RIKERS REVIEW:2003

A CONCISE, CLEAR AND ACCURATE

REVIEW OF GENERAL SURGERY
INFORMATION AND FACTS IN
PREPARATION FOR THE AMERICAN
BOARD OF SURGERY IN TRAINING EXAM
(ABSITE)

Adam I. Riker M.D.

2003

RIKERS REVIEW: 2003

Adam Riker M.D.
Assistant Professor of Surgery
Department of Interdisciplinary Oncology
Multidisciplinary Breast Cancer Program
Multidisciplinary Cutaneous Oncology Program
H. Lee Moffitt Cancer Center & Research Institute
12902 Magnolia Drive, Tampa, Florida 33612
2003, by the author. This review is copyrighted; that means do not copy it in any way
without the expressed written consent of the author. Please respect this copyright and the
time and effort that has gone into this concise, fact-oriented review of general surgery for
the ABSITE. Much effort has been put forth to assure that the contained information is
accurate. However, general surgery is a rapidly changing field and thus one should
always confirm this information with a current general surgery textbook.
This review is a result of 8 years of training and is the accumulation of data and facts
obtained from studying for and taking sequential ABSITE exams and oral exams. I am
confident that this review will be helpful for improving your score on the ABSITE. Do
not look at this review the day prior to the exam, you will only do yourself a disservice.
Instead, slowly read it over the month prior, looking up those areas that do not make
sense to you, or seem confusing. Finally, it must be said that this review is in no way a
substitution for what every resident should already be doing. Preparing for the ABSITE is
a year long process, with the best way to do well is by constantly trying to read up on
general surgery topics, attending conferences and journal clubs, going over the anatomy
for your cases the next day and keeping updated on the most recent developments in
general surgery.
I welcome any helpful input, comments or questions about this review. Please feel free to
contact me via e- mail me at rikerai@moffitt.usf.edu, good luck on the exam.

Table of Contents
Topic

Pages

Breast
Orthopedics
Renal, Adrenal, Pituitary
Spleen
Thoracic/Mediastinum/CV
Head and Neck
Skin/Melanoma/Sarcoma
Transplant
Pancreas
Hand
Burns
Vascular
Esophagus
Stomach
Small+Large Bowel/Rectum
GU/OB/Gyn-Onc/Neurosurg.
Coagulation
Infections/Critical Care/Trauma/ICU/FEN
Parathyroid/Thyroid
Hepatobiliary
Pediatric Surgery
Anesthesia
Miscellaneous

4-7
7-8
8-9
9
9-12
12-13
13-14
15
15-16
17
18
18-20
20-22
22-23
23-25
25-26
27
27-30
30-31
31-32
32-33
33-34
34-36

BREAST

Intraductal papilloma: the most common cause of bloody nipple discharge;

treatment is with excision of the involved lactiferous duct only; remember, all
kinds of stuff causes nipple discharge (Tricyclics, cimetidine, HRT,
phenothiazines, thiazide diuretics, metoclopramide, reserpine); pathologic nipple
discharge, particularly bloody, is almost uniformly benign (10% of all patients
with any type of nipple discharge have cancer); more worrisome if unilateral;
Thoracodorsal nn.>>>>latissimus dorsi, if cut>>>>weak arm adduction at
shoulder; Long thoracic nn.>>>serratus anterior, if cut>>>winging of the
scapula; medial pectoral nn. >>>both major and minor; lateral pect. nn. to pec.
minor only; Batsons plexus of vertebral veins are valveless and therefore breast
cancer cells gain access directly to the spine>>>spine mets.
GAIL model: of risk assessment over a 5-yr period for invasive breast cancer;
age, race, age at menarche, age at 1st birth, h/o DCIS or LCIS, bx. with atypia, +
family history; magic # is 1.66%
Lumpectomy + axillary node dissection + XRT to the breast is equivalent to
MRM in terms of survival
Axillary nodal dissection: level I=lateral to pectoralis minor, level II=posterior
to pectoralis minor, level III=medial to pectoralis minor
Contraindications to BCT: Multicentric disease, bad cosmetic result (large
lesion in a small breast), large primary, usually >4cm, lack of access to XRT, EIC
Medullary cancer: has a favorable prognosis and tumor biology despite its often
very large appearance at initial presentation
Pagets disease: Most often associated with an underlying infiltrating ductal or
intraductal cancer; The first presentation is often eczema and itching of the nipple
areolar complex with some superficial erosions or ulcerations; Patients will have
tried steroid creams without improvement; Frequently no palpable abnormality;
Diagnose by punch biopsy; Early diagnosis>>early treatment (if there is an
associated palpable lesion or (+) MMG>>mastectomy only; if there is no palpable
lesion and (-) MMG, then BCT may be considered with complete resection of the
nipple areolar complex + XRT)>>>excellent prognosis; ALND only if there is an
invasive component to the cancer
Mondors disease: Will almost always be presented with a pt. with a palpable
cord (superficial) leading to the axilla and they will ask you what to do; This is
superficial thrombophlebitis of the veins; completely benign and treated with
NSAIDS
Mastodynia: Treat with Danazol, OCPs, primrose oil?; tamoxifen and Vitamin
E has been shown to not be useful
Cystosarcoma Phyllodes: Treat with WLE only with adequate (4 cm if possible)
margins; no need to do nodal dissection; spread is like sarcoma via
hematogenously
Giant fibroadenoma: seen primarily in adolescents, <16 y/o, as a solitary, firm,
NT large mass, > 5cm usually, asymmetric and prominent veins; This is
completely benign and treated with enucleation only (do not do a MRM)

In a patient who has undergone neoadjuvant chemo., even though the tumor may
disappear, you should realize that there is a 90% chance of residual tumo r there
which must be treated with surgery
Stewart -Treves: lymphangiosarcoma in a pt. who previously underwent a MRM
about 10-15 years ago. Pt. develops a purple mass on the arm
Angiosarcoma of the breast: pts. usually 10-15 years younger than typical IDC;
lymph node spread is rare, spreads hematogenously, tx. with simple mastectomy
without LND; ? benefit of XRT, chemo. no benefit
DCIS: age 54-58, 2% incidence, can have pain, a mass or nipple discharge,
microcalcifications are present in vast majority, 1/3 premenopausal, 18%
incidence of synchronous invasive carcinoma, 40-80% mutlicentric, 10-20%
bilateral, 2% axillary mets., 25-70% incidence of a subsequent cancer (ipsilateral)
with an interval of 5-10 years; if it comes back, it will most likely be an
infiltrating ductal carcinoma; the greatest risk for recurrence is size > 2.5cm and
comedo necrosis; Treat with salvage mastectomy.
DCIS: 4 subtypes: papillary (best prognosis), cribriform, solid, and comedo
(worst prognosis); Comedo assoc. with poor prognostic indicators: overexpression
of HER-2/neu, ER/PR (-) receptor, high thimidine index, p21 ras oncogene
expression, aneuploidy and high S-phase fraction
DCIS: local recurrence following a lumpectomy alone is 17%; if you give XRT
to the breast after lumpectomy, this decreases the local recurrence rate to 7%.
There is absolutely no difference in overall survival. XRT only helps decrease
local recurrence rate.
Comedo DCIS represents a high grade, aggressive, poor prognosis type of DCIS;
It is only for this form of DCIS would you probably perform a SLNB with
lumpectomy and XRT
The most common genetic abnormality in breast cancer is a mutation in the tumor
suppressor gene p53 (seen in 30-40% of all breast cancers)
Locally advanced cancer seen in patients with primary tumors > 5cm (T3
lesion), fixed or matted axillary nodes (N2 disease), primary tumor fixed to the
chest wall (T4 lesion) and inflammatory breast cancer. For any of the above, give
neoadjuvant chemo. prior to any surgery. Remember, even if the patient has a
great response to neoadjuvant chemo., you must assume there will be residual
microscopic disease at the primary site (in over 90% of cases), therefore, you
need to operate after neoadjuvant chemo, most likely with MRM.
In a pt. with a low risk of tumor recurrence (T1N0MX) and ER+, the addition
of chemo. (CMF) adds no improvement in survival compared to tamoxifen alone
Trials with adjuvant chemo. do not demonstrate any comparable reduction in
cancer in the opposite breast (as tamoxifen does)
LCIS: It is not a premalignant condition; it is a marker for the development of a
subsequent cancer; there are no clinical signs, seen on pathology specimen for
some other breast surgery, there are no microcalcifications, 1% incidence of
axillary mets., 70-80% bilaterality, incidence of a subsequent infiltrating ductal
cancer developing is 20-35%, in either breast at a 15-20 year interval from the
time of diagnosis; There are only 3 treatment options for all patients: bilateral

simple mastectomies, close follow-up with yearly MMGs, and tamoxifen. There
is no confusion on this.
Inflammatory breast cancer: Patient presents with an inflamed, tender breast,
often near and/or involving the nipple areolar complex with enlargement of the
entire breast; they will have been previously treated with ABX. for a suspected
breast abscess or mastitis which doesnt get better. Do a punch biopsy for
diagnosis; cancer cells penetrate and involve the dermal lymphatics; treat with
neoadjuvant
chemo.>>>>mastectomy>>>>XRT>>>>consolidation
chemo.
Associated with a 50% 5-yr survival
Tamoxifen: It is a SERM (selective estrogen receptor modifier); It binds to the
estrogen receptor on cancer cells and prevents any estrogen from binding to it.
Remember, it is an anti-estrogen for breast tissue, but acts as an estrogen for other
tissues like endometrium, bone and liver. Thus, this is why tamoxifen causes a
slight increase in the risk of developing endometrial cancer (and DVTs and
PEs). It is effective in ER/PR + pre- and post- menopausal women as an adjuvant
endocrine therapy at 20 mg/day; 5 years duration (no improvement if given for 10
years). NSABP P1/24: high risk women (GAIL>1.66%, >60y/o, LCIS) have a
49% reduction in risk for the development of invasive breast cancer in the
ipsilateral and contralateral breast; increased survival in stage I,II pts. NSABP-24:
DCIS>>>lumpectomy and XRT>>>randomized to placebo vs. tamoxifen;
tamoxifen associated with a decrease in all breast cancer events (invasive ipsi.
cancer 3.4% in placebo vs. 2% in tamofien group, with similar decrease in noninvasive cancer)
CIs to SLNB are: multifocal disease, palpable axillary adenopathy, primary
tumor >5 cm, locally advanced cancer, pt. who received neoadjuvant chemo.
In patients with negative LNs, tumor size is the most important prognostic factor
for relapse; <1cm>>>>90% 10- yr. Survival; >1cm>>>25-44% of stage I,II
patients will develop recurrent disease, therefore, adjuvant chemo. is indicated in
these patients with either AC (adria/cycloph) or CMF (cyclo/methotr/FU)
BRCA 1, BRCA 2: About a 60-80% lifetime risk of developing breast cancer if
mutation is present (general population is 12%); BRCA1 (chrom.#17) is also
associated with ovarian cancer and prostate cancer; higher occurrence of
medullary cancer; BRCA2 (chrom# 13) is associated with male breast cancer;
higher occurrence of tubular- lobular invasive cancer
Li-Fraumeni Syndrome: AD/ SBLA (Sarcoma, Breast, Leukemia,
Adrenocortical Cancer); Breast cancer is the most common cancer associated with
LFS, but overall accounts for <1% of all breast cancers; caused by germline
mutation in the TP53 tumor suppressor gene>>>protein product is p53.
For patients s/p lump/breast irrad./ALND>>>>would give axillary radiation to
patients with high risk features: >5 (+) nodes, bulky nodes >2cm, extranodal
extension of tumor
Radiation mastitis: Occurs most commonly after XRT and doxorubicin; Tx. of
choice is pentoxifylline
Lobular carcinoma of the breast: uniform cells seen in a single file (Indian
filing)

BIRADS classification: 0=incomplete, 1=negative, normal, 2=benign finding,

3=prob. benign finding, risk of malig. ~1-2%, 4=suspicious abnormality, bx. is
recommended (really required), 5=highly suggestive of malignancy, high prob. of
cancer, bx. Required
Triple test for palpa ble abnormalities: based on physical exam, MMG and
FNA>>>NPV=100%, PPV=75%
In general, adjuvant chemo. (usually CMF) is used in all breast cancer patients
who are premenopausal with a primary tumor >1cm, +/- tamoxifen if ER/
Any pt. with a very strong family history of breast cancer should have their 1st
screening MMG 10 years before the earliest age of cancer onset in family
member; Otherwise, without any history, current recommendations are 1st MMG
at age 40
ORTHOPEDICS

Salter-Harris Fractures: In general, a grade III, IV or V fracture are

intraarticular and general need open reduction and fixation
A Volkmanns contracture often will occur with a supracondylar humerus
fracture which results in a compromised anterior interosseous artery; This
results in a deep forearm flexor compartment syndrome with a need for
fasciotomies; The first sign will often be pain in the forearm with
extension>>>median nerve injury; paralysis and paresthesias are late findings; tx:
4 compartment fasciotomies (lateral and medial)
The earliest and most reliable sign of anterior tibial compartment syndrome is
referred pain to the anterior compartment on passive plantar flexion of the toes
and ankle
Monteggia fracture : Proximal ulnar fracture with a radial head dislocation
Galeazzi fracture : fracture of the distal radial shaft with dislocation of the distal
ulna
Colles fracture : Always pt. who falls on the outstretched hand; fracture of the
distal radial metaphysis with fx. of carpal scaphoid bone; pain over snuffbox
Nursemaids elbow: Always presented with a young child whos mother yanks
and pulls on the outstretched arm, causing a dislocation at elbow; tx. with
pronation of arm
Chance fracture : Always presented with a restrained pt. in a high speed car
wreck with rapid deceleration; This is a 3rd lumbar vertebral fx. which causes a
small bowel injury (perforation) and/or mesenteric injury (tearing of vessels); If
presented with this>>>EXLAP.
Shoulder dislocation: 90% are anterior with greatest risk to the axillary nerve;
exception seen with seizures and electrocution causing a posterior injury
Ewings sarcoma : Usually <20 yoa/ associated F/C/N/V/malaise/anemia and
increased ESR/ onion skin appearance on XRAY (elevation of periosteum)
Osteogenic sarcoma : Usually <20 yoa/ enlarged painful mass/ sunburst
appearance on XRAY/ no symptoms like Ewings; tx: preop. Chemo.
1st >>>surgery>>>XRT

Slipped capital femoral epiphysis : Always presented with a 10-15 y/o fat child
(male or female) c/o knee pain after after a fall; this is referred pain from the hip;
tx. with immobilization until stable
Torn Achilles: always presented with an athlete (tennis player serving) who after
feels a sudden severe pain in the calf after jumping
Femoral shaft fracture is treated within 24 hours with IM rod fixation; In
children, these are always treated conservatively with traction
Open femoral fractures: operative debridement within 8 hours>>>repeat within
24-48 hours>>>empiric ABX>>>never close these primarily, wait 5-7 days for
secondary closure
RENAL, ADRENAL, PITUITARY

JG cells, decreased Na, hyperkalemia and decreased BP in afferent

arterioles>>>>increased renin production by the macula densa>>>>conversion of
angiotensinogen to angiotensin I>>>>angiotensin converting enzyme in the lung
converts>>>>angiotensin I to AG II>>>>AG II causes a potent vasoconstriction
and an increase in aldosterone (RE: both can be in response to hemorrhage and
hypotension)
Adrenal incidentaloma: All non- functioning tumors greater than 6 cm. should
be resected as the risk of adrenocortical carcinoma increases. Do not forget to R/O
a pheochromocytoma prior to any surgery, do so by sending 24 hour urine
catechols and metanephrines.
Acute Adrenal Crisis: This is adrenocortical insufficiency; Classic signs are
hypotension/hypoglycemia/hyperkalemia(+/- N/V/ anorexia/ lethargy/ confusion)
/ bronzing of the skin; tx. with hydrocortisone, saline and glucose
The best screening test for an extra-adrenal pheo is a 24 hour urine catechols
and metanephrines; Can localize the mass with an I(131) MIBG scan (better than
MRI or CT)
PNMT is made only in the adrenal medulla; it converts NE>>>EPI; therefore,
you can differentiate b/t an adrenal pheo. vs. an extra-adrenal pheo. by the ratio of
NE:EPI; Adrenal pheo>>>high EPI, low NE; extra-adrenal pheo>>>low EPI and
high NE
Cushings syndrome: prolonged exposure to excessive cortisol; most common
cause is exogenous synthetic steroids; Cushings disease specifically refers to
chronic hypersecretion of ACTH>>>adrenal cortex with >90% caused by a
pituitary adenoma; can treat with cyproheptadine which blocks the release of
CRH from the hypothalamus, causing regression in 30-50% of patients with
Cushings disease
Cushings syndrome: dx. by 24 hour free cortisol markedly elevated; to
determine where the problem is, check plasma ACTH levels; if from adrenals,
plasma ACTH is undetectable; if from pituitary or ectopic source, plasma ACTH
is normal to elevated
High dose dexamethasone test: results in suppression of ACTH levels in
patients with a pituitary source, no suppression with ectopic producing ACTH
tumor or adrenal source
8

Bromocriptine : is a dopamine agonist and inhibitor of prolactin secretion and is

used to treat patients with prolactinomas (with over 70% response rate)
Primary hyperaldosteronism: Increased serum aldosterone/low plasma renin
activity/HTN/hypokalemia/weakness/polyuria/plasma aldosterone:renin ratio >20
is diagnostic; usually due to a single adrenal adenoma
Secondary hyperaldosteronism: high PRA, treat medically, no surgery
Chronic
renal
insufficiency/failure
(CRF):
The kidneys dont
work>>>phosphate retention>>>hyperphosphatemia; decreased hydroxylation of
Vit.D and decreased active Vit.D3>>>decreased Ca absorption by the
gut>>>increases
PTH
production>>>vicious
cycle
of
secondary
HPTH>>>osteomalacia, osteitis fibrosa cystica, ectopic calcifications (Calcium
binds to excess PO4); tx: dialysis with low phosphate bath, bisphosphonates
(etidronate and pamidronate) to bind PO4 and stabilize the bone matrix
SPLEEN

ITP: circulating IgG antibodies to platelets causing their destruction; The spleen
is the source of these antibodies; F:M 3:1; Acute ITP occurs in kids <16 yoa and
over 80% recover without specific therapy (dont wack out their spleen);
However, if they dont improve and in the adult, try 2 months of steroids 1st ; if no
response>>splenectomy; if the patient responds to steroids but recurs
later>>>splenectomy; Dont forget to give pneumovax. For kids, prophylactic
PCN until adolescence (age 12 to 16 y/o).
Hypersplenism: Is a syndrome of splenomegaly and pancytopenia with a normal
BM; peripheral blood smear normalizes after splenectomy
Splenic vein thrombosis: Most commonly seen secondary to pancreatitis and
presents often as an UGI bleed +/- splenomegaly, abd. pain and chronic anemia;
EGD reve als gastric varices; TX: splenectomy
Splenectomy is of benefit for patients with portal HTN when pt. has gastric
varices (only instance)
TTP: hemolytic anemia/decreased platelets/neuro symptoms/ fever/renal
dysfunction (all seen in only 40%); F:M 2:1; poor prognosis, especially during the
1st attack; Initial tx: exchange plasmapheresis + plasma infusions; no benefit for
splenectomy
Sickle cell disease: sequelae include atrophy, infarction, splenomegaly (early)
with later atrophy; no rupture
A patient with splenosis will not have Howell-Jolly bodies on a peripheral blood
smear (splenic remnants removes them from the circulation)
Hereditary spherocytosis : deficiency of spectrin; splenomegaly; AD; dx. by
osmotic fragility test; tx; curable with splenectomy
THORACIC/ MEDIASTINUM / CV

3 Ts of the anterior mediastinum: teratoma/thymoma/thyroid(substernal)

Most thymomas (50-60%) are associated with myasthenia gravis (MG), with
only 10-30% of MG patients having a thymoma
9

Chondrosarcoma: most common primary chest wall tumor/slow growing/

painful/ M>F/ usually involves 1st 4 ribs arising from the anterior cartilage/ en
bloc resection with good 4-5 cm margin if possible
MG assoc. with proximal mm weakness/generalized weakness/ptosis; it is a
deficiency of the Ach receptors due to Abs bound to them;treat with
acetylcholinesterase inhibitors (tensilon); Any patient with MG and symptoms
should have a thymectomy because almost all improve after surgery
Thymoma: most common anterior mediastinal tumor (neurogenic tumors arise in
the posterior mediastinum); All thymomas should be resected; of all patients with
thymomas, 50% will have MG; only 10-15% of pts. with MG have thymoma;
Treat prior to surgery with plasmapheresis and stop tensilon to decrease pulm.
secretions and prevent inadvert. cholinerg. weakness; Almost all are retrievable
through a standard collar incision; rarely a partial superior median sternotomy is
necessary; If malignant (as determined by clinical behavior and not type), treat
with post-op. XRT (it decreases local recurrence and increases survival)
Pulmonary sequestration: Extralobar sequestrations: Left sided/have their
own pleura/ >50% assoc. with other congenital anomalies, especially CDH; blood
supply usually directly from the aorta with venous drainage via azygous and
hemi-azygous; Intralobar: no separate pleura, has a bronchial connection, L
sided more common, artery from aorta in 70% of cases and runs within the
inferior pulmonary ligament; venous drainage is into the pulmonary veins; tx:
resection
FRC=ERV+RV; VC=IRV+TV+ERV; TLC=IC+FRC or VC+RV
Thoracic outlet syndrome rarely involves the artery or veins and over 90%
present with neurological deficits, many involving the ulnar nerve
first>>paresthesias
SVC syndrome: 90% are due to a lung cancer, usually bronchogenic carcinoma;
primary collateral around the SVC is the azygous vein to the IVC below the
diaphragm; S/S: headache, SOB, confusion, dizziness, venous distention, facial
edema, plethora, hoarseness, dyspnea; Treatment in most cases of symptomatic
SVC syndrome is with XRT first. However, standard treatment (non-emergent) is
with diuretics, fluid restriction, +/- steroids, (+XRT +chemo for advanced cases)
Pre-thoracotomy PFTs: If you are going to do a lobectomy, you need a minimal
FEV1 of 800ml; fo r a pneumonectomy>2L; for a wedge resection >600ml; an
FEV1 of <500ml/sec is prohibitive as well as a pt. with COPD with CO2 retention
(resting PCO2 of >45); post-op. FEV1 should be at least >0.8L-1.0L
IIIB lesions are unresectable (T4 lesions are into the mediastinum, great vessels,
esophagus, trachea, vertebrae, and effusions; N3 nodes are also unresectable into
the contralateral chest, inot the scalene mm and/or subclavian region
Small cell lung cancer is treated with chemo., not surgery; extra-pulmonary
manifestations are Cushings syndrome (ACTH secretion from tumor) and
polymyositis and MG-like syndrome, increased ADH (hyponatremia); squamous
cell>>>PTH- like substance>>hypercalcemia; non-small cell (ie:
adenocarcinoma)>>>hypertrophic osteoarthropathy (clubbing)
Some IIIA tumors (non-small cell,+ipsi. nodes) are tx. with neoadjuvant chemo
and XRT followed by surgical resection
10

Tetrology of Fallot is the most common cyanotic lesion in children <2yoa;

transposition of the great vessels is the most common cause of cyanosis and
heart failure in the newborn
Pancoast tumor: Almost always will involve the sympathetic chain early on
causing the classic Horners syndrome; ulnar nerve can also be involved
Hamartoma of the lung: most common benign tumor of the lung/ presents as a
solitary pulmonary nodule/ mostly composed of cartilage/ slow growing/ contains
popcorn calcifications/ CT-guided FNAB often diagnostic
Only 5% of coin lesions are malignant (solitary pulmonary nodule): most are
granulomas; However, in a pt.>80 y/o a coin lesion is associated with a cancer in
nearly 100% of the cases, for pt.<50 y/o>>>50% chance; Always ask to look at
old CXRs to see if nodule has changed or stayed the same
Non-small cell cancer with a (+) supraclavicular node is a stage IIIB and is not
respectable, treat with XRT and chemo. (N1: peribronchial or ipsi. hilar / N2: ipsi.
mediastinal and subcarinal / N3: any contralateral nodes); All T4 lesions (malig.
pleural effusion or invasion of adjacent structures) are at least a IIIB stage; stage I
and II tumors are treated primarily with resection and lobectomy (dont wedge)
Stanford Classification of Aortic Dissection: A= ascending (Debakey I,II)
dissection and all should be surgically repaired; B=descending (Debakey III) and
medical treatment for most, rare to operate
Left to right shunt: pulmonary HTN secondary to excessive pulmonary blood
flow>>>arteriolar thickening; seen with VSD, ASD, AV canal, TAPVR, Truncus
arteriosus, do not get with pulmonic stenosis; main complication of a L>>R shunt
is CHF and pulm. HTN
Right to left shunt: get cyanosis, clubbing and exercise intolerance; seen with
TOF (most common in children) and Transposition of great arteries (most
common in newborn)
IABP: decreases afterload/increases coronary perfusion pressure/decreases
PVR/exacerbates AI
Congenital Lobar Emphysema: progressive hyperexpansion of 1 or more lobes
of the lung; air is trapped during breathing>>>over- inflation of
lung>>>mediastinal shift away from side; most common in upper lobes, 14% of
children with other congenital anomalies; usually seen in 1st 1-2 months of life;
TX: resection of affected lobe
ASD: left to right shunt, many asympt., fatigue, palpitations, exertional dyspnea,
gracile habitus (thin, long narrow bones, poor mm. devclopment), split S2,
systolic murmur, dx. With 2D ECHO; tx: surgery, unless pt. has high PVR
PDA: It is kept open with PGE1; close it with indomethacin (80% success); F>M
3:1/rubella in the 1 st trimester causes syndrome of mental retardation, cataracts
and PDA/ produces a L>>>R shunt/ never produces cyanosis/slow tissue
development b/c of decreased peripheral blood flow/hallmark is a continuous
machinery murmur with a palpable thrill/susceptible to bacterial endocarditis with
s.viridans (most common after the first decade)
TOF: VSD, RV hypertrophy, pulmonic stenosis (obstruction of the RV outflow
tract), overriding aorta; symptoms: polycythemia, clubbing (hypertrophic
osteoarthropathy), CVAs, brain abscess, endocarditis, hypercoagulable;
11

hypercyanotic spells (TET spells); boot-shaped heart, squatting is common b/c

this increases SVR>>>increases pulm. Blood flow; tx: Blalock-Taussig SC
artery>>>PA shunt followed by definitive corrective surgery later; primary CI to
corrective surgery is a severely hypoplastic PA
Type I pneumocytes: gas exchange; type II pneumocytes secrete surfactant to
decrease the surface tension
LIMA: the best conduit to use for CABG with the highest 10- yr. Patency rate
(>90%); Using the LIMA is assoc. with a lower overall operative mortality and a
lower incidence of future cardiac events such as MI and repeat CABG
Small cell lung cancer is th most common tumor to produce ectopic ACTH
Chylothorax>>>chest tube and TPN 1st , try for at least 2 weeks (50-70%
success), if unsuccessful>>>thoracic duct ligation (80% success); if both fail, try
pleuroperitoneal shunt
Actinomycoses: is not a fungus, it is a microaerophilic bacteria, forms abscesses,
treat with ABX; Histoplasmosis is a fungus; it is the most common systemic
fungal infection in the U.S. and endemic to the Miss. River basin; can get
calcified lymph nodes in lung and mediastinum from past infections
Blastomycosis: see cutaneous and pulmonary infections together; Aspergillosis:
fungus ball; treatment almost always entails a lobectomy b/c of ineffective antifungal therapy; Coccidiomycosis : Always presented with a migrant worker from
the San Joaquin Valley; this is a fungus
HEAD AND NECK

Early stage I, II treated with either XRT or surgery (not both, same outcome) and
advanced stage III, IV are treated with combination XRT+surgery (superior
outcome compared to either one alone)
XRT alone is the best treatment for SCC or BCC of the nose, eye, lip, eyelid,
inner and outer canthi with cure rates of 96% (BCC), 92% for SCC.
SCC of the H + N: stage I and II (up to 4 cm, no nodes) single modality tx. with
either surgery or XRT; stage III, IV combined modality
Freys syndrome: gustatory sweating, most often seen after parotid surgery; pt.
gets sweating/flushing/warm sensation over-pre-auricular area with eating; tx:
botulinum toxin A with response rate close to 100%
Glottic cancer: if the cords are fixed, tx. with surgery and XRT; if not XRT alone
Cholesteatoma: Associated with pars flacida (marginal perforation of the TM)
secondary to OM or eustachian tube obstruction; after TM perf.>>>desquamation
of squamous cells>>>accumulate>>>destroy bone, including ossicles>>purulent
labrynthitis>>>facial paralysis, intracranial infection; you will see white pieces of
crud in the middle ear on exam +/- destruction of the adjacent temporal bone; tx:
radical/modified mastoidectomy
Juvenile angifibroma: purplish polypoid mass in the nose; non- metastasizing but
locally aggressive; pt. is pre-pubescent with frequent nose bleeds; tx: excision
only after pre-op embolization
Salivary gland tumors: benign: pleomorphic adenomas: most common benign
tumor of the parotid; do not enucleate, do a superficial parotidectomy with
12

preservation of the facial nerve/ Warthins tumor (papillary cystadenoma

lymphomatosum; adenolymphoma); 70% are bilateral; path contains oncocytes;
malignant: All malignant tumors of the parotid gland warrant a total
parotidectomy with facial nerve preservation and only sacrificed if directly
involved; mucoepidermoid is the most common malignant parotid tumor; most
common in children; for a low grade(slow growth, low recurrence rate), treat with
total parotidectomy; for a high grade (very aggressive, 60% local recurrence rate,
regional mets 50%, distant mets 30%) treat with total parotidectomy, facial nerve
preserva tion if possible, neck dissection (selective for N0, modified or radical for
N+); adenoid cystic: most common tumor of the submandibular glands; treat
same as mucoepidermoid; acinic cell: 13% of malignant parotid tumors; spectrum
from indolent to aggressive; adenocarcinoma: 12% of parotid tumors and a high
% of minor salivary gland tumors; most are high grade, treat as with
mucoepidermoid; If you see a SCC of the parotid, submandibular or salivart
glands, it is probably a met. from somewhere else, rather than a primary lesion,
therefore should look for a primary
Postop. XRT: is indicated for all high grade tumors of the parotid and salivary
glands (all histologies except low grade mucoepidermoid and acinic cell tumors
<3cm), close surgical margins, recurrent disease, skin, bone nerve or extraparotid
involvement, positive nodes, gross residual or unresectable disease
Erythroplakia is worse (pre -malignant) than leukoplakia: Retinoids can
reverse leukoplakia and reduce the chance of a secondary H + N malignancy
SKIN/ MELANOMA / SARCOMA

Actinic keratoses: is a pre- malignant lesion and should be resected with adequate
margins; seborrheic keratoses, cavernous hemangioma and junctional nevi
are not
Merkel cell tumor: rare, aggressive tumor of the dermis, neuroendocrine in
origin, high frequency of locoregional recurrence even after adequate 2 cm
margin; highly radiosensitive and should use XRT to the excision site and
regional nodes; 85% express somatostatin receptors and are (+) on octreotide scan
Extremity melano ma: 3.7mm lesion has a >50% chance of nodal involvement
(clinically negative); 1.6 to 3.7mm>>>35% chance; 1.5mm or < has a 15%
chance of nodal involvement
Subungal melanoma: remove the nail and biopsy>>if positive>>amputation at
one joint proximal
The only survival benefit for a prophylactic LND is for males, <60 yoa with a 12 mm lesion without ulceration; All melanoma patients with palpable adenopathy
get a therapeutic LND
Dysplastic nevus syndrome: familial tendency to develop atypical moles and
melanoma; 10% of cases have such a genetic component
Among congential nevi, only the giant congenital nevus (>20cm in diameter) is a
precursor to melanoma
Stage of melanoma has a direct correlation with long term survival; the thicker
the melanoma, the poorer the 5-yr survival

13

Any patients with a known h/o melanoma and palpable lymph nodes, confirmed
by FNAB to be melanoma, should undergo a complete, therapeutic LND
Surgical margins: Any lesion <1 mm>>>1 cm margin is adequate; 1-4mm>>>
2cm margin; >4mm>> at least 2cm, 3cm is probably better; For head and neck
and distal extremity, <1mm lesion >>>1 cm margin and >1mm>>>at least 1 cm
margin (no data, this is accepted surgical practice)
Sentinel LNB: Current recommendation are to perform a SLNB on any lesion
>1mm tumor thickness; Overall, if the SLNB is (-), the rest of the LN basin is
also (-) (90-96% of the cases); Remember, the background must be <1/10 the
reading of the sentinel node by gamma probe.
The only known adjuvant therapy for patients that has been shown in some trials
to be beneficial in improving overall and disease free survival in resected stage II
and stage III patients with melanoma is Interferon-alpha (2A) (not gamma), called
INTRON-A. Currently, this is standard of care
Interleukin-2 is FDA approved for treating patients with metastatic melanoma
(stage IV) and metastatic renal cell cancer. It is given IV at 600,000 IU/kg q8
until DLT; the side effects are a systemic leak syndrome causing hypotension;
The SBP can be supported with inotropes in the ICU
Soft tissue sarcoma (STS): All arise from mesoderm/Most common sarcoma
overall is malignant fibrous histiocytoma (MFH), second is liposarcoma/Biologic
aggressiveness is best predicted by grade (not stage)/ survival is best predicted
by grade , not stage/high grade sarcomas (# mitoses per high power field) have a
high metastatic potential and most often spread hematogenously to the lung
STS biopsy techniques do not include FNA/ can sometimes get diagnosis by a
core needle biopsy/ If less than 5 cm, can attempt an excisional biopsy, if >5cm,
try a percutaneous core biopsy or incisional biopsy/The incision on the extremity
is a longitudinal incisional directly over the mass (so if you do a WLE later, you
encompass this scar in it)
STS: Surgery + XRT is better than surgery alone for local control, but no
difference in overall survival; chemo (primarily doxorubicin-based) doesnt work,
so dont give it
Epithelioid sarcomas are high grade sarcomas with a known propensity for
multi- focal disease @ presentation; it occurs in very young males/mostly
limbs/rarely H&N/has a tendency to spread locally
Hyperthermic isloated limb perfusion: Is used for STS in an attempt to preserve
the limb (which would otherwise need to be amputated due to advanced disease);
utilizes melp halan (without TNF) with an overall major tumor response rate of
87% (CR=36%, PR=51%), with limb salvage in 84% of all patients
Retroperitoneal sarcomas: Most common is liposarcoma (42%) and
leiomyosarcoma (26%); CT and MRI are essential before operating; Do not need
to biopsy pre-op except only if you have a suspicion it is a lymphoma, or
unresectable or a metastasis and not a sarcoma primary; Surgical resection with
negative margins remains the standard primary treatment for all patients with
localized retroperitoneal sarcoma

14

TRANSPLANT

Hyperacute rejection: This is an antibody (B-cell) mediated event; can test with
the lymphocytotoxic crossmatch (B-cell crossmatch); kidney is the most
susceptible organ; will often see immediately after vascular clamps are released
during surgery
Renal transplant rejection: tenderness over the graft with enlargment, fever,
malaise, HTN, increased WBC, oliguria and increased creatinine; dx. is confirmed
by renal biopsy; tx: high dose IV prednisone, azathioprine and irradiation
OKT3: A monoclonal antibody (made in mice) that binds to the CD3 TCR
complex; Rapamycin: macrolide antibiotic that inhibits T cell activation and
maturation; FK506=Tacrolimus: macrolide antibiotic that acts by
inhibiting/blocking calcineurin-calmodulin complex>>>NF-AT activity
decreased, prevents cytokine transcription of IL-2 gene and therefore arrests Tcell activation; CyA: same action as FK506, but is a fungus; CyA blocks TCR
signal transduction but does not inhibit co-stimulation, T-cell becomes active
again without CyA; Can overcome CyA effects with exogenous IL-2 and thus
CyA is a maintenance agent and not a rescue agent for rejection; ALG:
polyclonal Ab prep. against many different antigens on T-cells. It is made in a
horse (ATGAM), basically removes T-cells from the system; side effects include
severe thrombocytopenia, chills, fever, skin rash
Azathioprine: purine analogue, interferes with DNA synthesis; MTX: inhibits
DHF reductase and prevents conversion of folic acid to THF acid
The most frequent complication after a liver transplant is always the biliary
anastomosis (leak/obstruction/stricture); blood supply for this usually is from the
hepatic artery
Graft thrombosis is the most common complication following pancreatic
transplantation and usually occurs within the 1st 24 hours; tx: remove the
transplant
PANCREAS

Mucinous and serous cystadenomas are benign lesions, but cannot reliably be
differentiated from malignant lesions, therefore you resect all cystic lesions of the
pancreas because of the chance that it may come bacl on path as a mucinous or
serous cystadenocarcinoma; In general, serous has central calcification,high
glycogen levels, low CEA and low CA19-9 with mucinous just the opposite with
peripheral calicification
Primary pancreatic lymphoma: diagnosis based on CT- guided biopsy, if
unsuccessful, can do an open biopsy. There is no role for extensive surgery for
pancreatic lymphoma; treat with chemo (Doxorubicin-based)
Glucagonoma: is a malignant pancreatic islet cell tumor assoc. with decreased
A.As in serum/increased glucagons in serum/weight loss/NIDDM/ severe
mm.wasting/cachexia and a characteristic rash called necrolytic migratory
erythema (this will never appear as an answer); You must identify the rash as a

15

raised, red, pruritic rash that can progress to bullous lesions that slough; increased
risk of DVTs and PEs;
Metastatic glucagonoma: Debulk if possible; if not resectable, treat with
octreotide
Nesidioblastosis: childhood hypoglycemia (~40 mg/dl) with no known etiology;
treatment is with 95% pancreatectomy with sparing of the duodenum; do not do a
splenectomy
Insulinoma: usually found in the tail of the pancreas (not in gastrinoma triangle),
usually solitary and readily curable with enucleation; when malignant (rare),
tumor debulking, streptozotocin and diazoxide is helpful to control the
hypoglycemia; most common islet cell tumor
Factitious insulinoma: check a C-peptide level, if absent>>factitious (almost
always presented with a health care worker with glucose of 40)
Prolactinoma: #1 cause of pituitary adenoma with galactorrhea and irregular
menses; tx. with bromocriptine with >75% response rate, if not transphenoidal
resection
Pancreatic cancer: Almost always presented with a pt. with painless jaundice,
weight loss and back pain; assoc. with k-ras mutations;tx: Whipple vs. biliary and
gastric bypass
Somatostatinoma: steatorrhea and diarrhea +/- stones; VIPoma: diarrhea and
achlorohydria
MEN IIA/IIB: mutation in the ret proto-oncogene; chromosome #10
MEN I: pit/panc/para, most common presentation in over 90% is
hyperparathyroidism, chromosome #11; MEN II: MCT defines MEN II; MEN
IIA: MCT/pheo/para, do not forget about the pheo. because this is what you will
operate on first, before treating the hyperparathyroidism; MEN IIB:
MCT/pheo/mucocutaneous lesions/marfanoid (think of Abe Lincoln), very
aggressive, poor survival
Adrenal incidentaloma: resect all >5cm; prior to resection, check to R/O pheo.
With urine metanephrines and catechols. b/c if present, need to prepare patients
for OR (alpha blockade etc..)
Pheochromocytoma: control the BP with an alpha blocking agent like
phenoxybenzamine, follow this with Beta blockade if they get tachycardic
(always give the alpha blockade before the Beta blockade)
Ransons Criteria: LDH>350, age>55, WBC>16, glucose>200, SGOT>25; after
48 hours: HCT drop>10%, BUN up >5, Ca<8, PO2<60, BD>4, fluid sequest. >6L
Annular pancreas: Abnormal fusion and rotation of the ventral pancreatic
primordium; forms a thin band of normal pancreatic tissue completely around the
2nd portion of the duodenum; do not cut this band, you will get a fistula; tx:
duodenoduodenostomy or duodenojejunostomy (do not do a gastrojejunostomy)
Pancreatic divisum: dorsal and ventral pancreatic ducts dont fuse together
resulting in the main pancreatic duct draining via the minor papilla; results in
development of pancreatitis due to a relative outflow obstruction of the main
pancreatic duct; tx: duodenojejunostomy or gastrojejunostomy

16

HAND

The most common carpal bone fx. by far is the scaphoid bone (80%); this
causes tenderness in the anatomic snuffbox
Swan-neck deformity: usually occurs as a complication of a Mallet finger: blunt
trauma to tip of finger (ball hits end of finger head on) causes avulsion of the
extensor tendon mechanism +/- bony fracture
Kanavels Tenosynovitis (suppurative flexor tenosynovitis): fusiform swelling of
digit/digit held in flexion/ pain evoked on passive extension/tenderness along the
synovial sheath; s.aureus most common, look for Eikenella (not sus cept. To
PCN); treatment of all human bites requires surgical exploration in the OR (I+D)
DeQuervains disease: compression of the extensor pollicic brevis and abductor
pollicus longus in the 1st dorsal compartment; F:M 10:1; cause most commonly
related to overuse; pain and tenderness of radial styloid in anatomic snuff box; +
Finkelstein test tx: initially with rest/splint/steroid injections with improvement
within 6 weeks; if not, surgery
Boutonnieres deformity: disruption of the central tendon slip leads to volar
displacement of lateral bands with a flexion deformity of the PIP (joint stuck in
flexion) and extension deformity of the DIP (hyperextension)
Dupuytrens contracture: Almost always presented with a white, middle-aged,
diabetic, alcoholic; causes contracture of the palmar aponeurosis most commonly
the 3rd and 4th digits/ afflicts primarily northern Europeans/M>F by
2:1/AD/nodule formation within the palmar fascia with fixation to tendons; no
known non-operative tx. therefore operate on all; surgical tx. with open
fasciectomy with partial or complete fasciectomy; can be confused with a lowgrade fibrosarcoma on path
Human bites (including fist to teeth in a fight): 1st step in management is
surgical exploration, I+D in the O.R., leaving the wound open with drainage of
joints; wound heals by secondary intention; most common organisms are s.aureus,
s.viridans, and eikenella corrodens which is an anaerobic GNR sensitive to PCN)
Animal bites: dog bites rarely become infected, however, >50% of cat bites do;
for cat bites look for pasteurella multocida; most require only local wound care,
empiric ABX. and immobilization
Carpal tunnel syndrome: F>M (they will almost always give you a postmenopausal typist or secretary); + phalen test; + Tinels test, compression of the
median nerve with neuropraxia within the carpal tunnel; medical tx. 1st with
steroid injections, splinting of the wrist in a neutral position, NSAIDS, diuretics to
decrease the edema (??); if no improvement, surgery
Thumb apposition and abduction>>median nerve; finger abduction, cross
fingers>>ulnar nn.; extensor mm.of wrist (no intrinsic mm. of the hand)>>radial
nn.
Ulnar nerve injury: claw deformity; radial nerve injury: waiter tip deformity
(cannot extend wrist or thumb)

17

BURNS

Silver Sulfadiazine: Broad spectrum/does cover candida/poor eschar

penetration/not painful to apply/does not cover PSA/hemolytic anemia in G6PD
def./reversible leucopenia
Mafenide: Broad spectrum/does not cover candida/good eschar penetration/
painful to apply/carbonic anhydrase inhibitor/wastes HCO3 and retains
chloride/hyperchl.met.acidosis/ hemolytic anemia in G6PD def.
Silver Nitrate: Broad spectrum/stains everything black/causes hyponatremia and
hypochloremia
High voltage injury: bone has a high resistance (nerves the least) and this is
where most damage occurs; get a hemoglobinuria and myoglobinuria; tx. with
alkalinization of urine with HCO3 and mannitol, brisk urine output of 50cc/hr
All burn patients get an ileus if >25% TBSA and following resuscitation, return
of GI motility by the 3rd to 5th day
Conversion of a partial to a full thickness burn with necrosis is the most sensitive
sign of burn wound infection/sepsis
Scar carcinoma: Marjolins ulcer: this is a squamous cell carcinoma which
often occurs in previous burn sites that have beenn grafted; Also found in chronic
wounds; 20% incidence of LN mets., poor prognosis
Corticosteroid injections directly into the lesion, with or without scar excision is
the treatment of choice for both keloids and hypertrophic scars
TENS: type I is seen in kids; uncommon, due to exfoliative toxin, PCN-resistant
S.aureus; type II: high mortality (25-50%), caused by anything with sulfa in it
and other things like viral infections, cancers; fever, sore throat, malaise,
sloughing of the dermal-epidermal junction (Nikolskys sign); can occur
anywhere from mouth to anus, all mucosa at risk; treatment is supportive, IVIG is
experimental
VASCULAR

Inflammatory aneurysms: 5% of all AAAs/ tend to be >7cm/tender on exam,

lots of pain/ marked thickening of the media and adventitia (not intima)/ dense
adherence to the duodenum, ureters and IVC, much harder to dissect free of
adjacent structures/increased ESR and C-reactive protein in >75% of patients
Restenosis following CEA: F>M/ more common in smokers/ is reduced by
using a patch at first surgery/ due to intimal hyperplasia
Wilkes Disease: Vascular compression of the duodenum by the SMA; factors
assoc. with this are acute weight loss, placement of a body cast, prolonged
recumbency, and placement of spinal rods (scoliosis repair); test of choice is an
UGI with SBFT; tx: duodenojejunostomy
Buergers disease (thromboangitis obliterans): Almost always presented with a
young, male smoker with claudication; occurs in arteries and veins/ M>F 4:1/
Only 5% come to amputation if treatment is followed with quitting smoking and
exercise +/- pentoxyfilline (trental)

18

Dysphagia lusoria: anomalous R SC artery coursing b/t the trachea and

esophagus causing compression of the esophagus with severe dysphagia; tx:
carotid-subclavian artery bypass
70% of all patients with LE claudication will improve or remain the same with
non-operaitve therapy; only 20-30% experience worsening of this and only <10%
will ever come to amputation secondary to ischemia: non-operative therapy with
quitting smoking, exercise and pentoxyfylline is the standard therapy for most
patients with claudication
Popliteal artery aneurysms: present with ischemia (secondary to thrombosis,
only rarely rupture); most common peripheral aneurysm (70%), bilat. in 50-75%,
assoc. with other aneurysms, especially AAA (50%), occurs predom. in males b/t
50-70 years old; repair all >2 cm.; some say repair ALL regardless of size in all
patients without serious operative co- morbidities; repair with exision and
interposition bypass grafting with reverse SVG if possible; compartment
syndrome can easily develop after surgery, think about doing 4-compartment
fasciotomies (this is a reperfusion injury)
Popliteal entrapment syndrome: presented as calf claudicatio n in a young,
healthy male; vessels travel around the medial head of the gastrocnemius mm.
with plantar flexion resulting in loss of pulses/M>F 15:1/ bilat. in 25% of
cases/majority present with thrombosis and absent pedal pulses, tx: acutely with
thrombolytics then mm. lysis (treat with resection of the medial head mm.
insertion); chronic with bypass
Fibromuscular dysplasia: 2nd most common in the ICA/see a string of beads
appearance on angio./ no therapy if asymptomatic/ not assoc. with
atherosclerosis/F>M/most common in the renal arteries/symptomatic tx. with
serial transluminal dilatation
Renal artery aneurysms: presents as dissection and thrombosis, occasionally
with rupture/F>M secondary to fibromuscular dysplasia/risk of rupture greatest
for pregnanc y and HTN, aneurysms >2 cm./tx: direct open repair and bypass
grafting (>90% success)
Femoral artery aneurysms: All symptomatic and asymptomatic aneurysms
>2.5cm should be fixed
Non-occlusive mesenteric ischemia: If there is narrowing of the lumen, but no
clot, do not operate, try papaverine through the SMA
NASCET: 26% (medical) vs. 9% (surgery) at 2 years; beneficial for symptomatic
patients with stenosis > 70%
ACAS: 11% (medical) vs. 5% (surgery) at 5 years; beneficial for asymptomatic
patients with stenosis > 60%
Subclavian steal syndrome: due to a proximal occlusion/stenosis of the
subclavian artery>>>vertigo, diplopia and arm claudication; the most common
site of atherosclerotic disease of the upper extremity is the origin of the
subclavian artery proximal to the vertebral artery; may hear a supraclavicular
bruit; symptoms due to decreased flow in the posterior cerebral arterial flow; tx:
subclavian to carotid interposition graft
Effort thrombosis: caused by a first rib (compression of SCV b/t 1 st rib and
clavicle) causing stenosis +/- occlusion of the subclavian vein (Paget-Schroetter
19

syndrome); sudden onset of arm pain, swelling and cyanosis in an otherwise

healthy patient who performs some form of repetitive arm activity (carpenter,
baseball player, weightlifter); acute events>>thrombolytics +/- coumadin; chronic
tx. with anti-coagulation for minimum 3 months; definitive tx: transaxillary rib
resection
Splanchnic artery aneurysms: splenic artery is the most common (60%); can tie
off splenic artery (and preserve the spleen), but not the vein; prone to rupture in
pregnancy; splenectomy for all pregnant pts. with aneurysm and women of child
bearing age who may conceive
Aortocaval fistula: spontaneous ruptue of a AAA into the IVC; you see high
output CHF in 33% of patients, tachycardia and venous HTN, marked leg
swelling; tx: repair by closing fistula from within the aneurysm sac
ESOPHAGUS

Boerhaaves Syndrome: Usually presented with a drunk who presents after

heavy retching and emesis; Diagnosis 1st with plain neck and chest>>look for
mediastinal air; 2nd>>H2O-soluble esophagram, followed if necessary by barium;
ith M/M is lowest with primary repair in <24 hours via a thoracotomy (no
resection or defxn.)
Plummer-Vinson Syndrome: dysphagia/spoon fingers/Fe-defic. Anemia/ fibrous
webs at cricopharyngeus mm.; All patients will develop malignant lesions of the
oropharynx, hypopharynx and esophagus
Diffuse esophageal spasm: hallmark is a pt. who c/o chest pain and dysphagia
(often the pt. will have already seen a cardiologist for this); the gold standard for
dx. is standard manometry; medical treatment is only minimally effective with
nifedipine; surgical tx. is a long myotomy carried through the LES onto the
stomach with a partial wrap
Adenocarcinoma now accounts for the majority (>50%) of esophageal cancers,
with squamous cell second
The single best test for both establishing and quantifying the amount of reflux is
the 24-hour pH monitoring
Traction diverticulum: mid-esophagus, small, usually secondary to
histoplasmosis or TB in the adjacent nodes, usually asymptomatic and do not
require surgery; it is a true diverticulum
Premalignant lesions: achalasia/reflux esophagitis/Barretts/radiation
esophagitis/caustic burns/Plummer-Vinson/leukoplakia/diverticula/ectopic gastric
mucosa/familial keratosis palmaris
Barretts esophagus: normal stratified squamous replaced with columnar lined
epithelium; dx. with EGD and bx.; A previous Nissen does nothing to cause
regression of Barretts; High grade dysplasia mandates an esophagectomy
The single most important CI to a transhiatal esophagectomy is the surgeons
assessment on palpation of the esophagus through the hiatus to see if the tumor is
fixed to contiguous structures and therefore unsafe
Esophageal reflux strictures are best treated with dilatation, Colles gastroplasty
(to augment length of the foreshrortened esophagus) and fundoplication
20

The effects of a truncal vagotomy are that it abolishes vagally mediated receptor
relaxation, causing an increase in emptying of both solids and liquids; also get an
increase in gastrin, decrease in pancreatic exocrine function, decrease in HCO3,
decrease in bile secretion, increase in fecal fat, decrease in CCK; increase risk of
gallstones secndary to decreased GB emptying; most common side effect after a
truncal vagotomy is diarrhea, controlled with dietary changes +/- somatostatin
Zenkers diverticulum: Occurs most commonly on the left; best test for dx. Is a
barium swallow; pt. c/o regurg. of undigested food and halitosis; can treat with a
crycopharyngeal myotomy only if small, otherwise, need a myotomy and
diverticulectomy (some will suspend it); Approach always from the left neck,
anterior to the SCM; it is a false diverticulum of the pulsion type; Epiphrenic
diverticulum is a false pulsion type, located in the distal esophagus and always
approached through a left thoracotomy
Esophageal cancer: Adjuvant XRT alone>>>no benefit; adjuvant chemo.(single
or multiple)>>> no benefit; periop. Chemo. or XRT>>> no benefit; Data supports
neoadjuvant XRT + chemo. followed by surgery; 3 yr survival is 32% vs. 6%
(surgery alone)
When doing a transhiatal esophagectomy, you must preserve the right
gastroepiploic artery; try to preserve the right gastric, but you can sacrifice if
you need extra lengt h;
The most common cause of esophageal perforation is iatrogenic (45-75%); ??
perf.>>>plain neck and CXR (90% of the time, dx. is made)>>free perf.+<72
hours>>>reinforced primary repair; if walled off perf., minimal symptoms and no
sepsis>>>conservative management>>>if fails>>>reinforced primary repair; free
perf. of >72 hours>>consider resection, cervical esophagostomy, G-tube, J-tube;
if you cant make the dx. with plain films, do a gstrograffin swallow 1 st , followed
by barium
Almost all esophageal perf. of <24 hours are repaired primarily; approach based
on location: cervical>>>left neck, thoracic>>>right posterolat. thoracotomy,
lower 1/3>>>left thoracotomy; Even those >24 hours, primary repair is still the 1st
choice of treatment; debride>>secure clo sure>>drainage>>reinforce with
autologous tissue (Thal flap or fundoplication, omentum, pleura, diaphragm,
intercostal mm., pericardium)
Achalasia: incomplete LES relaxation (<75% relaxation), aperistalsis in the
body, neurogenic degener., beak- like narrowing on esophagram, increased
incidence of cancer/ tx. most effectively with Heller myotomy and fundoplication
(never do a 360 wrap b/c it will be too tight, instead, use a partial wrap like a
Toupe)
Symptoms of achalasia: barium swallow>>motility testing>>EGD>>mild
symptoms>>observe or >>>dilatation (repeat x3) or nitrates and Ca-channel
blockers; if symptoms not controlled or become worse>>>Botox (repeat x3)>>no
relief>>>myotomy and partial wrap
Severe caustic injury: Lye (liquefaction) is worse than acid (coagulation); early
EGD is the gold standard; tx: EXLAP>>>total gastrectomy (for black tissue),
transhiatal esophagectomy, cervical esophagostomy and a J-tube; post-corrosive

21

esophageal cancer is increased a 1000 fold, therefore, must take out the
esophagus; reconstruction with the colon is preferred (vs. the stomach)
Only give neoadjuvant chemo and XRT for patients with T2,T3 or (+) nodes
esophageal cancer; Do not give for T0 or T1 b/c 90% survival with surgery alone
EUS is the gold standard for staging all patients with esophageal cancer;
Squamous cell cancer is the predominant form of esophageal cancer in black
men
Transhiatal: Anast. Leak>>>16%, Chylothorax>>3%, leak in chest,
mortality>>uncommon, recurrent nn. Injury>>11%, gastric necrosis>>yes
Ivor-Lewis: Anast. Leak>>>10%, Chylothorax>>3%, leak in chest,
mortality>>50%, recurrent nn. Injury>>4%, gastric necrosis>>no
STOMACH

Late post-gastrectomy dumping syndrome: pt. c/o sweating, dizziness,

occasional fainting about 2-4 hours after meals (not 30 minutes>>early); dx. with
a prolonged glucose tolerance test; tx. same as early dumping
Can treat early dumping with decreased carbs./decreased sugar/increased protein
in diet; can add pectin +/- octreotide
Mallory-Weiss tears do not extend into the esophagus; they extend into the
stomach along the lesser curvature just distal to the GE junction (only 8-10%
extend into the esophagus); the tear is almost always limited to the mucosa only
and most stop bleeding without surgical intervention; arterial bleeding from left
gastric; never use an S-B tube (can make the tear worse)
Carneys triad: GIST of the stomach/pulmonary chondromas/extra-adrenal
paragangliomas
There are four main post-gastrectomy syndromes: dumping (early and
late)/reflux bile gastritis/afferent loop syndrome/post-vagotomy diarrhea; blind
loop syndrome is not a syndrome of gastrectomy
A type II ulcer (antral and duodenal) is generally benign and assoc. with gastric
hypersecretion; treatment of choice is vagotomy and antrectomy to include the
ulcer
Never do a parietal cell vagotomy for a type III ulcer because of a very high
failure rate
Alkalinity, A.A.s and Ach, proteins and gastric distention all act on the antral Gcell and cause gastrin release; gastrin, histamine and Ach all act on the parietal
cell causing HCL release (inhibited by secretin); secretin stimulates the release
of H2O and HCO3 from pancreatic ductal cells, neutralizing gastric acid,
increasing bile flow, decreasing GI motility and decreasing gastrin release
In the presence of a perforated gastric ulcer, definitive ulcer surgery should only
be performed if there is a known history of PUD (therefore, pt. with an unknown
H.pylori status and NSAID has an unknown history); pt. also needs to be stable to
perform a PCV (+ h/o PUD); Recalcitrant PUD best treated with a V+A, not
PCV; for a perforated ulcer, unstable pt., do a V+P
Treat a type I gastric ulcer (lesser curve, nml. acid) with a partial gastrectomy or
simple ulcer excision; you dont need to do a vagotomy b/c increased acid is not
22

the problem; type II and III: V+A with a B-I or B-II; type IV: near total
gastrectomy with R-en-Y esophagojejunostomy
Early dumping can almost always be managed with dietary changes like
decreasing frequent small meals, high protein, low carbs and sugar, low salt and
fluid, lie supine after meals, add pectin
Gastric ulcer: type I: along the lesser curve, nml. to low acid, perforation, blood
group A; type II: body and duodenum, hypersecretion, hemorrhage and
obstruction and perforation; type III: prepyloric, hypersecretion, hemorrhage,
perforation, blood group O; type IV: high on lesser curve near GE jxn., low acid,
hemorrhage and perforation; type V: NSAID use and ASA
Vagotomy and antrectomy has the lowest recurrence rate; V+P has the highest
morbidity; HSV has the highest recurrence rate (15%), but the lowest M+M
Type III paraesophageal hernia: GE jxn. is displaced into the thorax with a
hernia sac containing fundus and body; has both organoaxial and mesoaxial
rotation of the stomach (can get strangulation and perforation of the stomach)
All type II rolling hernias (paraesophageal) should be repaired: Has a normal
G/E junction below the diaphragm (intact angle of His); fundus and body rolls
alongside the esophagus with organoaxial rotation of the stomach; has a
peritoneal sac; repair + fundoplication is the mainstay of tx. with anchoring of the
stomach to the anterior abd. wall and arcuate ligament
Type I sliding hiatal hernia: GE jxn. displaced into the thorax, slides back and
forth, no hernia sac;
Early MALT lymphomas can be effectively treated by eradicating H.pylori,
without surgery; for late, advanced disease, total gastrectomy (probable standard
R2 nodal dissection)
Only 15-20% of all patients with PUD have H. pylori, but almost all (90%)
duodena l ulcers are associated with H.pylori; It is associated with an increased
risk of cancer and is classified as a level I carcinogen
GIST: complete surgical resection remains the primary treatment of choice;
unresponsive to chemo.
GI tract lymphomas : early stage I,II: treat with surgery followed by XRT and
chemo.; for stage III,IV: XRT and chemo., no surgery, resect only for
complicationsm
Gastric lymphoma: curative resection followed by adjuvant chemo and XRT is
the best treatment option
Megaloblastic anemia can be seen secondary to chronic afferent loop
obstruction>>>blind loop>>>bacterial overgrowth>>vit. B12 def.

SMALL BOWEL /LARGE BOWEL/ RECTUM

Duodenal ulcers: assoc. with smoking, HpTH, high calcium, COPD, uremia,
P.vera, and liver disease; treat wit h a V+P without resection of the ulcer (you
oversew the ulcer and place an omental patch); remember, antrectomy without
vagotomy is the accepted standard of tx. for gastric ulcers, but if an antrectomy is
done for a duodenal ulcer, it requires the addition of a vagotomy
23

HNPCC (Lynch I, II): AD/familial form of colon and rectal cancer/not assoc.
with FPC/6% of all CRCs; predisposed to right-sided colon cancers by 40-45
yoa; Lynch I: site specific and no extracolonic malignancies and Lynch II (those
with extracolonic malignancies) such as endometrium, ovary, stomach, small
bowel, urinary tract and biliary tree; begin surveillance at 25 yoa; more common
on the right side;tx: subtotal colectomy; mutation in the DNA repair genes
(Mismatch repair genes, MSH2, MLH1,PMS1,PMS2)
The most common complication of a Meckels in the adult is obstruction (not
bleeding as in the child)
Surveillance colonoscopy is advocated at 8 years of disease (not at a specific
age) in patients with UC
The treatment for radiation proctitis is instillation of 4% formalin
Crohns disease: transmural inflammation/granulomas/skip lesions/
cobblestoning/primary sclerosing cholangitis / ankylosing spondylitis/ erythema
nodosum/ pyoderma granulosum/ episcleritis/iridocyclitis
Celiac sprue: are at an increased risk of future malignant GI disease, especially
T-cell lymphomas
Toxic Megacolon: Seen in pt. with UC/ treat with bowel rest/NGT
decompression/high dose steroids/ABX; if no improvement in 48 hours, consider
abdominal colectomy, ileostomy with Hartmanns or mucous fistula
UC: assoc. with increased risk of cancer that increases with the duration of time
having UC(10% at 10 years);
In the non-asian population, 95% of diverticular disease occurs in the left colon;
in Asians, 15-20% occurs in the right colon
FAP: AD/>100 adenomatous polyps in colon/All pts. will develop cancer if not
treated/genetic defect in the APC gene on chromosome #5/polyps begin around
puberty/ must perform EGDs because 70% will develop gastric and duodenal
polyps which are also at risk for cancer/10% get desmoid tumors which should be
resected (if not respectable, tx. with tamoxifen or clinoril (PG inhibitor));
definitive tx. for FAP is colectomy with ileoanal pouch; if you do an ileorectal
anastomosis, you must monitor the anastomosis with bi-annual scopes to look for
recurrence (rectum still at risk); must screen all family members from 10-40 yoa +
EGD q1-2 years after age 30 (look for gastric and duodenal adenomas); tx: total
proctocolectomy with ileostomy or total colectomy with ileorectal anast. (if <50
polyps in rectum and no cancer) or total proctocolectomy with ileoanal anast.
Gardners syndrome: FAP + Osteomas + Epidermal inclusion cysts
Turcots syndrome: FAP + brain tumors
Peutz-Jegher: AD/mucocutaneous melanotic pigmentation/multiple
hamartomatous polyps of the GI tract; no malignant potential
Juvenile polyposis : occurs at any age/AD/adenomatous (neoplastic) and juvenile
(non- neoplastic components)/ anemia/clubbing/ tx. with aggressive polypectomy
with C-scope or total abd. colectomy
Ischemic Colitis: Left sided cramping/seen after surgery, often AAA
repair/abdominal pain/bloody diarrhea/temp./LLQ tenderness/thumbprinting on
contrast enema/submucosal hemorrhage and edema

24

Carcinoid: check urine for 5-HIAA levels, the main metabolite of serotonin; most
common site is the appendix, and 90% of small bowel primaries in the ileum; tx.
carcinoid with liver mets with octreotide +/- alpha-INF, hepatic artery
embolization, chemo., resection; Bronchial carcinoids>>>Cushings syndrome,
assoc. with N-myc and c-jun activation; p53 has not been implicated
Malignant carcinoid syndrome : hepatomegaly, diarrhea, flushing, right heart
valvular failure, asthma, malabsorption and pellagra; tx: hepatic resection
(debulking is helpful for symptom control); if unresectable, tx. with octreotide
and niacin (to prevent pellagra)
Hallmark of carcinoid heart disease is : endocardial fibrosis involving the right
heart, in particular the tricuspid valve and chordae
Anal fissures: posterior midline in 95% of cases; best tx. with lateral internal
sphincterotomy; botox. also effective therapy; topical NTG not so good, causes
bad headaches; if lateral fissure, think Crohns disease
Colorectal mets. to the liver: poor prognosis associated with <1cm margins, >3
mets. in any given lobe, bilobar disease, short DFI, Dukes C primary lesion
Celiac disease, Crohns, HIV, transplant patients, AIDS, Wegeners
granulomatosis, RA, Wiscott-Aldrich: All associated with small bowel
lymphomas with almost all being NHL (B-cell)
GU/ OB / GYN-ONC / NEUROSURG.

An isolated extraperitoneal bladder rupture can be treated without an operation

with a Foley for 2 weeks; f/u with a cystogram prior to removal; intraperitoneal
injuries must be repaired in OR
Bladder cancer: superficial or in-situ: transurethral excision or fulgaration or
laser ablation; can repeat for a superficial recurrence, but the treatment of choice
becomes intravesical BCG or BCG + mitomycin or thiotepa or doxorubicin
Bladder cancer with any muscle invasion: segmental cystectomy if a 2 cm.
margin is possible; if not, treat with radical cystectomy and pelvic LND for
diffuse disease; urethrectomy should be included if cancer involves the trigone or
prostatic urethra or those with carcinoma in-situ of the urethra; che mo. given to
those with metastatic disease (+ pelvic LNs included) or those with a recurrence;
Most kidney stones are calcium oxalate stones (75%) worldwide; they are
radioopaque and easily seen on KUB and CT; CaPhos. stones seen with HPTH,
RTA, medullary sponge kidney; CaMgNH4PO4 stones are called struvite stones
and seen primarily with UTIs (15%)
Seminomas are extremely radiosensitive and is the treatment of choice following
orchiectomy; will never have an elevated alpha-FP or HCG; many will have
elevated neuron specific enolase (NSE); uncommon presentation may be a young
male with a large anterior mediastinal mass>>>seminoma vs. NSGCT; if + nodes,
cisplatin as well
NSGCT (non-seminomatous germ cell tumor): will often have elevated alpha-FP
and HCG; are not radiosensitive and therefore treat with surgery followed by
chemo.; stage I: orchiectomy, retroperitoneal LND; stage II: same, stage III or

25

large stage II: chemo 1st (cisplatin-based), re-staged, if residual tumor, more
chemo; if not, then surgical resection
Left spermatic vein>>>L renal vein; Right spermatic vein>>>IVC
Left varicocoele after age 40>>>think about a renal cancer b/c remember, the left
spermatic vein drains into the left renal vein; A right varicocoele may mean an
obstruction of the IVC; Varicocoeles present as a bag of worms of worms on
palpation with pain; indications for treatment are persistent pain, low sperm count
and large size; tx: ligation of the spermatic vein and all collaterals
If a young women has an indeterminate, large ovarian mass, it is appropriate to
remove the ovary on that side, fallopian tube and do a complete staging operation;
never perform a complete TAH/BSO; Also , if you see a mass on U/S, you can
watch it for 3 menstrual cycles safely and see if it goes away with serial U/S
exams;
Endometrial cancer: the most common malignancy of the female genital tract;
risk factors: no children/obesity/HTN/DM/late menopause; hallmark is abnormal
vaginal bleeding after menopause; A malignancy must be ruled out in any postmenopausal woman with bleeding
All abnormal PAPs are followed with a colposcopy and biopsy; Any gross
cervical abnormality found on exam (even with a normal PAP) should get the
same; if no diagnosis, then proceed to cervical conization or LLETZ; Further, all
CIN 3 is treated with conization or LEEP
Cryptorchidism: Most testes will descend by 9 months, therefore wait at least
this long to operate; should be surgically repositioned by 2 years old; decreased
fertility and increased testicular degeneration; increased chance of malignancy
even after operative repair with bilateral orchiopexy
Anterior spinal artery syndrome: Bilat. loss of motor fxn., pain and sensation
below the level of the lesion with sparing of position and vibratory sense and light
touch sensation; seen with acute rupture of a cervical disc followed by occlusion
of the anterior spinal artery
Brown-Sequard syndrome: ipsilateral loss of motor fxn. and position/vibratory
sense with contralateral loss of pain, temp and sensation below the level of the
injury
Central cord syndrome: bilateral loss of motor fxn., pain , temp. and sensation
in upper extremities with sparing of the lower extremities; usually due to a
hyperextension injury
There is no benefit to using ABX for basilar skull fractures with otorrhea or
rhinorrhea
A herniated disc b/t L4 and L5 impinges on the L5 nerve root
C1 fracture: Jefferson fracture>>fx. of lateral masses; Odontoid fracture , type
I: tip only, II: across the base (most common), III: across base and extend into the
body of the axis; C2 fracture: posterior elements fracture

26

COAGULATION

von Willebrands Disease: Increased bleeding time, PTT can be elevated, PT

normal; AD; TX: cryoppt., Factor VIII conc. or DDAVP
Protein C deficiency is associated with a warfarin- induced skin necrosis
Highest viral risk for blood transfusion is CMV infection
Impaired sensitivity of Factor V to protein C is called activated protein C
resistance and is caused by a point mutation in factor V (Factor V Leiden); This
is prevalent in 3-5% of the general population and may account for up to 30% of
all idiopathic venous thromboembolic cases (the most common reason)
Hemophilia A: Factor VIII deficiency, X-linked recessive, increased PTT,
normal PT and BT
Cryoppt. is used primarily to replace factor VIII and fibrinogen, although it also
has vWF, F XIII and fibronectin
Vitamin K deficiency is caused by antibiotics that kill gut flora (which make it);
can see with malnutrition and TPN
ATIII: inactivates thrombin, complexes with heparin to remove factor XII, XI, X,
IX from blood, made primarily by mast cells, ATIII deficiency = lupus
anticoagulant = anticardiolipin Ab that intereferes with phospholipids and
lipoprotein
Arachidonic Acid>>>PGI2 and TXA2 (enzyme necessary is cyclooxygenase,
COX-1); irreversib le inhibition with ASA; TXA2 potent vasoconstriction,
decreases cAMP, increases Ca mobilization, increases platelet activation,
decreases adenylate cyclase (prostacyclin does all the opposite)
INFECTIONS /CRITICAL CARE/ TRAUMA/ ICU/ FEN

High dose steroids in the trauma patient are only indicated for patients with blunt
spinal cord injury (give methylprednisolone @ a bolus of 30mg/kg followed by
5.4 mg/kg for 24 hours); Do not give at all if > 8 hours out from the time of the
event
A parasternal stab wound at or around the 5th ICS mandates a DPL (not a
thoracotomy); emergent thoracotomy only if you have a pericardial tamponade,
hemothorax of >1.5L initially or hemorrhage of > 250ml/hr + shock; perform an
anterolateral thoracotomy (not posterolateral)
A left subclavian artery injury is best approached via an anterior thoracotomy
through the 3rd and 4th ICS, or creating a trap door incision using this approach; A
right SCA injury is best approached via a median sternotomy
Never do a cricothyroidotomy on a child <12 y/o; for an emergent airway, do a
needle cric. or trach.
RSBI= breaths/min/L, freq/TV, most sensitive indicator for (un)successful
weaning from vent>>extubation
The only absolute CI to MAST trousers is pulmonary edema
Tumors cannot usually be detected until about 30 doublings = 1 gm of tumor =
10(9) cells; A lethal tumor burden is only 3 more doublings, 10(12) cells

27

Patient post-op. with drainage from wound 12-24 hours after surgery: dont forget
about Clostridium perfringens: open wound, send G-stain, if GPRs, give PCN
G (high dose) and take back to OR for Wide debridement to healthy appearing
tissue with return to OR in 24 hours
Cortisol must be present with IL-6 in order to make acute phase proteins
Chronically ill patients on TPN get acalculous cholecystitis
A-aDo2 gradient is normal with hypoventilation and high altitude, it is increased
with V/Q mismatch, diffusion defect and shunt
Hypoxemia: most commonly results from V/Q mismatch secondary to shunting
with an increase in deadspace ventilation; for diffusion abnormalities, V/Q
mismatch and hypoventilation>>>100% O2 will correct the hypoxemia; this will
not correct for shunt
Risk factors for the development of an UGI bleed in the ICU: mechanical
ventilation and coagulopathy (4% risk with either one or both, <0.5% if neither),
SCI, CHI, MSOF, severe burns
Risk factors for post-op. pneumonia: >60 y/o, trauma, CHI, Impaired airway
reflexes, ETT>48 hours, Upper abd or thoracic operation, low serum albumin,
neuromm. disease, use of an NGT, prolonged use of prohylactic ABX
Hemorrhagic shock: peripheral vasoconstriction/decreased CO/increased
ADH/increased glucocorticoids/ increased A-a gradient
Lung compliance: change in volume / change in pressure; compliance is
increased with emphysema and decreased with pulm. edema, ARDS, pulm
fibrosis, pneumonia
RQ= CO2 production/O2 consumption; RQ>1 too many carbs, RQ=0.85 is mixed
fat and carbs, RQ=.6 to .7 is fat consumption; a lower RQ in a septic patient
reflects impaired glucose metabolism, increased gluconeogenesis and a greater
reliance on lipids as an energy source
TPN formulation: Any % solution is 1 gram per 100 ml, always. ie: D20 = 20
gm per 100ml or 200 gm per liter; therefore: 500ml of D40W= 500ml x
40gm/100ml x 3.4 kcal/gm = 680 kcal; 500 ml of 8.5% A.A.s= 500ml x
8.5gm/100ml= 42.5 gm protein; 500 ml of 10% lipids= 500ml x 1.1 kcal/ml =
550kcal; 3-omega fatty acids are better than 6-omega FAs and reduce inflamm.
Mediators; try for a calorie: Nitrogen ratio of 150 kcal per gram of nitrogen;
DEKA are fat soluble vitamins; Fat=9/carbs=3.4/protein=4; growth hormone
given with TPN results in a positive nitrogen balance and positive phosphorous
balance, no effect on potassium, increased wt. gain secondary to H2O and Na
retention
SBP: Ascites with low protein (<1g/dl) are 10X more likely to develop SBP
than those with protein levels >1g/dl; high protein renders resistence to SBP;
duration of ABX based on ascitic PMN count>>>check q48 hours>>>when <250
can stop ABX; high recurrence rate after 1 st episode (50% @ 6 months); This is a
single organism disease with E.coli, step and Klebsiella accounting for 85% of all
cases
ETT size for a child = 16 + age/4; normal SBP= 70 + (2 x age)
Stress ulceration: current indications include pt. on a vent., coagulopathy, SCI,
head injury, MSOF and severe burns
28

Coronary perfusion pressure=DBP-CVP (80-8=72); <25 is fatal; 65% of the

coronary blood flow occurs during diastole
Oxygen extraction ratio (O2ER)= O2 uptake/O2 delivery (=VO2/DO2)
DO2 (O2 delivery)= CO x PO2; SVR= (MAP-PCWP)/CO x 80
Water deficit: observed Na 140/140 X 0.6 X body wt. (in kg.)
Albumin half life =20 days/pre-albumin=2-3 days/transferrin=8days/retinal
binding protein=10 hours
1 gram of nitrogen = 6.25 grams of muscle protein; N2 balance= (protein
intake/6.25) (24 hour UUN + 4)
BCAAs are lysine, isoleucine and valine and preferentially used by muscle for
energy; BCAA>>BCKA>>alanine, glutamine and glutamate>>>liver>>glucose
(Cori cycle)
In starvation, 75% of fuel needs of brain are met by acetoacetate; decrease
glucose>>>decreased insulin>>>increased glucagon>>>increased fat
mobilization>>>TGs>>>FFAs + glycerol>>>liver>>>ketones
Increased aromatic AAs as sepsis worsens and liver fxn decreases causing
encephalopathy, hypotension and vasodilatation
Arginine enhances wound healing; it is also the precursor for Nitric Oxide (NO)
PEEP: increases FRC/improves pulmonary compliance/decreases intrapulm.
shunt fraction/ increase deadspace by overdistending the alveoli/ can increase
ICP/causes fluid retention and edema secondary to increase in ADH
Class II hemorrhage occurs when you lose 750ml -1.5 liter of blood; this is the
first time that you see a decrease in the pulse pressure; Class III is the first time
to see tachycardia (pulse >120), decrease in SBP and U/O
ARDS: major criteria: hypoxemia (increased FIO2), low compliance, decreased
FRC, bilat. Pulm. Infiltrates (fluffy), increased deadspace ventilation;
Prerenal azotemia: Urine SG<1.020, Na<20, RFI<1, FENa<1%, urine
osmol>500, BUN/Cr ratio >15:1
In a pt. with a normal PCWP, with a C.I.<2, think about increasing SBP with DA,
followed by IABP insertion;
Angiography and external fixation is the tx. of choice in a patient with a pelvic fx.
that continues to bleed (will usually continue to bleed after external fixation)
DPL: positive if you get gross blood, bacteria on G-stain, TB or amylase >serum,
>500WBC/ml, >100,000RBC/ml (blunt), >20,000 RBC/ml (penetrating)
FRC= ERV+RV; VC=IRV+TV+ERV
FENa: Urine Na x Plasma Cr / Plasma Na x urine Cr
Osmolarity= 2(Na) + glucose/18 + BUN/2.8
Pancreatic and duodenal trauma have a mortality of 20% with 75% of
duodenal injuries from penetrating trauma; Basically, never do a Whipple for
trauma unless it is your last and only option; Intraop pancreatography is often
very helpful to define proximal pancreatic ductal injuries and susbsequent stenting
across such and injury
Important intracellular buffers are proteins and phosphates; for RBCs the
primary intracellular buffer is Hgb; extracellular buffers are primarily HCO3
and H2CO3 system; pH=pK + log (HCO3)/(H2CO3), at ph=7.4, a 20/1 ratio

29

Low magnesium parallels low K; 20-30% Mg is protein bound; too much

Mg>>>lose DTRs
Amrinone: phosphodiesterase inhibitor, increases CO, decreases SVR;
phenylephrine has pure alpha-1 activity; isoproterenol has pure beta-1, Dobs>>B1, some B-2, NE>>alpha and beta
PARATHYROID AND THYROID

Secondary HPTH: Occurs in almost all patients with advanced renal failure and
on dialysis; Will have bone disease secondary to HPTH; Increased serum PTH
causing renal osteodystrophy (kidney loses calcium, keeps phosphate, cannot
hydroxylate Vit.D therefore causes decreased absorption of calcium by the gut
which in turn causes PTH levels to increase); tx: 1st with oral calcium
supplements, restrict phosphate in die t to <600mg/d, increase phosphate bindingresins and Vit D analogues; decrease aluminum in dialysis bath and diet (it
accumulates in the bone causing osteomalacia)
Indications for surgery: In pts. with symptoms from secondary HPTH or from
tertiary HPTH and CRF: hypercalcemia in a renal transplant pt./ pathological fx.
secondary to renal osteodystrophy/ secondary symptoms to HPTH like pruritus,
bone pain, soft tissue calcification, and calciphylaxis, Calcium x Phosphate
product >70: Treatment of choice is a 4-gland parathyroidectomy with immediate
autograft in the SCM (fxn. in 87% of pts. @ 20 month f/u)
53 y/o with a 2 cm mass in post. neck, FNAB>>>benign appearing thyroid cells
with papillary features, no thyroid masses, what next? Pt. has metastatic
papillary cancer of the thyroid from an occult thyroid primary. Due to her age,
+ mets, she should have a total thyroidectomy, MRND, followed by post-op. RAI
ablation
If you see a really high calcium (>15), think about parathyroid cancer; Death
from tumor growth is rare, death usually from uncontrollable hypercalcemia
therefore aggressive reoperation required with maximal tumor debulking (often
including the thyroid lobe on the involved side); the only certain sign of tumor
recurrence is a re-occurrence after resection
Hyperthyroidism during pregnancy is usually due to Graves disease; treat with
PTU (not B-blockers, not surgery, not RAI)
Parathyroid glands: the superior glands are from the 4th branchial pouch, blood
supply for both from the inferior thyroid artery; superior gland is anterior to the
recurrent nerve
MCT: R/O MEN IIA; Treat the pheo. 1st ; increased calcitonin/siblings are at
risk/abnormal pentagastrin stim. Test; only the differentiated thyroid cancers take
up RAI (I131), MCT does not
If you see amyloid on pathology, it is diagnostic of MCT
Hurthle Cell Cancer: 3-10% of thyroid cancers/ As size increases, malignant risk
does as well, tumors >4cm>>>65%, 6-10cm>>>80%; very difficult to
differentiate b/t benign and malig. on FNAB; Has a poorer prognosis compared to
follicular and papillary, more aggressive and metastasizes earlier; Does not take

30

up I131; total thyroidectomy is appropriate treatment for all Hurthle cell

cancers and adenomas >4cm
Injury to the superior laryngeal nn. (external branch) will produce a lowpitched voice and you lose the ability to produce high-pitched singing (weakened
high pitch control)
Recurrent laryngeal nerve injury: paramedian location of the ipsilateral cord; if
permanent, can try teflon injections into cord
Thyroid storm: 20-30% mortality, fever, hypotension, CHF, circulatory collapse;
tx. with KI to suppress thyroid fxn., steroids to tx, assoc. adrenal insuff., Bblocker for tachycardia and PTU to suppress thyroid hormone synthesis and
conversion of T4>>T3; PTU can cause agranulocytosis and aplastic anemia
AMES criteria for high or low risk: Age>45 has a poorer prognosis, Mets. at the
time of dx.>>poor prognosis, Extent and Size : larger size has poorer prognosis;
females have an improved survival compared to males
Primary treatment for MCT is a total thyroidectomy and central node dissection;
you can treat a recurrence with an octreotide scan which detects calcitonin
HEPATOBILIARY

Sickle cell/chemotx./prosthetic valves/hereditary spherocytosis all are assoc. with

an increased incidence of cholelithiasis
Pyogenic liver abscess: Very often presented with an Asian person who recently
has been in Asia and is now back in US presenting with fevers, WBC +/- RUQ
pain; commonly follows cholangitis, diverticulitis or appendicitis; treatment is
CT-guided needle aspiration and IV ABX
Porcelain gallbladder: Anyone with a porcelain gallbladder should have a
cholecystectomy b/c there is a 35-65% risk of GB cancer
Echinococcal cysts (hydatid cysts): Invariably given a migrant wirker or
someone who has traveled to Mexico; treat with surgical resection (tx. of choice)
+/- ABX. Be careful to not spill cyst contents into the abdomen; do not do
percutaneous procedures
Brown pigment stones are most commonly found in the CBD (not black stones)
Amoebic liver abscess: caused by E.histolytica; pt. presents with F/C/N/V/D;
Flagyl is the mainstay of treatment, however, if no effect, may need open drainage
Emphysematous cholecystitis: Any evidence of air in the GB wall and clinical
symptoms requires IV ABX and emergent operation
There is no reason to perform a lap. chole in a diabetic with asymptomatic
cholelithiasis; Current indications for pre-op. ABX for a lap. chole. are: acute
cholecystitis, age>60 yoa, obstructive jaundice, CBD stones
All hepatic adenomas require resection because of the increased risk of
malignancy (10%); Tc99 scan is negative, cold nodule; no Kupffer cells;
definitely associated with OCP use; abdominal symptoms are common
FNH: central stellate scar; Tc99 hot, + Kupffer cells, possibly assoc. with OCPs,
tx. by stopping OCPs; no symptoms

31

Treatment of a type I (most common) choledochal cyst is by roux-en-Y

hepticojejunostomy and excision of the entire cyst (do not attempt a primary duct
anastomosis)
Hemobilia following hepatic injury suggests bleeding directly into the biliary
tract from a lacerated hepatic artery; the treatment of choice is angiography with
embolization
Hepatorenal syndrome: Cr>1.5, Cr clearance <40ml/min, no benefit from fluid
challenge, urine volume <500ml/day, urine Na<10, urine osmolarity>plasma
osmolarity
Primary sclerosing cholangitis (PSC): 4th leading indication for
transplant/unknown etiology/progressive liver failure>>>cirrhosis>>>portal
HTN/70% of cases occur in men/assoc. with chronic UC/onion skin changes on
biopsy are pathognomonic; ERCP for dx.
Hemangioma: Giant ones in kids>>>Kasabach-Merritt Syndrome: children
with a palpable abd. mass, high-output CHF and coagulapathy due to
sequestration of platelets and fibrinogen
Budd-Chiari Syndrome (BCS): The preferred therapy for acute and subacute
BCS is a side-to-side portocaval or mesocaval shunt; use TIPS for fulminant
hepatic failure (as a bridge to transplant); Usually see acute onset of ascites, with
high protein in it
Known risk factors for HCC are: HBV, ETOH cirrhosis, any cirrhosis,
aflatoxins, vinyl chloride, hemochromatosis (not primary biliary cirrhosis)
Kasai procedure: is most successful if performed before 3 months of age (b/c the
fibrosis is progressive with biliary atresia)
PEDIATRIC SURGER Y

Wilms tumor: occurs usually b/t 1-5 years old/primary therapy is surgical
resection/good overall prognosis/Bilateral Wilms>>>Bilateral nephrectomy with
safe renal transplant after 1 year/responds well to chemo./associated with the
WT1 tumor suppressor gene/ 3 syndromes: WAGR, Beckwith-Wiedeman and
Denys-Drash/ Tx. of Wilms is with resection for local control and chemo. (XRT
for advanced disease); staging: I: limited to kidney/complete resection, II: still
completely resected, extends beyond the kidney +/- capsular extension or
invasion, III: residual tumor in abdomen or tumor rupture or peritoneal implants +
(+) L.N.s, IV: hematogenous mets.>>>other organs; V: Bilateral renal
involvement; I,II: resection and chemo.; III,IV: resection and chemo and XRT;
All anaplstics: resection, chemo and XRT; if ?? unresectable>>neoadj. Chemo
and XRT>>>resection if shrinkage occurs
Neuroblastoma: neural crest origin; 40% from adrenal medulla, elevated HVA
and VMA (90% have this), increased ratio of VMA/HVA is good prognosis; dx.
Requires histologic confirmation by direct tumor biopsy; stage with CT of C/A/P,
bone scan>>classify into high, intermediate or low-risk groups at diagnosis; high
risk: >1 year old, stage III,IV, unfavorable histology, increased ferritin, increased
LDH, increased NSE; tx. of low risk>>surgery, high risk>>neoadjuvant chemo.
(with initial surgery for dx. and port placement only) with complete gross

32

resection reserved for a 2nd look procedure after chemo.; N- myc is a protoncogene seen in 30% of tumors
Omphalocoele: midline at umbilicus/covered with a peritoneal sac/ assoc. with
other congenital abnorm.s/ may contain eviscerated organs such as liver
Meckels diverticulum: caused by a persistent omphalomesenteric duct; can
contain gastric or pancreatic tissue; usually painless rectal bleeding ~2 yoa
Duodenal atresia: prenatal U/S reveals polyhydramnios with fetal distention of
stomach and duodenum; double-bubble on CXR>>do a BE to r/o microcolon +/obstructing meconium; assoc. with trisomy 21 in 30% of cases, 38% with
congential heart defects
Intussusception: repeated bilious vomiting usually in the 1st year of life; currentjelly stools; use abdominal U/S 1st to dx. (accuracy close to 100%); can dx and tx
with BE (30 cm above buttocks)
Gastroschisis: prolonged ileus at birth/ defect is lateral and to the right of the
umbilicus/no peritoneal sac/inflamm. peel from irritation by amniotic fluid/ only
rarely assoc. with congenital abnorms
Pneumatosis intestinalis: is never an indication to take a neonate to the OR for
NEC; portal venous gas, free air, a fixed and dilated bowel loop, abdominal
erythema and mass, bacteria in paracentesis fluid, uncontrolled persistent acidosis
and thrombocytopenia are all indications for Ex Lap.
NEC: Will almost always be presented with a neonate receiving enteral feedings
who becomes intolerant of feeds; prematurity plays a major role in the
development of NEC; most will survive without an operation with bowel rest,
systemic ABX and TPN
Testicular torsion: acute, severe onset of testicular pain assoc. with N/V without
a cremasteric reflex; must operate within 6 hours or risk testicular necrosis
Indications for ECMO: aADO2 diff.>610 for 8 hours; acute deterioration,
barotrauma, cardiac failure, does not stabilize on conventional therapy,
oxygenation index>40 for >2 hours; delayed CDH repair facilaited by ECMO
results in improved overall survival, reduction in pulmonary compliance after
surgical repair and decreased barotrauma
Neonates are obligate nose breathers
Thyroglossal duct cyst: Remnant of thyroglossal duct extending from the
foramen cecum of the tongue to thyroid isthmus; Always midline; +/- if it gets
infected; tx: Sistrunk procedure (complete excision of cyst including central
portion of the hyoid bone)
Urachus connects the bladder to the umbilica cord in utero and incomplete
closure at birth results in either a persistent fistula, draining sinus or urachal cyst;
tx. with I+D followed by elective complete cyst excision
ANESTHESIA

Nitrous (not nitric) causes peripheral neuropathies, megaloblastic anemia and

BM depression/ sevofluorane and enflurane produce fluoride ions and can cause
ARF/ Isoflurane can cause a coronary steal syndrome/ Halothane can cause a
halothane hepatitis, seen in middle age fat women/ pancuronium is a vagolytic/
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succinylcholine is a vagotonic/ Atracurium is metabolized by Hoffman

degradation (plasma pseudocholinesterase) and therefore does not affect the liver
or kidney
CO2 embolism: causes acute IVC obstruction; Increased CVP, PAP, CO with
decreased SBP with an abrupt decrease in ETCO2; put pt in left lateral decub.,
trendelenberg
Succinylcholine: depolarizing agent (only one); metabolized by plasma
pseudocholinesterase; acts on the Ach receptor
Ketamine: causes a dissociative state/ causes an increase in HR, SBP and CO
with bronchodilatation, increased CBF and increased O2 consumption/ should not
use in pts. with increased ICPs or uncontrolled CAD and HTN; does not depress
respiration; can cause acute intermittent porphiria; produces amnesia and
analgesia
Malignant hyperthermia: the earliest and most sensitive and specific sign is an
unexplained rise in the ET CO2; this is rapidly followed by tachycardia, PVCs,
hyperkalemia, increased CPK, mm. rigidity, respir. and metabolic acidosis,
cardiovascular collapse; known triggers are all inhalational agents and
succinylcholine; abnormal Ca release in skeletal mm. causes sustained mm.
contractures; tx: stop surgery, stop inhalational agents, 100% O2, protect the
kidneys from myoglobinuria and rhabdomyolysis, cool pt., IV dantrolene whichs
interferes with Ca release from the sarcoplasmic reticulum
All esters have only one I in their name; broken down to PABA, Very allergenic,
safer than amides, shorter half- life
MISCELLANEOUS

GI bleeding: technetium sulfur colloid scan: can detect a LGI bleed as low as 0.5
ml/min, but patient has to be actively bleeding/ tagged RBC scan detects at 1
ml/min and remains in circulation for up to 24 hours and therefore you can bring
the patient back and look again/ mesenteric angiography detects at 1ml/min; can
infuse vasopressin which stops the bleeding in about 85% of cases, however high
chance for re-bleeding within 48 hours
IMA>>>superior rectal artery; IIA>>>middle rectal artery; IIA>>>internal
pudendal>>>inferior rectal artery
Inguinal ligament is the most inferior part of the external oblique aponeurosis;
All hernias have a defect in the transversalis fascia;
Left vagus>>anterior>>hepatic branch; right vagus>>posterior>>celiac branch
and criminal nerve of Grassi
Ventral pancreas>>>uncinate process and inferior portion of head; dorsal
pancreas>>remainder of the pancreas; uncinate is to the left and behind the
portal vein and SMA, in front of the aorta and IVC, below and ventral to the left
renal vein
Give Vit. A to overcome steroid- induced healing impairment (25,000 IU/ml) or
GHRF or anabolic steroids
Arginine is a conditionally essential AA that promotes collagen deposition,
wound healing, immune function, NO production
34

Glutamine decreases the risk of infectious complications and increases nitrogen

balance overall
P. vera : primary has a low EPO, secondary has high EPO (physiologic response
to high altitude)
Arterial supply to the adrenal: superior adrenal artery (from inferior phrenic a),
middle adrenal artery (from aorta), and inferior n artery (from renal artery);
venous drainage is usually via 1 main vein; left adrenal vein>>>left renal vein;
right adrenal vein>>>IVC
Triglycerides are broken down into monglycerides and (2) FFAs which combine
with bile salts and fo rm micelles (single most important step in fat absorption);
micelles (FFAs, monglycerides, phospholipids, cholesterol, bile salts) are broken
up at the brush border and TGs are re-synthesized in the cells of the gut with
formation of chylomicrons which are absorbed by the lacteals and transported to
the thoracic duct>>bloodstreams
Metoclopramide is a DA antagonist, increases LES pressure, increases gastric
contraction, Ach augments release, used for delayed gastric
emptying/gastroparesis
Collagen: accumulates in the scar until 21 days, it shows up in a wound at day #3,
only fibroblasts before this, peaks at day #7; unique b/c of hydroxyproline which
requires ascorbic acid and oxygen; once in ECM, collagen cross- linking occurs;
inhibited by D-penicillamine and beta-aminopropionitrile
Endothelial cells, macrophages, neutrophils>>>L-arginine>>>NO converts GMP
to cGMP>>>causes PKC to dephosphorylate myosin light chains>>muscle
relaxation and vasodilation
IMA (internal thoracic artery): arises from the 1st portion of the subclavian
artery medial to the anterior scalene; posterior to the clavicle and one
fingerbreadth lateral to the border of the sternum; gives off anterior intercostals
and cutaneous branches and terminates as the musculophrenic and superior
epigastric arteries
Subclavian artery>>>Thyrocervical trunk>>>suprascapular artery 1st then
the transverse cervical artery, continuing on as the inferior thyroid artery
NaNitroprusside >>>NO>>>vasodilatation of both arterioles and venules;
decreased myocardial O2 consumption/increased HR/causes hypotension/cyanide
toxicity after 24-48 hours>>>severe lactic acidosis; tx. of cyanide toxicity is with
NaThiosulfate; use nipride for acute aortic dissection but must use with Bblocker concomitantly (decreased BP>>>inc reases contractility>>>worsens
dissection)
The most reliable independent predictor of a poor outcome after surgery is low
albumin (<2.6g/dl)
Pro-inflammatory cytokines: released by tissue macrophages: TNF and IL-1
(first wave)>>>IL-6 (second wave)
Splenic artery gives off: great pancreatic artery, left gastroepiploic and the dorsal
pancreatic artery>>>transverse pancreatic artery>>>caudal pancreatic artery
GDA/SMA>>>anterior and posterior pancreaticoduodenal arteries; inferior
pancreaticoduodenal artery is the first branch off of the SMA

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Busulfan and bleomycin>>pulmonary fibrosis; cyclophosamide >>hemorrhagic

cystitis (can prevent with mesna); dacarbazine and nitrosourea>>can enter CSF
b/c they are lipophilic; cisplatin>>peripheral neuropathy; mithramycin>>platelet
dysfxn., decreases clotting factors; doxorubicin (adriamycin)>>cardiomyopathy,
dose limit is 550 mg/m2, causes red urine (this is not blood); L-asparaginase>>
hepatotoxicity
Etoposide inhibits topoisomerase II; topotecan inhibits topoisomerase I; use
tretinoin to treat pro- myelocytic leukemia (M3)
1st lumbar nerve root>>>lumbar plexus>>>ilioinguinal nerve>>>travels under
the aponeurosis of the external oblique>>>superficial inguinal ring>>>supplies
sensation to the inguinal region, inner aspect of the scrotum, medial part of thigh
1st and 2nd lumbar roots>>>genitofemoral nerve>>mainly sensory; genital
branch supplies sensation to the skin and scrotum, medial thigh; femoral
branch>>>sensation to the anterior thigh
T8 level of diaphragm>>>IVC and phrenic pass through together; T10
level>>>esophagus and vagus; T12 level>>>aorta, azygous and thoracic duct
Neuroleptic malignant syndrome: usually presented with a pt. on a vent. Who
gets haldol for agitation; this is then followed by fevers, HTN, muscle rigidity and
obtundation; centrally mediated process probably due to an imbalance of DA; tx:
dantrolene and bromocriptine
PPV=a/a+b (TP/TP+FP); NPV=d/d+c (TN/TN+FN); sensitivity=a/a+c,
specificity=d/d+b; prevalence=a+d/a+b+c+d; RR=sens./specif.; s d= square root
of the variance; SEM=sd/sq.rt.of n; ANOVA is used for comparison b/t the
means of >3 variables
Nerves: axillary>>C5-6>>ABD shoulder; musculocut>>C5-6>>FLEX elbow;
radial>>C6-8>>EXT thumb; median>>C6-T1>>FLEX thumb interph. Joint;
ulnar>>C7-T1>>ABD index finger; femoral>>L2-4>>EXT knee; Obtur>>L24>>ADD hip; sup. Gluteal>>L5>>ABD hip; Inf. Gluteal>>S1>>EXT hip; Sciatic
(tibial)>>L4-S3>>plantar flexion of toe and ankle; Sciatic (deep peroneal)>>L4S2>>dorsiflexion of toe

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