of B12

Where is this complex absorbed?

Terminal ileum

How does omeprazole work?

Blocks H/K ATPase in parietal cell membrane

What is the treatment for bleeding Mallory–Weiss tear?

Oversew bleeding vessel through anterior gastrostomy

Define highly selective vagotomy:

Divide nerves of Latarjet, while preserving “crow’s foot” at pylorus

What is treatment of anterior perforated duodenal ulcer?

Graham patch

What artery bleeds in bleeding duodenal ulcer?

Gastroduodenal

What is treatment for H. pylori?

Amoxicillin 1 g BID, clarithromycin 500 mg BID, PPI × 14 d

What margins are required for an R0 resection in gastric cancer?

5 cm

Gastric metastasis to ovary

Krukenberg tumor

Where is Virchow’s node?

Subclavian

What margins are required for excision of GIST tumor?

1 cm

What immunohistochemical stain is positive in 95% GIST?

KIT (CD 117)


What chemotherapy is used for GIST?

Gleevec (tyrosine kinase inhibitor)

What is treatment of gastric lymphoma?

Chemotherapy/radiation

What is treatment of MALT?

Treat H. pylori (oral abx), then chemo (CHOP)

Criteria for gastric bypass

BMI>40, BMI >35 with comorbid conditions, failure of weight loss, psychological stability

What is the most common postgastrectomy symptom?

Diarrhea

What is treatment of dumping syndrome?

Diet modification (increase protein, decrease fat/carbohydrate) or Roux-en-Y

What is treatment of alkaline reflux gastritis?

H2 blockers, Roux-en-Y

What are the symptoms of afferent loop obstruction?

Abdominal pain, nonbilious emesis

Treatment of afferent loop obstruction?

Shorten limb to 40 cm

What is treatment of efferent loop obstruction?

Relieve obstruction (adhesions)

What is the treatment for gastric varices?

Splenectomy

What is the function of ghrelin?

Induces hunger

Where is ghrelin produced?

Endocrine cells of stomach

What is the function of leptin?

Stimulates satiety

Where is leptin produced?

Adipocytes

What is the function of peptide YY?

Stimulates satiety


Where is peptide YY produced?

Terminal ileum (hormone fragment)

What are the levels of ghrelin/ leptin in obese people and why?

Low ghrelin (compensatory) and high leptin (insensitivity)

How are the chloride and HCO3 levels affected in pancreatic secretions when stimulated?

The normal pancreatic secretions are isotonic, high chloride and low bicarbonate; when stimulated, it is the opposite (↓ Cl- & ↑HCO3)

Gastrin acts on what?

Phospholipase, which activates the IP/ DAG pathway, increasing calcium, and activating phosphorylase kinase, which in turn increases HCl production via H/K ATPase

What increases insulin secretion?

Glucose, glucagon, CCK (cholecystokinin)

What contracts the gallbladder?

CCK

What medication causes relaxation of the sphincter of Oddi?

CCK

What cells produce gastrin?

G cells in antrum

What cells produce insulin?

Beta cells (pancreas)

What cells produce glucagon?

Alpha cells (pancreas)

What cells produce somatostatin?

D cells in antrum

What cells produce secretin?

S cells (duodenum)

What cells produce motilin?

Intestinal cells

What cells produce CCK?

I cells (duodenum/jejunum)

What does motilin do?

Migratory motor complex

What medication acts on motilin to increase bowel motility?

Erythromycin


What is the treatment of TTP?

IVIG

What is SGOT?

AST; elevated from ETOH

What is the best test to evaluate liver function?

PT

Which liver enzyme is the most predictive of metastatic colon cancer?

Lactate dehydrogenase (LDH)

What is the most accurate method to measure portal venous pressure?

Measurement via the umbilical vein, if patent; the splenic vein can also be accessed via percutaneous spleen puncture; normal portal pressure is 3–5 mm Hg

What is the treatment of a liver abscess after diverticulitis?

Percutaneous drainage

What are the characteristics of hemangioma with a contrasted MRI or CT?

Peripheral to central enhancement

Which liver cancer has the best prognosis?

Fibrolaminar

What is the most common type of choledocal cyst?

Type 1; fusiform dilation of the common bile duct

What is pancreatic divisium?

Failed fusion of the pancreatic ducts; the main drainage is the minor duct of Santorini in this disease; major complication is chronic pancreatitis; initial treatment is ERCP with stenting of the minorpancreatic duct

How often is bile recirculated?

The bile pool is normally about 2 g and is recycled 5–6 times per day; bile is reabsorbed in the terminal ileum

What is the cause of cholelithiasis in Crohn’s disease?

Inflammation of the terminal ileum causes malabsorption of bile salts; this decrease in bile circulation produces a supersaturating of cholesterol


What is the composition of primary CBD stones?

Brown stones made of calcium salts

What type of cancer is biliary ductal cancer?

Cholangiocarcinoma; surgery is best treatment; chemo/radiation is often not helpful

What are the biliary concentrations of Na+ and Clfor the GB vs. duct?

Gallbladder: Na+ 300 Cl- 10; hepatic duct: Na+ 150 Cl- 100; the gallbladder actively absorbs Na and water

What is the treatment of a cystic duct leak after cholecystectomy?

ERCP and stent

Where are chylomicrons made?

Enterocyte; the micelle is absorbed into the enterocyte and the chylomicron is formed; it then crosses into the lacteals

What converts trypsinogen to trypsin?

Enterokinase

What is the treatment of Clostridium perfringens which is resistant to penicillin?

Clindamycin

Which portion of the colon has the most absorption of water and electrolytes?

The cecum and ascending colon

What is stage 3 colon cancer?

Positive lymph node metastasis; needs Chemotherapy!

What is the best initial test for staging rectal cancer?

Endorectal ultrasound; MRI is another option if endorectal ultrasound is not available

What is first hit for colon cancer?

APC→KRAS→DCC→P53

Which is the most common gene associated with colon cancer?

P53

What is ERB-B?

It is a proto-oncogene associated with growth factor defects


Which genes are associated with HNPCC?

DNA mismatch repair genes; (MLH, MSH 1 & 2)

What are the colonic lesions associated with Peutz–Jeghers syndrome?

Hamartomas; no malignant potential

What is the management of appendicitis with a right lower quadrant abscess?

Percutaneous drain with antibiotics

What is the most common bacteria in the colon?

B. Frag

What is the treatment for SCC of the anus?

Nigro protocol; radiation and chemo first; if recurs, APR

What electrolyte abnormalities are seen with adrenal insufficiency?

Hypotension and hypoglycemia are caused by the decreased cortisol levels. The decreased aldosterone levels cause hyperkalemic hyponatremic metabolic acidosis

What metabolic abnormalities are seen from hyperaldosteronism?

Metabolic alkalosis from loss of hydrogen and potassium lost in the urine

What is the most common secretory tumor of the pituitary?

Prolactinoma; treatment is bromocriptine which is a dopamine agonist

What is the treatment for medullary carcinoma of the thyroid?

Total thyroidectomy and central node dissection

What genetic defect is found in medullary thyroid cancer?

RET proto-oncogene on chromosome 10

What is the treatment for a 9 cm nonsecretory adrenal tumor?

Excision, not biopsy. If carcinoma is suspected, abdominal approach is utilized over laparoscopic approach

One hour after thyroidectomy, the patient develops stridor and hoarseness. What is the next step?

Emergent neck exploration


What supplies sensory above the vocal cords?

Superial laryngeal nerve (internal branch)

What is the order of formation from tyrosine to epinephrine?

Tyrosine→Dopa→Dopamine→Norepi→ Epi; the conversion of Norepi→Epi is by PMNT which is only located in the adrenal medulla

What is the skin lesion with glucogonoma?

Necrolytic migratory erythema

What effect does magnesium have on PTH secretion?

Low magnesium levels inhibit PTH secretion

What stimulates antidiuretic hormone (ADH)?

Hypotension and serum osmolarity

What is common side effect of a gastrinoma?

Diarrhea

What is the treatment for familial hypercalcemic hypocalcinuria?

Observation; no surgery; the key for diagnosis is hypercalcemia with low urinary calcium

What is the indication for treatment of popliteal aneurysms?

If >2 cm or symptomatic; also look for synchronous aortic aneurysm

An Aortobifemoral bypass has a diminished distal pulse immediately after surgery. What do you do?

Take back to OR for embolectomy; make a transverse incision over the distal hood to observe the anastomosis and perform an embolectomy

What is the next step if an embolectomy reveals a spindle cell clot?

Echocardiogram looking for an atrial myxoma

What is the treatment for a popliteal artery aneurysm?

Bypass with exclusion if greater than 2 cm or symptomatic (pain or emboli)

What is the cause of intestinal atresias?

Intrauterine vascular events


Two-year-old child with fever and right lower quadrant pain and rectal bleeding. What is diagnosis?

Intussusception; barium enema is diagnostic and therapeutic

How fast does a nerve grow?

1 mm per day

What is the formula for FENa?

UN/PN × PC/UC

Which laboratory values are consistent with prerenal azotemia?

FENa <1%, urine osmol >500, urine sodium <20, or BUN/creatinine >20

What is the most likely nodal basin affected by uterine cancer?

Obterator nodes

What is the treatment for distal ureter injury?

Psoas hitch

What is the tumor marker for nonseminoma testicular cancer?

α-fetoprotein; this tumor is not radiosensitive as opposed to the seminomas; which are extremely radiosensitive

A supracondylar fracture with radial nerve injury presents 1 yr after repair with pain, weak forearm muscles, and smooth skin. What is the diagnosis?

This is reflex sympathetic dystrophy; treatment is with steroids, NSAIDs, physical therapy, and sympathetic blocking medications

How do you treat an open tibia fracture?

Antibiotics and debridement within 24 hr is the first-line therapy

Index Note: Page number in italics indicate figure only.

A Aaron’s sign, 9 Abbreviations, surgical, 3–8 Abdomen acute and referred pain, 251–253 signs of, 253–255 surgical, 25 penetrating trauma to, 271 radiology of, 215–218 surgical anatomy, 127–134, 128–131, 133 Abdominal aortic aneurysm (AAA), 159, 454–456 inflammatory, 454 mycotic, 454 ruptured, 454, 455 surgical approach for, 455–456 x-ray for diagnosis of, 216 Abdominal battle dressing, 116 Abdominal compartment syndrome (ACS), 103, 274 Abdominal incision midline, 131–132 transverse, 65, 65 in trauma patients, 67, 67 Abdominal pain, 252–254 Abdominal x-ray (AXR), 216 Abdominoperineal resection, drain following, 119 Abduction, 649 Abductor pollicis longus (APL), 506, 507 Above the knee amputation (AKA), 446–449. See also Amputations Abscess anorectal, 332, 332–333 Bezold’s, 546 brain, 719–720 breast, 209 epidural, 212 intraperitoneal, 120 liver bacterial, 28 pancreatic, 214 parapharyngeal, 536 prostatic, 749–750 retropharyngeal, 536 splenic, 209 Acetabular fractures, 670–671 Acetaminophen, 178 antidote for overdose, 179 Acetazolamide, 176, 425

Acetylcysteine, 177 Achalasia, 802 Achilles tendon rupture, 684 Acid ingestion, 803 Acidosis, 202 Acoustic neuroma, 546, 714 Acromioclavicular (AC) joint, 681–682 Actinic keratosis, 22 Activated clotting time (ACT), 167 Acute interstitial nephritis (AIN), 150 Acute kidney injury (AKI), 147–143, 147–149 classifications of, 148 creatinine and, 148 FENa and, 149 in ICU, 148 intrarenal, 149 mortality, 148 nonoliguric, 147, 148 tests for, 148 ultrasound, 148 urine Na+ and, 149 urine osmolarity in, 149 urine output and, 147–148 Acute lung injury, P:F ratio with, 162 Acute narrow angle glaucoma, 774 Acute respiratory distress syndrome (ARDS), 28, 423–425 defined, 22 PaO2 to FiO2 ratio for, 162 P:F ratio with, 162 vs. TRALI, 171 Acute tubular necrosis (ATN), 149–150 Addisonian crisis, 24, 157, 384 Addison’s disease, 383–384 Adduction, 649 Adductor canal, 134 Adductor pollicis, 509 Adenocarcinoma of bladder, 753 of gallbladder, 361 of small intestine, 312–313 Adenoma bile duct, 340–341 colonic villous, 31 small-bowel, 29 Adenopathy axillary, 239 supraclavicular, 240 Adenosine triphosphates (ATPs), 203 Admirand’s triangle, 354 Adrenal arteries, 136

815

816 Index Adrenal cortex, 23 Adrenal glands, venous drainage of, 136 Adrenal incidentaloma, 27 Adrenal insufficiency, 24, 177, 812 in ICU patients, 188–189 induction agent associated with, 234 as surgical complication, 188–189 Adriamycin. See Doxorubicin Adson–Brown tissue forceps, 37 Adult polycystic kidney disease, 745 Adult respiratory distress syndrome (ARDS), 22 Aerobic metabolism, 203 Afferent arteriole, 147 Afferent loop syndrome, 183, 183–184, 808 AIN. See Acute interstitial nephritis (AIN) Air bronchogram, 221 Air embolism, traumatic, 580 Airway pressure release ventilation (APRV), 144 AKA. See Above the knee amputation (AKA) AKI. See Acute kidney injury (AKI) Alanine aminotransferase (ALT), 343 Alcock’s canal, 134 Alcohol withdrawal, 196 Aldara, 333 Aldosterone, 742 Alkali ingestion, 803 Alkaline reflux gastritis, 186, 808 Allen’s test, 441 Allergic conjunctivitis, 774 Allograft, 290 Allograft bone, 649 α cells, 111 α-fetoprotein (AFP), 238, 814 Alpha angle, 172 Alpha interferon (α-IFN), 321 Alveolar–arterial (A-a) oxygen gradient, 421 Alveolar–capillary barrier, 424 Alveolar ventilation, 798 Amblyopia, 764 American Society of Anesthesiologists, Physical Status classification, 223 Amino acids, in liver failure, 200 Aminocaproic acid (Amicar), 176 Aminophylline, 425 Amiodarone, 432 Amphotericin B, 154, 207 Amputations, 445–449 above-the-knee, 446–449 below-the-knee, 446–449 Chopart’s, 449 Gritti-Stokes, 449 indications for, 446 Lisfranc’s, 449 operative technique for, principles of, 447 Pirogoff ’s, 449 ray, 445, 445

Syme’s, 445, 445 transmetatarsal, 446, 446 traumatic, 512–513 Amyand, Claudius, 35 Amyand’s hernia, 257 Amylase, 247 Anaerobic metabolism, 203 Anal canal, 330, 330 Anal cancer, 330–332 NIGRO protocol, 332 risk factors for, 331 signs/symptoms of, 331 stages of, 331 Anal condyloma, 333 Anal fissure, location of, 133 Anal fistula, 105 Anal margin, 330, 330 Anal melanoma, 31 Anal pruritus, 333 Anal stricture, 333 Anal verge, 330, 330 Analysis of variance (ANOVA), 12 Anaphylactic shock, treatment of, 24 Anaphylaxis, 197 Anastomosis, 107 cyst-enteric, length of, 160 functional end-to-end, 90, 90, 104 Anesthesia, 223–235 cardiac depression and, 72 characteristics of, 794 contraindications for, 72 coronary artery disease, 72 epidural, 233–234 inhalation anesthetics, 231 Mallampati classification, 223–225, 224–225 muscle relaxants, 227 Physical Status classification, 223 regional, 232–233 spinal, 233–234 Aneuploidy, 237 Aneurysms, 454–457 abdominal aortic, 454–456 left ventricular, 602–603 of sinus of valsalva, 596 thoracic aortic, 618–622 visceral arterial, 29 Angiodysplasia, 334 Angled DeBakey vascular clamp, 38 Angle of His, 131 Anion gap, formula for, 161 Anisocoria, 764 Ankle and foot injuries, 678–680 Ankyloglossia, 547 Annular pancreas, 476 Anorectal abscess, 332, 332–333 ANOVA. See Analysis of variance (ANOVA) Antecolic, defined, 8

Index 817 Anterior cruciate ligament (ACL) rupture, 683 Anterior drawer test, 683 Anterior scalene muscle, 124 Anterior spinal artery syndrome, 621 Anterior tibial artery, 439, 440 Antibiotic-associated colitis, 30 Antibiotics, 205–207 beta-lactam, 205, 206 empiric, 205, 211 for infection, 214 prophylactic, 205 Anticholinesterases, cholinergic effects of, 229 Anticoagulant-induced obstruction, 311 Antidiuretic hormone (ADH), 813 Antidotes, 426–427 Antiplatelet antibodies, 165 Antithrombin, 169 Anuria, 147 urine output for, 158 Anus, 330–333 anal condyloma, 333 anorectal abscess, 332, 332–333 cancer of, 330–332 length of, 132 Aorta, 443 visceral branches of, 451–452 mesenteric arteries, 451 renal arteries, 451–452 Aortic aneurysms, 618–622 Aortic regurgitation (AR), 603, 608–609 Aortic stenosis (AS), 603, 605–608 as surgical risk, 71 Aortic valve replacement (AVR), 604–605 Aortobifemoral bypass, 437, 813 Aortocaval fistula, 455 Aortoenteric fistula, 297 Aortogram false-positive, 29 thoracic, 31 Apert’s syndrome, 535 Aphthous ulcers, 217 Apnea, 534 Appendectomy, 318 drain following, 119 Appendiceal artery, 106 Appendiceal cystadenoma, 318 Appendiceal mucocele, 318 Appendicitis, 209, 214, 316, 812 acute, 316–317 in pregnancy, 317 Appendix, 316–318 Appendix carcinoid, 157 Appendix testis, 723, 723 Apple core lesion, 217 Aprotinin, 167, 322 APRV. See Airway pressure release ventilation (APRV)

Aquacell, 116 AR. See Aortic regurgitation (AR) Arachidonic acid, 164 ARDS. See Acute respiratory distress syndrome (ARDS) Argatroban, 176 Argon beam coagulator, 174 Arteriovenous malformations (AVM), 717 Arthrodesis, 650 Arthroplasty, 650 AS. See Aortic stenosis (AS) Ascites, portal hypertension and, 349 Aspartate aminotransferase (AST), 343 Aspergillus infection, in transplant recipients, 647 Asphyxia, traumatic, 579–580 Aspiration pneumonia, 581 Assist control (AC), 142 Astigmatic keratotomy (AK), 772 Astigmatism, 764 Astrocytoma, 713 Atelectasis, 138, 180 Atlantodental interval, 220 ATN. See Acute tubular necrosis (ATN) Atrial septal defects (ASDs), 585–587 Atriocaval shunt, 270, 270 Atypical hyperplasia, 237 Auerbach’s plexus, 246 Autograft, 290 Autograft bone, 649 Automatic implantable cardioverter defibrillator (AICD), 638–639 Auto PEEP, 141, 422 AV fistula, 467–468 Avitene, 174 AVR. See Aortic valve replacement (AVR) Axillaryadenopathy, 239 Axillary artery, 126, 443 Axillary lymph nodes, 238 Axillary nerve, 680 Axillobifemoral bypass, 437 Azotemia, 147 prerenal, 149 Aztreonam, 206

B Bacitracin, 175 Back pain, low, 696 Bacteremia, 204, 240 Bacterial conjunctivitis, 774 Bacterial infection, in blood transfusion, 162 Bacterial prostatitis, 748–749 Bacteroides fragilis, 208 Baer hugger, 202 Balfour retractor, 38 Bandage scissors, 39, 39 Bankart’s fracture, 650

818 Index Bariatric surgery, 304–306 anastomotic leak, 304–305 gastrojejunostomy stenosis, 305 jejunoileal bypass, 306, 306 lap-band, 305, 305 long limb gastric bypass, 304 Barium enema (BE), 217 Barium esophagogram, 577, 577 Barlow test, 688 Barrett, N., 35 Barrett’s esophagus, 803 Basal cell carcinoma (BCC), 416, 799 Base deficit, 421 Batson’s vertebral plexus of veins, 370 Battle, William, 35 Bayonet forceps, 39 B cells, 112 cytokines and, 114 B12 deficiency, 315 Beaumont, William, 32 Beger procedure, 89, 89 Bell clapper deformity, 486 Bell’s palsy, 546 Below-the-knee amputation (BKA), 438, 446–449. See also Amputations Bennett’s fracture, 521, 655 Benzodiazepine, 432 Bergman’s triad, 182 Bernard–Soulier syndrome, 166 β-blockers, 178 overdose, treatment for, 180 β cells, 111 β-lactam antibiotics, 205 Bezoar, defined, 8 Bezold’s abscess, 546 Bier block, 233 Bile, 350–352, 810 Bile duct adenoma, 340–341 arteries to, 350 injuries, laparoscopic cholecystectomy and, 259 ligation of, 268 Biliary ductal cancer, 811 Biliary ducts, 121 Biliary dyskinesia, 353 Biliary strictures, 358–359 benign, 358 Bismuth classification of, 358 Biliary tract, 350–363 absorbable suture for, 60 anatomy of, 350 bile metabolism/physiology, 350–352 biliary dyskinesia, 353 biliary strictures, 358–359 Caroli disease, 359–360 common bile duct exploration, 356–358, 357

endoscopic retrograde cholangiopancreatography (ERCP), 356 gallbladder tumors, 361–362 gallstones, 354–356 hemobilia, 363 imaging of, 352–353 oriental cholangiohepatitis, 359 periampullary tumors, 360–361 primary biliary cirrhosis, 363 Bilirubin, 351–352 Billroth I, 16 Billroth II, 16 Billroth, T., 32 Bimodal distribution, defined, 11 BiPAP mask. See Nasal bilevel positive airway pressure (BiPAP) mask Bipolar coagulation, 173 Bipolar electrocautery, 173, 173 Bird’s beak sign, 215 Bites infections associated with, 211 spider, 115, 179 Bladder, 750–756 acute cystitis, 751 adenocarcinoma of, 753 anatomy, 750 hemorrhagic cystitis, 753 interstitial cystitis, 752 squamous cell carcinoma of, 753 transitional cell carcinoma of, 754–756 Bladder pheochromocytoma, 382 Bladder Veress needle puncture, treatment for, 107 Blaisdell maneuver, 88 Bleomycin, 240, 241 side effects of, 24 Blind loop syndrome, 182, 315 Blind study, defined, 11 Blood products, 162–172 platelets (See Platelets) Blood soilage, finger, 169 Blood transfusion, 162 calcium following, 165 risk of death, 170 Blood urea nitrogen (BUN), 149 Blowout fracture, 768 Blue toe syndrome, 26 Blumberg’s sign, 253 Blunt trauma cardiac arrest, 24 cranial nerve injury in, 29 Boari flap, 759, 759 Body mass index (BMI) formula for, 161 for gastric bypass, 157 Boerhaave’s syndrome, 26 Bogota bag, 97, 97 Bone-cutting forceps, 40

Index 819 Bone tumors, 698–699 Bookwalter retractor, 40 Bouchard’s node, 526 Bouveret’s syndrome, 26 Bovie, 34, 104, 192 Bovie hemostasis, 173 Bowel clamp, 42 Bowel injuries, 284 Bowel, layers of, 128, 128 Bowel necrosis, with SBO, 24 Boxer’s fracture, 521, 651 Box, thoracic, 286 Brachial artery, 443 incision for repair of, 66, 66 Brachial plexus, 544 Brachiocephalic trunk, 443 Brain abscess, 719–720 anatomy of, 700–703 anterior circulation of, 701 Broca’s area, 701 cardiac output to, 160 cavernous sinus, 703 circle of Willis, 702, 702 draining vessels of, 702 frontal lobes, 700 occipital lobes, 701 parietal lobes, 701 posterior circulation of, 701 temporal lobes, 701 Branchial cleft anomaly, 545 Braun procedure, 93, 93 BRCA2, 378–379, 805 Breast, 370–379 abscess, 209 anatomy of, 370–371 benign mass, 28 cancer, 372, 804–806 BRCA1/BRCA2, 378–379 cathepsin D, 378 ductal carcinoma in situ (DCIS), 23, 379 estrogen receptor (ER) in, 377 HER-2/NEU, 377 lobular carcinoma in situ, 23 mammograms for detection of, 373–374 nodal metastases, 374–376 progesterone receptor (PR) in, 377 PSA level in, 239 relative risk of, 372 risk factors for, 20 staging, 374–375 triad of error with, 372 tumor suppressor genes, 378 discharge, 371 physiology of, 371 Breast conservation therapy contraindications to, 806 role of radiation in, 806

Breast mass, 805 Breath stacking, 143 Breslow tape, 489 Bronchial carcinoid, 322 Bronchiectasis, 558–559 Bronchoalveolar lavage (BAL), 212 Bronchogenic cyst, 474, 558 Brown-Séquard lesion, 797 Brown-Séquard syndrome, 23 Budd-Chiari syndrome, 27 Buerger’s disease. See Thromboangiitis obliterans (TAO) Bulldog clamp, 41 Bumetanide (Bumex), 176 BUN. See Blood urea nitrogen (BUN) Bupivacaine, 232 Burns, 287–297 alkali, 292, 294 combined skin graft/sandwich graft, 293 cyanide toxicity, 288 electrical, 293, 294 escharotomy incisions, 289, 289 exfoliative skin diseases, 296–297 fluid resuscitation in, 291, 293 Goulian knife, 287, 287 grafts, types of, 290 hydrofluoric acid, 292, 295 inflammation in, 295 inhalation, 293, 294 nutritional requirements in, 293 partial-thickness, 293 percentage of, estimation of, 291 posterior pituitary response to, 295 tar, 294 vasoactive amine in, 295 Watson knife, 287, 287 wound infection, 290–291 zones of injury, 288, 288 zone of coagulation, 288 zone of hyperemia, 288 zone of stasis, 288

C CA 15-3, 238 CA 19-9, 238 CA 50, 238 CA 125, 238, 782 CABG. See Coronary artery bypass grafting (CABG) Cachexia, 790 CAD. See Coronary artery disease (CAD) Calcaneus fracture, 679 Calcitonin, 392, 399, 652, 801 Calcium with albumin, 155, 161 in cell biology, 110

820 Index Call-Exner bodies, 781 Cameron’s criteria, 574 Cameron’s ulcer, 297 cAMP, 110 Cancer. See also specific type breast ductal carcinoma in situ, 23 lobular carcinoma in situ, 23 risk factors for, 20 cells, nutrient for, 200 gallbladder, 31 hypertension in, 409 testicular, 16 in transplant patients, 648 Candida infection, 117, 204, 208–209 Cantlie’s line, 130 Cantor tube, 118 Carbapenem, 206 Carbenicillin, 205 Carbohydrates calorie content of, 158 dietary sources of, 247 digestion, steps in, 247 respiratory quotient for, 162 Carbon dioxide, end-tidal, 234 Carboxyhemoglobin, 292–293 Carboxypeptidase, 249 Carcinoembryonic antigen(CEA), 238 Carcinoid bronchospasm, catecholamines in, 322 Carcinoid crisis, 322 Carcinoids, laboratory test for, 25 Carcinoid syndrome, 16 Carcinoid tumors, 319–322 clinical manifestations, 320 pathology/histology, 319–320 serotonin levels in, 319 treatment, 320–322 valvular lesions with, 319 Carcinoma of cervix, 777–778 ductal carcinoma in situ, 23 gastric, 28 lobular carcinoma in situ, 23 Cardiac arrest, blunt trauma, 24 Cardiac depression, anesthesia and, 72 Cardiac index (CI), 630 Cardiac injury, chest-penetrating wound with, 107 Cardiac output, 160, 629–632 formula for, 161 Frank–Starling relation, 630 low cardiac output syndrome, 630–632 physiological determinants of, 629 septic shock and, 202 Cardiac risk aortic stenosis, 71 Goldman criteria for, 70–71

Cardiogenic shock, 633 Cardiopulmonary bypass (CPB), 627–629 functions of, 627 partial, 627 postperfusion syndrome, 629 profound hypothermia and, 628 thrombosis, prevention of, 628 total, 627 Cardiovascular surgery, 582–640 cardiac tumors, 639–640 cardiopulmonary bypass, 627–629 congenital heart disease, 582–597 aneurysm of sinus of valsalva, 596 atrial septal defects, 585–587 central cyanosis, 582 in children, 582 coarctation of aorta, 593 cyanotic heart disease, 583–584 Ebstein’s anomaly, 591, 591 Eisenmenger’s syndrome, 596–597 hypoplastic left heart syndrome, 595 incidence of, 582 palliative shunts for, 597 patent ductus arteriosus, 587–588 pulmonary artery sling, 596 pulmonary overcirculation and, 583 tetralogy of Fallot, 590, 590 total anomalous pulmonary venous connection, 593–594, 594 transposition of great vessels, 592, 592–593 truncus arteriosus, 589, 589 vascular rings, 595–596 ventricular septal defects, 584–585 coronary artery disease, 597–603 acute ischemic mitral regurgitation, 601–602 acute ventricular septal defect, 600–601 coronary anatomy, 597, 597–598 coronary artery bypass grafting, 598–599 left ventricular aneurysm, 602–603 diseases of great vessels, 618–622 thoracic and thoracoabdominal aortic aneurysms, 618–622 heart transplantation, 622–627 postoperative intensive care management, 629–639 automatic implantable cardioverter defibrillator (AI CD), 638–639 cardiac ICU, 635–636 cardiac output, 629–632 hemorrhage, 634–635 hyperdynamic myocardium syndrome, 634 hypertension, 633 hypotension, 633 intra-aortic balloon pump (IABP), 637–638

Index 821 left ventricular assist device (LVAD), 638 myocardial ischemia, 632 valvular heart disease, acquired, 603–618 aortic valve, 603–609 infectious endocarditis, 616–618 mitral valve, 609–613 prosthetic valves, 614–616 pulmonary valve, 614 rheumatic heart disease, 614 tricuspid valve, 613 Caroli disease, 359–360 Carotid artery, extracranial internal, 125 Carotid body tumor, 468 Carotid cavernous fistulas, 703 Carotid disease, 450 Carotid endarterectomy (CEA), 450 Carpal–metacarpal (CM) dislocation, 522 Carrel, Alexis, 32 Castroviejo needle holder, 41 Cataract, 773 Catecholamines, 381 Cathepsin D, 378 Catheters, 122–123 central line, 76–77, 76–77, 123 (See also Central line catheter) central venous, 222 Foley, 105 intravenous, 122 percutaneous, 121 pigtail, 122 rubber, 35 Swan-Ganz, 78–81, 79–81, 222 CAT scratch fever, 489 Cattel maneuver, 88, 88 Caudal block, 234 Cauliflower ear, 192 Caustic esophageal injuries, 575–576 Cavernous hemangioma, 340 Cavitron ultrasonic surgical aspirator (CUSA), 174 C cells, 112 CCK (cholecystokinin), 809 Cefotetan, 169, 173, 206 Ceftriaxone, 206, 356 Celiac artery, 451 Celiac trunk, 806 Cell biology, 108–114 Cell cycle of tumors, 237 Cells cycle of, 108 endocrine, 111–112 immune system, 112–113 pulmonary, 111 Cell wall, 108–109 Central line catheter, 76–77, 76–77, 123 in burn patients, 211 femoral, 77, 77

internal jugular, 76, 76, 77 subclavian, 76, 76, 77, 104 Central venous catheter, 222 Cephalization, 181 Cephalosporins, 177, 206–207 first-generation, 206 second-generation, 206 third-generation, 207 Cerebral blood flow (CBF), 704 Cerebral palsy (CP), 691 Cerebral perfusion pressure (CPP), 161, 421, 704 Cerebrospinal fluid (CSF), 703–704 Cerebrospinal fluid rhinorrhea, 500 Cervical disc herniation, 709–710 Cervical intraepithelial neoplasia (CIN), 777 Cervical lymphadenitis, acute, 547 Cervical spine, 706–711, 707 radiology of, 219–220, 220 Cervical spondylitic myelopathy (CSM), 710–711 Cervical spondylosis, 710 Cervix, carcinoma of, 777–778 Chancroid, 729 Chandelier’s sign, 9 Charcot’s joint, 695 Chemosis, 764 Chemotherapy, 240–241 fluorouracil, 241 mercaptopurine, 241 methotrexate, 240 thioguanine, 241 Chest penetrating injury to, 31 radiology of, 221–222, 222 x-ray, 218, 221, 222 Chest wall tumors, 548–549 benign, 548, 549 chest wall reconstruction, 549 malignant, 548, 549 onion-peel appearance, 548 primary, 548 sunburst appearance, 548 Chest wound, sucking, 285 Chief cells, 111, 806 Chief gastric cells, product of, 18 Choanal atresia, 489 Cholecystectomy, 103, 369 drain following, 119 laparoscopy, 259 Choledochal cyst, 475, 475, 810 Choledochojejunostomy, 100, 100 Cholelithiasis, 191 in Crohn’s disease, 810 Chopart’s amputation, 449 Chordomas, 716 Christmas disease, 167 Chromic gut sutures, 60

822 Index Chronic gastric atony, 187–188 Chronic obstructive pulmonary disease (COPD), 213 Chylomicrons, 811 Chylothorax, 551 Chymotrypsin, 249 Cilastatin, 206 Cimino procedure, 89, 89 Cisatracurium, 795 Cisplatin, 241 Clamp angled DeBakey vascular, 38 bowel, 42 bulldog, 41 DeBakey aortic, 42 kidney pedicle, 47 Lahey thyroid, 48 removing, 37 Satinsky, 52, 52 vascular, 52 Claudication, treatment of, 22 Clavicular fracture, 662 Claw toe, 695 Claybrook’s sign, 9 Clay shoveler’s fracture, 650 Cleft palates, types of, 503 Cloquet, node of, 134 Cloquet’s hernia, 256 Clostridium difficile, 30, 212 Clostridium perfringens, 811 Clotting factors in hemophilia, 17, 159 liver, 23 RBCs and, 165 thromboelastography and, 172 vitamin K–dependent, 159 CMV, in transplant recipients, 647–648 C-myc, 237 CN VI palsy, 27 Coagulation regulation, inhibitors in, 169 Coagulopathy antibiotic associated with, 173 in brain injury, 168 colloid fluid associated with, 174 Coarctation of aorta, 593 hypertension in, 407–408 CO2 gas embolism, 261–262 Colectomy sigmoid, 96 transverse, 95 Colitis, antibiotic-associated, 30 Collagen, 165 Collar button ulcers, 217 Collar incision. See Thyroid incision Collaterals of Winslow, 437 Colles’ fracture, 650, 667 Colloid, defined, 8 Colon, 251

anatomy and physiology, 324–325 bacterial load of, 251 cancer, 325–326 innervation of, 251 ischemic colitis, 327–328 length of, 132 motility, 251 nutrient of, 25 obstruction, 326–327 Ogilvie’s syndrome, 327 Colon cancer, 811 bacteremia associated with, 240 CEA levels in, 238 Lynch syndrome, 239 Colon injury, infection after, 285 Colonized, defined, 8 Colon perforation, antibiotic in, 793 Colon polyps, 16 Colostomy, 308–309 Colostomy stenosis, 308 Comminuted fracture, 654 Common carotid arteries, 443 Common femoral artery, 439 Common iliac artery, 439 Compartment syndrome, 513–514, 660–662 Compartment syndrome, abdominal, 103 Conductive hearing loss, 537 Congenital bleeding disorder, 29 Congenital lobar overinflation, 474 Conjunctival emphysema, 770 Connell’s stitch, 55, 55 Conn’s disease, 157 Conn’s syndrome, hypertension in, 408 Conscious sedation, 235 Continuous positive air pressure (CPAP) mask, 140, 140 Continuous veno-veno hemofiltration with or without HD (CVVHD), 153 Convection, defined, 152 Cooper’s hernia, 256 Copper deficiency, 200 Cordotomy, 721 Corlopam. See Fenoldopam Cornea, 771 Corneal abrasions, 767, 774 Corneal ulcer, 774 Coronary artery bypass grafting (CABG), 598–599 Coronary artery disease (CAD), 72 Coronary artery, hole repair near, 59, 59 Coronoid fractures, 667, 667 CPAP mask. See Continuous positive air pressure (CPAP) mask CPB. See Cardiopulmonary bypass (CPB) Crack ulcer, 235 Cranial nerve injury, in blunt trauma, 29 Craniopharyngioma, 717 Crawford technique, 621

Index 823 Creatinine clearance, 146 Cricoid cartilage, 73 Cricothyroidotomy, 72–75, 73–75 incision in, 73, 73 indications for, 72 percutaneous tracheostomy, 74, 74–75 trachea, maintaining route into, 73, 73 tube insertion, 74, 74 Crigler-Najjar syndrome, 344 Criminal nerve of Grassi, 128 Crohn’s disease, 30, 106–107, 335–338 bypass in, 336 colonic resection in, 336 infliximab in, 338 intraoperative signs of, 106 long segment small bowel strictures in, 336, 336 short segment small bowel strictures in, 335 Cryoprecipitate, 167, 168 Cryptorchid testis, 736–738 Csendes procedure, 93, 93 C-spine film, 219–220 Curling’s ulcer, 18 Cushing, Harvey, 33 Cushing’s disease, 715 Cushing’s syndrome, 382–383, 715 hypertension in, 408 Cushing stitch, 56, 56 Cushing’s ulcer, 18 Cut-off sign, 215 Cutting needle, 57, 57 reverse, 58, 58 CVVHD. See Continuous veno–veno hemofiltration with or without HD (CVVHD) Cyanotic heart disease, 583–584 Cyclooxygenase, 164 Cyclophosphamide, 241 Cyclosporine, 175, 338, 648 Cystadenoma, 342, 369 Cystic adenomatoid malformation (CAM), 473, 474 Cystic duct leak, after cholecystectomy, 811 Cystitis, acute, 751 Cystosarcoma, 806 Cytokines, 113–114 acute phase reactants, 113 after endotoxin, 113 B cells and, 114 in meningococcemia, 114 with procoagulant effect, 114 Cytotoxic T cells (Tc ), 112

D Dacryocystitis, 764, 773 Dalteparin, 176

Damage control, 273–275 Dantrolene, 179, 228 Dapsone, 179 Davol drain, 121 DCIS. See Ductal carcinoma in situ (DCIS) DDAVP for diabetes insipidus, 177 role in coagulation, 165 DeBakey aortic clamp, 42 Decubitus ulcers, 115–116 Deep palmar arch, 443 Deep peroneal nerve, 680 Deep-space infections, of hand, 515–516 Deep sulcus sign, 9, 220 Deep venous thrombosis (DVT), 28 upper extremity, 465–466 Dehiscence, defined, 69 Delirium, 196–197 Delorme procedure, for rectal prolapse, 330 Delphian nodes, 124, 124 δ cells, 112 Demarcation, defined, 8 Demerol. See Meperidine Denonvilliers’ fascia, 134 Denver and LeVeen shunts, 344 De Quervain’s stenosing tenosynovitis, 526–527 De Quervain thyroiditis, 394–395 Dermoid tumors, 488 Desmoid tumors, 414–415 Dexamethasone, 176, 178 Dexon sutures, 60 Diabetes, defined, 154 Diabetes insipidus (DI), 15, 154, 157, 177 Diabetic ketoacidosis (DKA), 192–193 Diagnostic peritoneal lavage (DPL), 83–84, 84 catheter placement for, 104 RBC and WBC count for, 158 for trauma, 103 Dialysis indications for, 151 modalities, 152 Dialysis membrane, pore size of, 152 Diamox. See Acetazolamide Diaphragmatic rupture, traumatic, 28 Diaphragm, nonabsorbable suture for, 60 Diarrhea, postvagotomy, 185 Dibenzyline. See Phenoxybenzamine Dieulafoy ulcer, 300 Diffuse axonal injury (DAI), 219 Diffusion, defined, 152 Diffusion hypoxia, 231 DiGeorge’s syndrome, 26 Digestion, 247–249 of lipids, 247–248 of proteins, 248–249 Digoxin, 155, 175 toxicity, 195

824 Index Diplopia, 764 Diprivan, 230 Dislocations, 649 elbow, 665, 665 hand, 522 hip, 671–674, 671–675 knee, 677 wrist, 522–523 Distal tubule, 147 Distribution, defined, 10 Diversion colitis, 308 Dopamine, 147 Dorsalis pedis artery, 439 Dorsiflexion, 649 Double barrel shotgun sign, 217 Double-blind study, 11 Double bubble sign, 217 Double duct sign, 217 Double Kocher incision, 65, 65 Doxorubicin, 799 Doyen rib stripper, 43 Drain(s), 118–122 Davol, 121 following abdominoperineal resection, 119 following acute rectal perforation, 119 following appendectomy, 119 following cholecystectomy, 119 following rectal perforation, 119 following sarcoma removal, 119 following splenectomy, 119 intraperitoneal, 118 intraperitoneal abscesses, 120 Jackson-Pratt, 119 peritoneal, 119 for pleural effusion, 118 Drain tract infection, 118 Dubin-Johnson syndrome, 344 Duchenne muscular dystrophy (DMD), 692 Ductal carcinoma in situ (DCIS), 23, 378 Dumping syndrome, 187, 808 Dunphy’s sign, 10, 316 Duodenal augmentation, 283, 283 Duodenal diverticulization, 283, 283 Duodenal hematoma, 281–282 Duodenal injuries, 281–283 Duodenal obstruction in newborn, 475–476 Duodenal ulcers bleeding, 298–299, 299, 807 food intake and, 18 indications for surgery with, 18 Duodenal webs, 476 Duodenum, 28 Duoderm, 117 Dupuytren’s fasciitis and contracture, 527 Duval clamp forceps, 43, 43 Duval procedure, 365 D5W, 156 D5W½ NS, 156

Dysphagia, 547, 802 Dystonia, promethazine-induced, 179

E Eagle–Barrett syndrome. See Prune belly syndrome Ear anatomy of, 540 hearing tests, 540–541 infections of, 538–540 mucoid otitis media, 539 serous otitis media, 538–539 vestibular neuritis, 539–540 sensorineural hearing loss, 541 tumors of congenital lesions of ear, 541 glomus tumors, 540 posterior fossa tumors, 540–541 Eaton–Lambert syndrome, 566 Ebstein’s anomaly, 591, 591 Eclampsia, in pregnancy, 785 Ectopic testis, 735 Ectopic ureter, 760 Efferent loop syndrome, 184–185, 808 Eikenella, 211 Eisenmenger’s syndrome, 583, 596–597 Elbow dislocations, 665, 665 Elbow fractures, 666, 666–667, 667 Electrolytes, 154–157 abnormalities, 154–155, 157 deficiency, 156 in lactate Ringers, 157 muscles/skin necrosis, 178 Electron transport chain, 110 Embryology, gastrointestinal system, 136–137 Emergencies endocrine, 193–194 neurologic complications, 194–197 tracheostomy complications, 192–193 Emergency thoracotomy, 82–83, 82–83 incision in, 82 mobilization of lung, 82, 82 pericardial sac, cutting of, 83, 83 thoracic aorta, clamping of, 83, 83 EMLA cream, 235 Empiric antibiotics, 205, 211 Empyema, 550 Encephalocele, 719 Endocarditis, 214 Endocrine system, 379–390 adrenals, 379–384 adrenocortical insufficiency, 383–384 anatomy, 379–380 Cushing’s syndrome, 382–383 glucocorticoids, 380 mineralocorticoids, 381 pheochromocytoma, 381–382

Index 825 cells of, 111–112 emergencies related to, 193–194 glucagonoma, 385–386 insulinoma, 386–387 neuroendocrine GI tumors, 385 nonfunctioning islet cell tumor, 387–388 somatostatinomas, 389–390 surgical medications of, 177 VIPomas, 388–389 Endometrial cancer, 778–779 Endometriosis, 255 Endophthalmitis, 764 Endoscopic retrograde cholangiopancreatography (ERCP), 356, 481 Endothelial cells pulmonary capillary, 111 vascular, 113 Endotracheal tube (ETT), 127, 222 double-lumen, 141, 141 medication administration by, 22 End points of resuscitation, 421–422 End-to-end anastomosis (EEA), 90, 90, 104 End-to-side portacaval shunt, 347, 347 Enteric duplication, 477 Enteric infections, 314 Enterococcal infection, 208 Enterocutaneous fistula, 19, 200 Enteroenterostomy, 69 Enterohepatic circulation, 351 Enterokinase, 249, 811 Eosinophilia, 25, 168 Eosinophils, 168 Epidermoid cyst, 545 Epididymal adenomatoid tumors, 738 Epidural abscess, 212 Epidural anesthesia, 233–234 Epidural bloodpatch, 234 Epinephrine, 180, 232 Epistaxis, 197–198 ε-aminocaproic acid (εACA), 167 ERB-B, 811 Erb B-2, 237 Eructation, defined, 69 Eschar, defined, 8 Esmolol, 426 Esophageal cancer, 803 Esophageal foreign body, 472–473 Esophageal manometry, 802 Esophageal perforation, 802, 803 Esophageal webs, 576 Esophagectomy, 803 Esophagogastroduodenoscopy (EGD), 105 Esophagus anatomy, 566–567 barium esophagogram, 577, 577 benign tumors, 29, 574–575 leiomyoma, 574–575 caustic injuries, 575–576

esophageal diverticula, 569–570 esophageal webs, 576 motility disorders, 567–569 oropharyngeal dysphagia, 568–569 scleroderma, 569 perforation, 571–574 pharyngoesophageal diverticulum, 570–571 epiphrenic diverticulum, 571 Esotropia, 764 Essential amino acids, 248 Essential fatty acids, 247 Esthesioneuroblastoma, 546 Estrogen, role of, in mammary development, 371 Etomidate, 180, 230, 794 Eucaryotic cells, 108 Eventration of diaphragm, 473 Eversion, 649 Ewing’s sarcoma, 25 Exotropia, 764 Exstrophy of bladder, 485 Extensor carpi radialis brevis (ECRB), 506, 507 Extensor carpi radialis longus (ECRL), 506, 507 Extensor carpi ulnaris (ECU), 507, 508 Extensor digiti minimi (EDM), 507, 508 Extensor digitorum communis (EDC), 507, 508 Extensor indicis proprius (EIP), 507, 508 Extensor pollicis brevis (EPB), 506, 507 Extensor pollicis longus (EPL), 506, 507 External iliac artery, 439 Extra-articular fractures, of hand, 520–521 ExtraCorporeal Membrane Oxygenation (ECMO), 470 Extraction ratio (ER), 433 Extraperitoneal bladder injury, treatment of, 120 Extremity injuries, treatment of, 24 Extrinsic coagulation pathway, 163, 163 Extrinsic extensors, of hand, 506–509 Extrinsic extensor tightness, 508 Extrinsic flexors, of hand, 505–506

F Facial cellulitis, 534 Facial fractures, 497–500 frontal sinus fractures, 499 nasal fracture, 498 nasoethmoidal orbital fracture, 498–499 orbital floor fracture, 500 radiographic evaluation, 497 signs and symptoms of, 497 supraorbital fractures, 499 zygoma fractures, 498

826 Index Facial nerve, 495–496 Factor VIIa, 167 recombinant, 168 Falciform ligament, 130, 217 False lateralizing signs, 717 False-negative, defined, 10 False-positive, defined, 10 Falx sign, 219 Familial hypercalcemic hypocalcinuria, 813 Familial hypercholesterolemia, 789 Fasciotomy four-compartment, 25 leg, 135 FAST exam, 218 Fat calorie content of, 158 respiratory quotient, 162 Fat emboli syndrome, 182 Fat-soluble vitamins, 18 Fatty liver of pregnancy, 785 Felty’s syndrome, 23, 405 Femoral anteversion, 693 Femoral artery, 134, 135 Femoral nerve, 680 Femoral shaft fractures, 676 Femoral triangle, 134 Femoral vessels, order of, 16 Femorodistal bypass, 438 Femorofemoral bypass, 437 Femur fracture, 160 FENa. See Fractional excretion of sodium (FENa) Fenestrated tracheostomy tube, 142, 142 Fenoldopam, 147, 176 Ferris-Smith tissue forceps, 44, 44 Ferritin, 238 Fever, 212–213 atelectasis and, 138, 789 malignant hyperthermia and, 213 postoperative, 18, 230 radiology for, 218 FeV1, for lung resection, 158, 160 Fibrinolysis, 166 thromboelastography and, 172 Fibroadenoma, 805 Fibroblasts, 113, 165 Fibronectins, 791 Fibrosarcoma, 414 Fibrotic lung injury, 424 Fine needle aspiration (FNA), 396–397, 800, 801 Finger blood soilage, 169 Finger fracture technique, for liver hemostasis, 277 Finger-pad defects, 525 Finney pyloroplasty, 102 Finochietto chest retractor, 82, 82 Finochietto rib spreader, 44

Fish retainer, 44, 44 Fistulas, 323–324 enterocutaneous, 200, 323–324 external and internal, 323 high-output, 323 low-output, 323 simple, 323 tracheoesophageal, 192–193 tracheoinnominate artery, 193 FK-506, 175, 642–643 Flaps axial/arterial, 491 fasciocutaneous, 491 for head and neck reconstruction, 544–545 indications for use of, 491 muscle, 491 pedicle, 492, 492 random pattern, 491 Fleming, A., 34 Flexor carpi radialis (FCR), 505 Flexor carpi ulnaris (FCU), 505 Flexor digitorum profundus (FDP), 505 Flexor digitorum superficialis (FDS), 505 Flexor pollicis longus (FPL), 505 Flow cytometry, 237 Fluconazole, 209 Fluid rate, maintenance, formula for, 161 Fluids, 154–157 intravenous, 156 Fluorouracil (5-FU), 241 Foley catheter, 105 Follicular cells, 112 Follicular thyroid cancer, 21 Food poisoning, 314 Foot and ankle sports injuries, 684 Foramen lacerum, 700 Foramen magnum, 700 Foramen ovale, 700 Forced duction exam, 500 Forceps Adson–Brown tissue, 37 Bayonet, 39 bone-cutting, 40 Duval clamp, 43, 43 Ferris-Smith tissue, 44, 44 Maryland dissecting, 49, 49 rat-toothed, 51 Russian, 52, 52 Forearm fractures, 667–668 Foregut, 137 Foreign bodies in esophagus, 472–473 in trachea, 472 Forssmann, W., 34 Fournier’s gangrene, 723–724 Fowler-Stephens orchiopexy, 737 Fractional excretion of sodium (FENa), 149, 428, 795, 814

Index 827 formula for, 23, 161 prerenal, 159 Fractures acetabular, 670–671 clavicular, 662 elbow, 666, 666–667, 667 eponyms, 655 femoral shaft, 676 forearm, 667–668 general principles, 654–655 of hand, 520–521 healing, 656 hip, 675–676 humerus, 664 open, 656–658 patellar, 677 pediatric, 687, 687 pelvic, 668, 668–670, 669 scapula, 662–663 tibial shaft, 678 Fragmin. See Dalteparin Frazier suction, 45, 45 Fresh frozen plasma (FFP), 167 Frey procedure, 90, 90 Frontal sinus fractures, 499 Fungal infection in immunosuppressed patients, 647 intraperitoneal, 28 Fungus, defined, 109 Furnas traction test, 499 Furosemide, 178–179 in chronic heart failure, 181 Fuzzy border sign, 220

G Gait analysis, 653–654 Galeazzi fracture, 650, 655, 666 Gallbladder cancer, 31 Gallbladder emptying, 352 Gallbladder tumors, 361–362 Gallstones, 26, 354–356 cholesterol, 354 classification of, 354 and gallbladder cancer, 361 pancreatitis, 30, 366 pigment, 354–355 risk factors for, 19 Gambee stitch, 55, 55 Gamekeeper’s thumb, 522 Gardner syndrome, 15 Gastrectomy, 191 Gastric acid secretion, 250 Gastric cancer, 300–302 lymph nodes, 301, 301–302, 302 TNM staging system, 300–301 Gastric cancer, bowel preparation for surgery, 106

Gastric carcinoid, 304 Gastric carcinoma, 28 Gastric inhibitory peptide (GIP), 243, 244 Gastric leiomyoma, bleeding, 297 Gastric lymphoma, 302–303, 410–411, 808 site of, 28 Gastric MALT, 806 Gastric sarcoma, 28, 303–304 Gastric tonometry, 201 Gastric ulcers, 235–236, 235–236, 299–300 Dieulafoy ulcer, 300 indications for operation with, 18 type II, 24 type III, 24 type IV, 24 types of, 299–300 Gastric varices, 808 Gastrin, 809 Gastrinomas, 30, 813 Gastrinoma triangle, 30 boundaries of, 131 Gastrin-releasing peptide (GRP), 243 Gastroduodenal artery, 806 Gastroenteritis, 314 signs/symptoms, 253 Gastrointestinal bleeding lower, 333–335 abdominal aortic aneurysm repair and, 334 causes of, 334 differential diagnosis of, 335 upper, 297–299 acute hemorrhagic gastritis, 298 bleeding duodenal ulcer, 298–299, 299 hemosuccus pancreaticus, 298 Gastrointestinal hemangiomas, 478 Gastrointestinal parietal cells, 111 Gastrointestinal system, embryology, 136–137 Gastrointestinal tract physiology of, 246–247 transplantation, 646 Gastrostomy percutaneous endoscopic, 101, 101 Stamm, 102, 102 GBM. See Glomerular basement membrane (GBM) G cells, 111 in stomach, product of, 19 GCS eye-opening score, 18, 157 GCS motor score, 18, 157 GCS verbal score, 18, 157 Gelpi retractor, 45 Genital herpes, 727–728 Gentamicin, 180 GERD, 802 GFR. See Glomerular filtration rate (GFR) Ghon complex, 559

828 Index Ghrelin, 808, 809 Gibbon, J. H., 34 Gigli saw, 46 Gilbert’s syndrome, 344 GIST tumor, 807, 808 Glanzmann thrombasthenia, 166 Glasgow Coma Scale (GCS), 157 for young children, 263 Glaucoma, 769–771 Glioblastoma multiforme (GBM), 713 Glomerular basement membrane (GBM), 145–146 Glomerular filter, 145 Glomerular filtration rate (GFR), 146 Glomus jugulare, 547 Glomus tumors, 540 Gloves, donning, 85, 85–86 Glucagon, 243–244, 809 Glucagonoma, 369, 385–386 Glucocorticoids, 380 Glycopyrrolate, 176 Goldblatt kidney, 763 Goldman criteria, for cardiac risk, 70–71 Golgi apparatus, 109 Gomez retractor, 46 Gonococcal urethritis, 726 Goodsall’s rule, 15 Goodyear Rubber Company, 33 Gowers’ sign, 692 Graham patch, 807 Gram-negative defined, 109 pneumonia, 204 Gram-positive defined, 108 pneumonia, 204 Granular casts, 150 Granulation, defined, 8 Greater saphenous vein, 461 Greenstick fracture, 654 Grey-Turner maneuver, 87 Grey Turner’s sign, 15 Griffith’s point, 133 Grillo procedure, 99, 99 Gritti-Stokes amputation, 449 Grynfeltt–Lesshaft’s triangle, 128 Grynfeltt’s hernia, 256 Grynfeltt’s triangle, 257, 257 Gunshot wounds (GSWs), 91, 263–264 bullet tumble, 264 bullet yaw, 264 cavitation, 264, 264 hollow-point bullet, 263 shotgun, 263 thoracic, 221 Gustilo classification, for open fractures, 656 Gut sutures, 60

H Haldol, 432 Haloperidol, 175 Halothane, 72 Halsted stitch, 56, 56 Halsted, W. S., 33, 34, 35 Hamburger sign, 316 Hammer toe, 695 Hand scrub, 214 Hand surgery, 504–527 anatomy related to, 504–511 dorsal skin, 504 extrinsic extensors, 506–509 extrinsic flexors, 505–506 nerves, 509–511 normal hand cascade, 504, 504 palmar skin, 504 tendon synovial sheaths, 504 de Quervain’s stenosing tenosynovitis, 526–527 dislocations of hand, 522 of wrist, 522–524 Dupuytren’s fasciitis and contracture, 527 emergencies, 512–514 compartment syndrome, 513–514 herpetic whitlow, 514 traumatic amputations, 512–513 finger-pad defects, 525 fractures and, 520–521 extra-articular fractures, 520–521 intra-articular fractures, 521 wrist fractures, 522–523 infections, 514–516 deep-space, 515–516 suppurative tenosynovitis, 514–515 nail and nail-bed injuries, 525 nerve injuries, 519–520 rheumatoid arthritis, 526 tendon lacerations, 516–519 trigger finger, 526 ulnar nerve compression, 524–525 Hangman’s fracture, 651, 708 Haptoglobin, 166 Harris–Benedict equation, 198 Hartmann’s pouch, 129 Hashimoto’s thyroiditis, 395 Hasson laparoscopy, 102 Hawthorne effect, 12 HDL (High-density lipoprotein), 248 Head and neck surgery, 528–547 anatomy ears, 537, 537 neck, 541–544 nose, 532–533 salivary glands, 528–529 ear, 537–541

Index 829 laryngeal surgery, 531–532 neck, 541–544 nose, paranasal sinuses, and face, 532–536 reconstruction, 544–545 salivary glands, 528–531 Heart size, 221 Heart surgery, hole repair near coronary artery, 59, 59 Heart transplantation, 622–627 contraindications to, 622 donor heart denervation, 624 early postoperative hemodynamic complications, 624–625 heterotopic, 623 immunosuppressive maintenance regimen for, 626 indications for, 622 infectious complications, 625–627 orthotopic, 623 preoperative period and procedure, 623 rejection and treatment, 626–627 Heberden’s node, 526 Hegar dilator, 46 Helper T cells (Th), 112 Hemangiomas, 478–479, 800 Hematuria, location of, 150 Hemicolectomy extended right, 94 left, 95 right, 94 Hemobilia, 363 Hemodialysis (HD), 152 CVVHD vs., 153 vascular access for, 466–468 Hemoglobin, affinity of, 160 Hemolysis, 166 Hemophilia, 167 clotting factors in, 17, 159 Hemophilia A clotting factor in, 17, 159 preoperative, 168 in the United States, 167 Hemophilia B, clotting factor in, 17, 159 Hemophilia C, 167 Hemorrhage, 797 Hemorrhagical shock, 202, 203 Hemorrhagic cystitis, 753 Hemorrhagic gastritis, acute, 298 Hemorrhoidal cushions anal, 133 position of, 23 Hemostasis, in cut vessel, 163 Hemosuccus pancreaticus, 298 Hemothorax, 158 retained, 798 Hemovac, 120, 120 Heparin, 165 complication of, 192

Heparin-induced thrombocytopenia (HIT), 165, 189–191 Heparin-induced thrombocytopenic thrombosis (HITT), 189–191, 791 Heparin, in pregnant patients, 783 Hepatic angiosarcoma, 411 Hepatic artery, 645 embolization, 321 ligation of, 268 Hepatic duct, segment III, 103 Hepatic encephalopathy, 345 Hepatic hamartoma, 479 Hepatic neoplasms, 478–479 Hepaticojejunostomy, 69 Hepatitis B, 212 Hepatitis C, 163 Hepatoblastoma, 479–480 Hepatocellular adenoma, 19 Hepatocellular carcinoma, 480 Hepatocystic triangle, 129, 129, 350 Hepatoma, 341–342 liver resection for, 342, 342 site of metastasis, 341 staging of, 341 Hepatorenal syndrome, 345 Herald hernia, 257 Hereditary spherocytosis, 405 Hernia repair, inguinal, 105, 106 plug and patch, 99–100, 99–100 Hernias, 256–258 anatomical considerations, 257–258 incisional, 258 inguinal hernia repair, 258 parastomal, 258 plug and patch repair, 258 types of, 256–257 umbilical, 258 Herpetic whitlow, 514 Hesselbach’s hernia, 256 Hewett, Crosswell, 35 High spinal, 233 Hilton, white line of, 132 Hindgut, 137 Hip disarticulation, 446 Hip dislocation, 671–674, 671–675 Allis technique for, 674, 674 anterior, 672, 672 closed reduction, 674, 674 complications after, 675 open reduction, 674 posterior, 673, 673 Shenton’s line, 671, 671 Stimson technique for, 674, 674 Hip fracture, 675–676 Histaminerelease, NDMRs and, 229 Histocompatibility antigens, 641 Hoffman degradation, 229, 795 Homograft, 290

830 Index Horner’s syndrome, 773, 804 Horseshoe infection, 515 Horseshoe kidney, 482 Hospital-acquired gram-negative rod infection, 206 Howell–Jolly bodies, 403 Human chorionicgonadotropin (β-HCG), 238 Human immunodeficiency virus (HIV) infections related to, 209–210 particle transmission, 169 Human leukocyte antigen (HLA), 640 Humerus fracture, 160, 664 Hunter, J., 32 Hyaline casts, 150 Hydatidiform mole complete, 782–783 partial, 783 Hydatid liver cysts, 339–340 Hydrocephalus, 717–718 Hydrocortisone, 178 Hydrogen breath test, 315 Hyperaldosteronism, 812 Hypercalcemia, 17, 795 Hypercalcemic crisis, 401 Hyperdynamic myocardium syndrome, 634 Hyperkalemia, 155, 795 Sch-induced, 228 treatment of, 17, 151 Hypernatremia, 154–155 Hyperopia, 764 Hyperparathyroidism hypertension in, 408 postoperative, 400–401 persistent, 400 recurrent, 400 Hyperphosphatemia, 156 Hyperplasia, 237 Hypertension portal, 345–349 and ascites, 349 cause of, 345 classes of, 345 medical treatment of, 346 postsinusoidal, 345 presinusoidal, 345 shunts for, 346–348, 347, 348 sinusoidal, 345 TIPS for, 346, 346 surgically correctable, 406–409 cancer and, 409 coarctation of aorta and, 407–408 Conn’s syndrome and, 408 Cushing’s syndrome and, 408 hyperparathyroidism and, 408 increased intracranial pressure (ICP) and, 408 neuroblastoma and, 407

pheochromocytoma and, 407 renal artery stenosis and, 407 renal parenchymal disease and, 409 Hypertension, relationship with epistaxis, 198 Hyperthermia, malignant, 179 Hypertrophic scar, 490 Hypertropia, 764 Hypervolemic hyponatremia, 154 Hyphema, 764, 770 Hypocalcemia, 155 Hypoglossal nerve, 543 Hypokalemia, 155 Hyponatremia, 154 Hypoparathyroidism, postoperative, 398 Hypophosphatemia, 156 Hypoplastic left heart syndrome, 595 Hypospadias, 485 Hypotension, 28, 29 closed-head injury, 201 Hypothermia, 155 effects on clotting, 169 Hypotropia, 764 Hypoventilation, oxygen-induced, 138 Hypovolemia, 432 Hypovolemic hyponatremia, 154 Hypoxia, causes of, 423

I Idiopathic retroperitoneal fibrosis, 761 Idiopathic thrombocytopenia purpura (ITP), 21 IDL (Intermediate-density lipoprotein), 248 Idural blood patch, 234 I:E ratio, 141, 162 normal, 422 reverse, 422 Ileoanal anastomosis, 337, 337 Ileum, 16 Ileus, 310 Iliac artery, external, 134 Ilioinguinal nerve transection, 106 Imipenem, 178, 206 Immune system, cells of, 112–113 Immune thrombocytopenic purpura (ITP), 403–404 Immunoglobulin, associated with anaphylaxis, 168 Immunonutrition, 199 Immunosuppression, 646–648 complications of, 646–647 infections, 647–648 malignancy, 648 Imperforate anus, 475 Incentive spirometry, 138, 138 Incidence, 12, 796

Index 831 Incision(s), 64–66 for brachial artery repair, 66, 66 for colostomy, 66 double Kocher, 65, 65 Lanz, 64, 64 laparotomy fascial, 103 midline abdominal, 131–132 paramedian, 65, 65 pericardium, 23 phrenic nerve, 23 place skin, 25 for popliteal artery repair, 66, 66 thyroid, 64, 64 transverse abdominal, 65, 65 for vascular access, 441 Inderal. See Propranolol Induction agents and lipid solubility, relationship between, 794 Infantile polycystic kidney disease, 482–483 Infections, 201–212 antibiotics for, 214 Aspergillus, 647 burns, 290–291 Candida, 117 deep-space, 515–516 drain tract, 118 of ear, 538–540 enteric, 314 enterococcal, 208 fungal, 204, 647 intraperitoneal, 28 horseshoe, 515 in immunosuppressed patients, 647–648 nosocomial, 28, 204 orthopedic, 685–686 osteomyelitis, 685–686 septic arthritis, 685 paraumbilical, 489 Pseudomonas, 212 spinal, 697 wound, 28, 117, 205 Infectious endocarditis (IE), 616–618 Infectious sialadenitis, 529–530 Inferior gluteal nerve, 680 Inferior lumbar triangle, 127 Inferior mesenteric artery (IMA), 451 Inferior thyroid artery, 800 Inferior vena cava (IVC) control of bleeding in injured, 91, 91 infrarenal, 105 suprarenal, 105 Inflammatory bowel disease, 335–338. See also Crohn’s disease; Ulcerative colitis Inflammatory shock, 201 Inguinal hernia repair, 105, 106 plug and patch, 99–100, 99–100 Inhalation anesthetics, 231

Insipidus, defined, 154 Insulin, 809 Insulinoma, 367–368, 386–387 Integrins, 791 Intensive care unit (ICU), formulas, 420–421. See also Surgical intensive care Intercondylar fractures, 666, 666 Intercostal artery, suturing of, 59, 59 Interleukin-2 (IL-2), 241 Intermaxillary fixation (IMF), 502 Internal auditory canal (IAC), 537 Internal iliac artery, 439 Internal jugular central line, 76, 76, 77 Internship, 2 Interossei functions of, 509 testing for, 509 Interstitial cystitis, 752 Intestinal atresias, 477–478, 813 Intra-aortic balloon pump (IABP), 637–638 Intracranial pressure (ICP) increased, and hypertension, 408 monitoring, 797 Intraductal papilloma, 805 Intraperitoneal abscess, 120 Intraperitoneal drain, 118 Intravenous anesthetics, 230 Intravenous catheters, 122 Intrinsic coagulation pathway, 163, 163 Intussusception, 814 Inversion, 649 IORT, 237 Irish’s node, 125 Iritis, 774 Iron therapy, 177 Ischemic colitis, 327–328 Islet cell tumor, nonfunctioning, 387–388 Islets of Langerhans, secretion of, 365 Isoproterenol, 426 Isovolemic hyponatremia, 154 ITP. See Idiopathic thrombocytopenia purpura (ITP)

J Jaboulay pyloroplasty, 101 Jackson-Pratt drain, 119 Jackson’s veils, 132 Jamieson scissors, 47 Jefferson fracture, 708 Jejunal loop, 186 Jejunoileal bypass, 306, 306 Jejunum, 16 Jiffy Pop sign, 10 Joint replacement surgery, 694 Jones’ fracture, 650, 655 Jugular foramen, 700 Jugular vein, 543

832 Index

K

L

Kanavel’s signs of flexor tenosynovitis, 514 Kaposi’s sarcoma (KS), 209, 410, 415–416 Kasabach-Merritt syndrome, 343 Kasai procedure, for biliary atresia, 471, 471 Keith needle, 58, 58 Keloids, 490, 794 and hypertrophic scars, 794 Keratitis, 771 Kerley B lines, 181, 221 Kernohan’s phenomenon, 704 Ketamine, 230, 794 Keuttner, 47, 47 Kidney injury scale, 279 Kidney pedicle clamp, 47 Kidneys, 738–747 adult polycystic kidney disease, 745 anatomy, 738–741 calcification, 216 cardiac output to, 160 multicystic dysplastic kidney disease, 745–746 oncocytoma, 746–747 pelvic kidney, 744–745 physiology, 741–743 pyonephrosis, 743 renal tubular acidosis, 744 xanthogranulomatous pyelonephritis, 743–744 Kidney stones, 16 Kienböck’s disease, 523, 667 Kienbock’s fracture, 650 Kiesselbach triangle, 198 Kleihauer-Betke test, 786 Knee dislocations, 677 Knee injuries, 676, 676 dislocations, 677 patellar fractures, 677 sports, 683–684 Knot one-handed, 61–63, 61–63 prolene, 60 slip, 54, 54 tying, 61–63 one-handed knot, 61–63, 61–63 Kocher, E. T., 33 Kocher maneuver, 87, 87 Kohler’s disease, 650 K-ras, 237 Kraske, 89 Krebs cycle, 110 Krukenberg tumors, 780, 807 KS. See Kaposi’s sarcoma (KS) K time, 172 Kulchitsky cells, 111 Kupffer cells, 113 Kwashiorkor syndrome, 200

Labor, postoperative premature, 29 Lachman test, 683 Lacrimal gland ostium, 533 Lactate fate of, 421 substrate for, 421 Lactate dehydrogenase (LDH), 810 Lactate Ringers (LR) defined, 156 electrolytes in, 157 sodium in, 159 Lactic acid, 200, 202–203 Lahey thyroid clamp, 48 Langenbuch, Carl, 32 Langer’s arch, 126, 126 Lanz incision, 64, 64 Laparoscopy, 259–262 advice pearls for, 107–108 argon laser during, 107 cholecystectomy, bile duct injury from, 259 and CO2 gas embolism, 261–262 Hasson, 102, 261 in pregnant women, 261 Laparotomy damage-control, 274, 275 trauma patient for, 272, 272 Lap-band, 305, 305 Laplace’s law, 161 L-arginine, 200 Larrey, D. J., 32 Larrey’s point, 128 Laryngeal cancer, 799 Laryngeal Mask Airway (LMA), 226, 226 Laryngeal papilloma, 546 Laser in situ keratomileusis (LASIK), 772 Latissimus dorsi, 805 Lavage, diagnostic peritoneal, 83–84, 84 LBBB. See Left bundle branch block (LBBB) LCIS. See Lobular carcinoma in situ (LCIS) LDL (Low-density lipoprotein), 248 Learning, adult, 1 Lebske knife, 48, 48 Le Fort fracture, 34 Left bundle branch block (LBBB), 78 Left ventricular aneurysm, 602–603 Left ventricular assist device (LVAD), 638 Leg bones of lower, 135, 135 compartments of lower, 134–135, 135 Legg–Calvé–Perthes disease, 688–689 Leg length discrepancy, 687–688 Leiomyoma of esophagus, 574–575, 801 Lembert stitch, 54, 54 Lens detachment, 767 Lens dislocation, 770–771

Index 833 Lepirudin, 176 Leptin, 808, 809 Leriche’s syndrome, 15 Lesser saphenous vein, 461 Leukoplakia, 545 Lid ptosis, 767 Life, signs of, 265 Li-Fraumeni syndrome, 26 Lillehei, R. C., 34 Lingual lipase, 247 Lingual thyroid, 391 Lingula, 221 Lipids, digestion of, 247–248 Lipoproteins, 248 Liposarcoma, 412–413 Lisfranc fracture, 650, 679, 679 Lisfranc’s amputation, 449 Lister, Joseph, 32 Liver, 338–345 anatomy of, 338–339 bacterial abscess, 28 cardiac output to, 160 clotting factors, 23 hydatid liver cysts, 339–340 segmental anatomy of, 129–130, 129–131 trauma to, 91, 91 tumors of, 340–342 benign liver cysts, 342 bile duct adenoma, 340–341 cavernous hemangioma, 340 hepatoma, 341–342 Liver cysts, benign, 342 Liver injury scale, 276–278 Liver transplantation, 643, 643–646, 792 caval stenosis, 645 cholangitis, 645 orthotopic, 643, 643–644 rejection, 645 renal failure after, 646 veno-venous bypass during, 644, 644 L-myc, 237 Lobectomy, 130 Lobular carcinoma in situ (LCIS), 23 Local anesthetics, 232 Locking stitch, 56, 56 Lone Star retractor, 49, 49 Lopressor. See Metoprolol Loupes, 49 Low cardiac output syndrome (LCOS), 630–632 Lower chest wound, 269 Lower esophageal sphincter (LES), 802 Lower extremity arterial occlusive disease of, 437–441 varicosities, 462–463 Lower extremity, surgical anatomy, 134–136, 135 Ludwig’s angina, 535

Lugol’s solution, 392 Lumbricals, 509 Lunate dislocation, 523 Lung anatomy of, 557 bronchiectasis, 558–559 cancer, 804 congenital lung lesions, 558 lobes, 221 lung nodules, 561–563 massive hemoptysis, 560–561 mycotic infections, 560 segmental anatomy of, 563, 563–564 tuberculosis, 559 Lung compliance dynamic, 422 static, 422 Lupus anticoagulant, 168 Lymphangitis, 209 Lymphatic zones, in neck, 543, 543 Lymphogranuloma venereum, 729 Lymphoma of breast, 804 pancreatic, 370 of small intestine, 313–314 Lynch syndrome, 239 Lynch tumors, 239 Lysosome, 109

M Macintosh blade, 226, 226 intubation with, 227, 227 Macrophages, 112 Mafenide acetate, 290 Magnesium distribution, in body, 156 Maintanance fluid rate, 161 Major histocompatibility complex (MHC), 640–642 Malencott tube, 122 Malignant fibrous histiocytoma (MFH), 412 Malignant hyperthermia (MH), 213, 795 dantrolene for, 228 Malignant potential, 237 Mallampati classification, 223–225, 224–225 Mallet toe, 695 Mallory–Weiss tear, bleeding, 807 Malpractice, avoiding, 3 Mammograms, 373–374 Mandibular fracture, 501, 503 Mannkopf ’s sign, 10 MAOI. See Monoamine oxidase inhibitors (MAOI) Marasmus, 200 Marcus Gunn pupil, 285 Marfan’s syndrome, 621, 794 Marjolin’s ulcer, 464 Markle’s sign, 253

834 Index Mary Joseph, Sister, 34 Maryland dissecting forceps, 49, 49 Massive hemoptysis, 560–561 Mattox maneuver, 88, 88 Maxillary fracture, 502 Maxillary torus, 546 Maxillofacial trauma airway obstruction in, 493 cerebrospinal fluid rhinorrhea, 500 emergencies, 493–494 facial fractures, 497–500 facial hemorrhage, 494 facial lacerations, 493 facial nerve, 495–496 mandible fracture, 501 nasal packing in, 494 parotid gland, 497 soft tissue wounds, 494–495 trigeminal nerve, 496–497 Maximum altitude (MA), 172 Maxon sutures, 60 Mayo brothers, 34 McBurney, C., 33 McKenney hemoperitoneum score, 285 Mean blood pressure, formula for, 161 Mean, defined, 10 Meandering artery of Gonzalez, 131, 131 Meandering esenteric artery, 451 Mechanical valves, 614 Mechanical ventilation, 142–144 Meckel’s diverticulum, 137 Meckel’s scan, 217 Median, defined, 10 Median nerve, 680 Median rhomboid glossitis, 547 Mediastinal tumor, differential diagnosis of, 22 Mediastinum anatomy of, 564, 564 mediastinal masses, 565–566 Medical condition, poor, 71 Medullary thyroid cancer, 21, 812 Medulloblastoma, 716 Meissner’s plexus, 246 Melanoma, 417–419, 799 amelanotic, 417 anal, 31 GI metastases, 419 in-transit disease, 419 local recurrence, 417 ocular, 418 pulmonary metastases, 418 regional recurrence, 418 sites of, 22 surgical margin for, 159 Ménière’s disease, 547 MEN-IIb tumor, 20 MEN-II tumor, 20 Meningioma, 713–714

Meningocele, 691, 719 MEN-I tumor, 20 Meperidine, 240, 794 Meralgia paresthetica, 721 Mercaptopurine (6-MP), 241 Merkel cell carcinoma, 417 Mesenteric arteries, 451 Mesenteric ischemia, acute, 452–454 Mesocaval shunt “H” graft, 347, 347 Messenger RNA (mRNA), 109 Metabolism, 203 Metaplasia, 237 Metatarsus adductus, 692 Methemoglobinemia, 192 Methotrexate, 240 Methylprednisolone, 178 Metoprolol, 176 Meyer-Weigert rule, 760 Mickey Mouse sign, 218 Microdochectomy, 371 Midgut, 136, 137 Migrating myoelectrical complex (MMC), 246 Miller–Abbott tube, 118 Miller blade, intubation with, 227, 227 Milrinone, 176, 425 Mineralocorticoids, 381 Minimum alveolar concentration (MAC), 231 Miosis, 764 Mirizzi’s syndrome, 356, 356 Misoprostol, 175 Mithramycin, 399 Mitochondria, 110 Mitotane, 383 Mitral regurgitation (MR), 611–612 Mitral stenosis (MS), 610–611 Mitral valve prolapse, 613 Mode, defined, 10 Modified Childs criteria, 23 Monoamine oxidase inhibitors (MAOI), 70 Monro–Kellie doctrine, 704 Monteggia’s fracture, 655, 666 Montgomery straps, defined, 8 Morton, William, 35 Motilin, 246, 809 Mouret, P., 34 6-MP, 241 MTX, 241 Mucoepidermoid cancer, 800 Mucoid otitis media, 539 Mucous neck cells, 111 Multicystic dysplastic kidney disease (MCDK), 745–746 Multiple endocrine neoplasia I (MEN I), 714, 801 Multiple endocrine neoplasia II (MEN II), 801 Münchausen syndrome, 26 Muscle relaxants, 227–229

Index 835 Muscles/skin necrosis, 178 Musculocutaneous nerve, 680 Mycobacterial arthritis, 516 Mycophenolate mofetil (MMF), 642 Mycotic infections, 560 Mydriasis, 764 Myelodysplasia, 691–692 Myelomeningocele, 691, 718 Myocardial infarction (MI), 30 perioperative, 71 postoperative, 70 Myocardial ischemia, postoperative, 632 Myofibroblasts, 113 Myoglobinuremia, 796 Myoglobinuria, treatment of, 18, 150–151 Myopia, 765

N Nail and nail-bed injuries, 525 Najarian, J. S., 34 Nasal bilevel positive airway pressure (BiPAP) mask, 140, 140 Nasal cannula, 139, 139–140 Nasal fracture, 498 Nasoethmoidal orbital (NOE) fracture, 498–499, 502 Nasogastric tube (NGT), placement of, 104 Native valve endocarditis (NVE), 616–618 Neck arteries of, 124–125 injured vascular structure in, 28 penetrating trauma to, 271 surgical anatomy, 124–127, 124–127 Neck triangle, 124 Necrolytic migratory erythema, 813 Needle cutting, 57, 57 Keith, 58, 58 reverse cutting, 58, 58 taper, 57, 57 Neostigmine, 177, 191 Neo-Synephrine. See Phenylephrine Nephron, regions of, 144–145, 145 Nephrotic syndrome, 169 Nephrotoxins, 150 Nerve injuries, hand, 519–520 Neuroblastoma, hypertension in, 407 Neuroendocrine GI tumors, 385 Neurofibromatosis (NF), 715 Neurologic complications, 194–197 alcohol withdrawal, 196 delirium, 196–197 digoxin toxicity, 195 seizures, 194–195 Neuromuscular blockers (NMBs), 227 Neuron-specific enolase, 238 Neurosurgery, 699–722

congenital neuromalformations, 718–719 epilepsy surgery, 721 hydrocephalus, 717–718 infections, 719–720 brain abscess, 719–720 subdural empyema, 720 neuroanatomy, 699–704 neuro-oncology, 712–717 acoustic neuroma, 714 astrocytomas, 713 meningioma, 713–714 neurocutaneous disorders, 715–716 pituitary tumors, 714–715 pain syndromes, 720–721 pituitary tumors, 705–706 spinal injuries and intervertebral disc disease, 706–712 cervical spine, 706–711 lumbar spine, 711–712 syringomyelia, 722 vascular malformations, 717 Neurotensin, 245 Newborn, duodenal obstruction in, 475–476 Night stick fracture, 667 Nikolsky’s sign, 296 Nimbex, 432 Nitrogen balance, 199 Nitrous oxide, 231 NK cells, 112 N-myc, 237 Node of Cloquet, 134 Node of Lund, 128 Node of Rosenmüller, 134 Nodule suppression therapy, 397 Nondepolarizing musclerelaxants (NDMRs), 228–229 Nonfunctioning islet cell tumor, 387–388 Nongonococcal urethritis, 727 Non-Hodgkin’s lymphoma (NHL), 409–410 classification of, 409 diagnosis of, 410 hypersplenism, 410 splenectomy in, 410 spread of, 409 Nonketotic hyperosmolar syndrome, 26 Nonoliguric AKI, 147, 148 Nonrebreather masks, 138–139, 139 Nonrecurrent laryngeal nerve, 391 Normal distribution, defined, 11 Nosocomial infection, 28, 204 nonsurgical, 793 NPV (negative predictive value), 796 Nucleolus, 109 Nucleus, defined, 109 Null hypothesis, 12, 796 Nursemaid’s elbow, 650, 692–693 Nutcracker, anatomic, 144 Nystagmus, 764

836 Index

O Oblique fibers, 127 O+ blood, 170 Obstetrics and gynecology, 775–787 anatomy, 775, 775 ovary, 777 uterus, 775, 775–776, 776 carcinoma of cervix, 777–778 complete hydatidiform mole, 782–783 endometrial cancer, 778–779 ovarian cancer, 779–782 partial hydatidiform mole, 783 pregnant surgical patient, 783–787 Obstruction, small-bowel, 19, 31 Obstructive sleep apnea (OSA), 534 Obterator nodes, 814 Obturator nerve, 680 Occlusion, acute arterial, 21 Occult ureteral injury, 106 Octreotide, 320–321, 324 Odontoid fractures, 708–709 Odynophagia, 547 Ogilvie’s syndrome, 191, 327 Oliguria, 147 urine output for, 158 Olsalazine, 338 Omeprazole, 807 Oncocytoma, 746–747 Oncogenes, 237 Ondansetron hydrochloride, 176 One-handed knot, 61–63, 61–63 Operative pearls, 103–107 Ophthalmology, 764–774 anatomy, 765, 765–766 cornea, 771 examination in, 766–767 glaucoma, 769–771 nontraumatic emergencies, 768–769 red eye, 774 refractive surgery, 771–772 trauma, 767–768 Orbital blowout fracture, 546 Orbital cellulitis, 768–769, 774 Orbital wall reconstruction, 502 Organ of Zuckerkandl, 380 Oriental cholangiohepatitis, 359 Oropharyngeal dysphagia, 568–569 Orthopedics, 649–699 ankle and foot injuries, 678–680 basic science, 651–652 biomechanics, 652–654 common eponyms, 650–651 emergencies, 660 clavicular fracture, 662 compartment syndrome, 660–662 elbow dislocations, 665, 665 elbow fractures, 666, 666–667, 667

forearm fractures, 667–668 humerus fracture, 664 scapula fracture, 662–663 femoral shaft fractures, 676 foot and ankle, 695 diabetic foot, 695 flatfoot, 695 toe abnormalities, 695 fractures eponyms, 655 general principles, 654–655 healing, 656 open, 656–658 hip trauma hip dislocation, 671–674, 671–675 hip fracture, 675–676 infections osteomyelitis, 685–686 septic arthritis, 685 joint reconstruction, 693–694 missed orthopedic injuries, 651 musculoskeletal oncology, 697–699 bone tumors, 698–699 soft tissue tumors, 697–698 unicameral bone cyst, 699 pediatric, 687–693 cerebral palsy (CP), 691 Duchenne muscular dystrophy (DMD), 692 hip disorders, 688 Legg–Calvé–Perthes disease, 688–689 leg length discrepancy, 687–688 myelodysplasia (spinal dysraphism), 691–692 nursemaid’s elbow, 692–693 pediatric fractures, 687, 687 scoliosis, 689–691 slipped capital femoral epiphysis (SCFE), 689 toeing-in, 692–693 pelvic and acetabular trauma acetabular fractures, 670–671 pelvic fractures, 668, 668–670, 669 peripheral nerve injury, 680 related terms, 649–650 spine, 696–697 low back pain, 696 spinal infections, 697 spondylolisthesis, 696–697 spondylolysis, 696 sports medicine, 681–684 foot and ankle sports injuries, 684 knee injuries, 683–684 rotator cuff pathology, 682–683 shoulder separation, 681–682 sprains and strains, 681 tibial shaft fractures, 678 trauma, 658–660

Index 837 traumatic knee injuries, 676, 676 knee dislocations, 677 patellar fractures, 677 Ortolani test, 688 Osgood-Schlatter disease, 650 Osmolarity of serum, 156 Osteoblasts, 113, 393, 651 Osteoclasts, 113, 393, 651 Osteogenic sarcoma, 546 Osteomyelitis, 685–686 diagnosis of, 686 of foot, 212 presentation of, 685 treatment of, 686 Osteopenia, 192 Osteotomy, 650 Ostomies, 306–309 Ovarian cancer, 779–782 Oxygen administration, 138–140, 139–140 CPAP mask, 140, 140 nasal BiPAP mask, 140, 140 nasal cannula, 139, 139–140 nonrebreather masks, 138–139, 139 Oxygen delivery, 161 determinants of, 423 Oxygen-induced hypoventilation, 138 Oxyhemoglobin dissociation curve, 165

P p53, 799 Paget–von Schröetter syndrome, 26 Pain, dealing with, 3 Paired t-test, 12 Palmaris longus (PL), 505 Palming, surgical instruments, 36 Pancoast tumor, 804 Pancreas, 92, 92, 364–370 anatomy of, 364 divisum, 367 endocrine tumors of, 367–370 fistula, 366 necrosis, 366–367 pancreatitis, 365–366 physiology of, 365 Pancreas divisum, 367, 481, 810 Pancreas transplant, 792 Pancreatic abscess, 214 drain following, 119 Pancreatic bud, 137 Pancreatic contusion, 267 Pancreatic duct injury, 267 Pancreatic duct transection, 267 Pancreatic fistulae, 366 Pancreatic islet cell tumor, 801 Pancreatic lymphoma, 370 Pancreatic necrosis, 366–367

Pancreaticoduodenectomy, 69 Pancreatic polypeptide, 245 Pancreatic pseudocyst, 369 Pancreatitis, 19, 365–366 chronic, 27, 365 gallstone, 30, 366 Pancuronium, 234, 794 Papillary thyroid cancer, 21 Paralytics, 229 Paramedian incision, 65, 65 Paranasal sinuses, 532–533 Paraneoplastic syndrome, 804 Parapharyngeal abscess, 536 Paraphimosis, 486, 729–730 Parastomal hernia, 256, 308 Paratesticular rhabdomyosarcoma, 724–725 Parathyroid glands, 399–402 autotransplantation, 402 hypercalcemic crisis, 401 physiology of, 399 postoperative hyperparathyroidism, 400–401 radiology of, 217 Parathyroid hormone (PTH), 399, 652 Paraumbilical infection, in newborn, 489 Parietal cells, 807 Parkland formula, 161, 796 Parotid gland, 497 Parrot’s beak sign, 215 Partial shunt, 348, 348 Partial thromboplastin time (PTT), 165–166 Passy-Muir trach plug, 433 Pasteur, Louis, 32 Patella, bipartite, 677 Patellar fractures, 677 Patent ductus arteriosus (PDA), 587–588 Patent foramen ovale (PFO), 586 Pathologic fracture, 654 PAV. See Proportional assist ventilation (PAV) PDPH. See Postdural puncture headache (PDPH) PDS sutures, 60 Pediatric orthopedics cerebral palsy (CP), 691 Duchenne muscular dystrophy (DMD), 692 fractures, 687, 687 hip disorders, 688 Legg–Calvé–Perthes disease, 688–689 leg length discrepancy, 687–688 myelodysplasia, 691–692 nursemaid’s elbow, 692–693 scoliosis, 689–691 slipped capital femoral epiphysis, 689 toeing-in, 692–693 Pediatrics, unstable resuscitation, 161

838 Index Pediatric surgery, 469–489 caloric requirements by age, 469 choledochal cyst, 475 congenital pulmonary cystic diseases, 473–474 duodenal obstruction in newborn, 475–476 ECMO circuit, 470 enteric duplication, 477 eventration of diaphragm, 473 foreign bodies in esophagus, 472–473 in trachea, 472 gastrointestinal hemangiomas, 478 genitourinary disorders exstrophy of bladder, 485 horseshoe kidney, 482 hypospadias, 485 infantile polycystic kidney disease, 482–483 prune belly syndrome, 486 ureteropelvic junction (UPJ) obstruction, 483–484 urethral valves, 484 vesicoureteral reflux, 484 hepatobiliary and pancreatic disorders hepatic hamartomas, 479–480 hepatic neoplasms, 478–479 hepatocellular carcinoma, 480 pancreas divisum, 481–482 rhabdomyosarcoma, 480–481 imperforate anus, 475 intestinal atresia, 477–478 IV fluid route, 469 Kasai procedure for biliary atresia, 471, 471 teratomas, 487–489 testicular torsion, 486–487 Pediatric trauma, 262–263 Pellagra, 322 Pelvic fractures, 668, 668–670, 669 unstable, 797 Pelvic hematoma, 268 Pelvic inflammatory disease (PID), 209, 255–256 Pelvic kidney, 744–745 Pemberton’s sign, 395 Penile cancer, 733–734 Penis and male urethra, 725–734 anatomy, 725, 725–726 chancroid, 729 genital herpes, 727–728 lymphogranuloma venereum, 729 paraphimosis, 729–730 penile cancer, 733–734 Peyronie’s disease, 731–732 priapism, 730–731 syphilis, 728 urethral cancer, 732–733 urethritis, 726–727

Pepsin, 249 Peptide YY, 245, 808–809 Percutaneous endoscopic gastrostomy (PEG), 101, 101, 216 Percutaneous iliac artery angioplasty, 437 Percutaneous tracheostomy, 74, 74–75 Percutaneous transhepatic cholangiography (PTC), 121 Periampullary tumors, 360–361 Pericardial tamponade, 635 Pericardium, incision, 23 Pericolostomy abscess, 308 Perilunate dislocation, 523 Perilymphatic fistula, 547 Peripheral artery aneurysm, 456 Peritoneal drain, 119 Peritoneal fluid, 218 Peritoneal lavage, diagnostic, 83–84, 84, 103 Peritoneum, 104 Peroneal (fibular) artery, 440 Peroxisome, 109 Perthes test, 462 Petit’s hernia, 256 Petit’s triangle, 127, 257, 257 PET scan, 798 Peutz–Jeghers syndrome, 812 Peyronie’s disease, 731–732 P:F ratio, 162 pH during acidosis, 202 and carbon dioxide, 161 urine, 147 Phacoemulsification, 773 Phantom limb pain, 180 Phenoxybenzamine, 176 Phenylephrine, 177 Pheochromocytoma, 15, 217, 381–382 hypertension in, 407 Phimosis, 486 Phlebitis, intravenous catheters and, 122 Phosphatidyl inositol phosphate (PIP), 110 Photorefractive keratectomy (PRK), 771 Phrenic nerve, 23, 124–125, 544 Phrygian cap, 133 Pierre Robin syndrome, 489, 535 Pigtail catheter, 122 Pirogoff ’s amputation, 449 Pituitary tumors, 705, 705–706, 706, 714–715 Placebo effect, 12 Placental abruption, 785 Plain gut sutures, 60 Plantar flexion, 649 Plasma cells, 112 Plasmin, 166, 167 Plastic surgery, 490–503 facial Langer’s lines, 490 flaps, 491–492 maxillofacial trauma

Index 839 cerebrospinal fluid rhinorrhea, 500 emergencies, 493–494 facial fractures, 497–500 facial nerve, 495–496 mandible fracture, 501 parotid gland, 497 soft tissue wounds, 494–495 trigeminal nerve, 496–497 reconstructive principles, 501–503 tissue expansion, 492–493 wound healing, abnormalities of, 490–491 Platelet aggregation, 164 Platelet count, 162 Platelet-derived growth factor, function of, 164 Platelet dysfunction thromboelastography in, 172 uremic, 168 Platelet factor 4, 190 Platelets, 162, 166 nitric oxide on, effect of, 165 prostacyclin on, effect of, 164 uremia on, effects of, 168 Platelet transfusion, 163 Platysma muscle, 541 Pleural effusion, 118, 221, 549 chylothorax, 551 empyema, 550 exudative, 549 transudative, 549 Plummer–Vinson syndrome, 26 Pneumatosis intestinalis, 216 Pneumocystis infection, in transplant recipients, 647 Pneumocytes, 24, 111 Pneumonia gram-negative, 204 gram-positive, 204 ventilator-associated, 210–211 Pneumothorax, 138, 219 tension, 221 Polydioxane sutures, 60 Polymethyl methacrylate (PMMA), 653 Polymorphonuclear neutrophil leukocytes, 166 Poole sucker, 50, 50 Popliteal artery, 439, 440 aneurysm, 813 incision for repair of, 66, 66 Popliteal entrapment syndromes, 459, 459–460 Porcelain gallbladder, 362 Portacath, 121, 121 Portal hypertension, 345–349 and ascites, 349 cause of, 345 classes of, 345 medical treatment of, 346 postsinusoidal, 345 presinusoidal, 345

shunts for, 346–348, 347, 348 sinusoidal, 345 TIPS for, 346, 346 Portal vein, ligation of, 268 Portal venous pressure, 810 Positive end-expiratory pressure (PEEP), 181, 430, 433 auto, 422 effects of, 798 Postdural puncture headache (PDPH), 233–234 Posterior fossa tumors, 540–541 Posterior tibial artery, 440 Postgastrectomy syndrome, 183 Posthitis, 486 Postperfusion syndrome (PPS), 629 Posttransfusion purpura, 170 Postvagotomy diarrhea, 185 Potassium phosphate, 432 Potassium replacement, 155 Pott’s disease, 697 Pott’s fracture, 650, 655 Pouchitis, 182–183 PP-secreting cells, 112 PPV (positive predictive value), 796 Pratt rectal speculum, 50, 50 Prealbumin, serum, 199 Prednisolone, 178 Prednisone, 178 Preeclampsia, in pregnancy, 785 Prefixes, surgical, 69 Prentiss maneuver, 737 Preoperative issues draping patient, 86 gloving, 85, 85–86 skin preparation, 85, 85 Prerenal azotemia, 149, 814 Presbycusis, 547 Pressure control ventilation (PCV), 143 Pressure, formula for, 22, 161 Pressure regulated volume control (PRVC), 143–144 Pressure support (PS) ventilation, 143 Prevalence, 12, 796 Priapism, 730–731 Primacor. See Milrinone Primary biliary cirrhosis (PBC), 363 Primary hyperparathyroidism (PHP), 801 Primitive neuroectodermal tumor (PNET), 716 Pringle maneuver, 86, 86, 345 double, 87, 87 Profunda femoris artery, 440 Progesterone, role of, in mammary development, 371 Prokaryotic cells, 108 Prolactin (PRL), 371 Prolactinoma, 705, 706, 800, 812 Prolene knot, 60

840 Index Promethazine, 175 Promethazine-induced dystonia, 179 Pronation, 649 Properitoneal hernia, 256 Prophylaxis antibiotics, 205 surgical, 213–215 Propofol, 234 Proportional assist ventilation (PAV), 144 Propranolol, 177 Prostacyclin, 164, 791 Prostate, 747–750 anatomy, 747–748 bacterial prostatitis, 748–749 prostatic abscess, 749–750 Prostatic abscess, 749–750 Prosthetic valve endocarditis (PVE), 617–618 Prosthetic valves mechanical valves, 614 tissue valves, 615 Prostigmin. See Neostigmine Protamine, 791 Protein calorie content of, 159 digestion of, 248–249 respiratory quotient for, 162 Protein C, 169 Protein C deficiency, 791 Protein S, 169 Proto-oncogenes, 799 Protozoan infection, in immunosuppressed patients, 647 Proud flesh, 491 Prune belly syndrome, 486 PRVC. See Pressure regulated volume control (PRVC) PSA, 238 P-selectin, 790 Pseudohyponatremia, 154 Pseudomembranous colitis, 30 Pseudomonas infection, 212 Pseudomyxoma peritonei, 318, 780 Psoas hitch, 759, 759, 814 PT, 792, 810 Pterion, 699 Pterygium, 773 Ptosis, 764 Pulmonary artery sling, 596 Pulmonary artery wedge, 126 Pulmonary capillary endothelial cells, 111 Pulmonary contusion, 432, 579 Pulmonary cystic diseases, congenital, 473–474 Pulmonary edema, 180–181 Pulmonary embolus, 466 Pulmonary fibrosis, 799 Pulmonary metastases, 411 Pulmonary sequestration, 474 Pulmonary tractomy, 92, 92

Pulmonary trauma, 579–580 pulmonary contusion, 579 traumatic air embolism, 580 traumatic asphyxia, 579–580 Pulmonary valve, 614 Pulmonary vascular resistance (PVR), 161, 421 Pulsus paradoxus, 8, 285 Purcutaneous mitral balloon valvotomy (PMBV), 611 Pyelophlebitis, 317 Pyloric exclusion, 282, 282 Pyloroplasty Finney, 102 Jaboulay, 101 Pyonephrosis, 743 Pyrosis, defined, 8, 69

Q Quadriceps active test, 684 Quinolones, 175, 207 Quinsy, 545

R Radial artery, 443 Radial nerve, 680 Radiation therapy, 238 Radical cholecystectomy, 362 Radiolucent kidney stones, 16 Ranson criteria, 19–20 Rapamycin (RAPA), 643 Rapid Shallow Breathing Index, 798 Rasmussen aneurysm, 559 Rat-toothed forceps, 51 Ravitch, M. M., 35 Ray amputation, 445, 445 RBC casts, 150 Recovery room protocol, 3 Rectal cancer, 328–330, 811 coloanal anastomosis, 329, 329 Dukes’ staging, 328 neoadjuvant, 328 total mesorectal excision, 329 transanal rectal cancer resection, 329 Rectum length of, 132, 160 peritoneal covering, 132 Recurrent laryngeal nerve, 800 Recurrent laryngeal nerve injury, 397–398 Red eye, 774 Red reflex, absence of, 767 Reduction, 649 closed, 649 open, 649, 655 Refeeding syndrome, 199 Refldan. See Lepirudin

Index 841 Reflex sympathetic dystrophy, 814 Refractory heartburn, 802 Refractory hiccups, 178 Refractory hypertension, ICU, 432 Regional anesthesia, 232–233 systemic toxicity from, 232 Reitz, B. A., 34 Relative risk calculation of, 13 of disease, 12 Renal arteries, 451–452 Renal artery stenosis, hypertension in, 407 Renal clearance, 741 Renal failure, postoperative, 28, 795 Renal parenchymal disease, hypertension in, 409 Renal transplant, 792 Renal tubular acidosis (RTA), 744 Renal vein, 136 obstruction, 146 Renin, 742 Replantation of amputated digit, 512–513 Respiratory care, 138–144 endotracheal intubation, 141, 141 incentive spirometry, 138, 138 mechanical ventilation, 142–144 oxygen administration, 138–140, 139–140 tracheostomy, 141–142, 142 Respiratory quotient (RQ), 198–199, 789 for carbohydrates, 162 for fat, 162 formula for, 198 for protein, 162 Resuscitation end points of, 202 unstable pediatric, 161 Reticulum, endoplasmic, 109 Retinal detachment, 767 Retractor Balfour, 38 Bookwalter, 40 Gelpi, 45 Gomez, 46 Lone Star, 49, 49 vein, 53 Retrocolic, defined, 8 Retrocolic Roux-en-Y procedure, 96, 96 Retrohepatic venous hemorrhage, 270 Retroperitoneal calcification, 215 Retroperitoneal trauma, 280–281 Retroperitoneum, zones, 133, 133 Retropharyngeal abscess, 536 Reverse cutting needle, 58, 58 Rhabdomyosarcoma (RMS), 413–414, 480–481 advanced, 414 alveolar, 413 embryonal, 413, 414 paratesticular, 724–725

pleomorphic, 413 sarcoma botryoides, 413 Rheumatic heart disease, 614 Rheumatoid arthritis, in hands, 526 Rhinitis, acute, 536 Ribosomal RNA (rRNA), 109 Ribosomes, free, 109 RICE treatment, for extremity injuries, 284 Riedel’s thyroiditis, 396 Ring sign, 10 Rinne’s test, 537 Riolan, space of, 132 Ripstein procedure, 98, 98 RMS. See Rhabdomyosarcoma (RMS) Robinul. See Glycopyrrolate Rocuronium, 229 Rokitansky-Aschoff sinuses, 350 Rolando’s fracture, 521 Rongeur, 51 Rosenmüller, node of, 134 Rotator cuff pathology, 682–683 Rotor’s syndrome, 344 Round ligament, 776 Round ligament pain, 255 Roux stasis syndrome, 185–186 R time, 172 Rubber catheter, 35 Russian forceps, 52, 52 Rx hyperphosphatemia, 156

S Sabiston, D. C., 35 Saddle block, 234 Saline, normal chloride in, 159 defined, 156 sodium in, 159 Salivary glands, 528–531 anatomy of, 528–529 sialadenitis, 529–530 sialolithiasis, 530–531 trauma, 529 Salter classification, of fractures, 687 Saphenous vein graft, 447 Sappey’s line, 128 Sappey, veins of, 128 Sarcoma botryoides, 413 Sarcoma metastasis, 239 Sarcomas, 239 Ewing’s, 25 gastric, 28 risk factors for, 22 Satinsky, 52, 52 SBO. See Small-bowel obstruction (SBO) Scab, 116 Scalene muscle, anterior, 124 Scalene muscles, 541

842 Index Scalpel blade, 37, 37, 53 Scaphoid fracture, 522–523 Scapholunate dissociation, 523–524 Scapula fracture, 662–663 S cells, 111 Schiller-Duval bodies, 781 Schilling test, 315 Schrock shunt, 122 Sciatic hernia, 256 Sciatic nerve, 680 Sciwora, 285 Scleroderma, 569 Scoliosis, 689–691 Secretin, 809 Segmentectomy, 131 Seizures, 194–195 inhalation anesthetics and, 231 Seldinger technique, 8 for percutaneous tracheostomy, 74–75 for placing central line, 77 Sellick’s maneuver, 235 Sensitivity, 11, 796 Sensorineural hearing loss, 537, 538 Sentinel loops, 215 Sepsis, 201 Sepsis, gram-negative, 793 Septal hematoma, traumatic, 533 Septal necrosis, 192 Septic arthritis, 515–516, 685 Septic shock, 201, 202 body temperature during, 202 Sequential compression device (SCD), 214 Serafini’s hernia, 256 Serous otitis media, 538–539 Serratus anterior, 805 Serum prealbumin, 199 Sestamibi scan, 401 Shenton’s line, 671, 671 Shock, 201–203 anaphylactic, 24 blood pressure during, 201 hemorrhagical, 202, 203 inflammatory, 201 refractory neurogenic, 202 septic, 201, 202 Shoulder separation, 681–682 Shunts end-to-side portacaval, 347, 347 mesocaval “H,” 347, 347 partial, 348, 348 side-to-side portacaval, 347, 347 transjugular intrahepatic portacaval, 346, 346 Warren distal splenorenal, 348, 348 SIADH. See Syndrome of inappropriate antidiuretic hormone (SIADH) Sialadenitis, 529–530 Sialolithiasis, 530–531 Sick euthyroid syndrome, 26, 433

Side-to-side portacaval shunt, 347, 347 Sigmoid colectomy, 96 Silvadene, 289, 293 Silver nitrate, 289 Silver sulfadiazine, 116, 289 SIMV. See Synchronized intermittent mechanical ventilation (SIMV) Sinusitis, 212 Sinusoids, 461 Skewed distribution, defined, 11 Skin lesions, 416–417 Skin preparation, surgical, 85, 85 Skull, 700 Sleep deprivation, 1 Slipknot, 54, 54 Slipped capital femoral epiphysis (SCFE), 689 Small-bowel obstruction (SBO), 19, 31 abdominal x-ray of, 216 bowel necrosis with, 24 ileus, 216 Small gastric remnant syndrome, 188 Small intestine, 16, 310–315 adenocarcinoma of, 312–313 adenoma, 29 benign tumors of, 311 blind loop syndrome, 315 enteric infections, 314 laceration to, 267 length of, 132 lymphoma of, 313–314 malignant tumors of, 311–312 obstruction, 310–311 (See also Small-bowel obstruction (SBO)) anticoagulant-induced obstruction, 311 ileus, 310 perforations, 267 transplantation, 646 transverse closure, 104 Smead–Jones stitch, 58 Smith’s fracture, 655, 667 Soap bubble sign, 10 Soft tissue sarcomas and lymphomas, 409–416 desmoid tumors, 414–415 fibrosarcoma, 414 gastric lymphoma, 410–411 Kaposi’s sarcoma, 415–416 liposarcoma, 412–413 malignant fibrous histiocytoma, 412 non-Hodgkin’s lymphoma, 409–410 pulmonary metastases, 411 rhabdomyosarcoma, 413–414 soft tissue sarcoma, 411 Soft tissue tumors, 697–698 Solitary pulmonary nodule (SPN), 561–562 Somatostatin, 809 Somatostatinomas, 369, 389–390 Space of Retzius, 134 Space of Riolan, 132

Index 843 Spanish, medical phrases in, 13–14 Specificity, 11, 796 Spermatic cord, tumor of, 724–725 Spider bite brown recluse, 115 dapsone for, 179 Spina bifida occulta, 718–719 Spinal accessory nerve, 543 Spinalanesthesia, 233–234 Spinal cord injury, 29 in cervical spine, 30 Sch in, 228 Spinal cord syndrome anterior, 24 central, 24 Spinal dysraphism. See Myelodysplasia Spine, 696–697 infections, 697 injuries and intervertebral disc disease, 706–712 cervical spine, 706–711 lumbar spine, 711–712 low back pain, 696 spondylolisthesis, 696–697 spondylolysis, 696 Spirometry waves, 422, 422 Spironolactone, 349 Spleen, 402–406 cardiac output to, 160 Felty’s syndrome, 405 hereditary spherocytosis, 405 immune thrombocytopenic purpura, 403–404 splenic vein thrombosis, 405 thrombotic thrombocytopenic purpura, 404–405 tumors of, 406 Spleen injury severity scale, 278–279, 279 Splenectomy, 300 drain following, 119 vaccinations after, 797 Splenic abscess, 209 Splenic cysts, 406 Splenic vein thrombosis, 405 Splenorrhaphy, 98, 98 Spondylolisthesis, 696–697 Spondylolysis, 696 Sports medicine, 681–684 foot and ankle sports injuries, 684 knee injuries, 683–684 rotator cuff pathology, 682–683 shoulder separation, 681–682 sprains and strains, 681 Sprains, 681 Squamous cell carcinoma of anus, 812 of bladder, 753 of larynx, 800

Squamous cell paraneoplastic syndrome, 804 Stamm gastrostomy, 102, 102 Staphylococcus aureus, 213 Status epilepticus, 194–195 Stensen’s duct injury, 529 Sterile, defined, 9 Sterile field, defined, 9 Sternocleidomastoid (SCM) muscle, 541 Stevens-Johnson syndrome (SJS), 296 Stewart–Treves syndrome, 411 Stitch Connell’s, 55, 55 Cushing, 56, 56 Gambee, 55, 55 Halsted, 56, 56 Lembert, 54, 54 locking, 56, 56 Smead–Jones, 58 U, 55, 55 Stomach, 299–304 cancer, 300–302 carcinoid, 304 laceration, 268 lymphoma, 302–303 rotation of, 136 sarcoma, 303–304 ulcers, 299–300 Strabismus, 764, 773 Strains, 652, 681 Strap muscles, 541 Streptozocin, 175 Stress, 652 Stress shielding, 653 Strike through, defined, 9 String sign, 216 Studying, 1 Sturge–Weber syndrome, 716 Subclavian artery, 125, 443, 803 Subclavian artery stenosis, 442 Subclavian central line, 76, 76, 77, 104 Subclavian vein, 126 Subdural empyema, 720 Subdural hygroma, 704 Subluxation, 650 Subungual hematoma, 525 Succinylcholine (Sch), 228, 794 Sudeck’s point, 133 Suffixes, surgical, 69 Sulfasalazine, 175 Superficial femoral artery, 439, 440 Superficial palmar arch, 443 Superior gluteal artery, 669 Superior gluteal nerve, 680 Superior laryngeal nerve, 391, 800 Superior lumbar triangle, 128 Superior mesenteric artery (SMA), 451 Superior thyroid artery, 800 Superior vena cava (SVC) syndrome, 581

844 Index Supination, 649 Suppressor T cells (Ts), 112 Suppurative parotiditis, acute, 530 Suppurative tenosynovitis, 514–515 Supraclavicularadenopathy, 240 Supraorbital fractures, 499 Supreme artery of Kirk, 129 Surgical abbreviations, 3–8 Surgical anatomy, 123–137 abdomen, 127–134, 128–131, 133 lower extremity, 134–136, 135 neck, 124–127, 124–127 thyroid, 123–124, 124 Surgical complications, 180–192 adrenal insufficiency, 188–189 afferent loop syndrome, 183, 183–184 alkaline reflux gastritis, 186 atelectasis, 180 chronic gastric atony, 187–188 dumping syndrome, 187 efferent loop syndrome, 184–185 fat emboli syndrome, 182 gastrointestinal, 182–183 blind loop syndrome, 182 postgastrectomy syndromes, 183 pouchitis, 182–183 heparin-induced thrombocytopenia, 189–191 postvagotomy diarrhea, 185 pulmonary edema, 180–181 Roux stasis syndrome, 185–186 small gastric remnant syndrome, 188 thyroid storm, 181 Surgical hemostasis, 173–174 Surgical instruments blade on scalpel, 37, 37 palming, 36 removing clamp, 37 types of, 37–53, 37–53 Surgical intensive care, 420–435 acute respiratory distress syndrome (ARDS), 423–425 antidotes, 426–427 end points of resuscitation, 421–422 ICU formulas, 420–421 landmark ICU papers, 427–429 medications, 425–426 oxygen delivery and consumption, 423 respiratory system, 422 Surgical maneuvers, 86–89 Blaisdell, 88 Cattel, 88, 88 double Pringle, 87, 87 Grey-Turner, 87 Kocher, 87, 87 Mattox, 88, 88 Pringle, 86, 86 Utley, 89, 193

Surgical medications, 175–180 antidote, 179 endocrine medications, 177 Surgical nutrition, 198–200 Surgical operation, endocrine, 29 Surgical positions, 66–68 Durant, 68, 68 Fowler, 67, 67 jack-knife, 67, 67 kidney, 67, 67 of patients with thoracoabdominal injuries, 67, 67–68 Sims’, 66, 66 supine, 68 Surgical prophylaxis, 213–215 Surgical radiology, 215–222 of abdomen, 215–218 of cervical spine, 219–220, 220 of chest, 221–222, 222 of trauma, 218, 218–219 Surgical residents, hierarchy in, 3 Surgical ulcers, 235–236, 235–236 crack ulcer, 235 gastric ulcers, 235–236, 235–236 Surgicel, 174 Sutures absorbable, 60, 61 around clamped bleeding vessel, 58, 58 materials for, 60–61 needles for, 57–58, 57–58 nonabsorbable, 60, 61 removal of, 54, 54 retention bridge, 57, 57 slipknot, 54, 54 techniques for, 54–59 train tracks with, 60 SVC syndrome, 803 Swan-Ganz catheters, 78–81, 79–81, 222 with cardiac tamponade, 81 indications for, 78 with pulmonary embolus, 81 volume status by, 78 Swan–Ganz pulmonary artery injury, 428 Swan, J., 35 Syme’s amputation, 445, 445 Sympathetic ophthalmia, 768 Synchronized intermittent mechanical ventilation (SIMV), 142–143 Syndrome of inappropriate antidiuretic hormone (SIADH), 14, 154 Syphilis, 728 Syringomyelia, 722 Systemic inflammatory response syndrome (SIRS), 201 Systemic vascular resistance (SVR), formula for, 161 Systolic blood pressure (SBP), in pediatric patients, 263

Index 845

T Tachycardia, 158 Tachykinins, 319 Tacrolimus. See FK-506 Tactile gnosia, 511 Takayasu’s arteritis, 460–461 Taper needle, 57, 57 T cells, 112 Temporal bone fracture, 797 Tendons, of hand lacerations, 516–519 partial tendon lacerations, 518 zones for description, 517, 517–518 Tendon synovial sheaths, 504 Tenesmus, 331 Ten horns sign, 10 Tension pneumothorax, 286 Teratomas, 487–489 dermoid tumor, 488 gastric, 488 ovarian, 488, 489 sacrococcygeal, 488 tumor markers, 487 types of, 488 Terminology prefixes, 69 suffixes, 69 Tertiary exam, 284 Testicular autotransplantation, 738 Testicular cancer, radiosensitive, 16 Testicular torsion, 486–487 Testis and epididymis, 734–738 anatomy, 734–735 cryptorchid testis, 736–738 ectopic testis, 735 epididymal adenomatoid tumors, 738 Tetralogy of Fallot (TOF), 590, 590 Thebesian veins, 136 Thenar muscles, 508 Theophylline, 179 Thioguanine (6-TG), 241 Thiopental, 230 Thoracic aortic aneurysms, 618–622 Thoracic aortogram, 30 Thoracic duct, 125, 543 Thoracic injuries, deadly dozen, 284 Thoracic nerve, during axillary dissection, 126 Thoracic outlet syndrome, 580 Thoracic surgery, 548–581 anatomy esophagus, 566–567 lung, 557 mediastinum, 564, 564 trachea, 552 chest wall tumors, 548–549 esophagus, 566–577

barium esophagogram, 577, 577 benign tumors, 574–575 caustic injuries, 575–576 esophageal diverticula, 569–570 esophageal webs, 576 motility disorders, 567–569 perforation, 571–574 pharyngoesophageal (Zenker’s) diverticulum, 570–571 lung, 557–564 bronchiectasis, 558–559 congenital lung lesions, 558 massive hemoptysis, 560–561 mycotic infections, 560 nodules, 561–563 segmental anatomy of, 563, 563–564 tuberculosis, 559 mediastinum, 564–566 mediastinal masses, 565–566 pleural effusion, 549 chylothorax, 551 empyema, 550 thoracic trauma, 578–580 pulmonary trauma, 579–580 tracheobronchial trauma, 578–579 trachea, 552–557 acquired aerodigestive tract fistulae, 555 malignant fistulae, 555 nonmalignant fistulae, 555 tracheal stenosis, 552–553 tracheal tumors, 554–555 tracheoinnominate artery fistulae, 556 tracheostomy, 557 Thoracoabdominal aortic aneurysms, 618–622 Thoracotomy emergency, 82–83, 82–83, 265, 265–267, 266 cutting pericardial sac, 83, 83 incision in, 82, 265 mobilization of lung, 82, 82 thoracic aorta, clamping of, 83, 83 Thorazine, 178 Three-vessel disease, 598 Thrill, defined, 9 Thromboangiitis obliterans (TAO), 458–459 Thromboelastography (TEG), 171–172 fibrinolysis and, 172 graph, 171 parameters, 172 Thrombophlebitis, in burn patients, 291 Thrombotic thrombocytopenic purpura (TTP), 404–405 Thromboxane, 164 Thyrocervical trunk, branches of, 125 Thyroid artery, 123 Thyroid cartilage, 73 Thyroid function tests, 393

846 Index Thyroid gland, 390–398 anatomy of, 123–124, 124, 390, 390–391 incision, 64, 64 physiology of, 391–393 postoperative hypoparathyroidism, 398 recurrent laryngeal nerve injury, 397–398 thyroid function tests, 393 thyroiditis, 394–396 thyroid nodule, 396–397 Thyroid hormone, synthesis and release, 391–392 Thyroiditis, 394–396 acute, 21, 394 chronic, 395 fibrous, 396 subacute, 21, 394–395 suppurative, 209 Thyroid lobectomy, 801 Thyroid nodule, 396–397 Thyroid-stimulating hormone (TSH), 393 Thyroid storm, 181 Tibia fracture, 814 Tibial nerve, 680 Tibial torsion, 693 Tibioperoneal occlusive disease, 437–438 Ticarcillin, 205 Ticlopidine, 170 Tinel’s sign, 721 Tinnitus, 800 Tissue expansion, 492–493 Tissue necrosis factor (TNF), 789 Tissue oximetry, 201 Tissue plasminogen activator (tPA), 167 Tissue valves, 615 Tobin index, 422 Tobin shallow breathing index, 427 Tobramycin/gentamicin “rule of sevens,” 433 Toeing-in, 692–693 Torticollis, 489 Torus fracture, 654 Total anomalous pulmonary venous connection (TAPVC), 593–594, 594 Total body surface area (TBSA) burn, 160 Total hip arthroplasty, 694 Total intravenous anesthesia (TOVA), 230 Toxic epidermal necrolysis (TEN), 296 Toxic shock syndrome, 210 Trachea, 552–557 acquired aerodigestive tract fistulae, 555 anatomy of, 552 malignant fistulae, 555 nonmalignant fistulae, 555 tracheal stenosis, 552–553 tracheoinnominate artery fistulae, 556 tracheostomy, 557 tumors of, 554–555 Tracheal foreign body, 472 Tracheobronchial trauma, 578–579

Tracheoesophageal fistula formation, 192–193 Tracheoinnominate artery fistulae (TIF), 193, 556 Tracheomalacia, acquired, 553 Tracheostomy, 106, 141–142, 142, 557, 799 complications to, 192–193 CXR following, 222 fenestrated trach tube, 142, 142 percutaneous, 74, 74–75 Tractomy, pulmonary, 92, 92 TRALI. See Transfusion-related acute lung injury (TRALI) Transduodenal sphincterotomy, 358 Transfer RNA (tRNA), 110 Transfusion-related acute lung injury (TRALI), 170–171 Transitional cell carcinoma (TCCa) of bladder, 754–756 of renal pelvis or ureter, 761–762 Transjugular intrahepatic portacaval shunt (TIPS), 346, 346 Transmetatarsal amputation, 446, 446 Transplantation antigens, 641 Transplant surgery, 640–648, 792 gastrointestinal tract, 646 heart, 622–627 immunosuppression, 646–648 immunosuppressive agents, 642–643 liver, 643–646 major histocompatibility complex (MHC), 640–642 mechanisms of rejection, 648 Transposition of great vessels, 592, 592–593 Transverse abdominal incision, 65, 65 Transverse colectomy, 95 Trapezius muscle, 541, 542 Trapezoid of doom, 260, 261 Trauma, 262–286 blunt cardiac arrest, 24 cranial nerve injury in, 29 history in, 262 bowel injuries, 284 in children, 29 circulation, 263 damage control, 273–275 diagnostic peritoneal lavage for, 103 duodenal injuries, 281–283 gunshot wounds, 263–264 injury scales, 275–279 kidney, 279 liver, 276–278 spleen, 278–279 lactic acid during, 202–203 to liver, 91, 91 management, 267–273 ocular, 767–768

Index 847 pancuronium for, 234 pediatric, 262–263 penetrating neck, 271 retroperitoneal, 280–281 thoracic, 578–580 thoracotomy, 265, 265–267, 266 urethral, 281 Traumatic septal hematoma, 533 Trendelenburg test, 462 Treves’ folds, 132 Tricuspid valve disease (TVD), 613 Trigeminal nerve, 496–497 Trigeminal neuralgia (TN), 720 Trigger finger, 526 Trimethoprim-sulfamethoxazole, 207 Trisegmentectomy, 131 Trocar bladder injury, treatment for, 107 Trocar bleedding. repair of, 108 Trocar placement, 107 Trocars, 260 Trousseau, A., 33 Truncal vagotomy, 100, 100 Truncus arteriosus, 589, 589 Trypsin, 249 T-tube biliary, removal of, 122 cholangiogram, 118 Tube feeding, 105, 200 Tube placement, in diagnostic peritoneal lavage, 84, 84 Tuberculosis (TB), 559 Tuberous sclerosis, 716 Tube(s) Cantor, 118 fenestrated tracheostomy, 142, 142 Malencott, 122 Miller–Abbott, 118 T-tube biliary, removal of, 122 cholangiogram, 118 Tumor markers, 238 Tumors adrenal incidentaloma and, 27 cardiac, 639–640 cell cycle of, 237 esophagus, 29 small-bowel, 29 Tuning fork analysis, for hearing loss conditions, 538 TURB (transurethral resection of the bladder), 763 Turcot syndrome, 27 Turf toe, 684 TURP (transurethral resection of the prostate), 763 Type I error, 12, 796 Type II error, 12, 796 Tyrosine, 813

U Ulcerative colitis, 335–338 Ulnar artery, 443 Ulnar nerve, 680 Ulnar nerve compression, 524–525 Ultrafiltration, defined, 152 Ultrasonic coagulators, 174 Umbilical hernia, nonabsorbable suture for, 60 Unicameral bone cyst, 699 Upper esophageal sphincter (UES), 566–567, 801 Upper extremity deep venous thrombosis, 465–466 Upper extremity, arterial occlusive disease of, 442–444 Urachus, 750 Urea clearance, 146 Uremia, 168 Ureteral injury, occult, 106 Ureteroneocystostomy, 69 Ureteropelvic junction (UPJ) obstruction, 483–484, 757 Ureters, during pelvic dissection, 106 Urethral cancer, 732–733 Urethral trauma, 281 Urethral valves, 484 Urethritis, 726–727 Urinary tract infection (UTI), 204, 215 Urine dipstick test, 146, 147 Urine osmolarity, 149 Urine output, 147, 148 for anuria, 158 for oliguria, 158 Urine pH, 147 Urine protein excretion, 146 Urine specific gravity, 147 Urobilinogen, in urine, 352 Urology, 722–763 bladder, 750–756 acute cystitis, 751 adenocarcinoma of, 753 anatomy, 750 hemorrhagic cystitis, 753 interstitial cystitis, 752 squamous cell carcinoma of, 753 transitional cell carcinoma of, 754–756 collecting system and ureters, 756 congenital and acquired disorders, 757 ectopic ureter, 760 idiopathic retroperitoneal fibrosis, 761 transitional cell carcinoma (TCCa), 761–762 ureteropelvic junction obstruction, 757 vesicoureteral reflux, 757–760, 758, 759 kidneys, 738–747 adult polycystic kidney disease, 745 anatomy, 738–741

848 Index Urology (Contd.) multicystic dysplastic kidney disease, 745–746 oncocytoma, 746–747 pelvic kidney, 744–745 physiology, 741–743 pyonephrosis, 743 renal tubular acidosis, 744 xanthogranulomatous pyelonephritis, 743–744 penis and male urethra, 725–734 anatomy, 725, 725–726 chancroid, 729 genital herpes, 727–728 lymphogranuloma venereum, 729 paraphimosis, 729–730 penile cancer, 733–734 Peyronie’s disease, 731–732 priapism, 730–731 syphilis, 728 urethral cancer, 732–733 urethritis, 726–727 prostate, 747–750 anatomy, 747–748 bacterial prostatitis, 748–749 prostatic abscess, 749–750 scrotum and spermatic cord, 722–725 anatomy, 722–723 Fournier’s gangrene, 723–724 tumor of spermatic cord, 724–725 testis and epididymis, 734–738 anatomy, 734–735 cryptorchid testis, 736–738 ectopic testis, 735 epididymal adenomatoid tumors, 738 U stitch, 55, 55 Utley maneuver, 89, 193, 556

V Vagotomy, truncal, 100, 100 Vagus nerve, 543 Valgus, 649 Valium, 432 Valve replacement, complications of, 615–616 Valvular heart disease, 603–618 aortic valve, 603–609 aortic regurgitation, 608–609 aortic stenosis, 605–608 cardiac valves, on chest x-rays, 616, 616 infectious endocarditis, 616–618 mitral valve, 609–613 mitral regurgitation, 611–612 mitral stenosis, 610–611 mitral valve prolapse, 613 prosthetic valves, 614–616 mechanical valves, 614 tissue valves, 615

valve replacement, complications of, 615–616 pulmonary valve, 614 rheumatic heart disease, 614 tricuspid valve, 613 Vancomycin, 207 Vancomycin-resistant enterococcal (VRE) infection, 205 Vanishing duct syndrome, 259 van Wassenaer, Baron, 35 Varicocele, 763 Varicose veins, 103 Varus, 649 Vascular access for hemodialysis, 466–468 incisions for, 441 Vascular clamp, 52 Vascular damage control, 275 Vascular endothelial cells, 113 Vascular rings, 595–596 Vascular surgery, 437–468 amputations, 445–449 above the knee, 446–449 below-the-knee, 446–449 Chopart’s, 449 Gritti-Stokes, 449 indications for, 446 Lisfranc’s, 449 operative technique for, principles of, 447 Pirogoff ’s, 449 ray, 445, 445 Syme’s, 445, 445 transmetatarsal, 446, 446 aneurysms, 454–457 abdominal aortic aneurysm, 454–456 peripheral artery aneurysm, 456 visceral artery aneurysm, 457 aorta, visceral branches of, 451–452 mesenteric arteries, 451 renal arteries, 451–452 arterial occlusive disease of lower extremity, 437–441 of upper extremity, 442–444 carotid body tumor, 468 extracranial cerebrovascular disease, 450 hemodialysis, vascular access for, 466–468 nonatherosclerotic vascular disease, 458–461 popliteal entrapment syndromes, 459–460 Takayasu’s arteritis, 460–461 thromboangiitis obliterans, 458–459 venous and lymphatic disease, 461–466 chronic venous insufficiency, 464–465 lower extremity varicosities, 462–463 upper extremity deep venous thrombosis, 465–466 venous anatomy and physiology, 461 venous insufficiency, diagnosis of, 461–462

Index 849 visceral ischemic syndromes, 452–454 acute mesenteric ischemia, 452–454 Vas injury, 106 Vasoactive intestinal polypeptide, 244 Vein of Mayo, 131 Vein retractor, 53 Veins of Sappey, 128 Velpeau’s hernia, 256 Venous circulation, anatomy of, 461 Venous cutdown, 75 Venous insufficiency chronic, 464–465 diagnosis of, 461–462 Venous oxygen saturation (SVO2), 798 Venous ulcers, 464 Ventilator-associated pneumonia (VAP), 210–211 diagnosis, 210 risk factors for, 210 treatment for, 211 Ventricular septal defects (VSDs), 584–585 Veress needle, 260 Verner–Morrison syndrome, 27, 368 Vertebral artery, 443 Vertebrobasilar disease, 450 Vesicoureteral reflux (VUR), 483, 484, 757–760 Vestibular neuritis, 539–540, 547 Vicryl sutures, 60 VIPomas, 31, 157, 368, 388–389 Viral conjunctivitis, 774 Viral infection, of burn wounds, 290 Viral transmission, 29 Virchow’s node, 807 Visceral artery aneurysm, 457 Visipaque, 150 Vitamin D, 399, 652 deficiency, 200 synthesis, steps in, 796 Vitamin deficiency, associated with antibiotics, 180 Vitamin E deficiency, 200 Vitamin K, 345 VLDL (Very low-density lipoprotein), 248 Vocal cord (VC) nodules and polyps, 531–532 Volume control (VC), 142 Von Hippel–Lindau syndrome, 27, 716 von Langenbeck, B., 33 von Willebrand factor (vWF), 165 VUR. See Vesicoureteral reflux (VUR) vWB disease, 791

W Waddle’s triad, 285 Waldeyer’s fascia, 135 Warfarin, 167, 178 for HITT, 191 skin complication of, 192

Warren distal splenorenal shunt, 105, 348, 348 Warthin’s tumor, 546 Washout phenomenon, 201 Waterhouse–Friderichsen syndrome, 27, 384 WBC casts, 150 WDHA syndrome, 368, 369 Weak arm adduction, 805 Weber’s test, 537 Wedge pressure tracing, 79–81, 79–81 with mitral regurgitation, 81, 81 pulmonary artery, 79–80 pulmonary capillary, 80, 80 right atrium, 79 right ventricle, 79 verwedged, 80, 80 Wedge resection, for bleeding gastric leiomyoma, 297 Weir extension, 64 Wernicke–Korsakoff syndrome, 27 Wertheim operation, 778 White line of Hilton, 132 Winged scapula, 805 Witzel procedure, 97, 97 Wolfe law, 652 Wolff–Chaikoff–White block, 392 Wound infections, 117, 204 antibiotics for, 117, 205 bacterial, 28, 208 Wounds, 115–117 cleansing, 30, 493 closure and healing, 116–117 decubitus ulcers, 115–116 healing, 116–117, 793, 799 drains and, 116 infection, 793 with subQ space, 116 Wound Vac, 116

X Xanthine oxidase, 295 Xanthogranulomatous pyelonephritis, 743–744 Xenograft, 290

Y Yersinia enterocolitica, 209

Z Zantac, 427 Zenker’s diverticulum, 570–571, 802 Zofran. See Ondansetron hydrochloride Zollinger-Ellison syndrome, 25, 368 Zuckerkandl’s tubercle, 124 Zygoma fractures, 498, 502

Advanced Surgical Recall 4e

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