The Concise Surgery Review Manual for the ABSITE & Boards [2nd Edition] 9798520440093

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The Concise Surgery Review Manual FOR THE ABSITE & BOARDS

2ND EDITION

Tommy Alan Brown, II MD | GENERAL SURGERY

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

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

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Contents 1.

Cell Biology & Hematology........................................................................................... 1

2.

Immunology, Inflammation, & Cytokines ..................................................................... 8

3.

Infection & Antibiotics ............................................................................................... 10

4.

Anesthesia, Medications, & Pharmacology................................................................. 17

5.

Fluids, Electrolytes, & Nutrition ................................................................................. 22

6.

Oncology ................................................................................................................... 28

7.

Transplantation ......................................................................................................... 31

8.

Wound Healing .......................................................................................................... 35

9.

Trauma...................................................................................................................... 36

10.

Critical Care ............................................................................................................... 55

11.

Burns......................................................................................................................... 62

12.

Plastics, Skin, & Soft Tissues....................................................................................... 67

13.

Head & Neck.............................................................................................................. 72

14.

Pituitary .................................................................................................................... 78

15.

Adrenal ..................................................................................................................... 79

16.

Thyroid ...................................................................................................................... 83

17.

Parathyroid ............................................................................................................... 89

18.

Breast........................................................................................................................ 92

19.

Thoracic................................................................................................................... 100

20.

Cardiac .................................................................................................................... 106

21.

Vascular .................................................................................................................. 108

22.

GI Hormones ........................................................................................................... 118

23.

Esophagus ............................................................................................................... 120

24.

Stomach .................................................................................................................. 125

25.

Liver ........................................................................................................................ 135

26.

Biliary System .......................................................................................................... 143

27.

Pancreas.................................................................................................................. 150

28.

Spleen ..................................................................................................................... 157

29.

Small Bowel............................................................................................................. 160

30.

Colorectal ................................................................................................................ 166

31.

Anal & Rectal........................................................................................................... 175

32.

Herniae, Abdomen, & Surgical Tech ......................................................................... 180

33.

Urology ................................................................................................................... 188

34.

Gynecology.............................................................................................................. 192

35.

Neurosurgery .......................................................................................................... 196

36.

Orthopaedics ........................................................................................................... 197

37.

Pediatric Surgery ..................................................................................................... 201

38.

Statistics & Pt Safety ................................................................................................ 210

39.

MIS ......................................................................................................................... 213

40.

Abbreviations .......................................................................................................... 214

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1. Cell Biology & Hematology A. Coagulation Factors 1) 2) 3) 4)

All from liver minus f VIII (f VIII & its cofactor vWF [from endothelium]). Extrinsic → f I (tissue factor) & VII. Intrinsic → collagen (exposed), f XII, kininogen, & prekallikrein. Vit K dependent cofactors → f II, VII, IX, & X (Also proteins C & S). a. Warfarin inhibits these. 5) Factor VII → shortest ½-life. 6) Fibrin → binds Gpllb/llla → cross-links PLTs. 7) Prothrombin (Xase) complex f II, V, & X + Ca++ + PF3. Is on PLTs. a. Catalyzes f IIa (thrombin). 8) Thrombin (f II, Key for coag) →→ fibrinogen → fibrin + FSPs. a. Activates f V & VIII, PLTs. Fibrin + PLTs → hemostatic plug. 9) Anti-thrombin III (Key for anticoag). Binds & inhibits f IIa, IX, X(MI), & XI. a. Heparin ↑ AT-III activity 1000 x. 10) Protein C → degrades f V, VIII, & fibrinogen. 11) FFP → ↑all factors, protein C & S, & AT-III. Immediate effect (thaw 1st). a. Corrects coagulopathy 2/2 liver dz or warfarin (↑PT). b. FFP INR is 1.1 on avg, but will not significantly ↓ INR to ≤ 1.6. 12) Cryo → Highest vWF-VIII concentration, also ↑ fibrinogen. a. Used in vWB dz & hemophilia A (f VIII def). 13) DDAVP → vasopressin analogue → release of f VIII & vWF from endothelium → corrects bleeding time. Use for acute uremic bleeding & acute DI.

B. Procoagulant agents (anti-fibrinolytics) 1) ε-Aminocaproic acid (Amicar) Inhibits plasmin →↓fibrinolysis. a. Txs→ bleeding s/p bypass, DIC, thrombolytic overdose. 2) Tranexamic acid (TXA) → Lysine analog. a. Binds plasmin & prevents fibrin break down.

C. Anticoagulation 1) Coumadin → Prevents vit K–dependent glutamic carboxylation of f II, VII, IX, X, & proteins C & S. a. SEs → skin necrosis, liver injury, & teratogen (crosses placenta). b. ↑Needs ↑ dose if on barbiturate/other cytochrome p450 inducer. c. Bridging i) D/c 5d before surgery & restart 24hrs s/p surgery. ii) Bridge for → mech heart valve, high-risk Afib, prior CVA/TIA, acute embolism, or high risk for VTE. A) NO CKD → LVX (d/c 1d preop, resume 1-2d post-op). B) CKD → UFH (d/c gtt 6hrs preop, resume 1-2d post-op). C) No bridge→ low-risk/chronic Afib, bicuspid Ao, or VTE w/ 5 g/dL, haptoglobin < 50 mg/dL (binds Hgb. (3) Tx → d/c txf 1st, IVF, diuretics, HCO3−, pressors, histamine blockers (Benadryl). Delayed → Ab-mediated vs minor Ags Tx →obs (usually). Nonimmune → 2/2 mech RBC destruction Tx → IVFs & diuretics. Febrile Nonhemolytic → Recipient Abs vs donor WBCs (1) MC txf rxn. Use WBC filters for future txfs. (a) Tx → slow vs d/c txf, supportive care. Anaphylaxis → Usually recipient Ab vs donor IgA in IgA-def pt

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(1) →bronchospasm, ↓HR, ↓BP, ↓EtCO2, urticaria. (2) Tx → d/c txf & IM epi 1st then IVFs, Lasix, pressors, steroids, histamine blockers (Benadryl). vi) Urticaria → Recipient Abs vs donor plasma proteins (or IgA in IgA-def pt) Nonhemolytic. (1) Tx → histamine blocker, supportive care. vii) Transfusion-Related Acute Lung Injury (TRALI) → Recipient WBCs vs donor Abs → clot in pulmonary capillaries, rare. (1) MC product asso w/TRALI → pRBCs. viii) PLT Alloimmunization → from previous TXF (1) Post-TXF purpura & ↓PLTs. Tx → IVIg, plasmapheresis.

8. Other Transfusion Problems i) MC bacterial contaminate → #1 skin flora (Staph epi), then GNRs (usually E. coli). ii) MC contaminated product → PLTs (2/2 to not being refrigerated, GPCs). iii) Autotransfusion (Cell Saver) → best way to ↓ txf rxn risk (relative CI in CA surgery, absolute CI → contamination [ie. bowel entry, abscess, etc]). iv) Chagas’ disease → can be transmitted w/TXF. v) Cold → ↓ clotting, 2/2 cold products or ↓body temp. vi) Diffuse bleeding from trauma pt → ensure 1:1:1 pRBC:FFP:PLT ratio & normothermia. vii) Dilution → occurs s/p ~10u of pRBCs. viii) HypoCa++ → ↓clotting (it’s required for clotting cascade). Occurs w/massive txf 2/2 citrate in products (preservative). (1) Tx →10-20mL 10% Ca++ gluconate per 500mL WB/pRBC (per SCORE).

9. Topical Hemostatic Agents Surgicel / Fibrillar → Oxidized regenerated cellulose → RBC lysis → artificial clot. ↓’s local pH. Poss antimicrobial. ii) QuickClot → Kaolin → activates f XII. (1) Previously contained zeolite → exothermic rxn. iii) Gelfoam / Surgifoam → Large surface area for clot. Possible ↑ infection rate. iv) Avitene / Microfibrillar Collagen → Scaffold for clot. Effective even s/p UFH given. PLTs must be >20. v) Thrombin → Uses circulating fibrinogen → clot. (As does FloSeal & Surgiflo). vi) Fibrin → Usually contains both fibrinogen & thrombin. vii) Arista → Absorbs H2O → concentrates PLTs & clotting factors. viii) HemoCon → Lyophilized chitosan (a glutaraldehyde cross-linked peptide) bandage → seals when wet. (1) ChitoFlex → A flexable form. i)

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2. Immunology, Inflammation, & Cytokines A. Major Histocompatibility Complex Classes 1) MHC I (One letter for MHC 1) i) Activates CD8+ T-cells. All nucleated cells. Inh NK cells (if cell doesn’t express it is destroyed by NK cell. Innate immunity. ii) There are three loci → HLA-A, HLA-B, HLA-C. 2) MHC II (Two letters for MHC 2) i) Activates CD4+ T-cells. On Ag presenting cells (macrophages, dendritic [MI], & mast cells). These APCs bring phagocytized material to thymus & lymphocytes. Cell-mediated immunity. ii) The HLA loci are HLA- DP, DQ, & DR. These are MOST important for matching a donor & recipient. 3) DAMPs (from injured tissue) & PAMPs (from infection) → interact w/TLRs in infection/injury → cytokine release → SIRS. i) SIRS → gene expression is ↑ for innate & ↓ for adaptive.

B. Antibodies 1) 2) 3) 4) 5) 6) 7) 8) 9)

Constant Region – recognized by PMNs & macrophages. Variable Region – Ag recognition. (Fc fragment does not carry variable region.) Monoclonal Abs → only 1 binding site to 1 epitope. Polyclonal Abs → multiple binding sites to Ag at multiple epitopes. IgA → secretions, Peyer’s patches & breast milk (newborn immunity); prevents gut adherence & invasion. IgD → membrane-bound, B cells (Ag receptor). IgE → allergic reactions, parasites. IgG → MC Ab. 2° immune response. Crosses placenta. Opsonin → fixes complement (requires 2 IgG). IgM → 1st Ab s/p exposure. Largest Ab. 5 domains (10 binding sites). Opsonin → fixes complement (requires 1 IgM).

C. Inflammation 1) IL-1 → Fever, released by macrophages, activates CD4+ T-cells, potentiates TNFα. 2) IL-2 → Cell-mediated immunity w/LAKs, stimulates formation of memory B-cells & Treg cells. 3) IL-4 → Differentiation of naïve T-cells to Th-cells. 4) IL-6 → ↑ hepatic acute phase proteins. 5) IL-8 → PMN chemotaxis. 6) IL-10 → Down regulates immune response. 7) L-selectins → located on leukocytes, bind to E- (endothelial) & P- (platelets) selectins. Rolling adhesion. 8) Beta-2 integrins → CD 11/18 molecules on leukocytes, bind ICAMs, etc. Anchoring adhesion.

D. Acute Phase Reactants 1) Positive (go ↑ w/infxn) → CRP, complement, serum amyloid A, ferritin.

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2) Negative (go ↓ w/infxn) → transferrin, transthyretin, RBP, albumin.

E. Innate Imunity – Humoral 1) Classical Complement Pathway → Ag:Ab complex. 2) Alternative Pathway → activated by C3 hydrolysis or Ag alone. 3) Mannose-Binding Lectin Pathway i) C3a,4a,5a → anaphylatoxins. C3b → opsonization/phagocytosis. C3a & C5a → potent chemoattractants C5b-9 → MAC complex.

F. Immunonutrition (Studies flip-flop widely. Below is per SCORE.) 1) Arginine → Best immunonutrient in elective pts. i) Pros: ↑growth hormone, IGF-1, prolactin, insulin, T-cells (& function). Improves wound healing. ii) Cons: ↑’s mortality in elderly male septic pts. 2) Glutamine → MI nutrient in stress overall/in general. i) Pros: Major carrier of skeletal m N, MC AA, conditionally essential, MI substrate in ammoniagenesis by kidney, helps cell-mediated immunity, protects/maintains gut mucosa. ii) ↓ mortality & LOS in ICU pts. 3) Omega-3 Fatty Acids → i) Pros: anti-inflammatory, ↓IL-6, IL-8, & TNF-α. Improves oxygenation & ↓vent days in ARDS pts. 4) MCC of immune def worldwide & in surgical pts → malnutrition.

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3. Infection & Antibiotics A. General 1) Gram pos → exotoxins

Gram Neg → eNdotoxins 2) Stomach → almost sterile; few GPCs & yeast. 3) Jejunum → 105, GPCs. 4) Ileum →107, GPCs, GPRs, GNRs. 5) Colon → 1011, anaerobes + few GPCs & GNRs. 6) Anaerobes → MC flora in GI. In colon, ratio is 1,000 anaerobes : 1 aerobe. a. Bacteroides fragilis → MC overall (anaerobe, colon). b. Escherichia coli → MC aerobe in colon. 7) Bacteria require ferrous Fe. Transferrin→↓ ferrous Fe. MetHgb→↑ ferrous Fe (↓pH & O2 tension, ↑ferrous Fe→ infection). 8) Gram-neg → LPS (Lipid A → most potent stim for TNFα).

B. Bites 1) Human Bites: Strep pyogenes, staph, Eikenella corrodens, fusobacter, peptostreptococcus, prevotella, porphyromonas; likely in that order from MCC to lesser common; virus most likely transmitted is Hepatitis C. 2) Dog Bites: Polymicrobial, MC are Eikenella corrodens, staph, & strep. Rabies chance low, but possible. 3) Tx → broad-spectrum abx (Augmentin/Unasyn, don’t close). a. PCN allergy → use doxy + clinda. b. Infected bite → Tx: I&D, abx [1Unasyn, 2Zosyn, 3ceftriaxone+Flagyl, or 4Levaquin+Flagyl], splint in extension if digit). 4) Snake Bites: 25% are “dry” (no envenomation). a. Viperidae (copperhead, cottonmouth, rattlesnake) → DIC & rhabdo. i) Significant swelling, ↑PT, ↓PLTs or fibrinogen → 4-6 vials CroFab. ii) Shock/significant bleeding → 8-12 vials CroFab & call 1-800-222-1222 (Poison Control). b. Elapidae (coral snake – red touches yellow = dead fellow) → irreversible ACh binding. Antivenom & supportive care. 5) Spider Bites: a. Brown Recluse (fiddle on head) → cytoxic/tissue necrosis. I&D/wound care. b. Black Widow (hourglass on abd) → affects neuromuscular jxn. Benzos, IVFs, ± antivenom.

C. Clean Lacerations

1° intention = close 2°= leave open 3°= DPC 1) 18hrs → w/o & DPC @ 48hrs. 2) Face → 1° closure w/in 24h. Close Galea w/abs sutures.

D. CLABSI 1) MCC → poor aseptic technique (MC bug → staph epi). 2) Overall fewest Cxs w/IJ CVC placed under U/S guidance. a. SubClav → least CLABSI, most PTX.

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b. Use a high frequency (better shallow resolution) linear probe. CLABSI in TPN line → BS abx + antifungals (candida coverage). 3) If ERSD → change over wire & give abx (80% salvage rate). 4) Tunnel cath infection → 70% salvage (d/c if permacath, but not if PD cath [see Hernia/Abd/Surg Tech section on PD caths]). 5) Exit-site (superficial only) → >95% salvage (if mild → topical abx).

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

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A) Best pre-op prep is mechanical + abx (typically neomycin). vi) Pre-op abx in penetrating colon injury reduces risk of SSI. 4) Pilonidal Disease – acute pilonidal infection → I&D. a. Never make/leave incision midline. Chronic → consider GIPS.

F. Nosocomial (#1UTI, #2SSI, #3PNA; #1 nosocomial c/o mortality is PNA). 1) VRE Tx → Linezolid. a. Greatest risk factor for VRE colonization → poor hand hygiene. 2) C. diff Contact precautions → gown, gloves, wash hands. a. Hand sanitizer NOT effective vs C diff. b. Greatest risk factor for C. diff colonization → recent abx. c. Ppx abx > 24hrs → ↑ C. diff x3, may ↑ SSI as well. 3) ESBL E. coli Tx → Meropenem. 4) PNA a. CAP MCC are Strep pneumo, viral, H. flu, Moraxella, MSSA. i) Occurs out of the hospital or w/in 1st 48hrs of admission. ii) Tx → Augmentin + Azithromycin (best per IDSA), or Levaquin x7d. b. HAP i) Occurs > 48hrs s/p admission & did not appear to be incubating at the time of admission. ii) The most significant risk factor for HAP → mechanical ventilation. iii) BAL 105 organisms. c. VAP BAL > 100K → think VAP. MCC overall → pseudomonas. i) Develops > 48 hrs s/p ETT. Risk ↑ as vent days ↑. ii) MC infectious c/o mortality in surgical pts. iii) Early: likely 2/2 aspiration → Staph, H. flu, Strep. pneumo. (MC GP [20-25% mort] → staph). Tx w/abx x 8d. iv) Late: Pseudomonas & Acinetobacter (MC GN [50% mort] → pseudomonas). Tx w/abx x 8d. 5) UTI → MC hospital-acquired infection. a. SCIP measure to ↓ UTI → d/c foley after 24-48hrs if able. b. Prevention → Maintain closed system/daily CHG baths in ICU→↓ UTI.

G. NSQIP

ACS & SIS Guidelines

(CR = colorectal)

-no smoking 4-6wks preop -CHG bath(+/-) -glucose control -MRSA screen(+/-) -mech + abx bowel prep (CR) -clip hair (PRN; no razors) -hand scrub -proper OR attire -new closure instruments (CR) -abx (see below) -normothermia -wound protector -triclosan suture (abd cases) -double glove -shower OK 12hrs post op -topical mupirocin -purse-string >1° ostomy closure -80% FiO2 -NPWD on top of staples (CR, vasc groin incision)

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H. SCIP Core Measures -abx w/in 1hr before incision -d/c abx w/in 24hrs (Grade Ia recc) -d/c foley by POD2 -hair removal by clipping -other “beneficial” → VTE ppx w/in 24hrs & standard glucose control ( Hep C (1.8%), > HIV (0.3%) 2) Transmission: blood to open wound > hollow needle > solid needle > blood to eye [ML in this order]. 3) HIV → start 2 or 3 drug ART within 72hrs, continue for 28 days. 4) Hepatitis B → healthcare workers who contact body fluids/sharps need vaccinated. If Ab & HBsAg negative→need HepB IG w/in 24hrs. 5) Hepatitis C Transfusion transmission rare (0.0001%/unit). 1-2% overall prevalence. a. Rare for fulminant liver failure to occur. b. Risks: Cirrhosis → 15%; chronic hepatitis → 60%; HCCa →1-5%. c. IFN may ↓ progression to cirrhosis. d. Needle stick from known Hep C positive pt → get anti-HCV Ab test w/in 48hrs. Negative → antiHCV Ab & ALT lvls 4-6mns s/p exposure, if negative → done.

J. Antibiotics 1) Ppx abx → any implant or aerodigestive entry. a. IHR w/ or w/o mesh → cefazolin. IHR w/mesh + h/o MRSA → vancomycin. 2) A mild allergy to PCN is NOT a CI to cephalosporins/β-lactams. a. 1st gen are good surgical ppx w/GP & some GN coverage. Give w/in 1hr of incision & redose q3h intraop if cephalosporin. 3) “Buy AT 30, CEL at 50.” a. Aminoglycoside, Tetracycline → 30S; Clindamycin, Erythromycin, Linezolid → 50S. 4) Anaerobics → clinda above diaphragm, flagyl below. 5) TB tx → “RIPE” Rifampin, Isoniazid, Pyrazinamide, ± Ethambutol. 6) Flouroquinolones → stop DNA gyrase bacterial DNA synthesis. 7) Tetracyclines → stop tRNA binding w/mRNA:ribosome complex. 8) Ertapenem → good solo agent for intra-abd infxn; covers GPs, GNs, & anaerobes. Has q24hr coverage/dosing. 9) Levamisol → immunostimulatory, antihelminthic. Adj tx for CRCa. Can cause SJS.

K. Mechanisms 1) Aminoglycosides →irreversible ribosomal binding, bactericidal. 2) Bacteriostatic abx → reversible ribosomal binding (tetracycline, clindamycin, erythromycin), Bactrim. 3) Inhibitors a. Cell wall synthesis → PCNs, cephalosporins, carbapenems, monobactams, vanc. i) β-lactams most effective when level is > MIC more than 50% of the time. ii) Penicillin A) ✓GPCs → anthrax, β-hemolytic Strep, C. perfringens & N. meningitides (GPRs), strep, syphilis. B) Ø Staph or Enterococcus.

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iii) Ampicillin & amoxicillin → above, + ✓enterococci. iv) Oxacillin & nafcillin → Anti-staph PCNs (ie. MSSA only). v) Augmentin (amoxicillin/clavulanic acid) & Unasyn (ampicillin/sulbactam) A) Broad → ✓ GPCs (staph & strep), GNRs, ± anaerobic coverage. B) ✓enterococci. C) Ø Acinetobacter, Pseudomonas, & Serratia. vi) Sulbactam & clavulanic acid → β-lactamase inhibitors. vii) Ticarcillin & piperacillin (antipseudomonal PNCs). A) Timentin (ticar-/clavulanic acid) & Zosyn (pipera-/sulbactam). B) GNRs → ✓enterics, Acinetobacter, Pseudomonas, & Serratia. C) Broad spectrum → ✓GPCs (staph & strep), GNRs, & anaerobes. D) SEs → ↑ NaCl load; can ↓ PLTs & WBC counts. viii) 1st gen cephalosporins (cefazolin, cephalexin). A) Cefazolin (Ancef) → longest ½-life → ✓ ppx, GPCs. B) Ø Enterococcus. ix) 2nd gen cephalosporins (cefoxitin, cefotetan, cefuroxime). A) Cefotetan → longest ½-life → ✓for ppx. B) ✓ GPCs, community-acquired GNRs, ± anaerobes. ↓ effectiveness vs staph. C) Ø Enterococcus, Acinetobacter, Pseudomonas, & Serratia. x) 3rd gen cephalosporins (ceftriaxone, ceftazidime, cefepime, cefotaxime). A) ✓GNRs ± anaerobic coverage Acinetobacter, Pseudomonas, & Serratia). Crosses blood/brain barrier. B) Ø Enterococcus. C) SEs → cholestatic jaundice, gallbladder sludge w/ceftriaxone. xi) Carbapenems (meropenem, imipenem). A) Broad – ✓ anaerobes, GPCs, & GNRs. B) Ø MEP: MRSA, Enterococcus, & Proteus. C) Cilastatin → prevents renal hydrolysis of the drug & ↑ ½-life (“keep it lastin’ w/cilastatin”). D) SEs → seizures. xii) Monobactam (aztreonam) A) ✓GNRs + Acinetobacter, Pseudomonas, & Serratia. xiii) Vancomycin (glycopeptides) → Cell wall protein binding. A) B) C) D)

✓ C. diff (PO/PR), Enterococcus, GPCs, & MRSA. 15-20mg/kg (actual wt) q8-12hrs (nml renal fxn & MIC =1mg/L). Peak → 20–40 μg/mL; trough → 5–10 μg/mL. AUC target of 400-600mg/hr w/in 24-48hrs → safest & most accurate way to dose per IDSA.

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E) Resistance 2/2 cell wall–binding protein change. SEs→ HTN, Redman syndrome (histamine release), neph- & ototoxicity b. 30s ribosome & protein synthesis → aminoglycosides, tetracycline. i) Aminoglycosides (gentamicin, tobramycin) A) B) C) D) E)

✓GNRs, Acinetobacter, Pseudomonas, & Serratia.

Ø anaerobes b/c it needs O2 to function. Resistance 2/2 modifying enzymes →↓active transport. ↑killing w/↑ level. Works well w/ampicillin for Enterococcus. 1. β-lactams (ampicillin, amoxicillin) facilitate its infiltration. F) Gentamicin → peak 6–10 μg/mL; trough < 1 μg/mL. G) SEs → reversible nephrotoxicity, irreversible ototoxicity. ii) Tetracycline → ✓ GNRs, GPCs, & syphilis. A) SEs → tooth discoloration (kids). c. 50s ribosome & protein synthesis → macrolides, clindamycin, linezolid, Synercid. Clindamycin → ✓Anaerobes, some GPCs, asp PNA, C. perfringens. SEs → C. diff. ii) Macrolides (azithro-, clarithro-, erythromycin, & fidaxomicin) A) Erythromycin SEs → nausea (PO), cholestasis (IV). i)

1. ✓ GPCs. Best vs CAP & atypical PNAs. 2. Binds motilin receptor → prokinetic. iii) Linezolid (oxazolidinones) → ✓GPCs (esp MRSA, VRE). iv) Synercid (streptogramin + quinupristin-dalfopristin) A) ✓GPCs (MRSA, VRE). d. DNA helicase (DNA gyrase) → quinolones. i) Quinolones (ciprofloxacin, levofloxacin, norfloxacin) A) ✓GNRs, few GPCs. Best when AUC/MIC > 25. B) ✓Acinetobacter, Pseudomonas, & Serratia. C) < 40% of MRSA are susceptible. = PO/IV efficacy. D) Ø Enterococcus SE → tendon rupture. e. RNA polymerase → rifampin. 4) Oxygen free radical production (→ breaks up DNA) a. Metronidazole (Flagyl) → ✓Anaerobes b. SEs→disulfiram-like rxn, peripheral neuropathy (long-term). 5) Trimethoprim → ↓dihydrofolate reductase →↓purine production. 6) Sulfonamides → PABA analogue, ↓purine production. a. Bactrim (Trimethoprim/sulfamethoxazole) i) ✓GNRs ± GPCs. ii) Ø Enterococcus, Acinetobacter, Pseudomonas, & Serratia. iii) SEs (many): teratogen, allergic rxns, renal, EM/SJS, hemolysis (G6PD-def).

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L. Resistance 1) 2) 3) 4) 5)

Aminoglycoside → 2/2 modifying enzymes. → ↓ active transport. Methicillin-resist. S. aureus (MRSA) → d/t cell wall–binding protein mut. PCN resistance → 2/2 plasmids vs β-lactamase. Transfer of plasmids → MC method. Vanc.-resist. Enterococcus (VRE) → d/t cell wall–binding protein mut.

M. Drug Levels 1) Peak high → ↓ dose amount. 2) Trough high → ↓ dose frequency (↑time b/w doses).

N. Fungal Infections (can present w/myalgias, rash, fevers → need to r/o invasive fungal infection). 1) Aspergillus → septate hyphae, narrow branching. Tx → voriconazole. a. Aspergilloma → Monad sign (lung mass w/in cavity w/air that stays nondependent on repositioning). i) Tx (only if bleeding) → angioemb + resect. b. Allergic BronchoPulmonary Aspergillosis (ABPA) → non-invasive, a hypersensitivity. Can cause fibrosis. Tx sxs w/bronchodilators + steroids, f/u serial CXRs, IgE, & PFTs. c. Chronic Necrotizing Aspergillus PNA & Invasive Aspergillosis → IV voriconazole. 2) Candida Need 2 Cx sites or eye involvement (need ophtho exam). a. New tests for invasive fungemia → β-D-glucan & galactomannan. b. Candidemia Tx → fungins (eg. Anidulafungin). c. C. albicans – common respiratory tract flora. i) Tx→ Fluconazole (non-albicans sp. often resistant); Anidulafungin for severe infections; Amphotericin for eyes, CNS, & heart infxn (nephrotoxic & ↓ K+). d. C. glabrata → caspofungin/anidulafungin ($), amphotericin (↑dose→more effective, but ↑oto- & nephrotoxicity). 3) Mucor → non-septate hyphae, broad branches. a. Tx → aggressive debridement + amphotericin B. 4) TPN is a RF for disseminated fungal infections (at least in burn pts).

O. Antifungals 1) Anidulafungin (Eraxis) → blocks cell wall glucan. 2) Amphotericin – binds cell wall sterols → alters permeability. a. SEs → nephrotoxic, fever, hypoK+, hypoTN, anemia. b. Liposomal type → ↓SEs. 3) Voriconazole & itraconazole → blocks ergosterol which is required in cell membrane. 4) Prolonged broad-spectrum abx + persistent fever → itraconazole. 5) Fungal sepsis other than candida & aspergillus → liposomal amphotericin.

P. Bacillus anthracis 1) INH anthrax 1-6d incubation → malaise, myalgia, fever → resp depression, chest pain, & diaphoresis. pPx → Cipro. 2) Tx → Cipro + clinda + rifampin. Q. HIV ↑ risk of opportunistic infxn → CD4 < 200 (need ppx Bactrim). 1) MCC b/l PNA in HIV pt w/CD4 30 sec think MH (cancel OR, obs 24hrs). A) AD mutation of the ryanodine receptor gene (RYR1), 2/2 succinylcholine & volatile anesthetics. B) 1st sx → ↑EtCO2 → muscle rigidity, lactic acidosis, & ↑K+. If only needs ↑ventilation (↑RR or TV) not likely MH, but if CO2 not improving + rigidity & fevers → likely MH. C) Tx → Dantrolene 2.5mg/kg q5m PRN x4 doses, prevents release of Ca++ from sarcoplasmic reticulum (Call 1-800-MH-HYPER). 2) Non-Depolarizing → Inh neuromuscular junction, competes w/ACh. ↑ action time w/myasthenia gravis. a. Cis-atracurium → cleared by Hoffman degradation in blood (0.3-0.6mg/kg, lasts 20-30m). i) Can be used in liver & renal failure. → histamine release. b. Pancuronium → slow acting, long-lasting; renal clearance (0.1-0.15mg/kg, lasts 60m). i) MC SE → tachycardia.

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c. Rocuronium → fast, intermediate duration; hepatic clearance. d. Vecuronium → fast, hepatobiliary clearance, no histamine release (0.1mg/kg, lasts up to 115m w/0.4mg/kg). e. Reversing drugs for nondepolarizing agents. i) Sugammadex → chelating agent for rocuronium. ii) Edrophonium → inh acetylcholinesterase → ↑ ACh. iii) Neostigmine – inh acetylcholinesterase → ↑ ACh. A) Used in Ogilvie’s (2mg push over 3-5min), MG & glaucoma. B) CI in pts w/prior 2nd degree heart block. iv) Adjuncts → Atropine (0.5mg [kid], 1mg [adult]) or glycopyrrolate given w/neostigmine or edrophonium to counter effects of ↑ ACh. 3) General anesthesia → hypoglycemia in DM pts. 4) Halothane → hepatitis, INH anesthetic w/highest cardiac depression. 5) MCC of intra-op brady → INH anesthetics.

C. Sedation 1) Benzodiazepines a. Midazolam (Versed) → Anxiolytic (0.5-1mg), muscle relaxant, anticonvulsant (1mg until status epilepticus breaks, max 0.2mg/kg), hypnotic, & amnestic (2mg). NO analgesic activity (like other benzos). b. CIWA Protocol → n/v, tremor, sweats, agitation, tactile/auditory/visual disturbances, HA, AMS/clouding. Tx w/benzos usually at scores of >8-10. 2) Dexmedetomidine (Precedex) → central α2 agonist → sedation, analgesia, axiolysis, & amnesia. Caution in heart block. No resp depression. SEs bradycardia, hypoTN (may be ↑’d in elderly). 3) Etomidate → ↓hemodynamic changes. Fast (for RSI). No analgesia. Continuous infusions → adrenocortical suppression. 4) Ketamine → thalamic/limbic dissociation → cataleptic state (amnesia, analgesia), good for short-term sedation & for kids. No resp depression. SEs → hallucinations & ↑catecholamines → ↑SBP, ICP(?), HR & EtCO2. 5) Propofol → no analgesia. Rapid on/off. Contains lipids. SEs → hypoTN (MC), resp depression, & Propofol Infusion Synd (PRIS). a. PRIS → @rates >80 → met acidosis, ARF, & cardiac failure → death. High mortality. ↑risk in young & w/↑ catacholamines. i) Monitor w/serial CPKs, lactates, & triglycerides.

LEVELS OF SEDATION & THEIR EFFECTS Airway

Min OK

Mod/Conscious OK

BP

NML

Typically NML

Response

NML

Purposeful

Ventilation

NML

OK

Deep Probably OK Typically NML Purposeful to repeated / noxious stimuli Probably OK

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General Anesthesia Not OK ↓ None Not OK

D. Analgesics 1) Somatic a. Opioid i) Morphine → analgesia, euphoria, resp depression, miosis, constipation, histamine release (causes hypoTN), ↓ cough. A) MC opioid w/↑ SEs in renal failure → morphine (also demerol & meperidine). ii) Demerol → analgesia, convulsions/seizures, euphoria, fasciculations, miosis, respiratory depression, & tremors. A) No histamine release. B) Seizures (normeperidine analogue buildup → avoid in renal failure). iii) Meperidine → ↑ SEs in renal failure 2/2 active metabolites. iv) Methadone → like morphine w/↓ euphoria. v) Hydromorphone vi) Fentanyl → fast; 80× morphine (NO cross-rxn w/morphine allergy). No histamine release/mast cell degranulation. IV form needs no hepatic or renal dose adjustments. A) Can cause chest wall rigidity & ↓responsiveness → give Narcan (0.42.0mg q2-3m PRN, >10mg → ? the dx). 1. Monitor for at least 2 hours s/p narcan given its ½ life of ~1 hour . vii) Sufentanil (most potent) & remifentanil (very fast). viii) 72% of opiates prescribed s/p IHR, lap chole, & lumpectomy are “left over.” ix) 6-10% of pts s/p common surgeries like above continue to fill opiate Rxs 36mns post-op. x) Decrease post-op opiod requirements by → giving ketorolac & using regional/neuraxial anesthetics. xi) In geriatric pts, reduce opiate to “lowest effective dose” → ~ 25-50% of nml adult dose. b. Local Anesthetics i) Act on Na+ channel of nerve membranes & stabilize them so they no longer conduct signals. ii) Types A) Ester → 1 “I” in name (eg. procaine, cocaine), PABA analogues → ↑allergic rxns. B) Amides → 2 “I’s” in name (eg. lidocaine, bupivacaine). iii) Add bupivacaine to lidocaine for both a long & short term block. iv) Don’t use epinephrine for digital blocks. v) Dosing 1mL = 1gm = 1,000mL (@ 100% conc). A) 1% Lidocaine W/O epi (aka plain) → 4-5 mg/kg of 1% = 0.4-0.5 mL/kg, max total: 300 mg [30 mL of 1% or 60mL of 0.5%]) ~1hr duration. B) 1% Lidocaine W/epi → 7 mg/kg of 1% W/epi = 0.7 mL/kg, max total: 500 mg [50 mL of 1% w/epi or 100mL of 0.5%]).

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2) 3) 4)

5)

C) For ↑ safety, 80% max dose if 3mn off steroids) response c. Class III (1.8%): severe systemic AM dose / Minor dz; diabetes, stable angina, & 25mg hydrocortisone AM dose / CKD. Mod 50mg hydrocortisone 10-59 mg/d then 1d taper d. Class IV (7.8%): severe systemic AM dose / dz constant threat to life: dialysis, 100mg Major hydrocortisone then cirrhosis, symptomatic CHF. 1-2d taper e. Class V (9.4%): actively dying & Adrenal 80mg hydrocortisone ≥ 60 mg/d Suppression Q8H then taper won’t survive w/o surgery w/in 24 hrs. f. Class VI: organ donor. 4) Cardiac Clearance Determines risk of MACE using RCRI. a. If pt has current angina/ACS or < 4 METS → stress test. b. Best cardiac clearance prior to major vascular surgery. i) Exercise stress if able, pharm if not. A) Dobutamine CIs: LBBB, V-paced, V-arrhythmia, Ca++ or β-blocker, ACS/prior MI. B) Thallium CIs: asthma, SBP latex (20%) > abx (13%). b. Kids → MCC latex > NMBs > abx. c. Rarely 2/2 inh anesthetics or hypnotics.

C. Reversal Agents for drugs 1) 2) 3) 4) 5)

Tylenol → N-acetylcysteine (150mg/kg over 1hr loading dose). Opioids → Narcan (0.4-2.0mg q2-3m PRN). Benzodiazepines → Flumazenil (0.2µg/kg [up to 3µg/kg]) β-Blockers → Glucagon (50mcg/kg LD then 1-15mg/h). Nondepolarizing paralytics → Neostigmine (2mg push over 3-5min).

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5. Fluids, Electrolytes, & Nutrition A. Crystalloids OSM = (2Na+)+(glucose/18)+(BUN/2.8) Insensible losses → 10mL/kg/d hypotonic (75% skin, 25% lungs). B. Sodium Chloride → resus IVF for losses from mouth to duo. 1) ¼ NS → Na+ 38.5, Cl- 38.5 ½ NS → Na+ 77, Cl- 77 + NS/0.9% → Na 154, Cl 154 HTS/3% → Na+ 513, Cl- 513 C. Lactated Ringers → resus IVF for losses past duo & burn resus. Na+ 130, K+ 4, Ca++ 2.7, Cl- 109, HCO3- 28. 1) Plasmalyte →Na+ 140, K+ 5, Mg++ 1.5, Cl- 98, Acetate 27, Gluconate 23. D. Hetastarch → coagulopathy.

E. Acid/Base (CO2 ↔ H+ + HCO3-) 1) Respiratory Acidosis ↑PCO2 2/2 ↓MV. 2) Respiratory Alkalosis ↓PCO2 2/2 ↑MV. a. MV = RR x TV. Goal MV ~5-10 L/min. 3) Metabolic Acidosis pCO2 = 1.5(HCO3-)+8 a. Δ-Gap (or “delta-delta”)=(pt’s AG - 12) – (24 - pt’s HCO3-) =Na+- Cl-- 36 i) 6 → multiple AG sources b. Anion gap = Na+ – (HCO3- + Cl-). Nml is < 10–15. i) + Anion gap A) MUDPILES = Methanol, Uremia, Diabetic ketoacidosis, Par-aldehydes, Isoniazid, Lactic acidosis, Ethylene glycol, Salicylates. B) Lactic Acidosis: TYPE A → 2/2 tissue hypoxia TYPE B → not 2/2 hypoxia (eg. 2/2 meth, cocaine) ii) Non-gap “Meth LAB” Meth = Lactic Acidosis type B A) Normal anion gap acidosis → usually lose Na+/HCO3− (RTA [proximal & distal], hypoaldosterone, diarrhea, ileostomies, small bowel fistulas). Resus w/LR (has HCO3− & less Cl- than NS). B) Tx → tx 1° source; can ↑pH if < 7.20 w/HCO3−. C) Cl- responsive (uCl- < 15) → 2/2 emesis, diuretics, H+ loss via aldosterone stimulation. D) Cl- resistant (uCl- > 25) → 2/2 ↑mineralcorticoids or hypoK+. E) Urine gap can tell b/w renal & non-renal causes of HCO3− loss (eg. diarrhea). uAG = uNa+ + uK+ -uCl-. 1. + value = renal loss (eg RTA). - = non-renal HCO3− loss. c. Compensation: pH 7.3, pCO2 25, HCO3- 18 best represents → metabolic acidosis w/comp resp alk. 4) Metabolic Alkalosis pCO2 = 0.7(HCO3- - 24)+40 a. Typically 2/2 contraction. b. NGT suction → hypochloremic, hypokalemic, metabolic alkalosis, & paradoxical aciduria 2/2→ i) ↓ Cl−& H+ ions 2/2 NGT (hypochloremia & alkalosis). ii) ↓H2O→ renal Na+ reabsorbtion for K+ (Na+/K+ ATPase) → ↓K+ (hypokalemia). iii) Na+/H+ exchanger activated →reabsorb H2O + K+/H+ exchange in an effort to reabsorb K+ → results in paradoxical aciduria. c. Tx → NS (need to correct Cl- deficit).

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d. Hypochloremic, hypokalemic metabolic alkalosis → 2/2 emesis, excessive NGT suctioning, pyloric stenosis. e. Primary loss of K+ w/ gastric losses → 2/2 renal exchange (renal Na+/K+ ATPase). C. Sodium Corrected Na+ = Na+ + 0.016(glucose – 100) 1) Obtain BMP + urine lytes/OSM to determine etiology. UOP uOSM pVol pOSM +

pNa

DI ↑ ↓ ↓ ↑ ↑/nml

Dehydration ↓ ↑ ↓ ↑ ↑/nml

SIADH ↓ ↑ ↑ ↓ ↓

CSW ↑ ↑ ↓ ↓ ↓

1° Polydispia ↑ ↓ ↑ ↓ ↓/nml

Water Deficit = TBW ([Na+ - 140]/140) TBW : M = 0.6 x kg / F = 0.5 x kg a. Iatrogenic → Babies & elderly more prone w/NS as IFV resus. Look for high serum (& uOSM, diff from DI). b. Rapid correction → cerebral edema. Correct < 8mEq/L/24hrs. c. HyperNa+ Hypovolemia → 2/2 burns, diarrhea, fistula, renal dz, osmotic diuretics, post-obstruciton. Tx → isotonic IVFs. d. HyperNa+ Euvolemia → 2/2 DI, insensible losses, hypodipsia. i) Diabetes Insipidus A) ↑/nml pNa+ conc (> 142 mEq/L, 2/2 water loss) points toward DI, particularly if uOSM < pOSM. (uOSM should = pOSM; nml is 275-295). B) Nml pNa+ not helpful, but if uOSM >600mOSM/kg, excludes DI. C) Acute → give DDAVP Chronic → give free H2O. + e. HyperNa Hypervolemia →2/2 Cushings, 3% HTS, 1°hyperaldosterone. 3) Hyponatremia Na+ Deficit = (140- Na+)(wt)(0.6 for men, 0.5 for women) a. General tx w/2L NS. Responder → likely hypoNa+ hypovolemia. Non-responder → likely euvolemic hypoNa+ 2/2 SIADH or diuretics. i) Central Pontine Myelinolysis → 2/2 rapid correction of hypoNa+ (Correct lvl needed for max antidiuresis → ↑↑↑ uOSM . ADH > physiologic range →ectopic ADH (MCC → bronchogenic carcinoma). ii) Type B Lowers OSM threshold for ADH release ("reset osmostat”). ADH secretion will stop once OSM gets below threshold. iii) Type C No change in ADH ↑ or ↓ OSM (stays in nml range). Can be 2/2 ectopic ADH. iv) Type D Nml ADH reg, but ↑uOSM even w/↓ADH. 2/2 germline mutation

→ constituently activated V2 receptor. Others → other antidiuretic & postreceptor aquaporin-2 defect (mediates ADH antidiuresis). v) Type E ↓ plasma ADH as sNa+ ↑w/HTS. Poss 2/2 abnml baroreceptor fxn despite normovolemia → minor BP or vol ↓→ ↑↑↑ ADH. Likewise, minor BP or vol ↑w/NS → ↓↓↓ADH. vi) SIADH Tx → Acute → Tolvaptan or democlcycline. Sub-acute/Chronic → 1st restrict water, 2nd diuretic. + vii) Suspect if hypoNa & ↓pOSM, & uOSM > 100 mOSM/kg. SIADH → uNa+ conc usually > 40 mEq/L, pK+ conc nml, nml acid-base, & ↓plasma uric acid conc. viii) Primary Polydipsia → ↓ pNa+ conc (< 137 mEq/L) w/ ↓uOSM (eg. < ½ pOSM) → usually water overload. ix) Pseudohyponatremia 2/2 ↑glucose/triglycerides (every 100 gluc > nml → add 1.6 to measured Na+), Multiple Myeloma. Tx → obs. e. HypoNa+ Hypervolemia → 2/2 CHF, cirrhosis, renal dz/nephrotic synd. i) Cirrhosis → ↑ADH & aldosterone → nml Na+, excess TBW. A) EtOH → ↓osm pressure response → inhibits ADH,↑diuresis.

D. Potassium

salivary K+ / colon > gastric > bile, panc, duo, & ileum. 1) Hyperkalemia EKG → Peaked T waves, can be 2/2 ESRD. a. Tx →"C BIG KD" (Ca++, Bicarb, Insulin, Glucose, Kayexalate, Dialysis/Diuretic). i) Ca++ gluconate (stabilizes cardiac membranes → prevents Vtach) → 1st Tx. 2) Hypokalemia MCC of sig hypoK+ → overdiuresis. a. Ø T-waves→ U-waves. May need Mg++ prior to K+ correction. b. ↑cardiac m. sensitivity & ↓ skeletal m. excitability (esp w/resp alkalosis).

E. Calcium 1) Hypercalcemia a. Ca++ >13 or ionized >6-7 → lethargy. b. Breast CA MC malignant cause, ↑ in lung SCCa 2/2 PTHrp, highest Ca++ levels seen. w/malignancy. Parathyroid CA has highest associated frequency. c. MC benign cause → Hyperparathyroidism. d. No LR (contains Ca++) or thiazides (retain Ca++). e. Tx 1st → NS at 200-300mL/h. 2nd add Lasix (loop diuretic).

24

i) Malignancy→ alendronic acid, calcitonin, HD, mithramycin. Familial Hypocalciuric Hypercalcemia i) Nml/high PTH, no/min sxs, 24hr U Ca++ 4-6hrs s/p inj), pain & swelling after blood flow restoration. i) 1st finding → pain w/passive motion. ii) Swollen & tense extremity. iii) Numbness in webspace between the great & 2nd toe (dee p peroneal nerve). iv) Distal pulses can be present → last thing to go. g. Dx → based on clinical suspicion (if suspected → fasciotomy). i) Pressure > 20 - 25 mmHg abnormal ii) Δp = diastolic - compartment pressure h. Tx → 1st →fasciotomy, 2nd → IVF resus (>100mL/hr UOP ± alkalinize urine w/bicarb. i) For leg → medial incision for superficial posterior+ deep posterior compartments & lateral incision for anterior + lateral compartments. A) You are through the fascia when muscle bulges B) Incise total length of compartment C) Remove all dead tissue ii) MC injured nerve with lower extremity fasciotomy (via ant/lat incision)→ superficial peroneal nerve (foot eversion). 4) Open Fractures / Gustilo Classification I → 10cm or farm/dirty/extensive damage i) IIIA → good coverage IIIB → needs flap IIIC → needs vascular repair b. I & II→ Ancef until closed III → add GN coverage Farm → add PCN c. Dirty open fxs require abx, washout, & temporary stabilization (ex fix preferred per OrthoBullets) prior to formal fixation. SBP >90 & O2sat >90% → each double Spleen + head inj → splenectomy.

F. Head MCC of death if pt reaches ED alive. mortality.

50

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

5) 6) 7) 8) 9)

51

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

19) Epistaxis a. Anterior → Kiesselbach’s plexus. Tx → packing. b. Posterior → 5 arteries (sphenopalantine, ant/post ethmoids, greater palatine, sup labial), hard to manage; try balloon tamponade 1st. c. May need angioemb of int maxillary or ethmoidal artery. 20) Mandibular Injury → MC sign → malocclusion. a. Dx → fine-cut facial CT scans w/recon. b. Tx → IMF (ORIF v upper & lower arch bars x 1-2mns). 21) Tripod Fracture → zygoma. Tx → ORIF.

G. Spinal Cord 1) Fall w/fx'd heel + back pain→ CT T & L-spine. 2) Cervical Spine a. C-1 burst/Jefferson fx – 2/2 axial loading. i) Tx → rigid collar.

52

b. C-2 Hangman’s fracture – caused by distraction & extension. i) Tx → traction & halo. c. C-2 odontoid/dens fracture i) Type I → above base (stable) ii) Type II → at base (unstable) iii) Type III → into vertebral body (unstable) d. Facet fxs/dislocations → can inj cord w/rotation + hyperextension, & ligament inj. e. Clearence Criteria (NEXUS) → “no NSAIDs” (Neuro def, Spinal process ttp, Altered, Intoxicated, Distracting injuries). i) Obtunded pt w/negative CT C-spine & likely prolonged ETT → clear C-collar (per EAST PMG). 3) Thoracolumbar Spine a. 3 columns i) Anterior – anterior ½ of the vertebral body + ant longitudinal lig. ii) Middle – posterior ½ of the vertebral body & post longitudinal lig. iii) Posterior – facets, lamina, SPs, + interspinous ligament. b. > 1 column inj → unstable. i) Burst fx → > 1 column, unstable. ii) Chance fx (flexion-distraction) asso w/intra-abd injury (33-50%). A) MC → small bowel (2nd MCC pancreas). iii) Wedge/compression fx → only anterior column, stable. iv) Fall onto feet → at risk for calcaneus, thoracolumbar, & wrist/forearm fxs. c. MRI if Sxs but no injury on CT (SCIWORA). 4) Emergent spine surgery if: a. Cord compression, evolving neurologic deficits, or open fx. 5) ↑ inj level → ↑ M&M.

H. Pediatric Trauma IV site pref order 1 in 10 minutes) iii) Vaginal bleeding iv) Abnormal fetal heart rate tracing v) Abdominal/uterine pain vi) Coagulopathy (eg, low platelets or fibrinogen > EtCO2 → alveolar dead space (ventilated, but not perfused). a. EtCO2 should normally nearly = PaCO2 (minimal dead space). 9) ARDS w/in 1wk of insult, not 2/2 to CHF, CXR w/bilateral infiltrates. a. Mild PaO2 ≤ 300-200 Moderate ≤ 200-100 Severe ≤ 100 b. Acute/Exudative (14d) ↑macrophages & mononuclear cells → repair. e. Best way to ↓ARDS mortality → low TV 6mL/kg > paralysis & proning. C. Shock Definition → inadequate tissue perf (most basic). CVP doesn’t always = IVF response. 1) Neurogenic → 2/2 TBI/SCI. Sympathetic/vasomotor tone loss → peripheral blood pooling (aka ↑venous capacitance). a. SCI → brady, hypoTN (vagally mediated). Tx → atropine. b. Sxs → ↓HR/BP/SVR, & warm skin. c. Tx→ 1st IVF resus. Phenylephrine (↑’s SVR) if cont ↓BP. 2) Cardiogenic → 2/2 MI, tamponade, or CHF exacerbation. a. Sxs → dyspnea, pulmonary edema, ↓CO & UOP. b. Ineffective contraction → pulm congestion → over distends → worse contractility. c. Tx → dobutamine (inotropic). Consider IABP to stabilize. If pulm edema → diuretics. d. IABP → use MAP (not SBP) to assess perfusion. ↑cerebral & coronary flow, ↑diastolic BP:time index, ↓ myocardial O2 demand & LVEDV. i) Absolute CI → Aortic regurg/AI, aneurysm, dissection, sepsis, & uncontrolled coagulopathy. e. Temp pacing for → High grade AV block, acute RV MI w/brady & hypoTN sxs, endocarditis w/brady sxs, complete block w/ventricular early repol. f. Sudden hemoptysis s/p Swan placement → leave ballon inflated & go to angio. g. Cardiac tamponade Sxs→Beck's triad (hypoTN, JVD, & ↓heart sounds). HypoTN 2/2 ↓right vent filling 2/2 pericardial fluid. i) Dx→1st ECHO sign → ↓ right atrial diastolic filling. ii) Tx → IVF resus to temporize until pericardial window/pericardiocentesis (pericardial blood usually doesn’t clot). h. PE Tx → anti-coagulate all (unless CI). i) tPA ± Trendelenburg procedure (median sternotomy, bicaval + aortic cannulation for bypass, open PA, massage lungs towards hilum, extract clot). ii) If right ventricular failure → 1st IVF. 2nd Norepi (less tachycardia, won’t exacerbate hypoTN).

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

D. Neurologic Concerns 1) Brain Death → complete & irreversible loss of cerebral & brainstem fxn. Usually considered = to cardiopulm death. a. Dx → usually made by neuro exam alone if the following prerequisites met: warm, nml vitals & lytes, underlying cause understood & able to cause neuronal death, & confounding intox/poisoning r/o.

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Neuro exam → coma, NO brain-generated response to external stimuli, & NO brainstem reflexes. ii) Apnea test (done once all other criteria met & pt is HDS enough to perform). iii) Ancillary tests → used when can’t use clinical criteria or as a supplement in young children. A) Tests of brain blood flow, especially those of brain perfusion, are the most reliable "stand-alone" laboratory examinations when clinical criteria cannot be applied. B) Definitive dx (best single test, not in combo w/PE) → brain radionucleotide scan. 2) Alcohol withdrawal Sxs→ agitation, tachy, & RASS = 2 → CIWA protocol-based benzo tx. 3) Delirium → Always reorient pts 1st, esp elderly. Haldol/restraints should be used cautiously (Haldol maybe neurotoxic). i)

E. Cardiac 1) Medications a. AntiHTN / Vasodilators i) Nipride → NO-mediated arterial vasodil. A) Cyanide (CN-) tox when >3mcg/kg/min for 7hrs. Check for metabolic acidosis & thiocyanate lvls. 1. CN- binds mitochondrial cytochrome C → stops electron transport chain → can’t use O2 → left-to-right shunt (↑SvO2). B) Tx → amyl nitrite, then Na+-nitrite. Also hydroxocobalamin (B12). ii) Nitroglycerin → NO mediated → mostly venodil → ↓pre-load → ↓ventricle wall tension. Also a coronary artery vasodilator. iii) ACE inhibitors →↓angiotensin II → mostly vasodil & ↓aldosterone. Sxs → cough & angioedema. A) ↓’s post-Ml mortality & prevents CHF. B) Absolute CIs → previous angioedema & renal artery stenosis. C) Relative CIs → ↓renal fxn, hypovolemia, & aortic stenosis. iv) Nitric Oxide → binds soluble guanylate cyclase receptor → ↑cGMP → vasodil. Arginine NOS Nitric Oxide A) Aka endothelium-derived relaxing factor (EDRF). B) Inhaled → selective pulm a vasodil. v) Sildenafil (Viagra) → NO-mediated selective pulm a vasodil. b. Pressors → ↑SVR & MAP (NE is also inotropic). i) Angiotensin II → ↑ aldosterone & vasopressin synthesis. $1200/bag (~1d). ↓AKI & pressor req vs NE, no mort diff (Athos). ii) Phenylephrine → α1 (vasocon). iii) Norepinephrine (NE, Levophed) (1-40 µg/min)→Mostly α1 + α2 (vasocon, most potent in GI). Some β1 (contractility). iv) Vasopressin (0.04 U/min) → V1 → arterial vasocon.

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c. Inotropes → ↑ cardiac output. Used in cardiogenic shock. i) Dopamine (1-20 µg/kg/min) A) Low (1-5) Renal D (↑renal & GI flow). B) Medium (6-10) β1 + β2 (↑contract & ↑HR). 1. Like low dose epi or dobutamine → ↑ SV & CO. C) High (>10) α1 (periph vasocon, ↑MAP). 1. Like phenylephrine. ii) Dobutamine (1-20 µg/kg/min) → β1 (contractility). Some β2 (vasodil) at ↑doses (>15 µg/kg/min). iii) Milrinone → cAMP PDE inh →↑ cAMP → Ca++ influx →↑ myocardial contract. Also pulm vasodil. A) NO down-reg like other inotropes → better for use long-term (eg awaiting heart TXP). iv) lsoproterenol → β1 (↑HR & contractility) + β2 (bronchon/vasodil). A) SEs → ↑heart metabolic demand & arrhythmias. Rarely used → may ↓BP (β2). v) Epinephrine (Epi, 1-20 µg/min) A) Low Dose (1-5) β1 + β2 1. Can ↓BP 2/2 β2> β1 activity.) B) High Dose (> 5) α1 + α2 d. Rate control i) Afib → Common early s/p lobectomy. A) Afib & not HDS → LMWH + emergent cardioversion. B) New onset, HDS → 1st β-blocker (metoprolol 5mg q5m x3; CCB if +COPD). Can try amiodarone + LMWH. Cardiovert if refractory. e. Pacing i) Can’t advance cath while placing wires → use fluoro. ii) CI to transvenous pacing → mechanical valve. iii) Transvenous pacing → pt unresponsive, EKG w/only tracer spikes + brady ventricular escape rhythm → 1st reposition wires, 2nd trans-cutaneous pacing, & 3rd replacement. iv) Failure to Sense → indiscriminant pacing artifact. v) Failure to Capture → pacing artifact w/o QRS. vi) Electromagnetic Interference Issues (eg. w/electrocautery). A) Cautery → EMI → brady/asystole. B) Ways to ↓EMI → reprogram to asynchronous mode, apply magnet (forces asynchronous mode), interrogate pre & post-op, use bipolar, ground pad away from pacer, use short bursts.

F. GI 1) Stress gastritis → ppx w/H2-blocker for coagulopathic or vent pt. a. PPI if taking at home. 2) Enteral nutrition w/in 36h for open abd → ↓ PNA. a. Absolute CI → hemodynamically unstable.

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3) PEG slips out early, dx to see if back in → gastrograffin KUB.

G. Renal 1) Rhabdomyolysis Initial Tx → IVF resus to UOP >100mLs/hr. 2) Contrast Induced Nephropathy Best RIFLE / preventive → prehydration w/crystalloid. Cr/GFR UOP AKIN 3) MI factor to calc eGFR→ #1-Cr, #2-sex, Risk / ↑ Cr 1.5x < 0.5mL/kg/hr x #3-race, #4-age (depends on formula). AKIN I ↓ GFR > 25% 6 hours 4) FeNa = Injury / ↑ Cr 2x < 0.5mL/kg/hr x [(U/P Na)/(U/P Cr)] x 100 AKIN II ↓ GFR > 50% 12 hours 5) Acute Kidney Injury < 0.3mL/kg/hr x Failure / Cr 4mg/dL a. If prerenal → isotonic IVF. 24 hours or AKIN III ↓ GFR > 75% anuria x 12hours b. Keep HCO3- > 12, pH > 7.15. Loss AKI > 4 weeks c. Keep Phos < 5 & K+ nml. ESRD AKI > 3 months d. Don’t ↓protein. 1-2 g/kg/d is needed in ICU pts. Avoid phos & K+. + FEUrea FENa 6) Typical indications to begin OSM BUN/Cr uNa renal replacement therapy: K+ Pre < 1% < 35% < 10 > 500 > 20 ≥ 6, pH ≤ 7.2, HCO3- < 12, 50Renal > 2% > 20 < 350 < 15 65% PaO2/FiO2 ≤ 200 w/volume Post > 4% > 40 < 350 > 15 overload, AKI >72hs. 7) Early (100mL/hr.

E. Burn Types 1) Thermal → Scald (MC), Flash, Flame, Blast, Steam/Smoke, & Contact. 2) Chemical 3) Electrical 4) Radiation 5) Friction

F. Chemical (4%) 1) Acid & Alkali → copious H2O irrigation (30-60min). a. Alkali → deeper burns 2/2 liquefaction necrosis. i) Stricture (early) &/or SCCa (late). EGD to (but NOT past) injury. b. Acid → coagulation necrosis. Tx → H2O irrigation x 30min. 2) Hydrofluoric Acid a. Tx → H2O irrigate x 30 min → neutralize w/topical Ca++ (1amp Ca++-gluconate + 100gm sterile lube) → intra-arterial Ca++ at/near site PRN. 3) Powder Tx → wipe away then irrigate w/H2O x 30min.

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4) Mineral Spirits Tx → irrigate w/H2O x 30min. 5) Tar Tx → cool (tar stored @ 250°F → continues to burn pt), then wipe away w/lipophilic solvent (glycerol/adhesive remover). 6) Phenol → NOT water soluble. Tx → use lipophilic solvent.

G. Desquamating conditions → epidermal detachment from dermis (desquamation). 1) EM → least severe form (self-limited; target lesions). a. Pt gets a few oral ulcers & skin lesions s/p starting new sulfa drug → d/c sulfa + local wound care/topicals. SJS → serious (< 10% BSA). SJS/TENs → more serious (> 10 to < 30% BSA). TENs → most severe (> 30% BSA). Staph Scalded Skin Syndrome → 2/2 Staph aureus (asso w/toxic shock synd). a. Sxs → fever, N/V/D, diffuse erythema, hypoTN, & desquamation. 6) Mouth, lungs, vagina, anus, & GI also involved. 7) 2/2 viruses & drugs (Bactrim [MC now], PCN [MC historically], & Dilantin). 8) Tx → IVF resus, topical abx, Telfa gauze wraps (non-stick → prevents wound desiccation). IV abx if 2/2 Staph. Poss STSGs. a. NO steroids & NO silvadene (if 2/2 sulfa). 2) 3) 4) 5)

H. Cold injury 1) Frostbite a. Need rapid re-warming (40-42°C in circulating water; want sensation to return). b. Tetanus prophylaxis, topical antibiotic, pain control. c. Avoid early surgery (even if dry gangrene) → may take 3-4mns to diff b/w viable & necrotic tissue. d. Allow time for the necrotic tissue to autoamputate. e. Avoid pressure on the area & use non-abrasive cleaning. f. Best way to rewarm frozen feet → 40°C bath. g. Best tx to prevent tissue loss in frostbite s/p rewarming → tPA.

I. Inhalation injury (9%) 1) 2) 3) 4)

MC 2/2 carbonaceous materials & smoke (NOT heat-doesn’t pass glottis). Important prognostic factor in burn → carries up to 50% mortality. Sxs → stridor, facial burn, wheezing, carbonaceous sputum. RFs → EtOH, trauma, closed space, rapid combustion, extremes of age (age< 10 or > 50), delayed extrication. 5) Tracheobronchitis → in minutes to hours s/p burn. 6) ETT indications → upper airway stridor or obs, worsening hypoxemia. 7) Massive IVF resus → worsen Sxs (pulm edema). 8) Dx → bronch (soot, erythema, edema, mucosal sloughing [for up to 5d]). 9) Keep intubated until cuff leak w/balloon down (ie.↓swelling) & nml ABG. 10) Cxs → PNA, airway obs, atelectasis, CO poisoning, & ARDS. 11) PNA → MC infection w/ >30% TBSA burns (up to 70-80% inc). a. MCC of death s/p sig burn. b. PNA RFs → #1 inhalation injury, #2 massive IVF resus w/pulm edema.

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J. Toxin inhalation 1) Carboxyhemoglobin COHgb pts are red CO has 200x Hgb affinity vs O. a. Most pulse ox will read COHgb as OxyHgb → falsely ↑sats. Need ABG. i) Pulse ox unreliable in burn until ABG shows COHgb 25% or >20% & preg/LOC/pH 1mL/kg/hr (best measure of resus in burns). d. Ivy index = 250mL/kg in 1st 24hrs → ↑abd comp syndrome. 4) 2018 ABLS Guidelines LR (& Plasmalyte) preferred over NS. a. Initial/PreHospital Rate(mL/hr): ≤ 5yr→125, 6-13yr → 250, 14+→ 500. b. Acutal Resus Rate for 1st 24hrs (½ in 1st 8hrs, 2nd ½ next 16hrs). i) Flame/Scald A) thin scalp > upper back). b. STSG → Epidermis & variable quantities of dermis. i) ML to survive. STSG Cx over joint → 2°contracture. c. MCC of failure → seroma/hematoma. d. Using saline w/epi tumescence can help ↓ bleeding. 3) Contracture 1°→ immediately after harvest in OR. 2° → long term. a. Finger contracture s/p burn → z-plasty.

N. Infections 1) Dx of burn infxn → wound bx (NOT Cx/swab → colonization is nml). a. MCC → Staph aureus (2nd MC → pseudomonas). 2) Topical Antibiotics a. Silverlon → Best topical dressing that DOESN’T impair STSG take or wound healing.

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

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12. Plastics, Skin, & Soft Tissues Strength layer of skin → dermis Keratin → hair/nails Desmin→ muscle Vimentin → fibroblasts

A. Anatomy

B. Dermoid Cyst usually intra-abd or sacral, c/f CA, Tx → resect if superficial. C. Epidermal Inclusion Cysts (EIC) MC cyst, mature epidermal lining, filled w/keratin. Tx → resect (must include all cyst wall or → recurs).

D. Elastofibroma Dorsi MC in F >50yo. MC on right, infraclavicular. 1) Dx → MRI (fibrous fatty streaks). No CA risk. Tx → excise.

E. Ganglion Cyst at joints, MC wrist, filled w/collagenous synovial fluid. 1) Tx→ asp cures ~50% (if needs excision → remove check valve as well).

F. Glomus Tumor NOT from glomus cells, benign, painful, contains vessels & nerves, MC @ fingertip/ear. Tx → resect.

G. Lipoma MC mesenchymal tumor, usually on back, neck, b/w shoulders. 1) Dercum Disease/Adiposa Dolorosa multiple, painful lipomas. MC F >50y. 2) Liposarcoma 2nd MC sarcoma. MC RP sarcoma.

H. Neuroma I. Keratoses 1) Actinic pre-cancerous, tan/pink/red, 2/2 sun exposure, Tx → diclofenac (ex Bx if c/f CA). 2) Seborrheic NOT pre-cancerous, keratinocytes, trunk, elderly. 3) Arsenical asso w/SCCa.

J. Keratoacanthoma from pilosebaceous gland, grows quickly, rolled edge, crater w/keratin, 5% CA risk, may involute. 1) Tx → always Bx, excision usually indicated.

K. Paraganlioma (chemodectoma) rarely CA, from glomus cells (neural crest chemoreceptors, regulate blood flow), secretes norepi, MC in abd overall (MC neck → carotid body, MC chest → Ao arch). 1) Tx → resect.

L. Trichilemmal Cyst → Scalp, no epidermal lining, filled w/keratin. 1) Tx → resect. M. Xanthoma benign, yellow, cholesterol, histiocytes, asso w/familial HLD. 1) Tx → resect.

N. Basal Cell Cancer 1) MC skin CA (& overall CA), 80% of non-melanoma skin CA (NMSC), pearly papule, rolled edges, telangiectasias. MC on upper lip. 2) High risk → any H&N, trunk/extremities >2cm, recurrent, prev XRT site, ill-defined, morpheaform, aggressive, immunocompromised pt. 3) Tx → WLE 4mm margins (wider margin or MOHS if high risk). Get frozen section of margin if not using MOHS.

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O. Squamous Cell Cancer 1) ~20% of NMSC. Well demarcated, scaly patch/plaque to fleshy, soft, granulomatous plaque/papule/nodule. MC on lower lip. 2) High risk → any H&N, hands/feet, anogenital, trunk/extremities >2cm, >6mm depth, recurrent, prev XRT site, ill-defined, neurologic sxs, aggressive, immunocompromised pt. (Very high risk = >4cm). 3) Tx a. Low/Intermediate Risk Margins: 2groin > 3H&N. b. Get PET & brain MRI. MUP has same or better prognosis as 1° dz. Resections a. WLE Margins i) Melanoma in situ 0.5-1 cm ii) < 1mm depth 1 cm iii) 1.1-2mm depth 1-2 cm iv) >2mm depth 2 cm b. Excision includes skin & subQ down to, but NOT including, fascia. c. Small bowel mets common → resect if able. If SBO w/asso mass in pt w/hx of melanoma → ex lap (NOT serial exams). d. 1° ant to tragus → 20% parotid mets → superficial parotidectomy. e. In-transit melanoma = St III → get PET, then resect ± isolated limb infusion ± intra-lesional tx.

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6) LNs a. Clinically - → SLNB if ≥ 0.75-0.8mm, consider if < 0.8mm + ulceration especially if >2/mm2 mitosis, young, +LVI, or combination of these. i) -SLNB → f/u w/H&P q3-6mn x5yrs, consider q1y imaging in 1st 5yrs. A) MSLT-I → just doing a SLNB ↑ 10yr DFS & DSS. ii) +SLNB → Surveillance U/S q4m x2 yrs then q6m x3 yrs. A) Surveillance is preferred over completion LND per NCCN. B) MSLT-II → + SLNBx doesn’t require completion LND (NO ↑survival), but is indication PD-1 inh (+BRAF tx if +BRAF mut). b. Clinically + → MRND or lvl 1-3 ALND (based on location of 1°). 7) CTX in melanoma → BRAF+MEK inh (vemurafenib & dabrafenib), PD-1 inh (pembrolizumab, nivolumab) +/- CTLA-4 inh (ipilimumab). R. Breast CA → MC to met to skin. Do Bx of lesion and re-stage BrCa.

S. Dermatofibosarcoma Protuberans 1) Uncommon exophytic, slow growing, low grade, spindle cell tumor arising in the dermal & subcutaneous tissues, particularly of the trunk. 2) Tx → MOHS is standard of care (per NCCN) vs complete excision. Re-excise if margins +. Excellent outcomes (~100% @ 10yrs). Radiosensitive. a. MOHS ↓ recurrence > WLE (1.1% vs 6.3%). 3) Low grade fibrosarcoma in baseline large breast = dermatofibrosarcoma protuberans → resect w/negative margins as above. 4) Large low grade fibrosarcoma in baseline small breast = dermatofibrosarcoma protuberans → mastectomy. T. Hidradenitis From apocrine sweat glands 1) RFs → Downs, women, African heritage, obese, excessive deodorant. 2) MC 2/2 corynebacter, porphymonas. 3) PASH → Pyoderma gangrenosum, Acne, Suppurative Hidradenitis. 4) Acute hidradenitis Tx → Topical clinda +/- low dose PO abx & CHG baths. 5) Acute hidradenitis w/abscess a. Tx → I&D deroofing + IV abx (if fever, cellulitis, or abscess). 6) Chronic, refractory hidradenitis a. Tx → Excising all involved skin & subQ, NPWD, may need STSG later. 7) Another way to classify is by Hurley Stage (1-3) 1) Single or mult w/o sinus tract Tx → topical clinda Tx → 12wks doxy or 2) w/sinus tract 10wks rifampin+clinda 3) Diffuse, covers entire area of body (esp if refractory to doxy). U. Flaps 1) Types a. TRAM → Based on superior epigastric aa & periumbilical perforators. i) CIs → previous upper abdominal scars. b. Fascial (eg. Tensor-lata flap). c. Deep Inferior Epigastric Perforator (DIEP) flap → fasciocutaneous, ↑ OR time, ↓ Cxs & LOS vs TRAM. d. Trapezius flap → based on transverse cervical artery.

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e. Pectoralis major flap → based on either the thoracoacromial artery or the internal mammary artery. 2) Complications a. MCC of flap failure → venous thrombosis. Presents as blue & congested w/↓cap refill. b. Venous congestion → arterial insufficiency → Doppler loss.

V. Decubitus Ulcers 1) Stage 1 – erythema & pain, no skin loss. Tx → pressure relief. 2) Stage 2 – partial skin loss. Tx → local tx & keep pressure off 3) Stage 3 – full thickness skin loss w/exposed subQ fat. a. Tx → sharp debridement (may need myocutaneous flap). 4) Stage 4 – Exposed bone, muscle, adipose tissue or tendon. a. Tx → myocutaneous flap.

W. Paronychia 1) Infxn where the skin & nail bed meet. MCC → Staph aureus. 2) Can progress under nail bed (erythema, swelling, pain) 3) Tx → abx; remove nail if purulent underneath; I&D if pus (via lateral incision)

X. Felon 1) Infxn in terminal joint space of the finger usually s/p splinter/cut to fingertip. MCC → staph aureus. 2) Tx → incision over the tip of the finger & along the medial & lateral aspects of the fingertip; prevents necrosis; avoid incision into fingertip pad (key part of fingertip sensation).

Y. Soft Tissue Sarcomas 1) MC → Malignant Fibrous Histiocytoma (MFH; aka undiff spindle cell). a. Tx → neoadj CTX then WLE. 2) 2nd MC & MC RP → liposarcoma. MC sarcoma mets → lung. MC location of osteosarcoma → knee. 3) MC in kids → rhabdomyosarcoma (MC subtype → embryonal. Worst subtype → alveolar). 4) Spread hematogenously, except: SCARE (Synovial cell, Clear cell, Angio-, Rhambdomyo-, Epitheliod). 5) Sarcoma prognosis is based on grade. 6) T1 < 5cm T2 ≥ 5cm N1 + regional LNs G1 well diff G2 mod diff G3 poorly diff G4 undiff 7) MI prognostic factor for RP sarcomas→ complete en bloc resection w/neg margins, 50% local recurrence, 20-30% have mets. 8) Most RP tumors are cancerous (MC RP CA → lymphoma). 9) 1st → CNBx. Ex bx if 10yo. a. Sxs → trismus (reduced jaw opening) & odynophagia. b. Usually Ø airway obstruction. c. Tx → 1st needle asp, 2nd I&D via tonsils if persists >24hrs (may need ETT to facilitate drainage. Drains w/swallowing s/p I&D). 4) Retropharyngeal Abscess Younger kids (usually < 10yo) or w/Pott's dz. a. Sxs → fever, drool, & odynophagia. An airway emergency. b. Tx → ETT, I&D via post pharynx. Drains w/swallowing s/p I&D. 5) Suppurative Parotiditis Sxs → pain, fever, mandible angle swelling. a. MCC → Staph aureus. Tx → IVF, abx, I&D.

F. Oral & Pharyngeal Cavity Cancer (Above Larynx) 1) Pharyngeal MC, but laryngeal MC c/o death. RFs → ETOH, tobacco, HPV (>90% HPV+ cases are 2/2 HPV 16), & EBV. ↑risk (5%) for lung CA (all need CXR). MC type → vast majority SCCa (ie. epidermoid). CA risk → ↑ w/erythroplakia vs leukoplakia. Division of oral cavity & pharynx marked by → Tonsillar pillars, jxn b/w hard & soft palate, & tongue papilla 7) Oral cavity includes → ant ⅓ tongue, ant tonsillar pillars, gingiva, hard palate, lips, & floor of mouth. 8) MC site for oral CA → lower lip (involves mucosa) 2/2 sun exposure. 9) Lip Ca Upper lip → Basal cell MC. Lower lip = MC location (80%) for upper aerodigestive SCCa (oral, pharynx & larynx). a. Tx → MOHS ± flap (if ⅓ lip removed), no ppx LNDx. 10) Tonsillar CA → considered an oral cavity CA. Ø sxs until lg, 2/2 EtOH/tobacco; MC SCCa, 80% LN+. Tx → tonsillectomy. 11) Tongue CA → worse functional outcomes at base. Need 2cm margin. a. Jaw invasion, early LN invasion (cervical chain) b. Tx→commando procedure (if invades jaw, removes part of mandible). 12) Oral Cavity CA → spreads to submental + submandibular nodes 1st. a. Exception → tongue CA goes to cervical LNs early (level II). 13) Pharyngeal CA → spreads to cervical LNs 1st. a. Nasopharyngeal CA Sxs → MC presentation → painless neck mass. Also, epistaxis or obs. Asso w/EBV, Chinese pts. Very responsive to XRT (do not resect). Stage I → XRT. Stage II+ → CTX-XRT. b. Oropharyngeal CA Sxs → neck mass, sore throat. c. Hypopharyngeal CA Sxs → hoarseness (early LN spread). 14) Location w/lowest survival rate → hard palate (b/c hard to resect). 15) Need 1 cm margin for all except → tongue (2 cm margin required). 2) 3) 4) 5) 6)

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16) Tx: a. Stage I + II oral cavity (< 4 cm, no nodal or bone invasion) → Resection. b. Stage I + II pharyngeal (< 4 cm, no nodal or bone invasion) → XRT. i) Include neck nodes w/XRT; hard to resect. ii) Note → nasopharyngeal SCCA is very sensitive to XRT (Stage I - XRT; Stage II - CTX-XRT). c. Stage III oral cavity or pharyngeal (> 4 cm or nodal or bone invasion) i) All get: 1) Resection, 2) MRND, & 3) post-op chemo-XRT ii) Exception → nasopharyngeal CA gets CTX-XRT only (no resection; include neck nodes in XRT field). d. Stage IV (mets) → palliative CTX-XRT (5-FU + cisplatin).

G. SCCa in LN of unknown primary MC CA dx’d on FNA of neck LN→ 1mm & NO clin. + LNs 3) If on scalp, face, ear → resect + superficial parotidectomy + cervical LNDx (only if palp dz; if none → SLNB). a. Ant to tragus → ant LNDx. Post to tragus → post LNDx. b. Adj Tx → IFNα (many SEs), XRT (↓ LR, but not survival).

I. Verrucous Ulcer → Low-grade, well-differentiated SCCa, usually inner cheek/buccal, presents w/leukoplakia, asso w/tobacco, mets rare, NOT aggressive. 1) Tx→full resection w/5mm margins ± flap, NO SLNBx/LNBx/CTX-RTX.

J. Acoustic Neuroma/Vestibular Schwannoma (CN VIII) → benign, slow, asso w/NF2, tinnitus/hearing loss/vertigo. MRI best. 1) Usually @ cerebropontine angle. CN VII @ risk. 2) Tx→crani + resect sup & inf vestibular nerves. XRT an option.

K. Maxillary Sinus CA Tx → maxillectomy. L. Laryngeal CA → Vocal cords. MC → SCCa. Sxs → hoarseness, dysphagia, asp, & dyspnea. 1) Tx →

Vocal cord only → XRT More than cords → CTX-XRT If +LNs(St III) → CTX-XRT & ipsilateral thyroid + MRND.

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M. Septal Hematoma Tx → drain (prevents necrosis & infection). N. Mastoiditis → Can destroy bone; 2/2 acute suppurative OM, ear pushed anteriorly; MCC Streptococcus pneumoniae. 1) Tx → typmanectomy + abx (masteroidectomy next step).

O. Esophageal Foreign Body → Dysphagia, most stuck distal to cricopharyngeus (95%). Tx → rigid esophagoscopy.

P. Torus Mandibular → Benign, congenital mass. Ant lingual mandible, DON’T OPERATE!

Q. Torus Palatini → Benign, congenital mass. Upper palate, DON’T OPERATE! R. Sleep Apnea → Can lead to cor pulmonale, MI, arrhythmia. 1) Tx → CPAP best, Uvulopalatopharyngoplasty (UPPP) best surgical option.

S. Hemangioma → MC benign H&N tumor (& MC overall tumor in kids). T. Cystic Hygroma → Congenital lymphatic malformation. Benign. Post to SCM. Tx → resect.

U. NIMS → Best indication is re-operative field (thyroid/parathyroid > CEA) or PHx of XRT 1) Incidence of nerve inj ~0.2-0.8% for thyroid surgery. No difference in RLN inj using NIMS/IONM vs intra-op RLN visualization (gold standard). 2) PPV 33%, NPV ~100%.

V. MRND → Ant cervical LNs, omohyoid, cervical br of CN VII, & submandibular gland. W. RND → Above +: CN XI, SCM, & IJ. No diff in survival compared to MRND.

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14. Pituitary

Incidentaloma → 10-15%

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

B. Craniopharyngioma Benign, MC kids 5-10yo. 1) Calcified cyst ~ ant pituitary. Rathke’s pouch remnant. 2) Sxs → HA, growth failure, bi-temporal hemianopsia, endocrine problems, hydrocephalus. 3) Tx → surgery for sxs. Frequent Cx post-op → diabetes insipidus.

C. Sheehan’s Syndrome → ↓ lactation & hypoTN post-partum → pituitary ischemia → Can lead to adrenal insuff. Tx → HRT.

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15. Adrenal

Incidentaloma → ~4%

A. Anatomy (External to internal) 1) 2) 3) 4)

Granulosa (Salt) Fasciculata (Sweet) Reticularis (Sex) Medulla (Sympathetics)

B. Adrenal Incidentaloma 1) Workup → lytes, PM cortisol (↑sens) or 24h urine (↑spec) cortisol, plasma aldosterone:renin ratio, 24h urine metanephrines.

C. Hormonal Effects 1) Preop hydrocortisone dosing (see table in Anesthesia chapter). 2) Hypercortisolism (Cushing Syndrome) MCC → exogenous. a. 1st test → 24hr urine cortisol.

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

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

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4)

5) 6)

7)

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

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d. Preoperative considerations i) 1st give → α-blocker (Phenoxybenzamine [α1& α2]), then IVF, then β-blocker [if reflex tachy]). A) Doxazosin: α2 only (Ø reflex tachy), long acting. B) Phentolamine: short acting. 8) Angiomyolipoma → benign. Don’t resect based on size if characteristic CT findings. Only resect for sxs.

D. Adrenalectomy 1) Always test for function prior to removal (metanepherines, BMP, etc). 2) Indications a. Non-homogenous/complex, >4-6cm, HU >10, 1cm while following, +FNA (don’t bx). 3) Right adrenalectomy approach requires → Kocher + mobilize right lobe of liver. 4) Left adrenalectomy → mobilize spleen & tail of pancreas (risk of injury). Phrenic vein passes medial to gland & into left renal vein near/with left adrenal vein.

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16. Thyroid

A. Thyroid Function & Anatomy 1) 2) 3) 4)

Endodermal origin, from foramen cecum. C-cells from 4th pouch (neural crest origin). T3 is most active & made peripherally. Inferior thyroid a crosses RLN → take arteries at gland to ↓nerve injury.

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

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c. Sxs→ usually asx; susceptible to infection (MC issue, ~10-70%), dysphagia, dysphonia, dyspnea, fistula. May be premalignant (MC → papillary thyroid CA). May be only thyroid tissue. d. Surgical indications → infection (MC indication), CA, ↑ size. e. Tx → resection → take mid-portion of hyoid + thyroglossal duct cyst all the way to tongue base (Sistrunk procedure). Use a lateral neck incision. f. Recurrence = 10.7%. Re-op for recurrence or infection.

C. Goiter Diffuse enlargement. MCC → iodine def. OR if sxs or c/f CA. D. Hyperthyroidism Most accurate test to dx → ↓TSH. 1) Best test to distinguish hyperthyroidism type → 123I scan(scintigraphy). 2) Grave’s Disease MCC of hyperthyroidism (80%). a. Toxic diffuse goiter; often in older women. b. Sxs only found in Grave's → exophthalmos, pre-tibial edema. c. 2/2 lgG to TSH receptor (activates it) = thyroid stimulating immunoglobulin (TSI) & long acting thyroid stimulator (LATS). d. Dx → ↓TSH, ↑T3/T4. 123I scan → diffuse homogenous uptake. e. Med tx usually effective (> 95%). i) Thionamides (50% recurrence). A) PTU→OK in pregnancy. Methimazole→NOT OK (→cretinism). 1. Both cause agranulocytosis. 131 ii) I (5% recurrence). iii) β-blocker (helps Sxs only). iv) Thyroidectomy if med Tx fails. Unusual to have to operate. A) Pre-op prep → methimazole until euthyroid, β-blocker, 14d of Lugol's (↓ friability & vascularity). OR only after euthyroid. B) Near total/bilateral subtotal (5% recurrence) or total thyroidectomy (need lifetime thyroxine replacement). C) Indications → suspicious nodule (MC), non-compliant, recurs s/p med tx, kids & pregnant women not controlled w/thionamides (131I is CI in pregnancy). 3) Thyroid Storm a. Usually post-op in Grave’s dz; fever tachy, HTN 2/2 no preop β-blocker, PTU, & Lugol’s. b. Tx → β-blocker, PTU, & Lugol’s, cooling blanket. i) Lugol’s (K+-iodine) → Wolff-Chaikoff effect → ↑I →↓T3/4 release. 4) Toxic Multinodular Goiter a. Older women. Usually non-toxic at 1st. b. Sxs → insomnia, airway compromise, ↑HR, ↓wt. c. Chronic low-grade TSH stim → hyperplasia. Path → colloid tissue. d. Thyroid scan → diffuse non-homogenous uptake. e. Tx → subtotal or total thyroidectomy preferred. i) 131I trial can be considered, esp if patient is elderly/frail, but NOT if compression or suspicious nodule present.

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A) 131I is less effective 2/2 non-homogenous uptake. 5) Single Toxic Nodule a. Younger women. Sxs when > 3 cm. Autonomous fxn. b. Dx → thyroid scan (localized hot nodule). U/S → may show adenoma. i) Ultimately 20% of hot nodules cause sxs. c. Tx → thionamides & 131I (95% effective); lobectomy if med Tx fails. 6) Trophoblastic & TSH-secreting Pituitary Tumors Are rare causes.

E. Hypothyroidism → Wt gain, cold intolerance, fatigue. 1) Tx → levothyroxine. 2) Myxedema coma →↓fT4(3cm, recurrent, h/o XRT, bloody, or c/f cystic PTC c. Non-diagnostic→q6-18mn U/S. Resect if >1.5cm or >1cm & suspicious. 1) Asymptomatic Thyroid Nodule W/U → get TFTs & U/S. Bethesda Class

Definition

CA Risk (% per SCORE)

Treatment

I

Non-diagnostic

5-10 (17)

Repeat FNA

II

Benign

0-3 (4)

Clinical f/u Repeat FNA (vs RNA gene panel to assess need for lobectomy)

AUS or FLUS III

Atypia of Undetermined Significance Follicular Lesion of Undetermined Significance

10-30 (16)

IV V VI

Follicular Neoplasm Suspicious Malignant

25-40 (26) 50-75 (75) >97 (99)

Lobectomy Lobectomy vs Total

a. Kids → 25--50% nodules are CA. Adults → 5% are CA. b. ↑CA rate w/ → hypervasc, microcalcs, irregular/heterogenous, taller-than-wide, hypoechoic. c. FNA if→ high suspicion & >1cm, mod (eg solid) & >1.5cm, low & >2cm. FNA PPV for cancer is 97-99%. d. 14-47% of incidental on PET-CT are CA. e. For nodules F:M = 8:1, but 2x more likely to be CA in M. 2) Follicular Neoplasia (or just follicular cells) a. If on FNA → lobectomy (~25% CA). If on path s/p lobectomy → done. b. MCC Intrathyroid round mass w/outer hypoechoic "halo sign" → follicular adenoma (PTC has one ~ 24% of the time). Tx w/lobectomy. 3) Lateral Aberrant Thyroid Tissue → Enlarged lateral neck LN w/nml-appearing thyroid tissue on FNA. a. Represents PTC w/lymphatic spread → total thyroidectomy, ipsilateral TLNDx, & I131.

B. Thyroid Cancers 1) Most familial thyroid CA are non-MTC (MC papillary) → FAP, Cowden synd, Carney complex, Pendred synd, Werner synd, usually AD w/↓prevelance. 2) Papillary (PTC) BRAF-V600+. a. MC thyroid CA, least aggressive, best prognosis, lymphatic spread, prognosis based on local invasion (NOT LNs), can be multicentric, Psammoma bodies (Ca++), Orphan Annie nuclei. Micro-LN+ → still good prognosis & no LNDx unless grossly involved. Cannot be St III or IV unless >55yo. b. Tx in pregnancy → Wait until post-partum. c. Thyroglobulin → marker for recurrence (only if s/p total thyroidectomy). Can be dx on FNA. C/f recurrence → get US 1st. d. Tx Do a Targeted Dx (TLND) of grossly/Bx + compartments. 131I post-op for → Mets, >4cm, or >1cm w/high-risk features. i) Low risk (1cm, b/l, multicentric, h/o XRT, or + margins → total thyroidectomy (synthroid to ↓TSH/growth [s/p 131I if getting 131I]).

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3) 4)

5)

6)

7)

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

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C. Post-Op Hypocalcemia 1) Must ID parathyroids on operative side, if accidently removed → visually confirm presence of other healthy/preserved parathyroid(s). 2) Usually w/in 24-72h. 3) Asx w/Ca ≥7.5 → obs + labs. 4) Asx or mild Sx w/Ca 13 & palp neck mass. iii) Tx → en bloc resection + ipsilateral thyroid + LNDx. A) ↑Ca++ 2/2 malignancy. No sxs → bisphosphonate & calcitonin. Sxs→1st IVF w/NS, 2nd diuretic, 3rd bisphosphonate + calcitonin. e. Dx → ↑PTH & Ca++, Cl:Phos > 33. Localize w/U/S. PRN SPECT vs 4D-CT. f. Tx of benign dz → parathyroidectomy (see end of chapter). g. Hypercalcemic crisis → IV resus w/NS, then lasix. i) Once Ca++ nml → parathyroidectomy. h. High Ca++ 1 wk s/p 3 ½ gland excision, nml Ca++ & PTH before d/c, on Ca++ & calcitriol → 2/2 too much Ca++. 2) Secondary MCC → CKD (Ca++ loss w/HD). a. Dx → ↑PTH 2/2 ↓Ca++ (maybe low/nml Ca++). Serum PO4- ↑. b. Sxs → pruritus, bone pain, fxs. c. Most don’t need surgery (med tx effective in 95%).

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d. Tx → Ca++ supplement & sevelamer chloride (Renagel → binds PO4-), calcitriol (Vit D), control dietary PO4- (limit dairy). i) Cinacalcet → mimics Ca++, inh PTH release (very effective). ii) Surgery if → PTH >800 pg/mL + ↑ Ca++ & PO4- or Sxs (calciphylaxis, bone pain, intractable puritis, persistent anemia, pathologic fxs). 3) Tertiary a. Corrected renal dz (ie s/p TXP) but continued ↑ PTH. b. Labs & OR indications → similar as 1° HPT (↑PTH & Ca++). c. Tx → 1st → med tx like for 2°. i) Surgical→ subtotal (3 ½) v total parathyroidectomy w/autoimplant. 4) Familial Hypocalciuric Hypercalcemia (FHH) ↑pCa++ w/↓uCa++ a. Need genetics, not OR. FHH → only absolute CI to parathyroidectomy.

C. Hypoparathyroidism 1) Pseudohypoparathyroidism → target tissue resistant to ↑PTH → ↓Ca++/growth & ↑PO4- 2/2 mutation in GNAS-1. a. Familial, ↓IQ, short/stocky, short 4/5th digit.

D. Multiple Endocrine Neoplasia (MEN) 1) Neoplasms develop synchronously or metachronously. AD. 2) MEN I (MEN1 gene, menin protein; on Ch11) “3 P’s” a. Parathyroid hyperplasia (90%) ↑PTH & Ca2+ If Vit D↓ → repleat. i) Usually 1st to have sxs (hypercalcemia, kidney stones). ii) Tx→ 4-gland resection with autotransplant/subtotal 3 ½ gland + thymectomy (↑ risk of thymic carcinoid). A) 4-gland/total resection → 6% permanent hypoparathyroidism. B) Subtotal 3 ½ gland → 50% recurrence. iii) Don't leave gland in neck → hard to re-op if recurrence. b. Pancreatic islet cell tumors (70%) i) Gastrinoma MC→ 50% mult, 50% CA. 2nd MC→Insulinoma (20%). A) MCC M&M in MEN I. c. Pituitary adenoma (70%) i) MC → Prolactinoma (Tx → Bromocriptine). 2nd MC → IGF-1. d. For MEN I, correct hyperparathyroidism 1st if simultaneous tumors. 3) MEN IIa (RET proto-oncogene; on Ch10) “2 P’s” a. Parathyroid hyperplasia (50%) same as above, but last to have sxs. b. Medullary CA of thyroid (>99%) ML to be Dx’d 1st. i) Tx → ppx total thyroidectomy ± central LNDx & MRND (if >1cm). ii) Nearly all patients get this (hallmark of MEN IIa & IIb); often b/l. iii) Usually 1st part to be sx (MC sx → diarrhea). iv) MCC M&M in MEN IIa, remove at 2-5yo. c. Pheochromocytoma (50%) Often bilateral, nearly always benign. i) Need to remove pheo 1st if simultaneous tumors. 4) MEN llb (RET proto-oncogene; on Ch10) “1 P” a. Medullary CA of thyroid (>99%) SAA except more aggressive than MEN IIa, remove at 6mn (if 918T mut) to 1yo. Consider central LNDx & MRND (if >0.5cm). b. Pheochromocytoma (50%) SAA. Remove pheo 1st if simultaneous. c. Mucosal neuromas (anywhere in GI tract). d. Marfan's habitus & musculoskeletal abnormalities

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5) Always check Ca++ on MEN I & IIa patients before operating on them. 6) Always check urine metanephrines on MEN IIa & IIb patients before operating on them.

E. Parathyroidectomy 1) Indications Pre-op localization → U/S ± Sestamibi. a. Sxs → Refractory bone pain (MC), fxs, pruritus. i) Indications → “Stones, bones, groans, & psychiatric overtones.” b. Asx, but refractory to med Tx w/any of following: i) 1 above nml, nephrolithiasis, DEXA T-score < -2.5, urine Ca++ > 400µg/d. c. 85% get relief with surgery. d. Surgery involves total parathyroidectomy w/auto-transplantation or subtotal 3 ½ gland parathyroidectomy (or resection of 1 gland if single adenoma). 2) Intraoperative considerations a. Send gland for frozen to confirm parathyroid tissue. b. PTH should drop > 50% 10 min s/p excision compared to pre-op levels, if not but close → wait 5 min & recheck PTH. Not close or PTH still too high → need neck exploration for ≥ 50% drop. i) 1st → 4-gland exploration (retro- & paraesophageal focused). ii) 2nd → Divide middle thyroid vein to better mobilize the thyroid. iii) 3rd → Resect cervical thymus. Consider PTH from IJs to lateralize. iv) 4th → close & get Sestamibi scan (>80% sensitivity). Do NOT resect nml glands or do sternotomy.

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18. Breast A. Infection 1) Mastitis a. Infectious MC asso w/breastfeeding. i) Nonlactating women S. aureus MC 2/2 chronic inflammation (eg actinomyces) or autoimmune dz (eg SLE). ii) Tx w/abx, if persists r/o a necrotic CA (incisional bx w/skin). b. Periductal (Mammary Duct Ectasia or Plasma Cell Mastitis) i) Sxs → creamy d/c, erythema, can have nipple retraction. Noncyclic pain. RFs → smoking, piercing. ii) Bx → dilated ducts w/inspissation & periductal inflammation. iii) Tx → if creamy, non-bloody d/c & not asso w/nipple retraction give abx & reassure. Otherwise or recurs → r/o inflammatory CA (incisional bx w/skin). c. Granulomatous → idiopathic, inflammatory, “burns out” in 1-2yrs. i) Multiple abscesses ± fistula at various locations. ii) Tx→ may respond to steroids (still bx 1st). 2) Abscess Asso w/breastfeeding. MC → S aureus, then strep. a. Tx → U/S guided-perc asp (try 1st) or I&D, d/c breastfeeding & pump, abx for cellulitis (Bactrim is safe). Bx if solid or fails to resolve. B. Galactocele Tx: 1st → reassure + pump 2nd → aspirate 3rd → I&D 4th → incisional bx.

C. Galactorrhea Asso w/amenorrhea. 1) 2/2 ↑ prolactin (pituitary prolactinoma), α-methyl dopa, metoclopramide, OCPs, phenothiazines, reserpine, TCAs.

D. Gynecomastia pinch test → >2-cm. 1) Recent, >5cm, or painful → send β-HCG, LH, testosterone, & estradiol. 2) 2/2 spironolactone, CCBs, antipsychotics, H2blockers, PPIs, cimetidine, marijuana. Most are idiopathic. 3) Dx→must get sex hormone levels if no clear etiology (eg meds, BRCA). 4) Tx → Obs vast majority (likely regresses). Resect if deforming or causing social probs. Tamoxifen 10-20mg/d resolves 60-90%. 5) Pseudo-/ Senescent Gynecomastia Older men, b/l. No TTP, mass, LAD, or nipple d/c. Tx → observe (benign).

E. Polymastia Accessory breast tissue. Usually in axilla (MC location). F. Polythelia Accessory nipple. From axilla to groin (MC breast anomaly).

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G. Mondor’s Disease / Superficial Thrombophlebitis of Breast 1) Palpable, painful cord in breast w/slight skin retraction; in lateral thoracic, thoracoepigastric, & superior epigastric veins. 2) Tx → warm compress & NSAIDs. Bx only when asso w/mass.

H. Mastodynia / Mastalgia 1) Cyclic MCC is fibrocystic disease. a. Tx → 1st reassurance, NSAIDs (±wt loss, sports bra). 2nd → Tamoxifen, starting OCP, danazol (dopa agonist, SEs) & bromocriptine (sig SEs). b. Evening primrose, d/c caffeine/nicotine not proven to be beneficial in metaanalysis. 2) Continuous MCC is infection. Tx → abx if infection.

I. Fibroadenoma MC breast mass in young F. “Popcorn” calcs on mammo. 1) Get a CNBx to prove → Broad sheets of cohesive cells w/uniform nuclei / conspicuous fibrous tissue w/ compression of epithelial elements. 2) Tx → 2-5cm N2 clinical/matted / 4-9 c. IIa →T+N=2(N ≤ 1) (92) T3 >5cm N3 clavicle/IMA / 10+ d. IIb →T+N=3(N ≤ 1) (81) T4 chest wall invasion e. IIIa → T+N = 4-5 (N = 1-2) (67) f. IIIb → T4 or N3 (54) g. IV → mets (20) MC met to axilla → lymphoma, NOT breast CA. MultiFOCAL → same quadrant. MultiCENTRIC → different quadrants. 7) Treatment a. In general needs “margins off ink,” imprint cytology or frozen section ↓need for re-excision. i) Stage IIIa-IV need staging chest CT. ii) Node negative (NN), Low risk (LR), ER- BrCa→no CTX. iii) NN, LR, ER+ → anti-estrogen. iv) NN, HR, ER+ → anti-estrogen +/- CTX (pre-menopause → both). v) NN, HR, ER- (TNBC 12-24% of all BrCa) → CTX. vi) NP, ER- → CTX. b. BCT + XRT i) No XRT needed s/p BCT only if → >70yo, St I, ER+, no other CA hx, & willing to take anti-estrogen. ii) Need negative margins. Local recurrence → 10% (usually w/in 2 years). iii) CIs to BCT → pt who can’t get XRT (prior BCT w/XRT, scleroderma, 1st trimester pregnancy, multicentric dz). c. Mastectomy i) Clavicle→inframam crease, latissimus→lat sternum, incl pec fascia. ii) Leaves 1%–2% of breast tissue, can preserve the nipple. iii) Local recurrence ~5%. SCORE recs leaving a drain. d. Modified Radical Mastectomy i) Removes all breast tissue, including the nipple areolar complex. ii) Includes axillary node dissection (except level I nodes)

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

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j.

Pregnancy (never give XRT) i) 1st trimester → MRM vs mastectomy + SLNB (no CTX). ii) 2nd trimester → MRM vs neoadj CTX w/BCT then postpartum XRT. iii) 3rd trimester → MRM vs mastectomy + SLNB, or Neo-adj CTX, BCT, & postpartum XRT. iv) CTX (except for tamoxifen, taxanes, trastuzumab, MTX, & folates) is safe in 2nd & 3rd trimesters. v) U/S is best 1st test for new mass during pregnancy. vi) No XRT or blue dye while pregnant. No breastfeeding after delivery. Radioisotope is safe. k. Males (RFs → BRCA II > I, CHEK2, Klinefelter, ↑ age, hepatic dz, EtOH). i) MC is ER/PR+, HER2 - IDC ii) Mastectomy + SLNBx + Tamoxifen if ER+. l. Reconstruction i) Tissue expanders A) Work by local recruitment & thinning dermis/epidermis →→ implant placement. B) Subpectoral pocket, minimal inflation. Slowly filled over next weeks & months →→ space for final implant. ii) Implants Concerning lesion by capsule → stereotactic CNBx. A) Breast Implant Asso Anaplastic Large Cell Lymphoma (BIA-ALCL) 1. Rare (1:10-20k). Fluid around implant >1yr after surgery. 2. Dx → U/S asp, send for cyto & CD30. 3. Tx → remove implant w/capsule intact. iii) Flaps A) TRAM 1. Smoking, especially >10pk/yr hx → ↑flap necrosis & abd hernia. Need to stop > 4wks prior to OR. 2. Blood supply of TRAM flap → epigastrics. 3. Best immediate recon s/p MRM, no h/o CABG or XRT → TRAM (likely DIEP flap now, but usually are delayed). iv) Post-op concern for seroma (w/o c/f infection) → aspirate to allow for apposition of tissue (per SCORE). m. Recurrence (if ER+ → 0.3-0.5%/yr, if ER- →1%/yr ( 200), bili (> 4), or amylase/lipase (> 1,000) for > 24hrs. If < 24hrs then ↓ → lap chole w/IOC. b. < 5% have retained CBD stone s/p lap chole → ERCP clears 95%. 2) Routine IOC → 10% incidental CBD stones. 3) If retained CBD stones on IOC intra-op: a. 1st → 1mg glucagon + NS flush (Best tx for retained CBD stone or non-filling of duodenum on IOC). b. 2nd → transcystic CBD exploration if cystic duct > 5mm & 5mm both proximal (PHD) & distal (CBD) to cystic duct → choledochotomy w/CBD exploration.

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5) Jaundice, ↑direct & indirect bilirubin, h/o RYGB, & nml ducts on U/S → MRCP to eval anatomy b/c no distal obs per U/S. 6) Lap CBD exploration (Try transcystic CBD exploration 1st). 7) Next step s/p repair of cholodocholotomy w/ 5-0 PDS over 14-16F T-tube → transTtube cholangiogram. 8) Acute cholecystitis & bile duct stone on U/S 10yrs s/p RYGB. Tx → chole w/CBD exploration.

G. Hydrops (Gallbladder Mucocele) → Long-standing obs w/o infection → bile reabsorption & mucous secretion. Tx → lap chole.

H. Adenomyomatosis 1) Thickened mucosal & muscle nodule asso w/Rokitansky–Aschoff sinus. Not premalignant. Does NOT cause stones, but can cause RUQ pain. 2) Tx → cholecystectomy.

I. Mirizzi Syndrome 1) Compression of CHD by 1) gallbladder infundibulum stone, or 2) gallbladder or cystic duct inflammation extending to hepatic duct → CHD stricture. Tx → cholecystectomy, may need HJ for strictures.

J. Lemmel Syndrome 1) Compression of intrapancreatic CBD by a periampullary duodenal diverticulum (aka choledochocele/type III choledochal cyst).

K. Cholangitis 1) MCC is bile duct obstruction resulting from choledocholithiasis. a. E. coli (#1) & Klebsiella (#2). 2) Charcot’s triad → RUQ pain, fever, jaundice. Reynolds’ pentad → Charcot’s triad + AMS & shock (suggests sepsis). 3) Elderly pt s/p major surgery w/↑ LFTs/bili/WBC/fever/NO filling on HIDA → perc chole. 4) Colovenous reflux occurs at > 200 mm Hg pressure → systemic bacteremia. 5) Tokyo Grade (1-3) & Tx Guidelines 1/Mild → IVF, Cxs, abx 2/Mod (if 2 of these: WBC 12k, ≥39°C, ≥75yo, bili ≥5, Alb ≤70% nml) → IVF, Cxs, abx, early drainage. 3/Severe (e/o end-organ dysfunction)→urgent drainage+IVF, abx, Cxs 6) Dx → ↑ AST/ALT, bili, alk phos, & WBCs. U/S → dilated CBD (> 8 mm, > 10 mm s/p chole) if 2/2 biliary obstruction. 7) Tx → 1st abx (eg. pip/tazo) + IVF resus, need chole in 6-8ks (still obstructed → ERCP w/sphicterotomy + stent before surgery). a. Obstructive jaundice → ↓vit ADEK. May need vit K pre-op (>24h best) ± FFP.

L. Hemobilia → 2/2 fistula b/w bile duct & hepatic arterial system. Classically present w/UGIB, jaundice, & RUQ pain. 1) MC s/p trauma or percutaneous liver procedure (eg PTC tube). 2) Dx → EGD 1st to r/o UGIB, then angiogram. 3) Tx → angioembolization; OR if that fails.

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M. Gallstone Ileus 1) MCC → fistula b/w gallbladder & 2nd portion of duo → SBO from gallstone (MC → in TI). 2) Rigler’s Triad → pneumobilia, stone outside gallbladder, & SBO. Best test → CT w/PO & IV contrast. 3) If duo adhered to GB during lap chole → run entire small bowel for stones to prevent gallstone ileus. 4) Tx → remove stone from terminal ileum → longitudinal incision proximal to stone (more dilated portion) → milk back/out → close transversely. a. Can leave gallbladder & fistula if too sick (usually the case). If NOT sick, perform chole & close duo (very rare).

N. Bile Duct Strictures MCC → Ischemia s/p lap chole (eg. clips too near CBD). Others → chronic pancreatitis, GB/bile duct CA. 1) Sxs → sepsis, cholangitis, jaundice. Strictures w/o h/o pancreatitis or biliary surgery → CA until proven otherwise. 2) Dx → MRCP for anatomy & mass → if can’t r/o CA → ERCP w/brushings. 3) Tx → if 2/2 chronic pancreatitis/ischemia → choledochojejunostomy (best longterm). If 2/2 CA, Tx w/CA.

O. Primary Sclerosing Cholangitis 1) 30-50yo M. Asso w/UC, pancreatitis, & DM. 2) Sxs → jaundice, fatigue, pruritus (2/2 bile acids), ↓ wt, RUQ pain. 3) Progressive fibrosis throughout intra- & extrahepatic ducts → portal HTN & hepatic failure. 4) Does NOT get better s/p colon resection for UC. 5) Cxs → cirrhosis, cholangiocarcinoma. 6) Tx → liver TXP needed for most; PTC, choledochojejunostomy or balloon dilation → symptomatic relief. a. Cholestyramine → ↓ pruritus sxs (↓ bile acids). Ursodeoxycholic acid → same, + improves liver enzymes.

P. Primary Biliary Cirrhosis → F. Med-sized ducts. Cholestasis→cirrhosis→portal HTN. +Antimitochondrial Abs. No↑ CA risk. 1) Sxs → jaundice, fatigue, pruritus, xanthomas.

Tx → liver TXP.

Q. Oriental Cholangiohepatitis / Recurrent Pyogenic Cholangitis R. Porcelain Gallbladder → No longer considered ↑ risk of gallbladder CA (previously said to be 15%).

S. Gallbladder Polyps (Best test → U/S; found in fundus, ↑wall thickness, anechoic & NO shadowing; adenomatous polyps are premalignant). 1) MC → cholesterol (95%, ML polyp seen on CT) CA RFs → sxs, >10mm (+ stones, 40mmHg) → ERCP + sphincterotomy. 3. Biliary pain, nml LFTs & CBD → medical tx only (no manometry or ERCP). 2) Tx → 1st ERCP ± sphincterotomy (see above). a. Pt may benefit from transduodenal sphincterotomy if + Naidi test (biliary cholic s/p morphine + neostigmine). i) Extensive Kocher. i) Longitudinal duodenotomy, lat @ end of 1st ⅓rd of duo. ii) ID papilla. iii) Sphincterotomy at 11 o’clock. i) Suture mucosa of CBD to duo (5-0 PDS). i) Close duodenotomy transversely. B. Choledochal Cysts Concerning findings → cystic, nodularity, type V, e/o invasion or + LNs. If peds → better outcomes if resected by 4 wks old. Type I II III

Choledochal Cyst Description Cylindric or fusiform CBD dilation Supraduodenal CBD diverticulum Intraduodenal CBD diverticulum (asso w/ SOD)

IVa

Intra & extra hepatic dilations

IVb

Extra hepatic dilations

V

Intra hepatic dilations

Treatment MC, 77-87% / resect w/Roux-en-Y HJ Simple cyst excision Choledochocele / sphincterotomy vs endoscopic resection Partial hepatectomy + wide hilar Rouxen-Y HJ. May need TXP. Complete resection + Roux-en-Y HJ Caroli dz (dz + renal cyst = Caroli synd) / supportive vs TXP

1) Choledochal cyst tx → b/c MC is Type I, MC Tx → resect + Roux-en-Y HJ. C. Cholangiocarcinoma 1) RFs → PSC, liver fluke, Hep C, thorotrast, Caroli dz. 2) Subtypes: papillary (best prog), sclerosing. 3) Resectable → Absence of: i) Retropancreatic & paraceliac nodal, or distant liver mets ii) Portal vein or main hepatic artery invasion (although some centers support en bloc resection w/vascular reconstruction. iii) Extrahepatic adjacent organ invasion, & disseminated dz. 4) Tx (consider surgery if no distant mets & tumor resectable): ALL get Portal LNDx (any other LN+ = mets).

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a. Upper ⅓ (Klatskin/perihilar tumors) i) MC, worst, usually unresectable. ii) Tx → try lobectomy & stenting contralateral bile duct if localized a lobe. b. Middle ⅓ → hepaticojejunostomy + trisegmentectomy c. Lower ⅓ → Whipple d. Palliative stenting for unresectable disease; capecitabine (BILCAP trial) or gem/cis for CTX, MSI high → pembro. e. Overall 5ys rate → 20%.

D. Gallbladder Adenocarcinoma 1) Rare, but 4x MC vs Gallbladder Cancer cholangiocarcinoma. TNM Depth St Tx 2) 10% dx’d incidentally s/p lap T1a Lamina propria Lap chole (~100% cure) 1A Muscularis Lap chole + wedge IVb+V chole. T1b propria (2cm margins) 3) Dx → 3 phase liver CT/CAP Perimuscular Lap chole, formal IVb+V, T2 1B or MRI, CA 19-9, CEA. tissue portal LNDx (≥3 LNs), CBD resection (send frozen) w/HSerosal/liver/ 4) RFs → GB wall thickening T3 IIA J, adj gemcitabine + cisplatin adj organ (esp >10mm), +LAD, wall N1 IIB enhancement (esp mucosal), Main PV, HA, Palliative (gemcitabine + T4 III 2+ organs cisplatin) stones >3cm. M1 IV 5) F/u→U/S + 3-phase liver CT q6m x2y, then q12m x5y ±LFTs/CEA/CA 19-9.

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27. Pancreas A. Anatomy Body/Tail → posterior to gastrocolic lig in lesser sac Uncinate process → rests on aorta, behind SMV SMV & SMA lay behind neck of pancreas Portal vein forms behind the neck (SMV & splenic vein) Blood supply a. Head → superior (off GDA) & inferior (off SMA) pancreaticoduodenal aa. (ant & post brs for each) b. Body → great, inferior, & caudal pancreatic aa (all off splenic artery) c. Tail – splenic, gastroepiploic, & dorsal pancreatic arteries d. Venous drainage → portal system 6) Lymphatics → celiac & SMA nodes 7) Ductal cells → secrete HCO3- (via carbonic anhydrase) 8) Acinar cells → secrete digestive enzymes 9) Exocrine function →amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase, HCO3-. a. Amylase → only 1 secreted active; hydrolyzes α1-4 glucose chain links. 10) Endocrine function a. α-cells → glucagon β-cells (islet center) → insulin δ-cells → somatostatin PP/F cells → panc polypeptide b. Islet cells → also produce VIP & serotonin. 11) Ventral Pancreatic Bud “Major VW goal → Drive Safe!” a. Duct of Wirsung (Major, AoV, distal), migrates posterior/right/clockwise to form uncinate & inferior head 12) Dorsal Pancreatic Bud a. Duct of Santorini (accessory, proximal), forms body/tail/superior pancreatic head. 1) 2) 3) 4) 5)

B. Developmental Disorders 1) Annular Pancreas → 2nd portion duo, trapped in panc band; KUB → double bubble; get duo obstruction (N/V, abd pain). a. Consider in child w/recurrent abd pain & ↑ amylase. b. Tx: Asx → nothing. i) Sx A) Neonate → DJ. B) Adult → DJ vs GJ (duo less mobile so unlikely able to do DJ). C) Adult w/obstructive jaundice → HJ w/biliary stent. D) Adult w/chronic pancreatitis + obstructive pancreatic stones or periampullary lesion → Whipple procedure. 2) Pancreatic Divisum Prevalence → 10%. a. Failed PD fusion → duct of Santorini stenosis. b. Most are asx; some get pancreatitis. c. Dx → MRCP – long minor papilla w/large duct of Santorini; major papilla will show short duct of Wirsung. d. Tx → ERCP with sphincteroplasty; open sphincteroplasty if fails.

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3) Heterotopic Pancreas MC in duo. 2nd MC ectopic tissue in Meckel’s. a. Tx → Usually asx, Resect if sx.

C. Pancreatitis 1) Acute a. MCC → 1st = gallstones, close 2nd is EtOH (per NIH). Also → ERCP, trauma, hyperlipidemia, hyperCa++, viral infection, meds (azathioprine, furosemide, steroids, cimetidine), genetic (PRSS1, CFTR, SPINK1), & autoimmune (IgG4; Tx → steroids). b. Sxs → abd/back pain, N/V, anorexia. Also → jaundice, left pleural effusion, ascites, or sentinel loop (dilated small bowel near pancreas 2/2 inflammation). c. Mortality rate 10% (hemorrhagic pancreatitis → 50%). Pancreatitis w/o obvious cause → need to worry about malignancy. d. Ranson’s criteria i) On admission → “GA LAW” - Glucose > 200, Age > 55, LDH > 350, AST > 250, WBC > 16. ii) After 48 hours → “Calvin & HOBBS” - Ca++ < 8, Hct ↓ 10%, PaO2 4, fluid Sequestration > 6 L. iii) 8 Ranson criteria met → mortality rate ~ 100%. e. BISAP → BUN > 25, Impaired mental status, 2 SIRS, Age >65, Pleural effusion (sen & spec > APACHE II & Ranson’s). f. Can see RP hemorrhage: i) Cullen sign → periumbilical. ii) Grey-Turner sign → flank. iii) Fox sign → inguinal. g. Dx Labs →↑ amylase (clears w/in 2d, low spec), lipase (clears w/in 4+ d), & WBCs. U/S → gallstones & possibly CBD dilatation. Abd CT → for Cxs (necrotic pancreas → doesn’t enhance). h. Tx → NPO, aggressive IVF resus. 2) Chronic Sxs → pain (MC), steatorrhea, malabsorption. a. MCC → EtOH. Can have pseudocysts (MCC). 3) Hereditary 80% have PRSS1 mutation (cationic trypsinogen gene). a. 50x more likely to get pancreatic CA. 4) Revised Atlanta Classification of Pancreatic Fluid Collections a. Non-necrotic i) Acute Peripancreatic Fluid Collection < 4wks A) Tx → supportive. ii) Pseudocyst > 4wks Will have ↑ amylase, ↓CEA & mucin. A) Most resolve on their own. Only operate at >6wks & 6cm (EGD w/cystgastrostomy). 1. If pseudoaneurysm → angioemb then EGD. 2. Tx if close to stomach/duo → endoscopic cystoenterostomy (even if large & thick walled).

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3. Tx if far from stomach/duo→ lap vs open cystoenterostomy. b. Necrotic (liquefactive) i) Acute Necrotic Collection < 4wks, Tx → supportive. ii) Walled Off Necrosis > 4wks (tx like pseudocyst per SCORE) c. Infected Pancreatic Necrosis i) Air in pancreas, fever, sepsis, + BCxs. ii) Tx → Abx (imipenem→best panc penetration), IVF, then step-up approach (PANTER). A) 1st Perc drain → endoscopic → retroperitoneoscopic → open.

D. Pancreatic Insufficiency Dx → >20gm fecal fat/24h. 1) MCC → chronic pancreatitis (#2 → cystic fibrosis). 2) Tx → low fat, high carb & protein diet, pancrease.

E. Pancreatic Leak / Fistula 1)

2) 3)

4)

5-15% s/p Whipple ISGPF Post-Op Pancreatic Fistula (POPF) Grade A/biochemical (Not a fistula) i) Drain amylase >3x nml & aSx on POD3. B Infected, needs IR/GI procedure, or present > 3wks. C Above + shock/organ failure/death. Leak Tx → ERCP w/stent. If no communication w/drain → perc drain. Fistula Tx → Abx 1st wk, octreotide; Low output (400mL/d) → NPO+TPN; ERCP w/sphincterotomy & stent if >6-8wks w/o closure. Octreotide → ↓output, but not time to resolution.

F. Pancreatic Cystic Neoplasms (PCNs) 1) Serous (↓amylase, CEA, & mucin) MC PCN Tx’d non-op. a. Most are serous cystadenomas, benign, glycogen-rich lining from centro-acinar cells. Anywhere in pancreas. MC F >60. b. Types → microcystic (many small cysts), oligocystic (fewer large cysts, sim to MCN or branch duct IPMN). c. Multiple cysts w/central calcification → pathognomonic. d. Tx → conservative (obs), malignant degeneration very rare. 2) Mucinous (MCNs) (↑CEA, ↓amylase) a. Almost exclusive to F, MC >40. Variable cellular atypia, secrete mucin, ovarianlike stroma, typically in tail or body, doesn’t communicate w/PD. b. Malignancy risk → resect. 3) Intraductal Papillary Mucinous Neoplasms (IPMNs) (↑CEA & amylase) a. M=F. Main duct, branch duct, or mixed. Makes mucin, variable cellular atypia → dilated PD. Adenoma (mild dysplasia), borderline (mod dysplasia), or carcinoma (high-grade dysplasia), w/ or w/o invasion. b. Types (Least malignant [low/mod] to most malignant [high]) i) Branch duct IPMN 3cm → Whipple. ii) Main & branch duct (Mixed) IMPN Tx like main duct.

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iii) Main duct IPMN →↑malignancy risk (~60%) → resect >5mm & young/healthy or >10mm. “Fish mouth sign” on EGD. 8% recur. c. 5YS s/p resection if invasive → 43% non-invasive → 77%. 4) Solid Pseudopapillary Neoplasms (SPNs) a. Rare, F < 35. MC in body or tail, both solid & cystic components & occasional calcifications. Malignant risk → resect.

G. Pancreatic Neuroendocrine Tumors (PNETs) 1) 1-2% of panc neoplasms. Functional or non. Spontaneous or genetic. Most regionally advanced or have mets. 2) Associated gene mutations → MEN1 (menin protein/TSG), DAXX (death-domain associated protein), & ATRX (α-thalassemia/mental retardation syndrome X-linked), ↑ C-to-G transversions. 3) Can debulk mets for sx relief, including liver (even consider liver TXP). 4) General Dx a. Labs i) Chromogranin A (CrA) Best for eval & surveillance, high sens/spec, corresponds w/tumor burden. A) False ↑ w/PPIs, atrophic gastritis, & hepatic or renal insuff. Get baseline & serial values. ii) Neuron-specific enolase (NSE) iii) Pancreatic polypeptide b. Imaging i) CT-Pancreas +/- MRI (↓T1/↑T2, Hypervasc, occasionally cystic or w/calcifications, better than CT to eval for liver mets), EUS (res 2-3mm, more sens than CT/MRI). ii) 68 DOTATATE scan → ↑affinity for somatostatin receptor vs octreotide, possibly better than selective Ca++ stim test. 5) Non-functional MC PNET overall. a. 40% of PNETs have NO hypersecretion, > ½ dx incidentally. b. MC Sxs → pain, anorexia, jaundice, or ↓ wt. c. Liver mets at dx 60-85%. Usually have ↑CrA, PP, or + SRS. d. Median survival → 38 months, 5ys → 43%. Prognosis depends on differentiation & met status. e. Tx i) 3cm, high risk (high-grade dysplasia/ ↑Ki67), near main duct → formal resection. iii) Adj CTX → octreotide/lantreotide/everolimus + 5FU + streptozocin.

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6) Functional (From most benign to most malignant) a. Insulinoma (MC functional) i) Whipple’s Triad → 1Fasting hypoglycemia (Prolonged/72h fasting glucose = gold-standard to dx), 2sxs of hypoglycemia (palpitations, tachycardia, sweating, syncope), & 3gets better w/glucose. Insulin : glucose > 0.4 (< 0.3 is nml). C-peptide : insulin should be =. Throughout, 90% are solitary. ii) Best localization study → Ca++ stim w/hepatic vein sample (spec for insulinoma) or Intra-op U/S (best in gen for PNET, 90-95% sen). A) In OR → 1) palp panc, 2) U/S panc, & 3) Bx panc tail (r/o nesidioblastosis). iii) Tx → 2mm from main duct → enucleate. >2cm or 225pg/mL. iv) Tx → resect, octreotide (CA→ 5FU & α-interferon [diff from rest]). c. Gastrinoma i) Refractory PUD & diarrhea (ZES, MC PNET in MEN I); 75-80% sporadic. 60% in duo wall [1st portion], 50% cured w/resection. ii) 90% malignant. 1/3rd have sx. iii) MEN 1 → more aggressive, 0-10% cured w/resection. iv) Gastrinoma (Pessaro’s) triangle CBD, panc neck, 3rd portion of duo. v) Dx criteria (off PPI > 2wks) A) Fasting gastrin >200 (>1000 is diagnostic) & 24h gastric acid >15mEq/hr. Secretin stim test if fasting gastrin not ↑much (>120-200 rise = gastrinoma). 1. Baseline gastrin → 2u/kg secretin IV → q5m gastrin x 30m. vi) Best localization study → octreotide scan. A) Intra-op → 1inspect triangle, 2U/S panc, 3palp duo, & 4open via lateral duodenotomy. vii) Tx → 2cm→formal resection + regional LND. viii) Palliation → octreotide & PPI (CA → 5FU & streptozocin). d. Glucagonoma Fasting glucagon > 1000pg/mL. i) Necrolytic migratory erythema, rash (face & groin; resolves w/resection), DM, thrombosis, stomatitis, glossitis, & anemia. ii) Tail (though some say throughout pancreas). iii) Tx → resect, octreotide AA, FA, zinc (CA → 5FU & streptozocin).

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e. Somatostatinoma Fasting somatostatin > 160pg/mL. i) DM, gallstones, & steatorrhea. In pancreatic head. ii) Tx → resect + chole (CA → 5FU & streptozocin).

H. Primary Pancreatic Lymphoma Wt loss, fatigue, anorexia, palp mass (usually >6cm), Ø jaundice (not obstructive). 1) Dx → ↑LDH & β-2 microglobulin. Nml CA 19-9. 2) Tx → CTX ± ERCP w/stent.

I. Ampullary Villious Adenoma/Carcinoma 1) MC benign periampullary mass → Villous adenoma. 2) Tx → ampullectomy if < 2-3cm, carcinoid or gastrinoma [need portal LNDx], solitary adenomas/adenomatous polyps.

J. Periampullary Adenocarcinoma 1) If unresectable, but has obstruction → GJ + biliary-enteric bypass.

K. Pancreatic Adenocarcinoma

Prognosis based on stage. 1) Male MC, 50-60s. Sxs → ↓ wt (MC), jaundice, pain. 5yr OS 5-8% → 20-25% w/resection. RF → tobacco #1, BMI, genetics. 2) CA 19-9 → panc CA serum marker (>1000 → likely neoadj CTX benefit). 3) Genetics → a. Peutz-Jeghers (STK11 mut) → highest risk. b. p16 mut → 95%. MC, a tumor suppressor, binds cyclin. c. Others → K-ras (2nd MC → 90%), TGF-β, p53, & C-to-T transitions. 4) Lymphatic spread 1st (If OR 1st → 78% will have +LNs). 70% in head. 5) MC type → ductal. Papillary & mucinous → better prognosis. 6) Dx → Labs → ↑conj bili & Alk phos. MRCP/Panc CT (irregr narrowing, displacement/destruction, vessel involvement). a. ↑Bili (>2.5) may falsely ↑ CA19-9. b. Some pts lack enzyme to make CA19-9 (will be undetectable). 7) At presentation, 20% have local dz (37% 5YS), 20% have regional dz (12% 5YS), & 60% have distant dz (3% 5YS). 8) Tx a. Boarderline/Unresectable → determined by ABC’s (Abuts vessels, Biology [?mets, CA19-9], Condition [ECOG]). i) Mets, aortic involvement, >180° SMA/celiac, unreconstructable SMV/PV, contact w/1st jejunal br to SMV. A) → Palliation w/biliary stents or HJ (for biliary obs), GJ (for duo obs), & celiac plexus ablation (for pain) + local XRT. ii) Neo-adj FOLFIRINOX (FOLate/leucovorin, 5Fu, IRINotecan, OXaliplatin) to try to make resectable b. Resectable → start w/staging lap, prognosis based on clear margins. i) CTX-XRT usually post-op. A) Gemcitabine + Capecitabine → ↑DFS x2, don’t use if BRCA+. B) FOLFIRINOX → ↑DFS x4, OS, & ↓ tox vs gem/cap.

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C) Pasireotide → ↓ leak rate (small duct & soft panc→↑leak rate). D) 40% 3yr DFS w/FOLFIRINOX in adj setting (vs 20% w/ gem/cap).

L. Biliopancreatic Surgeries 1) Kasai (for biliary atresia in newborns) → Jejunum to hepatic plate. 2) Puestow a. Longitudinal PJ, for ducts > 8mm → open along main pancreatic duct & drain into jejunum. 3) Beger a. A duo-preserving panc head resection (DPPHR) + Roux-en-Y PJ. b. For isolated panc duct dilation in head. Most would just do a pylorus-preserving Whipple. 4) Frey a. A partial head resection + Puestow of body & tail. 5) DPS → for nml or sm ducts & distal portion of the gland is affected. a. MCC of bleeding after → short gastrics. 6) Whipple 40% Cx rate. ML margin to be + → SMA/SMV. a. MCC → Delayed gastric emptying (35-70%). Tx → erythromycin. i) Or metoclopramide, but only 20% response + rebound once d/c’d. b. Inf pancreaticoduodenal a is encountered during Kocher maneuver. c. Isolated ant abd wall nodule on opening for Whipple → Bx w/frozen section. Takes antrum → ↓ acid. d. Steps i) Explore for mets (send frozen section if concerning lesion). ii) 270° dissection of SMV & SMA above 1st jejunal br. iii) Resect panc head & duo (send margin for frozen). iv) Create Roux limb. v) End-to-side PJ (Blumgart → stitch post-duo, through panc, ant duo; 1 superior to PD & 2 inferior). Antecolic if pylorus-sparing to ↓delayed gastric emptying. vi) End-to-side choledochojejunostomy. vii) End-to-side GJ. viii) Cholecystecomy. 7) Whipple vs pylorus-sparing pancreaticoduodenectomy → no sig diff in short or longterm outcomes. Pylorus-preserving saves gastric antrum (↑acid), pylorus, & prox 23 cm of the duo (DJ). CI if → prox duo, pylorus, or gastric antrum involved (→ standard Whipple).

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28. Spleen A. Anatomy 1) Filters, stims humoral & cell-mediated immunity, traps Ags, activates complement, Ab production, opsonins (tuftsin & properdin).

2) Site of extramedullary hematopoiesis (pathologic). 3) MC location of accessory spleen → splenic hilum (54%, #2 splenic pedicle-25%, #3 pancreatic tail-6%).

B. Infection MCC→ IVDU (Can also spread from endocarditis). 1) Tx → IV abx & splenectomy (gold-standard, esp if multiloculated. Some will try perc drain + abx if simple.)

C. Post-Splenectomy Sepsis Syndrome 1) 0.1% s/p splenectomy; ↑ in kids (↑M&M). MCC of OPSI → S. pneumonia (also HiB, Staph, N. meningitides). 2) 2/2 lack of IgM to encapsulated bacteria. Highest OPSI risk in kids s/p splenectomy 2/2 hemolytic do or CA. ML w/Wiskott-Aldrich. 3) Try to delay splenectomy til >5yo→↑Ab formation + vaccines. Kids < 5-10yo → consider ppx abx (PCN V 125mg BID) x2yrs (Most OPSI w/in 2yrs).

D. Hemangioma → MC splenic tumor, MC benign splenic tumor. Tx → splenectomy if sx.

E. Non-traumatic indications for splenectomy 1) Auto-immune hemolytic anemias (+Coombs test) a. ITP → Anti-PLT IgG (↓PLTs) → Petechiae, gingival bleeding, bruising, ecchymosis. Many causes (drugs, viruses, etc.). i) Nml spleen. + Coomb’s test. Kids jejunal > ileal. d. Tx → segmental resection for sxs. i) If into pancreas → duodenotomy, inversion of diverticula, excision. 2) MC periampulary tumor → pancreatic adenoCa. 3) 2nd portion of duo diverticula during OR in pt w/obs jaundice, before ERCP → open ant duo to assess relation to AoV.

C. Jejunum 1) 100 cm long; long vasa recta, circular muscle folds. Vascular supply → SMA. 95% NaCl & 90% H2O abs in jejunum. 2) Max abs all nutrients save for B12 (TI), bile acids (non-conj → ileum; conj → TI), Fe++ (duo), & folate (TI).

D. Ileum TI absorbs → B9, B12, vit ADEK, conj bile salts (as stercobilinogen). 1) Meckel’s Diverticulum a. Kids → MC, painless LGIB/hematochezia, true diverticulum, 2’ from ICV, bleeding MC w/gastric. b. 15-20% heterotopic cells (40-50% if pt has sxs), MC → gastric, 2nd MC → pancreas. c. Adults → present w/obs 2/2 band connecting Meckel’s to umbilicus (vitelline). d. Dx → 99mTc-pertechnetate (Meckel Scan). Only for GASTRIC tissue, not panc. If -, but ↑suspicion→dx lap. e. Tx (per SCORE) i) Found outside OR A) Incidental on imaging → leave alone. B) Sxs, palpable, or mass → segmental resection. ii) Found Intra-Op A) Adhesive band, but no mass palpable → diverticulectomy. B) Palpable mass/ulcer or Sxs c/w Meckel’s→ segmental resection. 1. Ulcers are usually located just outside the diverticulum so need segmental resection to include. C) Neither A or B → leave.

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E. Mesenteric Lymphadenopathy → Sim sxs as appy, but also diffuse TTP>RLQ, preceding URI in kids, CT w/RLQ LAD & nml/non-visible appy. MC infectious cause → Yersinia (others→Shigella & Campylobacter). Tx → abx only.

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

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vi) Tx PRRT/Lutathera → Tx-dose DOTATATE A) 4000 cGy XRT. 1) Tx → Usually obs. If must operate → resect or bypass (NO stricturoplasty b/c very friable).

N. Crohn’s → intermit abd pain, diarrhea, & ↓ wt; poss SBO & fistulas. Mouth to anus. Often rectum spared. MC involves → TI. 1) 15-35yo at 1st episode. Earliest finding → aphthous ulxers. 2) ↑ in Ashkenazi Jews. 3) 10-12x ML to get intestinal adenoCA (ML→ileum; duo MC in non-Crohns) 4) MC sites for initial presentation a. TI & cecum → 40%. Colon only → 35%. Small bowel only → 20%. Perianal → 5% (MC → skin tag, 2nd → fissure). 5) Path →transmural, segmental (skip lesions), cobblestoning, non-caseating narrow deep ulcers, creeping fat (pathognomonic). 6) Medical Tx a. Oral 5-aminosalicylates (eg, sulfasalazine, mesalamine), abx (eg, cipro, flagyl), glucocorticoids (systemic - prednisone, local - budesonide), immunomodulators (eg, azathioprine, 6-MP, MTX), & Biologic txs/anti-TNF (eg, infliximab, adalimumab). 7) Surgical indications → surgery NOT curative (unlike UC). a. Persistent/blind loop obs, abscess despite perc drain, megacolon (15% perf → MC TI), bleeding, fissures (NO SILS), persistent ECF, Perineal fistula (unroof), anorectovaginal fistulas (poss rectal adv. flap/colostomy). 8) Resection vs Stricturoplasty a. Resect bowel segment w/fistula + 1° repair of other involved organ. b. Stricturoplasty CIs → intra-abd sepsis, acutely inflamed phlegmon, fistulae, abscesses, tight/long/thick strictures. c. Very Short (≤2cm) isolated, or c/f malignant → resect + 1° anastomosis (↓Cx & r/o CA). d. Short Stricturoplasty (≤7-12 cm) i) MC recurrence site → at stricturoplasty (90%). ii) Heineke-Mikulicz stricturoplasty (longitudinal → transverse) iii) Judd strictureplasty (SAA, but w/resection of associated fistula tract at stricture) iv) Moskel-Walske-Neumayer strictureplasty (Y-shaped) e. Intermediate Stricturoplasty (>7-12 cm to ≤15-24 cm) i) Finney strictureplasty (longitudinal → fold bowel onto itself & close; --- → U) f. Long Enteroenterostomy (>15-24 cm) i) Michelassi strictureplasty (side-to-side isoperastaltic)

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9) SubQ abscess during ostomy takedown → drain abscess & leave ostomy, esp in Crohn's pt → likely represents a fistula/flare.

O. Short Gut/Bowel Syndrome 1) Sxs → diarrhea, steatorrhea, ↓ wt/nutrition/fat, B12, lytes, H2O. 2) Dx by sxs, not length. a. Sudan red stain → fecal fat. Schilling test → urinary radiolabeled B12. 3) Need ~75+ cm to live w/o TPN (50cm w/competent ileocecal valve). 4) Tx → ↓fat, PPI, Lomotil (diphenoxylate & atropine) a. Gattex (teduglutide) → GLP2 analogue, ↑mucosal growth, poss ↑gastric emptying & secretion. b. Best nutrient in short gut syndrome → glutamine.

P. MC mets to small bowel → Melanoma (→ SBO). 1) Small bowel diffuse gastric CA mets admitted for SBO → bypass. 2) Matted jejenal mass of mets causing SBO → bypass. Q. Enterocutaneous Fistula → HIS FRIENDS 1) High output (>500cc/hr; low output 1200mL/d) → loperamide. 3) Stoma Cxs a. Stenosis → 2/2 ischemia. Mild → dilation. Patchy → observe. b. Prolapse → MC w/loop (vs end). Reverse if able, NOT able→ repair w/Sugarbaker technique) c. Retraction → reposition likely needed if fixed. d. EC fistula → 2/2 full-thickness stitch through both bowel & skin → relocate. i) If w/synthetic mesh → explant mesh + relocate. ii) ECF at prior ostomy & if NO distal obs → wound care. e. Dusky on test tube exam above fascia only → obs below fascia → re-explore & revise. f. Hernia → ppx mesh ↓inc from 55 to 8%. MC w/end colostomy. LC w/loop ileostomy. i) Tx → Sugarbaker repair (recurrence 2cm → transduo polypectomy w/ f/u EGDs (40% CA risk >2cm). 2) Adenocarcinoma a. 30%, ML in duo (80% w/ ulcers duo/prox jejunum). MC 1° malig. sm bowel tumor. Rare. Sx’s → obs, jaundice, bleeding. b. Worrisome for CA → ulceration, severe dysplasia, & panc duct/CBD dilation. i) Tx → resection w/LNDx. 10cm prox & 5cm distal margins. A) 2nd portion of duo → Whipple. CTX → FOLFOX. 3) Carcinoid a. EC/Kulchitsky cells → serotonin. b. Get TIPS → Tricuspid Insufficiency & Pulmonary Stenosis. i) MC → SI (55%) > Rectum (20%) > Appy (17%) > Colon > stomach (SEER data). Good 10y prognosis. c. Tx: see above for appendix, otherwise → segmental resection & LNDx. d. Recurrence not on CT → Octreotide scan (most sens to localize). e. CrA most sens (~100%) to detect presence (yes/no, not where). f. Carcinoid synd → 5cm & 5mitoses/50HPF → imatinib for 3+ yrs. 5) Lymphoma 70yo M, MC ileal → NHL B-cell (Peyer’s patches), spares duo. ~25% perf. a. Asso w/Wegener’s, SLE, AIDS, Crohn’s, celiac sprue. 6) Enteropathy-Associated T-cell Lymphoma Celiac dz w/abd pain & wt loss despite gluten-free diet + fevers. Celiac also RF for small bowel adenoCA.

U. Witzel → tunneled jejunal tube (obstruction at J-tube → OR → reposition distally). 1) 20cm distal to LoT, 4-6cm serosal Lembert tunnel w/3-0 silk.

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30. Colorectal A. Anatomy Secretes K+ & reabsorbs Na+ & H2O (mostly in right colon & cecum) Absorbs vit K, B1, B2, B7. MC site of perf (w/comp ICV) → Cecum. Mucosa (columnar) → Muscularis mucosa (inner muscle layer b/w mucosa & basement mem) → submucosa → muscularis propria → serosa. 5) Retroperitoneal → Right, left, & sigmoid. 6) Intraperitoneal → Transverse, anterior upper & mid ⅓ rectum. 7) Plicae semilunares → form haustra. 8) Taenia coli → 3 longitudinal bands . Splay on appy & rectosigmoid junction. 9) Denonvilliers fascia (ant) – M → rectovesicular; F → rectovaginal. 10) Waldeyer’s fascia (post) – rectosacral. 11) Vascular supply a. Colon i) SMA (ileocolic, right, middle colic) → Right & ⅔ transverse. ii) IMA (left colic, sigmoid, superior rectal) → ⅓ transverse, left, sigmoid, & upper rectum. iii) Marginal artery of Drummond → SMA to IMA collateral along colon. iv) Arc of Riolan → SMA/middle colic to IMA near base of mesentery. v) Mucosa & submucosa → get 80% of blood flow. vi) Veins follow arteries (except IMV to splenic). Splenic + SMV → PV (behind panc). b. Rectum i) Superior rectal ( IMA), Middle rectal ( internal iliac; aka lateral stalks of LAR/APR), Inferior rectal ( internal pudendal  internal iliac). ii) Superior & middle rectal veins → IMV → PV. iii) Inferior rectal veins → internal iliac → IVC. 1) 2) 3) 4)

B. Colonic Inertia

Sitz marker test. + if >20% retained s/p 5d.

C. Colovesicular Fistula Sxs → urinary stool/air. 2/2 diverticulitis. Colovaginal Fistula Sxs→vaginal stool. MC in F vs above. 2/2 OB trauma. 1) Best test → CT w/PO &/or PR contrast only (not IV). Also get CSP & cystoscopy. a. For colovaginal, best is methylene blue soaked tampon in rectum then vaginal exam. 2) Tx → close bladder(/vagina), resect colon, reanastomose, diverting ileostomy, & put omentum b/w bladder(/vagina) &colon.

D. Diverticulosis 2/2 straining (↑ intraluminal pressure), ↓residue/fiber diet, ↑ refined carbs. Prevalence → 35%. 1) Mucosa herniation through sites arteries enter wall, ↑elastin. Colon thickens around area → narrowing. 2) MC side → Left/sigmoid (80%). MC bleeding side → Right (50%). 10-25% of diverticulosis → diverticulitis.

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3) MCC true LGIB, 2/2 disrupted vasa recta, usually significant, 75% stop, 25% recur. 4) Dx → r/o UGIB w/NGT (MCC hematochezia). Then CSP (best to find & tx w/hemoclips). a. Massive bleed (hypoTN responsive to IVF) → CTA then angio ± vasopressin 1st (find & coil). b. OR if hypoTN & not responsive → colectomy where bleeding (can’t find → subtotal colectomy). c. Can’t find intermittent bleed → tagged RBC. 5) OR for recurrent diverticular bleed, prior tagged RBC scan 1wk before + Left colon, no bleeding seen on pre-op endoscopy but tics from transverse colon to rectosigmoid junction, tx → L hemi if HDS (if not → subtotal colectomy + end ileostomy). MC side → Left. 1) Hinchey classification (The 4 “P’s”) a. I → Paracolonic II → Pelvic III – Purulent IV – Poop 2) Tx a. Uncomplicated → Tx: levofloxacin & Flagyl; 3-4d bowel rest (mild → out-pt tx), CSP in 6-8wks to r/o CA. b. Complicated (persistent obs s/p med tx, perf, peritonitis, can’t drain abscess or r/o CA). → Take all sigmoid to nml rectum. i) MC Cx → abscess (→ perc drain). CSP in 6-8wks to r/o CA. A) Deep pelvic abscess w/o tran-abd window → transgluteal. ii) STOP-IT trial → w/ source control, 4d abx is = longer abx courses.

E. Diverticulitis

F. Angiodysplasia ↑on right, less bleeding vs diverticular, recurs ↑ (80%), venous. Angio → tufts, ↓emptying. Ao stenosis 20%. Tx→CSP + cautery.

G. Ogilvie’s Syndrome Colon pseudo-obs, asso w/opiate, elderly, major surgery/infection/trauma. Can perf. 1) Tx → replete lytes (esp. K+); d/c meds w/↓motility (eg. morphine). NGT. > 10 cm (↑ perf) → decomp CSP & neostigmine 2mg IV over 5 mins + continuous EKG (80-90% effective); if fails & pt HDS → cecostomy (95% effective). a. CIs to neostigmine → ACS, 2nd/3rd ° heart block, & reactive airway. b. Not better 1-2 days or worsening or > 10-12cm → ex lap w/subtotal colectomy w/end ileostomy.

H. Melanosis Coli → benign spotty hyperpigmentation 2/2 laxatives. Tx → obs. I. Perforation 1) Post-Polypectomy Syndrome Tx: No free air→obs. Free air + aSx→IV abx, NPO, + serial exams. Free air + peritonitis→OR. J. Ischemic Colitis 1) Thumbprinting: wall hemorrhage/edema on Barium enema 2/2 ischemia. 2) Ischemic colitis best test→ CTA 1st (some say plain film), then flex endoscopy (no prep). 3) On CSP → erthymatous & edematous mucosa + small ulcers 4) 3 recurrences → consider fecal TXP. 3) C. diff toxic colitis (25% mortality) a. Tx→ subtotal colectomy + end ileostomy (since pt likely not HDS).

L. Amebic Colitis 1) 2) 3) 4) 5) 6)

Entamoeba histolytica; 2/2 contaminated food & water w/ cysts in feces. 1° infection → colon; 2° infection → liver. RFs → travel to Mexico, EtOH; fecal-oral transmission. Sxs → like UC (dysentery); MC chronic (3-4 BM/day, cramping, & fever). Dx →endoscopy → ulceration, trophozoites; 90% have anti-amebic Ab. Tx → Flagyl, di-iodohydroxyquin.

M. Actinomyces 1) Cecal (MC) mass, abscess, fistula, or induration; suppurative & granulomatous. Often confused for CA. Path → Yellow-white sulfur granules. 2) Tx → PCN or tetracycline, drain abscess.

N. Microscopic Colitis 1) Diarrhea s/p pelvic XRT, sporadic basement membrane thickening, lamina propria lymphocytic infiltrate. Tx → budesonide.

O. Radiation Proctitis Sxs → bleeding, pain, stricture, fistula s/p pelvic XRT. 1) Tx → 1st sucralfate + Flagyl, 2nd argon/laser coag vs 4% formalin fixation. Earliest finding → mucosal edema. Sxs → bloody diarrhea, abd pain, fever, & ↓wt. Mucosa & submucosa. Strictures & fistulae unusual w/UC. Anal sparing. a. Distal rectum & contiguous (no skips). Friable mucosa (→ bleeding), pseudopolyps, distorted vascular pattern, & “collar button” ulcers. b. R/o infection. Proximal dz → backwash ileitis. Barium enema → ↓haustra, narrow, short, & ↓redundancy w/chronic dz. Medical Tx: sulfasalazine (or 5-ASA) & loperamide for maintenance. Acute flares → steroids. 5-ASA & sulfasalazine for remission. Cyclosporine or infliximab if steroid resistant. Extraintestinal manifestations → Arthritis, Arthralgias, Pyoderma gangrenosum, Erythema nodosum, Ocular dz, Growth failure, Megaloblastic anemia (↓folate & B12), & Stomatitis. Severe UC/Toxic colitis: > 6 bloody BM/d, ↑ HR/temp/WBC, ↓Hgb. Fulminant UC: > 10 bloody BM/d, ESR >30, + above. Toxic megacolon: above + distension & abd pain. ML location of perf w/UC → transverse colon. Initial Tx → NGT, IVF, steroids, bowel rest, & abx (cipro & Flagyl). 50% will still need surgery. a. Follow clinically & w/KUBs. Avoid barium enemas, narcotics, anti-diarrheal agents, & anti-Ach.

P. Ulcerative Colitis 1)

2) 3) 4)

5) 6) 7) 8)

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9) Tx a. UC surgical indications → massive bleed, intractable (>24-48hrs) toxic megacolon, acute fulminant UC (~15%), obs, any dysplasia (esp high-grade), CA, poss > 10yrs since dx to ppx vs colon CA. i) Emergent/urgent resections – total abdominal colectomy & bring up ileostomy (spares superior rectal a; hook back up later) b. Total proctocolectomy & IPAA (NO low rectal anastomosis in IBD) i) Protects bladder & sexual function. Need lifetime surveillance of residual rectum. ii) Ileoanal anastomoses often must be resected 2/2 dysplasia/CA, refractory pouchitis, or incontinence. iii) Diverting ileostomy for 6-8 wks to heal anastomosis. Infectious pouchitis → Tx: Flagyl. iv) MCCx s/p ileal pouch → SBO (11-26%). A) 2nd MCCx → leak/abscess. c. 3 Stage → 1) TAC + end ileostomy → 2) proctocolectomy + IPAA + DLI → 3) DLI reversal. d. APR w/ileostomy can also be performed 10) CA risk 1%/yr 10 yrs s/p dx if pancolitis. CA throughout colon. CSP yearly 8-10yrs s/p dx w/random 4 quadrant Bxs (≥32) of UC prox to sigmoid. a. If UC w/PSC → start screening immediately (↑CA risk). b. CA Risk: 10yrs → 2.1%, 20yrs → 10%, 30yrs → 50%, 40yrs → 75%. i) UC w/LGD → 20%. UC w/HGD → 42%. 11) Extraintestinal manifestations. a. MCC for needing total colectomy in kids → failure to thrive. b. Colectomy helps → most ocular/oral, arthritis, erythema nodosum, anemia, & 50% of pyoderma gangrenosum. Not PSC & ankylosing spondylitis. c. HLA B27 → sacroiliitis, ankylosing spondylitis, UC. Thromboembolic dz. Pyoderma gangrenosum (Tx → steroids.)

Q. Volvulus 1) Cecal a. Can cause LUQ pain (from RLQ pointing to LUQ) b. KUB showing cecal volvulus, HDS → go to OR & resect. 2) Sigmoid a. KUB showing sigmoid volvulus (from LLQ pointing to RUQ), HDS → detorsion w/CSP then → sigmoidectomy before d/c.

R. Granular Cell Myoblastoma Neural crest origin (poss. Schwann cells). Nearly all benign, submucosal. 1) MC location → skin/soft tissue, then aerodigestive (MC → tongue). 2) Tx → WLE/CSP excision. + margins → can observe.

S. Colorectal Polyps 1) Types a. Hyperplastic → MC polyp overall. No CA risk. b. Tubular adenoma → MC (75%) intestinal neoplastic polyp, generally pedunculated. 2 cm, sessile/villous lesions, > 3 polyps (>10→get genetics), ≥10mm, or high-grade dysplasia. Haggitt Levels for Malignant Polyps 1. Pedunculated w/invasion in head. 2. Pedunculated w/invasion in stalk. →Neg. margin polypectomy. 3. Pedunculated w/invasion in neck. 4. Pedunculated w/submucosa (SM1/2)/sessile → ≥ 2mm margin. High-risk → lower ⅓rd of submucosa (SM3), margin 2cm → 70% mets). ⅔ in colon have local or systemic spread. 2) Tx a. Colon or high rectal carcinoids → LAR w/TME. b. Low rectal carcinoids→ < 2 cm → WLE w/- margins. > 2 cm or invasion of muscularis propria → APR. c. CTX → 5FU, streptozosin, doxazosin, somatostatin. Mutation order: APC → Kras → DCC → p53 1) Screening a. Nml risk → 50yo, 40 (or 10 years before youngest dx in fam) for intermediate risk (eg FMHx of colon CA). b. LBOs are c/f CRCa. i) No peritonitis/ischemia → NGT, NPO, IVF, CSP ± stent (time to work up). ii) Peritonitis/ischemia → ex lap + TAC w/end ileostomy. c. Screening options i) High-sensitivity FOBT q1y. ii) High-sensitivity FOBT (False + → iron, beef, cimetidine, vit C.) q3y & flex sig q5y.

V. Colorectal Cancer

170

iii) Double contrast barium enema or CT colonography q5y. iv) CSP q10y Most sensitive → CSP. A) No CSP w/recent MI, splenomegaly, pregnancy/fluoroscopy planned. 2) Genetics a. FAP AD; >90% CA by 50yo. APC gene → ch 5 (>80% of de novo CRCa have somatic APC muts → no ↑risk to family). i) 20% of FAP syndromes are spontaneous (germ line muts). ii) MCC of death → CrCa. iii) Polyps (1000s) present after birth/in puberty. iv) No surveillance CSP w/suspected FAP → just flex sig for polyps starting at 1012yo. Need ppx TAC by 20. v) Desmoid tumors → resect if poss (incomplete → 80% recur). A) Sulindac & tamoxifen help if can’t resect (± doxorubicin/ carboplatin → 50% remission). vi) Duo Polyps → EGD q2y. 2nd MCC of death (MC s/p ppx colectomy). vii) Surgery → total proctocolectomy, rectal mucosectomy (controversial), & IPAA w/J-pouch. A) Total proctocolectomy w/end ileostomy is also an option. B) Post-op procto surveillance q2y for life. viii) Attenuated FAP (100s of polyps, not 1000s) ix) Gardner’s Syndrome → Colon CA (asso w/APC gene) + desmoids & head/jaw osteomas (MC extra-intestinal manifestation→get CSP). A) ML to have skin manifestations → Gardner synd > UC > Crohns. x) Turcot’s syndrome→ Colon CA (asso w/APC gene) + brain tumors. b. Mut Y Homolog-Associated Polyposis (MAP) MYH mut 10+ polyps i) Desmoids & duo adenomas. CAs → Thyroid, Ovary, Bladder, & Skin. ii) Like attenuated FAP, but MYH not APC + associated TOBS(↑) CA c. HNPCC i) 5% prevalence, AD. Asso w/DNA mismatch repair gene, MSI (MLH1, MSH2 [>PMS1 & MSH6)). MC to be on right. ii) Amsterdam Criteria → “3, 2, 1” → > 3 1st degree relatives, over 2 generations, 1 w/an asso CA < 50yo. iii) Lynch I → just colon CA risk iv) Lynch II → also ↑ ovarian, endometrial, bladder, & stomach CA. v) Need q1-2y surveillance CSP at 25, or 10yrs before youngest dx in fam. Also surveil for the other HNPCC CAs. vi) 50% metachronous lesions w/in 10yrs; multiple primaries common. vii) Test for MSI if → sporatic CRCa, poorly diff, or signet-ring on bx. viii) Tx → Need total proctocolectomy w/1st CA operation (f/u CSP q1y). d. Peutz-Jegher’s Syndrome → 90% lifetime overall CA risk. AD STK11 mut, hamartomas throughout GI (small & large bowel). No need for ppx colectomy. 500x ↑ small intestine CA risk. Get SBOs 2/2 polyp intussuception or obs. i) Extraintestinal → Mucocutaneous melanotic pigmentation.

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A) Other CAs→Breast(MC),cervical(screen@25yo), & stomach/duo. e. Familial Juvenile Polyposis → AD, SMAD4/DPC4 mutation. 10-38% CA risk. MC on right. CSP at 10-12yo. If adenoma on CSP → colectomy. Hamartomas can degenerate into CA. 3) Staging & Treatment a. CT CAP, EUS/MRI pelvis, CEA, LFTs. i) ↑↑↑CEA & no obv mets (or indeterminate CT) → PET. ii) Concerning LNs → indistinct, heterogenous, round, >9mm. b. Resections i) Need at least 12 LNs in specimen to stage. Get 5cm gross margins. ii) Colon (all require high ligation of arterial supply to ensure proper LN staging). A) Right colectomy → Include TI to right br of middle colic. B) Extended right colectomy → Include TI & both brs of middle colic up to splenic flexure. C) Left colectomy → From peritoneal reflection of rectum to splenic flexure. 1. Ligate IMA near its origin for adequate LN sampling in left hemicolectomy. 2. Ways to get more length for a tension-free anastomosis. 1IMV high ligation (18cm), 2IMA high ligation + splenic flexure mobilization (8cm), 3IMA high ligation (5cm). D) Extended left colectomy → From peritoneal reflection of rectum to include one/both brs of middle colic. Simple Staging E) Sigmoidectomy F) Total abdominal colectomy I - T1-2 G) Total proctocolectomy II - T3-4 iii) Rectum T2 MRI best for depth of invasion & LN III - N+ evaluation (vs U/S) IV - M+ A) Transanal excision → Submucosal (T1), 2 cm from puborectalis → neoadj CTX/XRT then LAR. 3. Best next step for BRBPR early s/p LAR → proctoscopy. 4. Need at least 1cm distal margin. C) AbdominoPeritoneal Resection 1. If < 2cm from levators.

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

c. CSP

→

1y, 3y, 5y.

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Colon & Rectal Adenocarcinoma TMN Tis

CIS, into lamina propria

T1

Into submucosa

T2

Into muscularis propria

T3

Colon (no XRT)

Stages 0

Tis

I

T1-2

Through propria into pericolorectal tissues

IIA

T3

T4a

Visceral peritoneum

IIB

T4a

T4b

Other organs

IIC

T4b

N1a

1 regional LN

IIIA

T1-2+N1; T1N2a

N1b

2-3 regional LNs

IIIB

T3-4a, N1; T2-3, N2a; T1-2+T2b

N1c

Deposit in subserosal, mesentary, nonperioclolic tissue

IIIC

T4a, N2a; T3-4a, N2b; T4b+N1-2

N2a

4-6 regional LN

IVA

N2b

>6 regional LN

IVB

All colon CA get segmental colectomy Adjuvant: T3 → Capecitabine or 5-FU + leucovorin >T3 → FOLFOX or CAPEOX

Rectal Trans-anal resection Trans-abdominal resection

If T3/4 or N1/2 or = Neoadjuvant XRT + Capecitabine OR Infusional 5-FU OR FOLFOX OR CapeOX

All for 6mns

AnyT/N, M1a Neoadjuvant/ Any T/N, M1b definitive CTX

M1a

1 organ

>2cm from dentate → LAR

M1b

>1 organ

72 hours of Sxs → medical tx 1st (surgery pain > hemorrhoid pain at this point; will fibrose, but ↑recurrence). 3) Internal hemorrhoids cause bleeding or prolapse a. Types Primary → slides below dentate w/straining. Secondary → prolapses, reduces spontaneously. Tertiary → prolapses, manually reduced. Quaternary → can’t reduce. b. Tx i) Surgical indications → recurrent bleeding, multiple thromboses, large external component, mod-severe pain. ii) 1° & 2° → banding (in office, stay at least 1-2cm proximal to denate line). iii) 3° & 4° → 3 quadrant resection (some use stapler, some only 2 columns at a time 2/2 c/f stenosis). MCC of Stenosis 2/2 → taking too much anoderm. iv) Milgan-Morgan → open (mucosa). Ferguson → closed. Whitehead → circumferential stapled. A) Resect to internal sphincter (NOT through). Take mucosa & submucosa w/venous plexus. B) Trans-Hemorrhoidal Doppler → find feeding vessel → ligate. C) Strangulated 4° hemorrhoids → urgent surgery 2/2 necrosis 1. Sxs → swollen, non-reducible, pain & bleeding. v) Post-op → sitz baths, stool softener, high-fiber diet, & lidocaine jelly.

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4) CXs a. MCCx → urine retention (20%) 2/2 pelvic spasm after local anesthesia wears off. Tx → place temporary Foley. b. Eschar sloughing → light bleeding late (5-10d) post-op (eg blood on TP). i) Tx → stool softeners, fiber supplements & hydration. Avoid local trauma & ASA (doesn’t need EUA). c. Early/significant bleeding (2/2 technical error, rare; eg toilet bowel full of blood) → EUA & suture ligation of bleeding. d. Sepsis → very rare s/p hemorrhoidectomy (Sxs → severe perianal pain, fevers, urine retention, c/f immunocompromise). i) Tx → IVFs, broad spectrum abx, & EUA (c/f abscess vs NSTI).

E. Perianal Sepsis 1) Pain, fever, urine retention (can happen s/p rubber band internal hemorrhoidectomy). Tx → IVF, IV abx, EUA, & I&D. Split anoderm → pain w/defecation (straining bowel movements); bright red bleeding. Often h/o constipation. 1) Can be s/p heavy narcotic use, back or perineal surgery. 2) MC location → posterior midline (90%). EUA to confirm Dx. 3) Sentinel piles seen if chronic. 4) Early medical Tx (< 4 weeks of sxs) → sitz baths, bulk fiber, stool softener, hydration, lidocaine jelly, 6wks topical NTG. a. Late medical Tx (> 3 months of sxs) → 6wks 2% topical diltiazem (CCB). Indicates difficult/refractory fissure. 5) Surgical Tx: a. Surgical indications → No improvement w/2 cycles of CCB; 6mn of medical Tx. b. Lateral subcutaneous internal sphincterotomy (LSIS) i) Considered the most effective Tx for anal fissures. ii) Feel groove b/w internal & external sphincter iii) 11 blade transverse cut through internal sphincter iv) Don’t pass dentate, cut external sphincter or mucosa, or perform in Crohns pt. 90% heal. v) Most serious Cx → incontinence (1%; pre-op it’s a CI to LSIS). 6) Botulinum toxin injection (40-100u b/w sphincters) → 60% heal. 7) Lateral or recurrent fissures → c/f Crohns (tx →biologic & flagyl), STDs/HIV, & anal CA → high-res anoscopy w/Bx.

F. Fissure

G. Lower GI Bleed 1) 2) 3) 4)

FOBT+ up to 3wks s/p bleed. Hematemesis → bleeding from pharynx to ligament of Treitz. Melena→ tarry stools; poss w/as little as 50mL of blood. Azotemia s/p GIB → 2/2 urea from blood broken down by bacteria (↑BUN & total Bili). 5) Arteriography → bleed ≥ 0.5mL/min. Tagged RBC → bleed ≥ 0.1mL/min.

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H. Rectal Prolapse (Procidentia) 1) Tissue is circumferencial/radial. 2) 3) 4) 5)

Involves all rectal layers.

2/2 pudendal neuropathy + lax sphincters. Starts 6-7cm proximal to anal verge. ↑ in F, straining, chronic diarrhea, s/p pregnancy, & w/redundant sigmoid. Medical Tx → high-fiber diet (Laxatives are CI). Surgical Tx → a. Old/frail → transanal/perineal rectosigmoid resection (Altemeier). i) Delorme → Like Altemeier, but only mucosal & submucosal excision. A) Used if less extensive. Inject submucosa w/dilute epi → aids dissection. b. Good condition → Frykman-Goldberg Sigmoidectomy & pexy residual colon, 1cm, round, anti-mesenteric. 2) colon FOS. 3) multiple pressure ulcers. 4) absence of other cause (eg. diverticulitis, CA, etc). 2) Tx → resect + end-to-end colo-colonic anastomosis.

K. Anal Incontinence needs EUS. 1) Neurogenic (gaping hole) → no good tx, consider SNS at S3. 2) Abdominoperineal descent → chronic damage to levators & pudendal nerves (obesity, multiparous women) & anus falls below levators. a. Tx → high-fiber diet, 1 BM/d limit; hard to tx. 3) Tx of OB trauma s/p 2-3mns max med tx or if asso w/fistula → anterior anal sphincteroplasty (close in layers if no fistula).

L. Infectious Pouchitis abd pain, fever, bloody diarrhea, urgency/tenesmus. Dx → procto w/Bx. Tx → IVF + cipro/flagyl.

M. Radiation Proctitis bleeding s/p pelvic XRT. 1) Tx → 1st – sucralfate enema. 2nd – argon beam (90% effective). 3rd – fix w/dilute formalin (90% eff, but ↑strictures).

N. Pilonidal Disease 1) Sinus/abscess over sacrococcygeal jxn/ gluteal cleft; ↑ in M. 2) Tx → I&D + pack; f/u w/surgical resection of cyst lining (61% recurrence historically) vs GIPS (resect cyst + punch bx out pits) → ↓recurrence (5.8% at 16mns).

O. Condylomata Acuminata 2/2 HPV. Tx → fulguration (podofilox is an option; from podophylin, less irritating).

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P. Anal Canal Cancer 1) Adenocarcinoma a. Tis = Paget’s Disease of the Anus b. Tx i) WLE if < ⅓ circumference, < 3 cm, submucosa (T1 tumors, 2-3mm margins), well diff, & no LVI. Otherwise → APR. ii) Adj CTX/XRT → same as rectal CA. 2) SCCa a. Types → epidermoid, mucoepidermoid, cloacogenic, & basaloid CA. b. Sxs → pruritus, bleeding, & palpable mass. c. Staging i) T A) Tis = Bowen’s disease, AIN II-III. Tx → high-res anoscopy + fulgaration. B) T1 = < 2cm C) T2 = > 2-5cm D) T3 = > 5cm E) T4 = Adjacent organs ii) N (FNA/ex bx suspicious LNs) A) N1 = Perirectal B) N2 = Unilateral internal iliac +/- inguinal C) N3 = Perirectal + inguinal +/- bilateral internal iliac d. Tx i) Nigro Protocol (CTX-XRT[5wks] w/5FU & Mitomycin-C [wks 1 &5]), not surgery. Cures 80%. 50Gy → anus, 35-45Gy → inguinal LNs. ii) Tx failures or recurs (give it 10-12wks to assess) → APR + myocutaneous flap (↑wound comp for anal SCCa s/p XRT). 3) Melanoma ⅓ spread to mesenteric LNs at dx. Anus 3rd MC site for melanoma (Skin & Eyes #1 & #2 – “SEA 1,2,3”). a. Mets to liver & lung early → accounts for most deaths. Sxs 2/2 sig mets. MC sx → rectal bleeding. MC lightly/not pigmented. b. Tx → WLE (=survival to APR in meta-analysis). Margin dictated by depth as standard for melanoma. No benefit for LNDx.

Q. Perineal Cancer (was Anal Margin CA; AIN in male → also r/o HIV 2/2). 1) SCCa Better prog vs anal canal SCCa. Asso w/HPV 16, 18, 31, 33, etc (like cervical). Ulcerating, slow growing; better prog in M. a. Tx i) T1 ( 2 cm, sphincter involved, or +LNs → CTX-XRT (5-FU & cisplatin) to preserve sphincter & possibly avoid APR. iii) Need inguinal LNDx if +LN clinically. b. SCCa just outside anal margin → tx like skin CA. 2) Basal Cell CA Central ulcer, raised edges, rare mets. a. Tx → usually WLE w/3mm margins; APR if sphincter involved.

179

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

180

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

181

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

a. Rate → 30% s/p emergent ex lap. Otherwise 10-15%. b. RFs → deep wound infxn, steroids, smoking, XRT, Diabetic nephropathy(↑risk s/p lap surgery), &SSI (↑rate x2). c. Separation of Components. i) Raise subQ flaps from midline to external oblique. ii) Incise the ext oblique (required) 2cm lateral to linea semilunaris & continue 5cm onto chest. iii) Separate ext & internal oblique as far as possible. iv) Need more length (2-4cm), incise → post rectus sheath. v) Don’t damage nerves going into post rectus running b/w the transversalis & internal oblique muscles. vi) Relative CI to SoC → prior DIEP. d. Retrorectus repair → dissection to semilunaris. i) Innervation to rectus is b/w transversus & internal oblique. e. ML to contact bowel → IPOM> underlay ( > retrorectus). f. Obese, DM, 7cm midline inc hernia, tx → lap preferred to open. g. Best facial closure → cont, slowly abs suture (PDS), 5mm bites/travel, 4:1 suture:wound length. h. Recurrence i) Renal path that ↑ risk of hernia after lap surgery → diabetic nephropathy. 4) Femoral Know how to dx on CT. ↑strangulation → repair all. a. Anatomy i) Superior – iliopubic tract/inguinal ligament ii) Inferior – Cooper/pectineal ligament iii) Medial - lacunar ligament (attaches to pubic tubercle; connects inguinal & pectineal ligaments) iv) Lateral - femoral vein b. Tx → McVay/Cooper’s/pectineal ligament repair. Mesh OK if NO bowel compromise (key → close space lateral to lacunar ligament by approximating iliopubic tract to Cooper's ligament). No mesh w/bowel compromise (eg perf or necrotic).

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

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19) Parastomal a. ↑ in colostomies (50% at 5yrs) vs ileostomies. b. RFs → fascial opening too large; stoma lateral to rectus sheath, obesity, COPD, age. c. Don’t fix unless sig sxs, most are tolerated well (< 10% need fixed). d. Absolute repair indications → obs, incarceration w/strangulation, severe pain. e. Relative repair indications → incarceration alone, severe prolapse. f. Tx → observe unless causing significant Sxs i) If surgery needed, relocate to rectus (preferred) (SCORE says 1st→local repair, 2nd→local repair+mesh, 3rd→relocate). ii) Prolapse → keep stoma at same site, fix hernia w/mesh (Sugarbaker technique, see ostomy cx in Small Bowel Ch) ± fix mesentery (if ostomy in rectus & fascia intact, but bowel prolapsing through). 20) Ventral i) See incisional & epigastric.

B. Rectus Sheath Hematoma Painful abd wall mass. MC s/p trauma 1) MC source if inf to umbilicus → epigastric vessel injury. 2) Fothergill sign → More prominent & painful w/rectus flexion. 3) Carnett sign → point of max TTP same spot when sitting or supine. 4) Types 1 → small, w/in rectus. Doesn’t cross midline or fascia. 2 → w/in rectus. Either crosses midline or dissects into transversalis fascia. 3 → below arculate, large, bleeding into peritoneum &/or space of Retzius. 5) Usually just need rest, analgesia, & transfusion PRN (90% success). Correct coagulopathy if risk > benefit (ie no mech Ao valve). Worsens → angio emb. (OR rarely needed).

C. Desmoid Tumors F, typically painless, benign, locally invasive, ↑↑↑ recurrence, asso w/Gardner’s syndrome. Fibrotic, Øcalcs, highly cellular. 1) Tx a. Abdominal wall 1st → OR, 2nd → XRT (or if not op candidate). b. Intra-Abdominal 1st → medical, 2nd → OR ± XRT. c. WLE if possible; if involves sig mesentery → don’t excise (often can’t resect completely) → Med Tx (sulindac & tamoxifen).

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D. Mesenteric Masses Most 1° tumors are cystic. Benign → MC peripheral. Malignant → MC near mesentery root. 1) Malignant → liposarcoma (#1), leiomyosarcoma. 2) Dx → abdominal CT. 3) Tx → resection ± resect associated bowel PRN (if unsafe/too much bowel → marsupialize). 4) Sclerosing Mesenteritis → well-circumscribed, fatty, near mesentery root, needs Bx to r/o CA.

E. Omental Masses 1) Cysts → usually no sxs, but can torse. 2) Tumors MC solid tumor→mets(Tx→omentectomy for CAs [eg ovarian]). 1° solid tumors → rare (⅓ malignant). a. No Bx 2/2 ↑ bleeding. Tx → resection. 3) Torsion → omentum twists around long axis w/vessels → mimics intra-abd perf → usually dx'd in OR, MC on right. a. 1° → no known path/prior surgery. 2° → MC vs 1°. 2/2 tumor, inflammation, adhesions, or herniae. 30s-40s, obese kids. b. Tx → resection. i) Serosanguinous fluid MC. If purulent → look for other etiology.

F. Epiploic Appendigits Tx → NSAIDs, OR only if abscess/peritonitis (in which case question the dx).

G. Radiation 1) CT Aorta > contrast vs cardiac cath, CT abd/pelvis, & KUB. 2) C-Arm positioning → x-ray source under table as far as possible (↓skin dose), image intensifier above & close (sharper image) → ↓scatter → ↓total radiation.

H. Stitch / European Hernia Society Guidelines → 5/5mm bites/apart > 1/1cm (p interrupted. 1) Slowly abs monofilament (ie. PDS). 2) Ppx mesh for open AAA repair → ↓hernia.

I. Peritoneal Dialysis Catheter OK to fix umbilical hernia at the same time. 1) Placement → Prox cuff in preperitoneum, tunnel a few cm away, distal cuff in subQ, & flush w/NS.

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a. Laparoscopic → Simple, quick, immediate usage, ↓migration vs open (3 vs 18%), & 1yr cath survival (94 vs 75%). b. Open → Precise & ↓perf risk. c. If outflow obstruction → omentectomy. 2) CI(s) → Only absolute is lacking functional peritoneum. a. Relative CIs → scar/adh, can’t self-dialyze, homeless, anura & obesity (lg vol), active inflam/CA, ostomy (do presternal cath), lg unrepairable abd herniae, & VP shunt. 3) Types a. Continuous ambulatory PD (CAPD) b. Automated PD (APD) c. Continuous cycles PD (CCPD) d. Nightly intermittent PD (NIPD) e. Tidal PD (TPD) f. Intermittent PD (IPD) 4) Infection a. MCC → coag neg staph (S. epidermidis). Dx → Abd pain, cloudy peritoneal fluid, & peritoneal WBC >100/mm3. b. Tx → intraperitoneal abx x2 weeks. not 2/2 S. epi → less likely to clear → d/c PD cath, insert temp HD cath, cont abx.

J. Pseudomyxoma Peritonei / Peritoneal Carcinomatosis 1) Semisolid mucous plastering peritoneum w/lg loculated cysts & scalloping. 2) MC in F, 50s-70s. 3) Disseminated Peritoneal AdenoMucinois (DPAM) a. Histologically benign, MCC → ruptured appy (60%) w/mucinous adenoma/adenoCA. 4) Peritoneal Mucinous CArcinomatosis (PMCA) a. Well-dif appendiceal/intestinal mucinous adenoCA. Up to 76% recur. b. Usually no sxs. MC 1st sx → ↑abd girth. c. Tx → cytoreduction of 1° & 2° implants, peritonectomy, omentectomy & HIPEC if ECOG ≤ 2, PCI < 14, & no extra-abd mets or RP dz. d. MI for HIPEC prognosis → complete cytoreduction. 5) Malignant ascites + SBO → predict incomplete resection & ↓ survival 6) Clear appy origin → right colectomy. Clear ovary origin → TAH+BSO.

K. Malignant Bowel Obstruction 1) Med Tx for sxs → glucocorticoids, antiemetics (typically Haldol, not metoclopramide or 5HT3 receptor antagonists → constipation), octreotide, antiAChs, analgesia, ± GI decompression. 2) Absolute CIs to surgery → recurrent ascites s/p paracentesis, diffuse palpable masses, multiple areas of obs, technically impossible, diffuse mets, or prox stomach involved. 3) Relative CIs → mult. intraabd tumors, ↓Alb., prev abd XRT, poor nutrition, liver/extraabd mets, or hepatic/renal failure.

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a. SBO w/o peritonitis 2/2 Stage IV CRCa (or ovarian) CA w/diffuse carcinomatosis w/implants throughout mesentery & omentum involving sig portion of bowel → palliative G-tube. b. Carcinomatosis, SBO w/o transition point, PEG in place, best next tx → opioids + ondansetron. c. W/ transition point & candidate → bypass.

L. Tuberculous Peritonitis Best test → quantaferon gold. 1) Wet type → abundant ↑density ascites (20-45 HU), smooth & thickened peritoneum & omental smudging. Thick strands of clumped mesenteric vessels. 2) Fixed fibrotic → omental mass w/matted bowel + nodular mesentery/bowel thickening, & occasional loculated ascites. A great mimicker of peritoneal carcinomatosis. 3) Dry/Plastic → fibrous rxn in peritoneum → adhesions & caseous LNs.

M. Pearls 1) Immediate pain s/p lap inguinal herniorrhaphy → back to OR. a. MC nerve in lap IHR → femoral br of gentiofemoral (medial thigh) or lateral femoral cutaneous (lateral thigh). 2) Pediatric IHR →open, high-ligation (floor/ring isn’t weak like adults). 3) MCC s/p herniorrhaphy → urinary retention. 4) Herniorrhaphy complication rates: overall ~10%, SSI-1-2%. 5) Fascial dehiscence → copious salmon-colored fluid from wound. a. Tx → OR to close fascia.

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33. Urology

A. Anatomy 1) Contents renal hilum ant to post → Vein, Artery, renal Pelvis (VAP). a. Right renal artery crosses post to IVC. b. Left renal vein crosses ant to aorta (usually). 2) Ureters cross over iliac vessels. 3) Left renal vein can be ligated from IVC 2/2 collaterals on left (left adrenal vein, left gonadal vein, left ascending lumbar vein). None on right. a. MCC of venous bleeding when dissecting L renal v if adrenal & gonadal tied off → ML avulsed inf phrenic vs lumbar vein 2/2 excess traction. 4) Right renal vein → NO collaterals → cannot be safely ligated. 5) Seminal vesicles → connected to vas deferens. 6) Erection (Point)→ Parasymp (pelvic splanchnic nerves). 7) Ejaculation (Shoot) → Symp (pudendal nerve). 8) Epididymis → saccular structure on top of testes. 9) Seminal vesicle → makes 95% of ejaculatory volume. 10) Sperm travels (“SEVEn UP”) Seminiferous tubules → Epididymis → Vas → Ejaculatory ducts → nothing → Urethra → Penis.

B. Nephrolithiasis 1) Sxs → severe colicky pain, restlessness. 2) Dx → U/A w/blood, KUB w/stones, CT → stones, hydronephrosis. 90% opaque. 3) Stone Types: a. Calcium oxalate (radio-opaque) → MC type (75%). ↑’d s/p TI resection 2/2 reabsorbed oxalate in colon. b. Mg++ ammonium phos (radio-opaque)/Struvite stones → asso w/urease organisms (eg. Proteus). Cause staghorn calculi.

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c. Uric acid (radio-lucent). RFs → gout, ileostomies, short gut. Ileostomy → ↓alkaline fluid → ↓ urine pH/vol → stones. d. Cysteine stones (either) → asso w/congenital d/o cysteine met. Prevent w/tiopronin (↓ cysteine solidification). 4) ESWL indications (best Tx) → intractable pain/infection, ↑obs/renal damage, 1 kidney, > 6 mm (can’t pass). + smoker → c/f bladder CA. + trauma → c/f collecting system inj.

C. Hematuria

+flank pain → c/f RCCa

D. Hydrocele → PAINLESS. Transilluminates (peritoneal fluid). Most idiopathic. If noncommunicating → most resolve by 1yo. 1) Does NOT affect fertility. If acute → suspect tumor (eg. Pelvic or abd). 2) Tx: Jabonlay bottleneck repair → scrotal incision, remove excess sac, evert edge, & sew edge behind cord. Use inguinal approach if c/f CA. 3) MCCx is scrotal hematoma.

E. Varicocele → Engorgement of veins → NO transillumination. Does affect fertility. 1) Dx → CT abd (r/o RCCa). CA obs left renal vein → obs left testicular vein → left varicocele. a. This is why you can divide left renal vein near IVC b/c kidney still drains via gonadal & adrenal vein. Not true on the right!

F. Spermatocele → MC scrotal cyst (sup & separate from testis). U/S → hyperechoic w/o transillumination. 1) Tx → remove if sxs.

Does NOT affect fertility

G. Ureteropelvic Junction Obstruction Tx → pyeloplasty (relieves obs). H. Vesicoureteral Reflux 1st→CT/IVP, then retrograde pyelo PRN. Tx→re-implant ureter into bladder w/tunnel → ↓reflux.

I. Ureteral Duplication MC urinary malformation. Tx → re-implantation in bladder if obs. Not a CI to kidney donation for TXP.

J. Hypospadias → Ventral Tx → repair at 6mns w/penile skin. K. Epispadias → Dorsal Tx → surgery. L. Horseshoe Kidney → usually inf poles. Cxs → UTI, urolithiasis, hydronephrosis. Tx → may need pyeloplasty if obs. M. Bilateral Absence of Vas Deferens→sweat chloride test (cystic fibrosis). N. Persistent Urachus → b/w umbilicus & bladder. 10% have bladder outlet obs. 1) Dx → voiding cystourethrogram (for obs). 2) Tx →resect sinus & cyst, close bladder, & relieve any obs.

O. Epididymitis 2/2 inflam/infection (MC→Chlamydia). MCC acute scrotal pain in men (MC 95% 5ys. Stage IV (eg. Lungs mets) → 5% 5ys. Tx → radical nephrectomy (kidney, adrenal, fat, Gerota's) w/Regional LNDx. Isolated lung mets → resect. a. Partial nephrectomy if nephrectomy would make pt depend on HD (eg tumor 2.5 or bilateral). b. Penchant to grow into IVC/right atrium (can pull tumor thrombus out). c. Adj CTX-XRT (doxorubicin based), IFN, IL-2 (all marginal). Renal pelvis transitional cell CA→radical nephroureterectomy. Von Hippel-Lindau → RCC, CNS tumors, pheos.

Y. Oncocytomas → benign Z. Angiomyolipomas → hamartomas, 2/2 tuberous sclerosis, benign

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AA. Congenital Adrenal Hyperplasia + Testicular Mass → Adrenal rest on testes, confused for CA. Tx → steroids (regress).

BB. Testicular Cancer MCC of CA death in 25-35yo M. Sxs→hard painless mass. Tx→ inguinal orchiectomy (scrotal incision disrupts lymphatics). 1) Most testicle masses → malignant. Dx → U/S. CT CAP (for RP & chest mets). ↑LDH w/↑tumor. Get β-HCG & AFP levels. 2) 90% → germ cell (seminoma vs nonseminoma). Undescended testicles (cryptorchidism)→↑testicle CA risk (ML seminoma). 3) Seminoma MC, very radiosensitive. a. Dx → Nml AFP, 10% have ↑β-HCG. b. Tx →All get inguinal orchiectomy & RP XRT; CTX for mets. 4) Non-Seminomatous a. “Non-radiosensitive” From embryonal remnants (choriocarcinoma, teratoma, yolk sac). Dx → ↑AFP & β-HCG in most. b. Tx → Inguinal orchiectomy & RP LNDx (Early LN mets. Take cord at internal ring). Stage II+ → CTX.

CC. Prostate Cancer 1) MC CA in US for M. 2nd MC CA death in M (MC → lung CA) 2) Sxs → none (MC); obs/irritative (eg frequency, dysuria); hematuria; ED. 3) Screening → NO survival benefit (DRE or PSA) a. PSA → not specific/sensitive; ↑ w/prostatitis, BPH, chronic cath. Nml → < 4. ↑Alk phos → c/f mets/extracapsular dz. 4) Dx → TRUS w/6-12 Bxs (prognosis asso w/histology), CT scan, PSA, Alk phos, & DEXA. a. MC site → posterior lobe. MC mets → bone (Osteoblastic. X-ray → hyperdensity). 5) Stage IA s/p TURP (not palpable, not on imaging). Tx → nothing. a. TURP can cause hypoNa+. 6) Stage I + II (T1/2 [confined to capsule]), either: a. 1) Watchful waiting (if >75yo or ↓life expectancy), 2) XRT, or 3)radical prostatectomy w/pelvic LNDx (lifespan > 10yrs). 7) Stage Ill (through capsule) or Stage IV (invades adj structures/mets) → XRT & androgen ablation (leuprolide [GnRH analogue, flutamide (anti-androgen, ± bilateral orchiectomy [most effective]). 8) XRT helps bone pain & ↓local recurrence. 9) Prognosis → ↑PSA, Gleason grade, & age → ↑ mets.

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34. Gynecology A. Anatomy 1) Round lig → Anteverts uterus (uterus →through inguinal canal → labia majora). 2) Suspensory/lnfundibular lig → Peritoneal fold from ovary to pelvic wall. Contains ovarian a, v, & n. 3) Broad lig → Side of uterus to pelvic floor & walls. Contains Cardinal lig. 4) Cardinal lig → Keeps cervix & vagina at base of broad lig. Contains uterine a & v.

B. Ectopic Pregnancy 1) MC ectopic site → fallopian tube ampulla. 2) Sxs → abd/pelvic pain, missed period, vaginal bleeding, + β-HCG, hypoTN (= ruptured ectopic → go to OR now). U/S → no intra-uterine pregnancy. 3) RFs → previous ectopic/tubal surgery/PID, smoker, ↑age. ⅓ preg s/p tubal surgery are ectopic. 4) Life-threatening bleed → ligate ant br of internal iliacs/hypogastics. 5) Tx → MTX vs laparoscopy (Not ruptured → salpjngotomy, hemostasis, repair tube. Ruptured/Not HDS → salpingectomy) a. MTX CIs Absolute → nursing. Relative → β-HCG >5000, ≥3.5cm + FHTs. Incomplete → tissue through os. Threatened → 1st tri bleed + heartbeat. Ectopic → see above. Missed → 1st tri bleed, closed os, U/S→sac, & NO heartbeat.

C. Abortions

D. Endometriosis Sxs→infertility, dyspareunia, dysmenorrhea. Occ. involves rectum→BRBPR w/menses. Endoscopy→blue mass. 1) MC site → ovaries. Dx lap → allows dx & tx. 2) Tx→OCPs, Danazol, NSAIDs. Refractory & Premenopause→ablate (58% recur). Post→TAH (18% recur) or TAH-BSO (8% recur) E. Pelvic Inflammatory Disease 2/2 N gonorrhoea & Chlamydia (infertility d/t fallopian tube scars). Tx→ceftriaxone+doxy.

F. Mittelschmerz 2/2 Graafian follicle rupture 14d s/p onset of prior menses → RLQ/LLQ pain (confused w/appy).

G. Tuboovarian Abscess → ascending infection (eg. PID) 2/2 upset cervical mucous barrier. a. Tx → HDS/HDN, NOT ruptured, 9cm → percutaneous drainage (OR if peritonitis or not HDS).

H. Ovarian Torsion Sxs → rapid RLQ/LLQ pain, n/v. 1) Tx → de-torse (resect only if necrosis). I. Ovarian Cysts 1) 2) 3) 4)

Dx → U/S.

> 95% benign (follicular, luteal, & thecal). Simple cyst < 10 cm → < 1% CA risk. CA MC post-menopause (↓oophorectomy threshold). Tx → laparoscopy (preferred). Use endocatch bag (spillage upstages ovarian CA).

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5) CA RFs → Post-menopause, last >2-3mns, >10cm, complex (septae, ↑vascularity, solid, papillary projections, thick wall), ↑CA-125. 6) Incidental Finding → Don’t touch! Get transvaginal U/S in 6-12wks. 7) Pre-menopausal Not concerning → transvaginal U/S in 6-12wks. Complex → 12% CA risk. Try to avoid oophorectomy (>95% benign). a. Tx → dx lap, cyst wall excision/fenestration. If c/f CA (ie. Complex & ↑CA-125) → lap oophorectomy w/frozen section. 8) Post-menopausal Complex → 15% CA risk. a. Complex, lasts >2-3mns, >10cm, or ↑CA-125 → lap oophorectomy w/frozen section (If +, get intra-op OBGYN consult → will likely convert to open TAH-BSO w/staging). b. Not c/f CA → serial U/S until one of above RFs.

J. Incidental Ovarian Mass in OR 1) Simple cyst → leave alone (see above). 2) Incidental mass during elective case + findings c/f CA (eg. peritoneal studding, thick septae, ascites, solid) → abort. 3) Adnexal mass + _______ = _______. bleeding = ectopic preg fever + d/c = TOA n/v = torsion 4) Anechoic & unilocular cyst → get CA-125 & TVUS in 3mns.

K. Polycystic Ovarian Disease 1) Sxs → amenorrhea, infertility, hirsutism. Tx → clomiphene. L. Uterine Leiomyomas (Fibroids) Sxs → bleeding (MC), cyclic w/menses, recurrent spont abortions, infertility. 1) Med Tx → GnRH analogues (eg leuprolide). If leiomyosarcoma on post-op path w/neg margins → NO further surgery.

M. Uterine Prolapse Uterus through vagina. RF → multiparity. Tx → ↓wt, D/C smoking (↓cough), pessary, trans-vag hyst.

N. Pregnancy Issues 1) Fetal loss rates: acute appy (1.5%), open appy (3%), lap (7%), perf (36%). 2) Rad (5mGy max throughout pregnancy), greatest risk in 1st 15wks. a. No radiation w/MRCP. b. HIDA is CI (↑radiation). c. Traumagram OK. d. CT Head < 0.005mGy. e. CT abd/pelvis (appy/preg protocol) 2.5mGy. 3) Viable (≥24wks) → Intra-op monitoring. 4) Previable (2cm → paraAo & pelvic LNDx. ii) Serous or clear cell → omentectomy.

V. Ovarian Cancer MC gynecologic c/o death. MC in 60s. Sxs → Abd/pelvic pain, change stool/urinary habits, vaginal bleeding. 1) ↓ risk → OCPs, bilateral tubal ligation 2) ↑ risk → nulliparity, late menopause, early menarche

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

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35. Neurosurgery A. Nerve Injury Types 1) Neuropraxia → MC (& mildest, like foot falling asleep) a. Interrupted conduction impulse → temp ↓func (motor > sense). Will recover. No axon/myelin sheath injury. b. Severe blunt trauma →6-8wks to recover. 2) Axonotmesis → Disrupted axon, intact myelin sheath → No sensation + paralysis. MC 2/2 crush. Regenerates 1mm/d. a. Wallerian degeneration antegrade toward end plate. 3) Neurotmesis→ Disrupted axon & myelin sheath → Worst. a. 2/2 stretch, contusion, laceration. OR for chance to recover. Central nerves do NOT regenerate.

B. Positional Nerve Injury → can occur w/appropriate padding. RF → DM neuropathy. MC → ulnar & brachial. Protective → fat.

C. Diabetes Insipidus → ↓ADH→↑UOP, ↓urine specific gravity, ↑serum Na+ & osm. 2/2 ETOH, TBI, lithium (nephrogenic). 1) Tx → DDAVP, free water replacement.

D. SIADH → ↑ADH → ↓UOP, ↑urine conc, ↓ serum Na+ & osm. 2/2 TBI. Tx → water restriction, then diuresis. E. Brain Tumors 1) Glioma → MC 1° brain tumor in adults/overall. 2) Medulloblastoma 3) Neuroblastoma 4) Astrocytomas a. Grade i) I – Pilocytic, Subepemdymal giant cell, Subependymoma ii) II – Low-grade fibrillary, Pleomorphic xanthoastrocytoma, Mixed iii) III – Anaplastic iv) IV – Glioblastoma multiforme (GBM) MC subtype, uniformly fatal.

F. Spine Tumors 1) Neurofibroma & Paragranglioma

G. Myelomeningocele Neural cord defect w/spinal cord herniation & nerve roots. MC in lumbar. 1) Tx → If ruptured, surgery to prevent meningitis.

H. Berry Aneurysm If