- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
What are the diagnostic tests of choice?
What is an MRCP?
What is the management of proximal bile duct cholangiocarcinoma?
What is the management of distal common bile duct cholangiocarcinoma?
Chapter 54 / Biliary Tract 381
Ultrasound, CT scan, ERCP/PTC with biopsy/brushings for cytology, MRCP
MRI with visualization of pancreatic and bile ducts
Resection with Roux-en-Y hepaticojejunostomy (anastomose bile ducts to jejunum) unilateral hepatic lobectomy
Whipple procedure
MISCELLANEOUS CONDITIONS
What is a porcelain |
Calcified gallbladder seen on |
gallbladder? |
abdominal x-ray; results from chronic |
|
cholelithiasis/cholecystitis with |
|
calcified scar tissue in gallbladder wall; |
|
cholecystectomy required because of |
|
the strong association of gallbladder |
|
carcinoma with this condition |
What is hydrops of the gallbladder?
Complete obstruction of the cystic duct by a gallstone, with filling of the
gallbladder with fluid (not bile) from the gallbladder mucosa
What is Gilbert’s syndrome? |
Inborn error in liver bilirubin uptake |
|
and glucuronyl transferase resulting in |
|
hyperbilirubinemia (Think: Gilbert’s |
|
Glucuronyl) |
What is Courvoisier’s |
Palpable, nontender gallbladder (unlike |
gallbladder? |
gallstone disease) associated with cancer |
|
of the head of the pancreas; able to distend |
|
because it has not been “scarred down” |
|
by gallstones |
What is Mirizzi’s syndrome? |
Common hepatic duct obstruction as a |
|
result of extrinsic compression from a |
|
gallstone impacted in the cystic duct |
382 Section II / General Surgery
C h a p t e r 55 Pancreas
Identify the regions of the pancreas:
|
1. |
Head |
|
2. |
Neck (in front of the SMV) |
|
3. |
Uncinate process |
|
4. |
Body |
|
5. |
Tail |
What structure is the tail of |
Spleen |
|
the pancreas said to “tickle”? |
|
|
Name the two pancreatic |
1. Wirsung duct |
|
ducts. |
2. |
Santorini duct |
Which duct is the main |
Duct of Wirsung is the major duct |
|
duct? |
(Think: Santorini Small duct) |
|
How is blood supplied to the 1. Celiac trunk S gastroduodenal S head of the pancreas? Anterior superior pancreaticoduodenal
artery
Posterior superior pancreaticoduodenal artery
2.Superior mesenteric artery S Anterior inferior pancreaticoduodenal
artery
Posterior inferior pancreaticoduodenal artery
3.Splenic artery S Dorsal pancreatic artery
Why must the duodenum be removed if the head of the pancreas is removed?
They share the same blood supply (gastroduodenal artery)
What is the endocrine function of the pancreas?
What is the exocrine function of the pancreas?
What maneuver is used to mobilize the duodenum and pancreas and evaluate the entire pancreas?
PANCREATITIS
Chapter 55 / Pancreas 383
Islets of Langerhans:-cells: glucagon-cells: insulin
Digestive enzymes: amylase, lipase, trypsin, chymotrypsin, carboxypeptidase
Kocher maneuver: Incise the lateral attachments of the duodenum and then lift the pancreas to examine the posterior surface
ACUTE PANCREATITIS
What is it? |
Inflammation of the pancreas |
What are the most common |
1. Alcohol abuse (50%) |
etiologies in the United |
2. Gallstones (30%) |
States? |
3. Idiopathic (10%) |
What is the acronym to |
“I GET SMASHED”: |
remember all of the causes |
Idiopathic |
of pancreatitis? |
|
|
Gallstones |
|
Ethanol |
|
Trauma |
|
Scorpion bite |
|
Mumps (viruses) |
|
Autoimmune |
|
Steroids |
|
Hyperlipidemia |
|
ERCP |
|
Drugs |
What are the symptoms? |
Epigastric pain (frequently radiates to |
|
back); nausea and vomiting |
What are the signs of |
Epigastric tenderness |
pancreatitis? |
Diffuse abdominal tenderness |
|
Decreased bowel sounds (adynamic ileus) |
|
Fever |
|
Dehydration/shock |
384 Section II / General Surgery |
|
What is the differential |
Gastritis/PUD |
diagnosis? |
Perforated viscus |
|
Acute cholecystitis |
|
SBO |
|
Mesenteric ischemia/infarction |
|
Ruptured AAA |
|
Biliary colic |
|
Inferior MI/pneumonia |
What lab tests should be |
CBC |
ordered? |
LFT |
|
Amylase/lipase |
|
Type and cross |
|
ABG |
|
Calcium |
|
Chemistry |
|
Coags |
|
Serum lipids |
What are the associated |
Lab—High amylase, high lipase, high |
diagnostic findings? |
WBC |
|
AXR—Sentinel loop, colon cutoff, |
|
possibly gallstones (only 10% visible |
|
on x-ray) |
|
U/S—Phlegmon, cholelithiasis |
|
CT—Phlegmon, pancreatic necrosis |
What is the most common |
Sentinel loop(s) |
sign of pancreatitis on |
|
AXR? |
|
What is the treatment? |
NPO |
|
IVF |
|
NGT if vomiting |
|
/– TPN vs. postpyloric tube feeds |
|
H2 blocker/PPI |
|
Analgesia (Demerol®, not morphine— |
|
less sphincter of Oddi spasm) |
|
Correction of coags/electrolytes |
|
/– Alcohol withdrawal prophylaxis |
|
“Tincture of time” |
What are the possible complications?
What is the prognosis?
Are postpyloric tube feeds safe in acute pancreatitis?
What are Ranson’s criteria for the following stages:
At presentation?
During the initial 48 hours?
What is the mortality per positive criteria:
0 to 2?
3 to 4?
5 to 6?
7 to 8?
Chapter 55 / Pancreas 385
Pseudocyst Abscess/infection Pancreatic necrosis
Splenic/mesenteric/portal vessel rupture or thrombosis
Pancreatic ascites/pancreatic pleural effusion
Diabetes ARDS/sepsis/MOF Coagulopathy/DIC Encephalopathy Severe hypocalcemia
Based on Ranson’s criteria
YES
1.Age 55
2.WBC 16,000
3.Glc 200
4.AST 250
5.LDH 350
1.Base deficit 4
2.BUN increase 5 mg/dL
3.Fluid sequestration 6 L
4.Serum Ca2 8
5.Hct decrease 10%
6.PO2 (ABG) 60 mm Hg (Amylase value is NOT one of Ranson’s criteria!)
5%
15%
40%
100%
386 Section II / General Surgery
How can the admission Ranson criteria be remembered?
How can Ranson’s criteria at less than 48 hours be remembered?
“GA LAW (Georgia law)”: Glucose 200
Age 55
LDH 350
AST 250 WBC 16,000
(“Don’t mess with the pancreas and don’t mess with the Georgia law”)
“C HOBBS (Calvin and Hobbes)”:
Calcium 8 mg/dL
Hct drop of 10%
O2 60 (PaO2)
Base deficit 4
Bun 5 increase
Sequestration 6 L
How can the AST versus |
Alphabetically and numerically: A before |
LDH values in Ranson’s |
L and 250 before 350 |
criteria be remembered? |
Therefore, AST 250 and LDH 350 |
What is the etiology of |
Fat saponification: fat necrosis binds to |
hypocalcemia with |
calcium |
pancreatitis? |
|
What complication is |
Gastric varices (treatment with |
associated with splenic vein |
splenectomy) |
thrombosis? |
|
Can TPN with lipids be given |
Yes, if the patient does not suffer from |
to a patient with pancreatitis? |
hyperlipidemia (triglycerides 300) |
What is the least common |
Scorpion bite (found on the island of |
cause of acute pancreatitis |
Trinidad) |
(and possibly the most |
|
commonly asked cause on |
|
rounds!) |
|
|
Chapter 55 / Pancreas 387 |
CHRONIC PANCREATITIS |
|
|
|
What is it? |
Chronic inflammation of the pancreas |
|
region causing destruction of the |
|
parenchyma, fibrosis, and calcification, |
|
resulting in loss of endocrine and |
|
exocrine tissue |
What are the subtypes? |
1. Chronic calcific pancreatitis |
|
2. Chronic obstructive pancreatitis (5%) |
What are the causes? |
Alcohol abuse (most common; 70% of cases) |
|
Idiopathic (15%) |
|
Hypercalcemia (hyperparathyroidism) |
|
Hyperlipidemia |
|
Familial (found in families without any |
|
other risk factors) |
|
Trauma |
|
Iatrogenic |
|
Gallstones |
What are the symptoms? |
Epigastric and/or back pain, weight loss, |
|
steatorrhea |
What are the associated |
Type 1 diabetes mellitus (up to one third) |
signs? |
Steatorrhea (up to one fourth), weight loss |
What are the signs of |
Steatorrhea (fat malabsorption from lipase |
pancreatic exocrine |
insufficiency—stools float in water) |
insufficiency? |
Malnutrition |
What are the signs of |
Diabetes (glucose intolerance) |
pancreatic endocrine |
|
insufficiency? |
|
What are the common pain patterns?
What is the differential diagnosis?
What percentage of patients with chronic pancreatitis have or will develop pancreatic cancer?
Unrelenting pain
Recurrent pain
PUD, biliary tract disease, AAA, pancreatic cancer, angina
2%
388 Section II / General Surgery |
|
What are the appropriate |
Amylase/lipase |
lab tests? |
72-hour fecal fat analysis |
|
Glc tolerance test (IDDM) |
Why may amylase/lipase be |
Because of extensive pancreatic tissue |
normal in a patient with |
loss (“burned-out pancreas”) |
chronic pancreatitis? |
|
What radiographic tests |
CT—Has greatest sensitivity for gland |
should be performed? |
enlargement/atrophy, calcifications, |
|
masses, pseudocysts |
|
KUB—Calcification in the pancreas |
|
ERCP—Ductal irregularities with |
|
dilation and stenosis (Chain of Lakes), |
|
pseudocysts |
What is the medical |
Discontinuation of alcohol use—can |
treatment? |
reduce attacks, though parenchymal |
|
damage continues secondary to ductal |
|
obstruction and fibrosis |
|
Insulin for type 1 diabetes mellitus |
|
Pancreatic enzyme replacement |
|
Narcotics for pain |
What is the surgical |
Puestow—longitudinal pancreaticojejunos- |
treatment? |
tomy (pancreatic duct must be dilated) |
|
Duval—distal pancreaticojejunostomy |
|
Near-total pancreatectomy |
What is the Frey procedure? |
Longitudinal pancreaticojejunostomy with |
|
core resection of the pancreatic head |
What is the indication for |
Severe, prolonged/refractory pain |
surgical treatment of |
|
chronic pancreatitis? |
|
What are the possible |
Insulin dependent diabetes mellitus |
complications of chronic |
Steatorrhea |
pancreatitis? |
Malnutrition |
|
Biliary obstruction |
|
Splenic vein thrombosis |
|
Gastric varices |
|
Pancreatic pseudocyst/abscess |
|
Narcotic addiction |
|
Pancreatic ascites/pleural effusion |
|
Splenic artery aneurysm |
|
Chapter 55 / Pancreas 389 |
GALLSTONE PANCREATITIS |
|
|
|
What is it? |
Acute pancreatitis from a gallstone in or |
|
passing through the ampulla of Vater (the |
|
exact mechanism is unknown) |
How is the diagnosis made? |
Acute pancreatitis and cholelithiasis |
|
and/or choledocholithiasis and no other |
|
cause of pancreatitis (e.g., no history of |
|
alcohol abuse) |
What radiologic tests should |
U/S to look for gallstones |
be performed? |
CT to look at the pancreas, if symptoms |
|
are severe |
What is the treatment? |
Conservative measures and early |
|
interval cholecystectomy (laparoscopic |
|
cholecystectomy or open cholecystectomy) |
|
and intraoperative cholangiogram (IOC) 3 to |
|
5 days (after pancreatic inflammation resolves) |
Why should early interval cholecystectomy be performed on patients with gallstone pancreatitis?
What is the role of ERCP?
HEMORRHAGIC PANCREATITIS
Pancreatitis will recur in 33% of patients within 8 weeks (so always perform early interval cholecystectomy and IOC in 3 to 5 days when pancreatitis resolves)
1.Cholangitis
2.Refractory choledocholithiasis
What is it? |
Bleeding into the parenchyma and |
|
retroperitoneal structures with extensive |
|
pancreatic necrosis |
What are the signs? |
Abdominal pain, shock/ARDS, Cullen’s |
|
sign, Grey Turner’s sign, Fox’s sign |
Define the following terms: |
|
Cullen’s sign |
Bluish discoloration of the |
|
periumbilical area from retroperitoneal |
|
hemorrhage tracking around to the |
|
anterior abdominal wall through fascial |
|
planes |