Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1232_Библиотеки_им_академика_М_И_Перельмана.pdf
128
K. Lung
Palpable lymph nodes—indicative of metastatic
abdominal malignancy
• Left supraclavicular lymph node (Virchow node)
or periumbilical lymph node (Sister Mary Joseph
node)
– Laboratory Values:
Hypokalemic, hypochloremic metabolic alkalosis
Paradoxical aciduria
Prerenal acute kidney injury
Increased serum gastrin
Decreased prealbumin
– Imaging:
Plain radiography—enlarged gastric bubble, may
have paucity of small and large bowel gas
Upper GI Study—retained contrast in the stomach
with little to no passage of oral contrast into the
small bowel
Computed Tomography (CT)—gastric distention
with retained stomach contents
• Delineate mechanical causes of obstruction
– Mass lesion or wall thickening (gastric, duo-
denal, pancreatic, or other malignancy)
– Intra-abdominal adenopathy
Magnetic Resonance Imaging (MRI)—similar to
CT
Ultrasound—neonates for diagnosis of hypertrophic pyloric stenosis
– Treatment:
NPO status
Nasogastric tube placement—gastric decompression and minimize risk of aspiration for future procedures (must know proper insertion technique and
patient positioning to minimize aspiration)
Proton pump inhibitor to decrease gastric secretions: Protonix (40mg IV every 24h)
Endoscopy—biopsy important to differentiate
between benign and malignant causes
Conservative management for benign causes: treat
underlying cause of obstruction
• Endoscopic balloon dilation of strictures
• Treatment of H. pylori
• Cessation of NSAIDs
Surgical Treatment
• Describe technique to perform total vs partial gastrectomy and lymph node dissection
• Describe enteric bypass in patients not candidates
for curative resection
– Endoscopic self-expanding metal stent (SEMS)
placement for patients with poor prognosis and
short life expectancy
– Laparoscopic gastrojejunostomy may provide
better long-term outcomes for patients than
SEMS
Endoscopic ultrasound gastrojejunostomy
using lumen-apposing metal stent
• Venting gastrostomy tube and jejunal feeding tube
placement
Common Curveballs
• Malnutrition—patients undergoing surgery should be
optimized with total parenteral nutrition for at least
1week prior to surgery
• Prior history of abdominal surgery including gastric
bypass
• Patient may aspirate during nasogastric tube placement
– In case of aspiration, start antibiotics to cover for aspi-
ration pneumonia
– Airway management, consider intubation if needed
• Patient develops perforation during endoscopic
procedure
– Patient needs to be evaluated for conservative manage-
ment versus surgical repair
• Patient develops leak after surgery
– Evaluate patient for clinical stability
– Start antibiotics for coverage of intra-abdominal infec-
tion
– If stable, consider CT imaging with oral contrast or
Upper GI study to delineate site of leak
– Conservative management vs. re-operation depending
on patient condition
If patient develops intra-abdominal collection, consult IR for percutaneous drainage
• Patient still having similar symptoms after surgery despite
wide-open anastomosis
– Many patients have delay in functional recovery of
stomach
• Consider surgery for malignant obstruction or benign
obstruction refractory to medical or endoscopic
management
– Surgery is optimal choice when resection is potentially
curative
• Benign etiologies may benet from pyloroplasty or
vagotomy
Clean Kills
• Not resuscitating patient, including IV uids and electrolyte repletion
• Not knowing how to place nasogastric tube
• Not being able to describe surgical procedure
41 Gastric Outlet Obstruction
129
• Rushing to the operating room without optimization of
patient nutritional status
• Not able to manage common post-operative complications
Bonus Points
• Discussion of medical optimization prior to surgical
procedure
– Address modiable risk factors prior to surgery includ-
ing preoperative smoking cessation, optimization of
nutritional status
– Role of neoadjuvant chemotherapy and/or radiation
therapy
• Describe D1 versus D2 lymphadenectomy in gastric
surgery
– D1 dissection—total gastrectomy (stations 1–7); dis-
tal/subtotal gastrectomy (stations 1, 3, 4sb, 4d, 5, 6, 7);
proximal gastrectomy (stations 1, 2, 3a, 4sa, 4sb, 7)
– D2 dissection—total gastrectomy (D1 + stations 8a,
9p, 11p, 11d, 12a); distal/subtotal gastrectomy
(D1+8a, 9, 11p, 12a); proximal gastrectomy (N/A)
– Ongoing discussion regarding D1 vs. D2 lymph node
dissection in the Western World regarding long-term
survival benet vs. increased morbidity
Initial management includes nasogastric tube for gastric
decompression to minimize the risk for aspiration. For
patients who are considered surgical candidates, typically
patients with malignant gastric outlet obstruction for which
surgery may potentially be curative, it is important to medically optimize these patients who are likely to be chronically
and severely malnourished. Management of post- operative
complications includes clinical stabilization, work-up with
imaging, and conservative versus interventional treatment.
Often, even after proper surgical treatment, the patient will
have slow recovery of stomach function. Be prepared to be
challenged with this. Some patients require prolonged nutritional support and gastrostomy tube decompression.
Bibliography
Koop A, Palmer WC, Stancampiano F.Gastric outlet obstruction: a red
ag, potentially manageable. Cleve Clin J Med. 2019;86(5):345–53.
https://doi.org/10.3949/ccjm.86a.18035.
Papanikolaou IS, Siersema PD.Gastric outlet obstruction: current sta-
tus and future directions. Gut Liver. 2022;16(5):667–75. https://doi.
org/10.5009/gnl210327.
Potz BA, Miner TJ.Surgical palliation of gastric outlet obstruction in
advanced malignancy. World J Gastrointest Surg. 2016;8(8):545.
https://doi.org/10.4240/wjgs.v8.i8.545.
Schmidt B, Yoon SS.D1 versus D2 lymphadenectomy for gastric can-
cer. J Surg Oncol. 2012;107(3):259–64. https://doi.org/10.1002/
jso.23127.
Words ofWisdom
Management of gastric outlet obstruction requires a multidisciplinary approach. A prompt and thorough work-up is crucial to narrow down a vast differential. Accurate diagnosis of
the etiology of obstruction is key to selecting the correct treatment approach, which includes conservative medical management, endoscopic management, and surgical treatment.
Duodenal Stump Complications
SunjayS.Kumar
42
Way Question May BeAsked?
A 77-year-old male patient develops fever, tachycardia, and
abdominal pain on postoperative day 7 after a subtotal gastrectomy for gastric cancer. A CT scan reveals a uid collection with foci of air around the duodenal stump. How would
you proceed?
How toAnswer?
• Always begin by a thorough history and physical examination.
– Previous operation and reconstruction (Billroth II,
Roux-en-Y).
• The initial management of a duodenal stump stula follows
basic general surgical principles: resuscitation of the patient,
establishment of source control, and antimicrobial therapy.
Surgical Treatment
• Controlling the intraperitoneal contamination can sometimes be achieved by percutaneous means, but if the
patient is in extremis, contamination appears extensive, or
the leak is very large, reoperation is likely indicated. As
the examiners describe the patient’s condition, it should
be clear to you which route they want you to choose.
• Surgical treatment consists of closure or control of duodenal stump, debridement of any devitalized tissues, and
wide drainage.
– Closure of duodenal stumps is often not possible due
to edema and friability of tissues.
– Tube duodenostomy into duodenal stump defect and
wide drainage is the primary treatment, in that case.
– Depending on patient condition, feeding access with
jejunal extension of gastrostomy tube or direct jejunostomy tube can be considered.
• Patients with peritonitis should have rapid resuscitation
and then proceed directly to operative management.
Based on how the examiners describe the patient’s condition, you must decide whether this is a damage control
operation or not.
– If damage control strategy is used, opt for a tube duo-
denostomy and wide drainage of the area.
– Do not do any operation fancier than this and do not
place a surgical feeding tube.
• Antimicrobial coverage should be directed at the typical
intra-abdominal pathogens; you may also consider antifungal coverage.
• The most conservative option for nutritional support is nil
per os and total parenteral nutrition. If the patient was a
reoperation after a recent primary operation, you may
consider a jejunostomy tube at the time of reoperation or
a percutaneous gastrojejunostomy tube.
• Depending on how high output the stula is, the patient
may require somatostatin or octreotide and even percutaneous biliary diversion.
Common Curveballs
• The patient presents with right lower quadrant or right
ank pain from right paracolic gutter or retroperitoneal
contamination.
Clean Kills
S. S. Kumar (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: sunjay.kumar@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_42
• Failure to adequately resuscitate an elderly, sick patient
prior to operative intervention.
131
132
S. S. Kumar
• Failure to describe tube duodenostomy and wide drainage
as the primary surgical management principle.
Words ofWisdom
Duodenal stump complications are much more rarely seen
than in the era of surgical treatment of peptic ulcer disease.
They are nevertheless still occasionally seen. Therefore, they
are favorite examiner’s questions. This topic often requires
frequent review, because actual experience with the problem
may be limited for newly minted surgeons.
Bibliography
Aurello P, Sirimarco D, Magistri P, Petrucciani N, Berardi G, Amato S,
Gasparrini M, D’Angelo F, Nigri G, Ramacciato G.Management of
duodenal stump stula after gastrectomy for gastric cancer: systematic review. World J Gastroenterol. 2015;21(24):7571–6. https://doi.
org/10.3748/wjg.v21.i24.7571.
Babu BI, Finch JG. Current status in the multidisciplinary manage-
ment of duodenal stula. Surgeon. 2013;11(3):158–64. https://doi.
org/10.1016/j.surge.2012.12.006.
Cholecystoduodenal Fistula
AllisonDoermann
43
Way Question May BeAsked?
A 74-year-old female with diabetes mellitus, hypertension,
and no surgical history is seen in the emergency department
with bowel obstruction symptoms. Obstruction series conrms the small bowel obstruction with air in the biliary tree.
What do you want to do?
The examinee may be given an X-ray with stone in the
RLQ or air in the biliary tree.
A 47-year-old male with no signicant past medical his-
tory presents with fevers and right upper quadrant abdominal pain. Abdominal ultrasound demonstrates air in the
gallbladder lumen, cholelithiasis, and pneumobilia. What
are the next steps in management?
May be given X-ray with stone in the RLQ or air in the
biliary tree.
Alternatively, examiners may present a scenario in which
the diagnosis of cholecystoduodenal stula is made intraoperatively during routine cholecystectomy for symptomatic
cholelithiasis.
How toAnswer?
• Obtain history, physical exam, and vital signs.
– Obtain history of any medical conditions, biliary colic
or gallstones, and malignancy history if any.
– Make sure to check for any hernias or surgical scars on
exam for the patient who presents with obstruction.
• Adequate resuscitation with IV uids and antibiotics if
the patient has signs of cholecystitis/cholangitis.
• Obtain a full set of labs including liver function tests.
• Obtain abdominal ultrasound if not already obtained.
• Get an obstruction series on an obstructed patient.
A. Doermann (*)
Department of Surgery, Thomas Jefferson University Hospitals,
Philadelphia, PA, USA
e-mail: Allison.Doermann@jefferson.edu
• CT scan is not necessary but may demonstrate cholecystoduodenal stula.
Surgical Treatment
• Before surgery, ensure the patient is adequately resuscitated with intravenous uids.
• Nasogastric tube should be placed if the patient is
obstructed.
• Antibiotics are started if the patient has cholecystitis or
cholangitis.
• This procedure (in the absence of obstruction) may be
performed with minimally invasive techniques.
• First check the status of the right upper quadrant (extensive scarring prevents denitive procedure).
• Treatment typically involves cholecystectomy, resection
of the stula, and closure of the duodenum.
• Duodenal closure can be accomplished with primary closure in two layers, Graham patch, or GIA stapler.
• In some cases, Billroth II reconstruction may be
necessary.
• Cholangiogram should also be performed to look for
other stones.
• If a patient presents with gallstone ileus, only enterolithotomy with removal of stone should be performed.
– Patients will require full laparotomy (be able to
describe).
– A longitudinal enterotomy should be performed along
the antimesenteric border a few centimeters proximal
to the stone.
– Stone should be “milked” back to enterotomy and
removed.
– Bowel should be run to look for additional stones.
– Only select healthy patients with few medical comor-
bidities should be considered for one stage procedure
with cholecystectomy and closure of stula at time of
surgery for obstruction.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_43
133
134
A. Doermann
• If stula identied during routine cholecystectomy for
symptomatic cholelithiasis—keep in mind what patient
was consented for and abide by the patient’s wishes.
• Denitive surgical treatment of the stula may need to be
delayed in order to obtain informed consent if there is the
possibility of repair of full thickness or serosal injury of
small bowel, Graham patch, or Billroth II reconstruction
were not discussed prior to the operation.
Common Curveballs
• The patient will have a history of malignancy.
• The patient will have an associated intra-abdominal
process.
• The patient will have severe scarring in the right upper
quadrant precluding denitive procedure.
• The patient will have bowel obstruction post-operatively
(missed a second stone).
• The patient will be septic/unstable.
• The gallstone will have eroded through hepatic exure of
colon rather than duodenum, and examiners will be asked
how to close the stula.
• The gallbladder will be cancerous that led to the
perforation.
• The patient will develop cholangitis or intra-abdominal
abscess post-operatively (changing scenario).
• Not getting obstruction series but skipping to CT scan if
patient presenting as obstruction.
• Not checking for prior surgeries.
• Not recognizing the problem.
• Not “milking” back the stone for gallstone ileus.
• Performing takedown of stula in unstable patients.
Bonus Points
• Cholecystoduodenal stula represents the most common
type of cholecystoenteric stula, representing 75–80%.
• The anatomical types of internal biliary stulas are cholecystoduodenal, cholecystoenteric, cholecystogastric, cholecystocholedochal, and cholecystoduodenocolic. It
represents 54–76% of all types of internal stulas.
Words ofWisdom
This is another oral board exam topic that is frequently given
but rarely seen in clinical practice. Such topics require extra
review to understand the management principles, since most
examinees do not have real-world experience to draw upon.
Bibliography
Post-operatively, the patient will have a biliary leak
(changing scenario).
Clean Kills
• Not checking for hernias.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=1000449.
Senthil Kumar P, Harikrishnan S. Cholecystoduodenal stula: a case
series of an unusual complication of gallstone diseases. Cureus.
2022;14(11):e31651. https://doi.org/10.7759/cureus.31651.
Townsend CM. Ch. 55: Biliary system; Benign biliary disease,
Calculous biliary disease. In: Sabiston textbook of surgery: the biological basis of modern surgical practice. 21st ed. Elsevier; 2021.
Abdominal Aortic Aneurysms
MadisonCrutcher
44
Way Question May BeAsked
A 67-year-old man presents to the clinic after a 4cm aortic
aneurysm was found incidentally on a CT scan after a fall.
How toAnswer
Full History
• Any symptoms of pain (abdomen, back, ank, groin)
• History of smoking
• History of other vascular disease (coronary artery disease,
peripheral vascular disease, carotid artery stenosis) or
symptoms (e.g., angina, claudication, transient ischemic
attack, amaurosis fugax)
• History of COPD
• History of hypertension
Full Physical Exam
• Pulsatile epigastric/periumbilical mass
• Tenderness over aneurysm
• Check for other aneurysms (e.g., popliteal fossa)
• Vascular/pulse exam
Diagnosis, Screening, and Surveillance of AAA
• Ultrasound: Reliable to conrm presence of AAA and
measure diameter; tends to overestimate the diameter by
~20%; used for initial screening and surveillance.
• Men with any history of smoking and aged 65–75years
old should get ultrasound screening for AAA, even if
asymptomatic.
• Computed tomography (CT) scan: more accurate in
depicting aneurysm size; more accurate conrming juxtaor suprarenal extent of aneurysm.
• One-time screening with ultrasound for AAA in men
65–75years of age who have ever smoked.
• Ultrasound surveillance:
– Less than 3cm—no further testing.
– 3–4cm—every 12months.
– 4–4.5cm—every 6months.
Indications for Repair
• Diameter of 5.5cm in men, 5cm in women
• Rapid rate of growth (>0.5cm in 6months)
• Symptomatic (abdominal or back pain)
• Signs of embolization
• Rupture
• Acute aneurysmal thrombus
Risk Factors for Rupture
• Chronic obstructive pulmonary disease (COPD)
• Hypertension
• Rapid increase in aneurysm size
• Absolute aneurysm size
Way Question May BeAsked
This 62-year-old man re-presents to the emergency department. He is now hypotensive with increasing abdominal
pain. CT shows AAA measuring 6cm.
How toAnswer
• Full history and physical exam as above
• Bedside abdominal ultrasound
• Permissive hypotension, tolerate systolic blood pressure
between 50 and 100; control double product (pulse and
blood pressure)
• Consider initiation of massive transfusion protocol so
blood product are immediately available
• Obtain rapid CT angiography
M. Crutcher (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_44
135
136
M. Crutcher
Open Repair
• Indications for open repair
• Short, extremely angled, heavily calcied, thrombus lled
infrarenal aortic neck
• Severe iliac disease
• Patient preference (can defer surveillance after EVAR)
• Steps
• Induction of anesthesia after patient is prepped and draped
– Prepped and draped from xiphoid to knees
– Midline incision from xiphoid to pubis
– Pack small bowel and transverse colon out of the way
with moist laps
– Ligament of Treitz divided and duodenum mobilized
to the right
– Dissection over the aorta with identication of the
inferior mesenteric artery
– Tricks for better suprarenal exposure:
Division of the lesser omentum and gastrohepatic
ligament
Medial visceral rotation
– Proximal control
Aortic neck encircled with tape as close to renal
artery origin as possible
If ruptured:
• Open gastrohepatic omentum and enter thru the
lesser sac
• Retract stomach and esophagus to left
• Clamp aorta as it exits the crura of the diaphragm
(may need to divide left crura)
• Allow anesthesia to catch up and begin blood
transfusions
• Replace the vascular clamp at the infrarenal
neck, if possible, once the patient stabilizes
– Distal control
Encircle common iliacs with vascular tape as distally as possible
If one iliac artery is or both arteries are too calcied
for clamping, attain individual control of the external and internal iliac arteries
Place distal clamps prior to proximal to prevent
embolization
– Heparinize (100mg/kg) 3min before cross clamping
– Aneurysm sac is opened and back-bleeding lumbar
vessels oversewn
– Aneurysm replaced with a Dacron graft in end-to-end
fashion
– Aneurysm sac closed over graft
– Peripheral pulses checked, protamine given, abdomen
closed
Inferior Mesenteric Artery (IMA)
• If it is chronically occluded, it may be ligated (already fed
by collaterals)
• If it has signicant back bleeding, it may be ligated (adequate collateral circulation)
• If it has sluggish ow, reimplantation should be considered (inadequate collateral circulation)
• If the patient had a prior colectomy, IMA may need reimplantation (loss of collateral ow)
Endovascular Repair
• CTA to evaluate preoperative anatomy
• Bilateral open or femoral percutaneous access with
micropuncture set
• Perform an aortogram
• Position the endograft below the lowest renal artery
• Deploy main body
• Cannulate the contralateral gate
• Deploy contralateral iliac limb
• Deploy remainder of the main body
• Balloon junctions of the graft
• Perform completion angiogram to assess for endoleaks
• Femoral access closure
Ruptured Patients
• Permissive hypotension with systolic blood pressure
between 50 and 100
• Induction of anesthesia after patient is prepped and draped
• Aortic occlusion balloon if rapid deterioration
Way Question May BeAsked
Your patient presents to the emergency department several
years after AAA repair with hematemesis.
Aortoenteric Fistula
• Rare complication
• Presents with herald upper or lower gastrointestinal
bleed—this is typically a bleed from smaller vessels in the
intestine wall, not from the aorta itself
• Should be considered in patients with past surgical history of EVAR or open aortic graft
• Imaging
– Evidence of inammation or bleeding into the bowel
on CT scan
– Direct visualization of graft material on upper
endoscopy
• Procedure
– Proximal and distal control (similar to open aorta)
– Removal of entire affected graft
– Wide debridement of affected tissues
– Irrigation with antibiotic solution
– Reestablishment of arterial ow (in situ or
extra-anatomic)
Dacron soaked in rifampin
Silver impregnated
Cryopreserved allograft
– Coverage with omentum or surrounding tissue
– Long-term intravenous antibiotics
44 Abdominal Aortic Aneurysms
137
Common Curveballs
• Incidental intra-abdominal pathology: do not perform
concurrent colectomy or cholecystectomy
• Bowel injury: repair enterotomy, irrigation, consider
antibiotics
• Ureteral injury: methylene blue administration can help
identify injury, intraoperative urology consultation
• Post operative colonic ischemia: exible sigmoidoscopy
to evaluate, if transmural ischemia or sepsis is present, the
involved colon should be resected (Hartmann’s
procedure)
Clean Kills
• Missing the diagnosis
• Not taking patient to surgery for appropriate surgical
candidate
Summary
In asymptomatic patients, abdominal aortic aneurysms
(AAA) are typically found on astute physical exams, incidentally on abdominal imaging done for other reasons, or
through screening tests. Risk factors for AAA include a
history of smoking and some connective tissues diseases.
Surgeons should have basic knowledge of screening regimens and indication for elective repair. Risks for AAA
rupture include hypertension and COPD.Ruptured AAA
patients often present dramatically with sudden onset of
abdominal back, ank, or groin pain and hypotension. A
high index of suspicion, appropriate bedside or rapid
imaging modalities, and prompt surgical intervention are
necessary for successful rescue of such patients.
Bibliography
Ferranti K.Abdominal and aortoiliac aneurysm. 2023. https://www.sur-
gicalcore.org/modulecontent.aspx?id=1000548.
Perler BA.Open repair of abdominal aortic aneurysms. In: Cameron
JL, Cameron AM, editors. Current surgical therapy. 13th ed.
Philadelphia, PA: Elsevier; 2019. p.901–4.
Prushik SG, Cambria RP. Endovascular treatment of abdominal aortic
aneurysms. In: Cameron JL, Cameron AM, editors. Current surgical
therapy. 13th ed. Philadelphia, PA: Elsevier; 2019. p.905–10.
Schaub TA, Upchurch GR. Abdominal aortic aneurysm. American
Family Physicians; 2006. p.1198–204.
Smeds MR, Nukala M.Management of infected grafts. In: Cameron
JL, Cameron AM, editors. Current surgical therapy. 13th ed.
Philadelphia, PA: Elsevier; 2019. p.1022–8.
Part V
Stomach