Radiation Proctitis

Question: Treatment of radiation Proctitis with persistent bleeding
Answer: first sucralfate enemas then argon beam coagulation, then resection

Anal Cancer

Question: What is the treatment of Anal Cancer?
Answer See Below:
Anal Canal (above Dentate) - usually chemoradiation

    Adenocarcinoma - same concept as rectal cancer (if T1 and small < 3cm then WLE) - if not APR

    Squamous/Basaloid (cloacogenic), mucoepidermoid - NIGRO, if recurrent then APR

    Melanoma - no difference between APR and WLE

Anal Margin (below dentate) - usually excision

    Squamous of Basal - same concept as skin cancer, WLE although made need APR if sphnicters involved

    Bowen's disease - WLE with clear margins because this is malignant

    Paget's Disease - intractable itching, positive PAS, 1/3 with concurrent rectal cancer - WLE

Anal Anatomy

Question: Lymph Drainage of upper, middle, and lower rectum?
Answer: Upper and middle rectum lymph nodes drain to inferior mesenteric nodes whereas lower rectum drains into both inferior mesenteric and internal iliac nodes

Skin Grafts

Question: How dose a STSG get adequate nutrition/oxygen supply in the first week?
Answer: imbibition (diffusion from serum), then inosculation (capillary in-growth) in 2-7d

Appendicitis

Question: Etiology in Adults? Kids?
Answer: appendicolith (adults) -  lymphoid hyperplasia (children)
Question: Management of Cecal Fistula after appendectomy?
Answer: Non-operative management (most will close with time)

Appendiceal Carcinoid

Question: What is the treatment of an appendiceal carcinoid?
Answer: > 2cm or at base of appendix = Right hemicolectomy, < 2cm and not in base = appendectomy

Aneurysms (not abdominal aortic aneursyms)

rupture risk above inguinal ligament, thrombosis/emboli below inguinal ligament - bypass and exclude
Question: When do you operate:
Answer:
    - Splanchnic - repair all (50% rupture risk)
    - Splenic - > 2cm, symptomatic, pregnant or child bearing years
    - Iliac - > 3cm, symptomatic, mycotic
    - Femoral - > 2.5cm, symptomatic, mycotic
    - Popliteal - > 2cm, symptomatic, mycotic, often bilateral, most common complication is embolism (not thrombosis or rupture), screen for AAA
    - Renal - > 1.5cm, symptomatic, mycotic, women who want pregnancy

Minimum alveolar concentration

MAC = amount that will prevent 50% of patients from moving with incision Low MAC = more lipid soluble = more potent, but slower onset Question: What has the highest MAC? Advantage/Disadvantage? Answer: Nitrous = highest MAC = fastest onset, but low lipid solubility = less potent

Topical Antibiotics for Burns

QUESTION: What is the side effect and benefit of silvadene? Sulfamylon? Silver Nitrate?
ANSWER: Silvadene - NEUTROPENIA, best for Candida; Sulfamylon - METABOLIC ACIDOSIS (inhibits carbonic anhydrase), good eschar penetration; Silver nitrate - ELECTROLYTE ABNORMALITIES (hyponatremia and hypochloremia)
QUESTION: What do you treat hydrofluoric acid burns with?
ANSWER: topical calcium gluconate

Rule of 9's

QUESTION: What is the rule of 9's for adults and kids?
ANSWER: 9% each arm, 18% front trunk, 18% back trunk, 18% each leg, 9% head/neck, 1% perineum (child = big head/little legs so head = 18, and legs = 14)

Calorie Need in Burns

QUESTION: What is the calorie and protein need in burns?
ANSWER: Calories: 25kcal/kg/day + 30kcal/day x % burn; Protein: 1g/kg/day + 3g x % burn

Pancreatic Necrosis

QUESTION: What is the classic picture on CT scan? Who needs an operation?
ANSWER: Soap bubbles.  If septic and infected (CT guided aspirate) then antibiotics and drainage (necrosectomy)

Pancreatic Lymphoma

Very Rare, one time where CT guided biopsy might help with pancreatic mass
QUESTION: Management of primary pancreatic lymphoma
ANSWER: Chemotherapy, not surgery

Pancreatic Cancer

Most significant risk factor is smoking
90% adenocarcinoma (2/3 on the head of pancreas)
Ca-19-9, Ca-50. K-Ras
QUESTION: What are is the palliative surgery for obstruction secondary to pancreatic cancer?
ANSWER: Cholecystojejunostomy or choledochojejunostomy  and Gastrojejunostomy

Pancreatic Fistula

QUESTION: What is the management of a persistent pancreatic internal fistula
ANSWER: Drain pancreatic fluid and keep NPO, then ERCP, then pancreatic resection or drainage procedure depending on location of fistula

Chronic Pancreatitis

Recurrent bouts of pancreatitis with chronic pain usually due to alcohol
QUESTION: What is the surgical management of chronic pancreatitis
ANSWER: Peustow (Lateral pancreatico-jejunostomy) if diffusely dilated duct > 8mm, Pancreatectomy for pain with normal duct

Serous Cystadenoma

Presentation - Older Woman with central scar on CT scan
QUESTION: Management of serous cystadenomas
ANSWER: Malignancy = very RARE - therefore, resection is for symptoms or unknown diagnosis

Mucinous Cystic Neoplasm

Presentation - Older Woman with peripheral eggshell calcifications on CT scan
QUESTION: Management of MCNs?
ANSWER: High risk features = size > 3cm, thick wall, peripheral calcifications, mural nodules (RESECT) - Therefore - lesions < 3cm without symptoms can be watched with serial imaging

Intraductal papillary mucinous neoplasm

Presentation - Older Male, PREMALIGNANT
QUESTION: Management of IPMNs?
ANSWER: Types (as determined radiographically) dictates treatment:
1. Main duct - high CA risk if main duct > 6mm, mucin on endoscopy, mural nodularity - resect all
2. Side branch - usually multifocal, lower malignancy risk
3. Mixed type (both main and side branch)

Pancreatic divisum

QUESTION: Why do patients with divisum have an increased risk of pancreatitis?
ANSWER: Minor Duct (Santorini) fails to fuse with Major Duct (Wirsung) and thus pancreas has to drain in minor papilla and sometimes can't handle drainage

Hereditary Pancreatitis

QUESTION: What is the etiology of hereditary pancreatitis? - treatment?
ANSWER: autosomal dominant trypsin inactivation gene that leads to uncontrolled enzymatic degeneration and greatly increases cancer risk - pancreatectomy

Gallstone Pancreatitis

5% of symptomatic patients with choleliathiasis can get gallstone pancreatitis
30% recurrence if gallbladder not removed
QUESTION: In gallstone pancreatitis, when do you do a lap chole? and who gets an ERCP?
ANSWER: wait for lipase to decrease to near normal and near resolution of symptoms and BEFORE DISCHARGE - if concerned for biliary obstruction (hyperbilirubinemia) or prior cholangitis get a pre op ERCP to clear duct

Gastrinoma

QUESTION: What are the important points of diagnosis for Gastrinomas?
ANSWER: Secretin stimulation test paradoxically increases gastrin levels (> 120) and octreotide scan is very helpful for localization due the high concentration of somatostatin receptors
QUESTION: What is Passaro's Triangle or Gastrinoma Triangle
ANSWER: the junction of the cystic and common bile duct superiorly, the junction of the second and third portion of the duodenum laterally, the junction of the neck and body of the pancreas medially

Insulinoma

MOST COMMON functioning neuroendocrine tumor but usually 90% benign

Whipple's triad - Hypoglycemic symptoms when fasting; <50 mg/dl blood glucose; Symptoms resolve with glucose

QUESTION: Diagnosis of insulinoma? and Treeatment
ANSWER: low fasting glucose with elevated C-peptide and localization with CT scan - enucleate if < 2cm, formal resection for > 2cm

VIPoma

WDHA syndrome or Verner-Morrison Syndrome - watery diarrhea, hypokalemia, and other achlorhydia or hypochlorydia
QUESTION: Why are VIPomas so bad and what is mangement?
ANSWER: VIPomas cause massive fluid loss and electrolyte abnormalities and are usually malignant at diagnosis.  Management includes resection but often patients are palliated with octreotide.

Somatostatinoma

Diabetes, gallstones, steatorrhea, hypochlorhydria (everything slows) QUESTION: Younger patient with exocrine pancreatic dysfunction and pancreatic head mass - diagnosis? Malignant? Treatment?
ANSWER: Somatostatinoma, usually malignant at time of diagnosis, resection

Glucagonoma

Diabetes, stomatitis, dermatitis (necrolytic migratory erythema - usually abdominal wall and perineum)
QUESTION: CT scan uses mass in tail of pancreas with diabetes and skin rash to perineum - diagnosis? management?
ANSWER: Glucagonoma - octreotide but if refractory to medical management than resection (distal pancreatectomy)

Pancreatic Pseudocyst

Due to pancreatitis (20%) and trauma
QUESTION: Chronic pancreatitis patient with large epigastric fullness - Diagnosis? Management?
ANSWER: Pseudocyst - allow to mature for 3 months, then ERCP and if duct involved cystogastrostomy and if not then perc drain

Tropical Pancreatitis

Hereditary pattern with mutation in trypsinogen inhibitor SPINK1 gene, associated with pancreatic duct stones
QUESTION: young patient who lives in the tropics with abdominal pain and diabetes - diagnosis? management?
ANSWER: tropical pancreatitis - pain medication and enzyme supplementation and possible endoscopic decompression

Malignant Hyperthermia

Question: Patient under general anesthesia suddenly has acute rise in end tidal CO2 - Diagnosis? Treatment? and how does the treatment work?
Answer: Malignant hyperthermia (autosomal dominant) - Dantrolene and stop operation, dantrolene stablizes sarcoplasmic reticulum

Acalculous Cholecysitis

QUESTION: What is the primary cause of acalculous choleysitis and management?
ANSWER: bile stasis; percutaneous cholecystostomy tube and doesn't need interval cholecystectomy

Budd-Chiari

occlusion of hepatic vein and IVC from web/membrane (Africa/Asia) or clot (western countries)
QUESTION: rapid-onset ascites with RUQ pain, liver failure and bloody abdominal tab - Diagnosis? and Treatment?
ANSWER: Budd-Chiari syndrome by duplex ultrasound; anticoagulation

Gallstone Ileus

QUESTION: What is the most common location gallstone ileus obstruction? Management?
ANSWER: Terminal ileum - enterotomy and remove stone with closure, only remove gallbladder if stable and minimal inflammation, otherwise leave gallbladder

Liver Abscess

- Pyogenic: MOST COMMON, perc drain and ABX, mostly from cholangitis, diverticulitis, appendicitis, usually GNR (E.coli)
- Amebic: due to Entamoeba histolytic (from Mexico), flagyl and perc drain if toxic
- Echinococcus: positive indirect hemagglutination, preop albendazole, surgical removal with etoh injection to avoid anaphylactic shock
- Schistosomiasis - prizquantel, associated with variceal bleeding, may need surgery to control bleeding
QUESTION: Historically what was the main cause of pyogenic abscesses? what is it now?
ANSWER: Bowel infection (diverticulitis/appendicitis) but now is bilary tract disease (cholangitis)
QUESTION: What is the best way to differentiate between different types of liver abscesses?
ANSWER: CT scan

Liver Metastasis

QUESTION: What percentage of colon cancer cases are eligible for liver met resection and what is 5 year survival after liver met resection?
ANSWER: 10% and 20% 5 year survival

Liver Cancer

- Hepatocellular: #1 WORLDWIDE Cancer due to Hepatitis C; Resection or transplantation for Milan Criteria (one lesion < 5cm, 3 lesions < 3, no mets, no vascular invasion)
QUESTION: Marker associated with HCC?
ANSWER: AFP (correlates with tumor size)

Liver Lesions Benign

- Hemangioma - MOST COMMON, Peripheral to central enhancement, hypervascular, Do nothing unless giant or symptomatic/consumptive (Kasabach-Merritt syndrome)
- Adenoma: HEMORRHAGE RISK and malignant transformation risk, usually young women on birth control, stop birth control pills and if same size, then resect
- Focal Nodular Hyperplasia: CENTRAL STELLATE SCAR, sulfur colloid scan positive although MRI usually diagnositc, no need for surgical resection.
QUESTION: Most common benign liver lesion?
ANSWER: Hemangioma
QUESTION: First step in management of hepatic adenoma?  If that doesn't work then?
ANSWER: Stop birth control pills, then resection

Jaundice

Unconjugated - Gilbert's (diminished glucuronyl transferase); Crigler-Najjar (glucuronyl transferase deficiency); Physiologic newborn (immature glucuronyl transferase)
Conjugated - Obstruction, Rotor's (inadequate storage); Dubin-Johnson (poor secretion)
QUESTION: In a patient with elevated direct hyperbilirubinemia due to obstruction, why would INR be elevated?
ANSWER: Bile helps absorb fat and Vitamin K is a fat soluble vitamin that is needed for the extrinsic clotting factor coagulation

Bilrubin and Bile

- Hemoglobin broken down to bilirubin; Bilirubin conjugated by glucuonyl transferase in liver and secreted in bile; conjugated bilirubin broken down by bacteria in terminal ileum to urobilinogen and reabsorbed in blood and excreted in urine (thus high levels will turn urine cola dark)
- Bile composed of bile salts, lecithin, cholesterol and bilirubin; Primary bile acids: cholic acid and chenodeoxycholic acid and Secondary bile acids: deoxycholic and lithocholic acids formed by anaerobic bacteria in the intestine
QUESTION: What increases bile acid synthesis?
ANSWER: ileal resection, by-pass, bile acid absorption inhibitors (Cholestyramine)

Liver Histology

QUESTION: Why are zone III acinar cells more prone to ischemia?
ANSWER: Zone I cells are near the artery, bile duct, and portal vein branch and thus are exposed to more toxins but get a better blood supply whereas zone III cells are around the hepatic vein branch and thus are more prone to ischemia but less toxins.

Pringle Maneuver

QUESTION: What is compressed with a pringle maneuver and how long can this be held?
ANSWER: portal vein posterior, common bile duct laterally, hepatic artery medially - 30 minutes

Liver Anatomy

Replaced Right hepatic artery - off SMA (in hepato-duodenal ligament laterally) (20%)
Replace Left hepatic artery - off left gastric (in gastro-hepatic ligament) (15%)

Replaced Common hepatic artery - off SMA (2%)
QUESTION: Hepatic artery and portal vein supply how much blood flow respectively? and which one mainly feeds cancer mets?
ANSWER: 25% / 75% but hepatic artery mainly supplies mets.

Metabolic Alkalosis

Question: Which lab value helps to determine the type of metabolic alkalosis?Answer: Urine Chloride.  If Urine Cl < 15 then it is chloride responsive metabolic alkalosis, meaning that chloride is lost via vomiting or through the kidney.  If Urine Cl > 15 than it is chloride resistant, meaning that chloride is retained secondary to exogenous bicarbonate administration or hyperaldosteronism

Hyponatremia

Question: Patient had brain tumor resection and now has LOW Na, HIGH urine output, HIGH urine sodium - Diagnosis? and Explain difference between Cerebral salt wasting and SIADH
Answer: Cerebral salt wasting.  SIADH will also have LOW Na but lower to normal UOP who are euvolemic

Hyponatremia

Question: 70 yo male becomes unresponsive and has a seizure after TURP with Na of 112 - Management?
Answer: 3% normal saline to increase Na by 1mEq/hr until at least 130

Daily Nutrition Requirements

Total Kcal: 25kcal/kg/day
Distribution of calories: Of the 1g protein/kg/day (20% should be in the form of essential AA’s). 30% of calories should be from fat, and the rest should be from carbohydrates.
Question: 80 kg man gets 80g of protein in TPN with total calories of 2000/day.  How many calories from fat should he receive and what volume of 10% dextrose should he receive daily.
Answer: 30% of 2000 calories = 600 calories from fat.  That leaves 2000-600-320 = 1180 calories from carbs.  1180 /4 = 295 gms of dextrose, which means 2950cc of 10% dextrose solution

Kcals

Question: What are the Kcals of protein? carbs? fats?
Answer : Protein: 4 Kcal/gm; Carbs: 4Kcal/gm; Lipids: 9 Kcal/ml

Free Water Deficit

Question: 70kg man with serum sodium of 168 - what is the free water deficit?
Answer: Deficit = (Na - 140)/140 x total body water (Men = 50% of weight, Women = 40% of weight) = (168-140)/140 x 35 = 7 Liters (half of which should be replaced in the first 24 hours)

Intracranial Pressure

Question: What is the appropriate CPP and how do you manage ICPs?
Answer: CPP = MAP - ICP; Should target CPP > 50; If ICP > 20-25 then early hyperventilation keeping paCO2 > 30, 3% NS for Na 155-160, Manitol for diuresis, barbituate coma to calm the ECG and thus decrease metabolic demand; and decompressive craniotomy

Diagnostic Peritoneal Lavage

Question: What is a positive DPL?
Answer: > 10cc blood on initial needle insertion; > 100,000 RBC if blunt or > 5,000 RBC if penetrating after infusion of 1 liter normal saline; bile or stool; WBC > 500; (NOTE - atleast 250 cc must be aspirated back to get an adequate DPL)

Duodenal Injury

Question: Injury to the duodenum - Management?
Answer: Hematoma on CT scan = observation, NGT - if no resolution that exploration; <50% lumen laceration = primary transverse repair with omental patch;  If complete transection, primary reanastomosis first; If reanastomosis not possible and injury in the first part of the duodenum than antrectomy, vagotomy and BI or BII reconstruction, if in the 2nd half of the duodenum than roux-en-Y duodenojejunostomy

Duodenal Diverticulization = BII, decompressive duodenal tube and peri-duodenal drainage
Pyloric exclusion = repair the duodenal injury, open the stomach, sew the pylorus closed and a GJ anastomosis

Thoractomy

Question: Indication for thoractomy?
Answer: Chest tube output > 1500 immediately, > 200 x 3 hours, > 2000 over 24 hours

Chest Trauma

Question: Best incision for proximal right and left carotid, innominate, proximal right subclavian artery?  Best incision for proximal left subclavian artery?
Answer: Sternotomy; Left anterolateral 3rd intercostal thoractomy

Burn Center

Question - When do you transfer a patient to a burn center?
Answer - 5-10-20 rule: 5% for any 3rd degree, 10% TBSA in extremes of age (<10 or >50), and 20%TBSA in all patients

Trauma

QUESTION: Patient hit chest on steering wheel now with abnormal EKG, Diagnosis? Management?
ANSWER: Diagnosis - Blunt cardiac injury (shock without hemorrhage or spinal shock, abnormal EKG, CI < 2.5, abnormal ECHO), Management - Admit for observation, EKG/troponin now and 8 hours later, if unstable = ECHO, if pericardial effusion = Sternotomy, cardiac repair

Large Bowel

Question: Immunocompromised patient on chemotherapy with right lower quadrant pain, fever, and CT scan demonstrates inflammation of the cecum. Diagnosis? Treatment? Mortality?
Answer: Typhlitis - Antibiotics/NPO, if perforation then requires a right hemicolectomy - 40-50% mortality

Bladder Injury

Trauma

Question: Bladder injury with extravasation on CT cystogram above the peritoneal reflection - Management?
Answer: Intraperitoneal bladder injuries require 3 layer bladder closure with absorbable suture

Question: Bladder injury that is extraperitoneal - Management?
Answer: Extraperitoneal bladder injuries require 7-10 foley placement with cystogram prior to removal.

Trauma

Questions: Pregnant responses to trauma?
Answer: 1) More blood volume but overall anemia but has delayed response to shock 2) higher baseline respiratory rate thus has poor response if tachypnea 3) chronic abdominal stretch desenitizes to peritonitis

Trauma

Question: Gunshot to buttock with blood on proctoscopy - management?
Answer: Intraperitoneal injury = primary colon repair, Extraperitoneal injury = if primary colon repair not possible then proximal colostomy and antibiotics

Appendix

Question: For stump appendicitis - how long should the appendiceal stump be to avoid stump appendicitis and what is the treatment?
Answer: At least less than 0.5cm and treatment is appendectomy with or without stump inversion

Endocrine

Question: What is MEN I, IIa, IIb and what is the most important initial management for each
Answer: MEN I - parathyroid hyperplasia, pancreatic islet tumor, pituitary adenoma (correct hyperparathyroidism first)
MEN IIa - parathyroid hyperplasia, pheochromocytoma, medullary thyroid cancer (resect pheochromocytoma first)
MEN IIb - Pheochromocytoma, medullary thryoid cancer, mucosal neuromas, marfanoid (resect pheochromocytoma first)

Skin

Question: Resection margins for melanoma <1mm deep? 1-4mm deep? >4mm deep?
Answer: 1cm, 2cm, 3cm

Burns

Burns

Question: Complication of 1) Silvadene? 2) silver nitrate? 3) Sulfamylon?
Answer: 1) neutropenia and thrombocytopenia, 2) electrolyte imbalance, 3) metabolic acidosis secondary to carbonic anhydrase inhibition

Oxygen-Hgb dissociation

Question: What shifts the oxygen-Hgb dissociation curve to the right and thus unloads oxygen?
Answer: (think increases! - increased acid (H+), increased CO2, increased temperature, increased ATP, increased 2-3 DPG (stored blood)

Ureteral Injury

Question: Treatment for ureteral injury at trauma laparotomy for 1) small segment <2cm, 2) upper injury that will not reach the bladder, 3) lower injury that might reach the bladder
Answer: 1) primary ureteroureterostomy with double-J stent, 2) either tie off both ends and obtain a percutaneous nephrostomy tube postoperatively with interval trans-ureteroureterostomy or immediate trans-ureteroureterostomy, 3) reimplantation of neoureterostomy over double-J stent or tack bladder to psoas (hitch) and reimplantation

Small/Large Bowel fuel supply

Question: What is the main fuel supply of the large and small bowel?
Answer: Colonocytes = short chain fatty acids; Small Bowel = Glutamine

Local Anesthesia

Question: What is the maximum dose of 1% lidocaine without epinephrine for a 70kg patient?
Answer: 35cc (5mg/kg = 350mg; 10mg per cc of 1% lidocaine, thus 350mg/10mg/cc = 35cc)

Question: What is the maximum dose of 1% lidocaine with epinephrine for a 70kg patient?
Answer: 49cc (7mg/kg = 490mg; 10mg per cc of 1% lidocaine, thus 490mg/10mg/cc = 49cc)

Question: What is the maximum dose of 0.25% marcaine for a 70kg patient?
Answer: 84cc (3mg/kg = 210mg, 2.5mg per cc of 0.25% marcaine, thus  210mg/2.5mg/cc = 84cc or about patient weight in kg in cc's)

Question: Which anesthetics are more likely to cause an allergic reaction?

Answer: Esters due to PABA analogue, Amides have an " i " in first part of name) are less likely to cause allergic reaction