Marchese ABSITE Review Book

Adrenal Glands
Anus
Aorta
Appendix
Bariatric Surgery
Biliary System
Breast
Cardiac
Coagulation
Colon & Rectum
Cutaneous Neoplasms
Endocrine Pancreas
Esophagus
Exocrine Pancreas
Hematology
Hernias
Liver
MEN Syndromes
Parathyroid Glands
Pediatric Surgery
Peripheral Arterial Disease
Plastic Surgery
Small Intestine
STS
Spleen
Stomach
Surgical Critical Care
Thoracic
Thyroid
Transfusion
Transplantation
Trauma
 Adrenal Glands
Embryology
 Cortex = mesoderm, medulla = ectodermal tissues of neural crest
Anatomy
 Arterial supply → superior adrenal from inferior phrenic / middle adrenal
from aorta / inferior adrenal from renal
 Venous drainage → L adrenal vein (2cm) drains into L renal vein after
joining the inferior phrenic vein, R adrenal vein (0.5 cm) drains into IVC
 Cortex → zona glomerulosa, zona fasciculate and zona reticularis
 Medulla → w/ chromaffin cells
Steroid Hormones Physiology
 Mineralocorticoids → aldosterone from zona glomerulosa stimulated by
angiotensin II & K+ levels, regulates volume & Na+ levels
 Glucocorticoids → CRF (from hypothalamus) stimulates ACTH (from
anterior pituitary) which stimulates glucocorticoid secretion from zona,
induces catabolic state / increases blood glucose
 Adrenal sex steroids → DHEA from zona reticularis stimulated by ACTH,
weak physiologic effects compared to gonadal sex steroids
Catecholamine Physiology
 Synthesized in adrenal medulla, rate limiting step is conversion of tyrosine to
L-dopa by tyrosine hydroxylase, NE converted to EPI by PMNT (exclusive to
chromaffin cells), degradation by COMT & MAO to VMA (excreted in urine)
Adrenal Insufficiency
 Primary due to autoimmune > infectious causes (e.g. tuberculosis) vs.
secondary due to ACTH deficiency (e.g. chronic exogenous glucocorticoid
use), Dx w/ AM cortisol / ACTH (cosyntropin) stimulation test / AM serum
ACTH (increased ACTH assoc. w/ primary vs. decreased ACTH assoc. w/
secondary adrenal insufficiency), Rx w/ mineralocorticoid (fludrocortisone)
& glucocorticoid replacement
Primary Hyperaldosterism
 Due to adrenal hyperplasia > aldosteronoma, p/w hypertension &
hypokalemia, Dx w/ aldosterone : renin ratio > 20 / increased plasma
aldosterone level, localize w/ CT / adrenal vein sampling to localize lesion,
Rx w/ laparoscopic adrenalectomy, check plasma aldosterone on POD#1 to
assess for cure
Cushing Syndrome
 Due to exogenous glucocorticoid use > Cushing disease (ACTH-secreting
pituitary adenoma) > primary adrenal Cushing syndrome / ectopic ACTH,
p/w obesity/ bruising / weakness/ HTN / hirsutism / amenorrhea /
decreased bone density (not improved after adrenalectomy), Dx w/24 hour
urine free cortisol / low-dose dextamethasone testing followed by ACTH 
undetectable ACTH = primary adrenal Cushing syndrome vs. detectable
ACTH = Cushing disease (suppression occurs w/ high-dose dexamethasone)
vs. ectopic ACTH syndrome (suppression does not occur w/ high-dose
dextamethasone)
Adrenocortical Carcinoma
  >50% of adrenocortical carcinoma are functional (p/w Cushing syndrome >
virilization), Dx w/ CT (heterogeneous mass w/ irregular borders / central
necrosis / hyperattenuation / delayed [<50%] washout), Rx w/ open
adrenalectomy w/ en bloc resection of adj. organs, adjuvant Rx w/ mitotane
Pheochromocytoma
 Assoc. w/ MEN IIA / IIB / VHL / NF-1, 10% bilateral / 10% malignant
(presence of metastasis) / 10% extra-adrenal / 10% familial, p/w HTN /
diaphoresis / palpitations, Dx w/plasma free metanephrines / 24-hr urine
metanephrines, localization via CT/ MRI / MIBG, Rx w/ resection w/
preoperative  adrenergic blockers (phenoxybenzamine)   blocker/
aggressive intraoperative volume replacement, postoperative complication =
hypoglycemia
Incidentaloma
 Dx w/ serum biochemical panel / adrenal protocol CT, Rx w/ adrenalectomy
if functional / >4 cm / growth >1 cm on repeat imaging, Rx w/ Bx if concern
for metastasis only once pheochromocytoma has been ruled out to avoid
HTN crisis (most common primary = lung > breast / melanoma)

Anus
Anatomy
 Anal canal  extends from distal rectum to anal verge (4cm in length),
dentate line marks transition from columnar to squamous cells
 Anal margin  extends beyond anal verge to perianal skin
 Internal sphincter  continuous w/ circular muscle of rectum, innervated
by autonomic nervous system w/ involuntary control
 External sphincter  continuous w/ puborectalis & levator ani, innervated
by pudendal nerve w/ voluntary control
 Vascular supply  inferior rectal artery
Anal Incontinence
 Rx w/ fiber / bulking agents / loperamide / biofeedback, operative Rx w/
sphincteroplasty / sacral nerve stimulator / colostomy
Rectal Prolapse
 Assoc. w/ female sex, age > 40, multiparity, vaginal delivery, p/w protrusion
of concentric rings, Rx w/ perineal (old patient / lower complication rate /
higher recurrence) vs. abdominal (young patient / high complication rate /
lower recurrence) approach
Rectocele
 P/w prolapse of anterior rectal wall into vagina, dx w/ defecography, Rx w/
fiber supplementation, operative repair w/ mesh and levatorplasty
Hemorrhoids
 Located in the left lateral / right anterior / right posterior positions, p/w
protrusion of radial rings, external hemorrhoids are distal to dentate line &
painful vs. internal hemorrhoids are proximal to dentate line & painless
(grades I – IV), Rx w/ fiber / stool softeners / sitz baths, Rx thrombosed
 external hemorrhoids w/ excision if < 72 hrs vs. incision if > 72 hrs, Rx grade
I / II internal hemorrhoids w/ band ligation (risk of perineal sepsis) vs. grade
III / IV w/ hemorrhoidectomy (closed vs. open), most common complication
of hemorrhoidectomy = urinary retention due to pelvic floor muscle spasm
Anal Fissures
 Due to split in posterior midline anoderm (lateral location assoc. w/ HIV /
IBD / malignancy), assoc. w/ passage of hard stool, Rx w/ Ca2+ channel
blockers / topical NO / botulinum injection (most effective non operative
technique), operative Rx w/ right LIS in patients w/ hypertensive sphincter
(risk of incontinence) vs. fissurectomy in patients w/ hypotensive sphincter
Anorectal Abscess
 Locations = perianal / intersphincteric / supralevator / iscioanal, Rx w/
incision and drainage + Abx in immunocompromised patients, Rx horseshoe
abscess (circumferential spread) w/ Hanley procedure
Fistula in Ano
 Parks classification  type I = intersphincteric (most common), type II =
trans-sphincteric, type III = suprasphincteric, type IV = extrasphincteric,
Goodsall’s rule = anterior fistulas drain in straight line, posterior fistulas
drain toward midline internal opening in curved fashion, Rx simple/low
fistulas w/ fistulotomy vs. complex/high fistulas w/ extensive sphincter
involvement w/ seton placement ± endoanal advancement flap / fibrin glue /
fistula plug, ligation of intersphincteric fistula tract is novel new technique
Rectovaginal Fistula
 Assoc. w/ obstetric trauma (most common) / IBD / rectal Ca / radiation, Rx
low fistula w/ advancement flap vs. high fistula w/ transabdominal repair, Rx
radiation induced fistula w/ colostomy
Solitary Rectal Ulcer Syndrome (SRUS)
 Benign process due to internal intussusception fro straining, p/w
hematochezia / anorectal pain / mucus discharge w/ single or multiple
ulcers, Rx w/ biopsy to r/o Ca / HFD / biofeedback
Anal Canal Neoplasms
 SCC  Rx w/ Nigro protocol (5-FU / mitomycin C & XRT), Rx recurrent
disease w/ APR
 Adenocarcinoma  Rx T1 lesions / <3 cm / occupying < 40% of lumen
circumference / located < 8 cm from anal verge w/ transanal excision, Rx all
other lesions w/ APR + chemo-XRT
 Melanoma  poor prognosis, Rx w/ WLE > APR (extent of surgery does not
correlate w/ long-term outcomes)
Anal Margin Neoplasms
 Condyloma acuminatum  assoc. w/ HPV 6/11/16/18, Rx w/ podophyllin
/ trichloroacetic acid / 5-FU / imiquimod / electrocauterization
 Verrucous carcinoma  giant condyloma accuminatum, Rx w/ WLE
 SCC  Rx w/ WLE (< 5cm) vs. chemoradiation (>5 cm)
 BCC  p/w central ulcer w/ raised edges, Rx w/ WLE
  Paget disease  p/w pruritus, assoc. w/ underlying visceral malignancy,
requires workup w/ colonoscopy & abdominal CT
Radiation Proctitis
 P/w rectal bleeding, Rx w/ sucralfate enemas / formalin / argon plasma
coagulation
Pilonidal Disease
 Occurs in young men at midline of sacrococcygeal region, Rx acute disease
w/ I&D lateral to the intergluteal cleft, Rx chronic disease w/ excision &
primary closure, rhomboid flap closure may be required in recurrent disease
Hidradenitis Suppurativa
 Assoc. w/ occlusion of apocrine glands by bacteria, p/w nodules & fibrosis,
can mimic complex anal fistula, confined to anal verge, Rx w/ weight loss /
local hygiene, may require I&D / excision of sinus tracts

Aorta
Thoracic Aortic Aneurysm
 Ascending thoracic aortic aneurysm  often due to connective tissue
abnormalities (e.g. Marfan syndrome), often asymptomatic but can p/w
compression of RLN / esophagus / bronchi, Rx acutely symptomatic & >5.5
cm, death due to aortic insufficiency / pericardial tamponade
 Descending thoracic aortic aneurysm (thoracoabdominal)  Rx w/
TEVAR (>5.5 cm) vs. open (>6.5 cm), TEVAR assoc. w/ decreased early & late
mortality compared to open repair, major complication = spinal cord
ischemia (decreased w/ endovascular repair & w/ reimplantation of
intercostal arteries during open repair)
Abdominal Aortic Aneurysm
 RF = tobacco / male gender / HLD / HTN, RF for rupture = aneurysm
diameter / growth rate of >1 cm/year, screening w/ one-time US in men @
age 65, Dx w/ CTA, medical Rx w/ smoking cessation (most effective) / β-
blocker / statin / ASA, surgical Rx (>5.5 cm / growth rate >1 cm/year) w/
open AAA vs. EVAR (neck length >15 mm / neck diameter >30 mm / neck
angulation <60° / CIA length >10 mm / CIA diameter 8-18 mm), EVAR assoc.
w/ decreased early mortality compared to open repair but no difference in
late mortality
Thoracoabdominal Aneurysm
 Less common, occurs in older patients w/ extensive atherosclerosis, 30%
asymptomatic, Rx symptomatic patients w/ open vs. EVAR, complications =
paraplegia / renal failure
Aortic Dissection
 Defect in intimal layer leads to false lumen between media & adventitia,
assoc. w/ Marfan syndrome / HTN / pregnancy, DeBakey classification =
type I (ascending & thoracoabdominal aorta), type II (ascending aorta), type
 III (descending aorta), Stanford classification = type A (any involvement of
ascending aorta), type B (no involvement of ascending aorta), p/w acute
onset of chest pain radiating to the back, Rx type A w/ emergent open repair
(median sternotomy), Rx type B w/ medical mgmt. + TEVAR (promote
thrombosis of false lumen & aortic remodeling) vs. open repair
(posterolateral thoracotomy) , death due to aortic valve insufficiency /
rupture w/ cardiac tamponade
Aortoiliac Occlusive Disease (AIOD)
 P/w claudication > rest pain / tissue loss, Dx w/ CTA, Rx w/ endovascular vs.
open repair (aortofemoral/ iliofemoral / femoral-femoral / aortoiliac
endarterectomy / axillofemoral = high risk patients)
 Leriche syndrome  due to lesion at aortic bifurcation, p/w decreased
femoral pulses / buttock claudication / impotence, Rx w/ aorto-bifemoral
bypass
Complications of Endovascular Surgery
 Endovascular surgery assoc. w/ increased number of reinterventions
compared to open surgery
 Endoleaks  type IA/B = proximal / distal graft attachment sites  Rx w/
extension cuffs, type II = patent lumbar collaterals  Rx w/
angioembolization, type III = overlap sites  Rx w/ secondary endograft,
type IV = graft porosity  observation, type V = expansion of aneurysm
without evidence of leak (endotension)  repeat EVAR
Complications of Open Surgery
 CAD = #1 cause of early mortality / renal insufficiency = #1 cause of late
mortality / pulmonary dysfunction / abdominal wall hernia / graft limb
thrombosis / anastomotic pseudoaneurysm (sterile vs. infected 
distinguished by Tc99m WBC scan) / aortic graft infection (MCC =
staphylococcus epidermidis, Rx w/ removal of infected graft & extra-
anatomic reconstruction) / aortoenteric fistula (p/w herald GI bleed, Dx w/
CT, Rx w/ removal of infected graft & extra-anatomic reconstruction)

Appendix
Embryology
 Midgut organ, originates as out pouching of cecum at 8th week
 Mucosa  columnar epithelium / neuroendocrine cells / mucin-producing
goblet cells, submucosa  lymphoid tissue
Anatomy
 Arterial supply  SMA  ileocolic artery  appendiceal artery (located in
the mesoappendix)
 Appendix located at the convergence of the taeniae coli at base of cecum
 Tip location variable  retrocecal (60%) > pelvic (30%) > retroperitoneal
(10%)
Pathophysiology of Appendicitis
 Obstruction of the proximal lumen (e.g. fecalith in adult or lymphoid
hyperplasia in child)  elevated pressure due to ongoing mucus secretion &
bacterial overgrowth  progressive distention leads to impairment of
venous drainage  mucosal ischemia  perforation (abscess / peritonitis)
Presentation
 Anorexia / nausea / diarrhea are common symptoms
 Distension of appendix responsible for initial periumbilical pain (visceral),
tip inflammation & irritation of parietal peritoneum responsible for RLQ pain
(somatic)
 Rovsing sign  RLQ pain on palpation of LLQ
 Obturator sign  RLQ pain on internal rotation of the hip (pelvic appendix)
 Psoas sign  pain w/ extension of the ipsilateral hip (retrocecal appendix)
Acute Uncomplicated Appendicitis
 Rx  prompt appendectomy w/ perioperative Abx
Perforated Appendicitis
 Assoc. w/ male sex / increasing age / 3 or more medical comorbidities
 Rx  prompt appendectomy w/ continuation of postoperative antibiotics ±
operative drain placement
 Patients w/ delayed presentation may be treated non operatively w/ IV Abx
± percutaneous drain placement, w/ outpatient colonoscopy to rule out
malignancy ± interval appendectomy
Appendicitis in Pregnant Patient
 Assoc. w/ increased risk of preterm labor and fetal loss, dx w/ US / MRI,
perform laparoscopic technique regardless of trimester
Presumed Appendicitis
 Still perform appendectomy (prevents future confounding diagnosis)
Neoplasms of the Appendix
 Carcinoid tumor  size predicts malignant potential, size > 2cm w/
involvement of the base require R hemicolectomy
 Adenocarcinoma  Rx w/ R hemicolectomy w/ regional lymphadenectomy
& FOLFOX
 Mucinous tumors  rupture results in pseudomyxoma peritonei

Bariatric Surgery
Overview
 Severe obesity defined as BMI > 40, obesity defined as BMI > 30
 Ghrelin (hunger hormone) produced in gastric fundus stimulates release of
neuropeptide Y and GH from the hypothalamus
 Metabolic syndrome includes DM2, HLD and HTN, occurs in patients with
central body obesity
Medical vs. Surgical Rx
 Medical therapy for severe obesity has limited short / long-term success
  Level 1 evidence shown in accumulated RCTs shows that bariatric surgery is
superior to medical therapy for treatment of DM2
 SOS study (Swedish Obese Subjects) demonstrated 80% decrease in annual
mortality of diabetic individuals in surgical weight loss group versus
matched control patients, also found fasting hyperinsulinemia (not BMI) was
predictive of positive bariatric surgery results in overall mortality, CV evens
and incidence of diabetes
 Despite limited success with medical Rx, severely obese patients need to be
given the chance to comply with a comprehensive weight loss intervention
prior to undergoing surgery
 Pharmacologic therapy includes phentermine (decreases appetite) and
orlistat (inhibits pancreatic lipase), these drugs have not been proven to be
effective alone in the severely obese patient
Mechanism of Action of Bariatric Surgery
 Restrictive (LAGB and LSG) and malabsorptive (RYGB, BPD and DS)
 Restrictive operations  decrease in appetite and induction of satiety center
triggered by stretch receptors in the proximal stomach via vagal feedback
 RYGB  small gastric pouch with restrictive components, as well as changes
in the enteroencephalic endocrine axis (decreased postoperative levels of
Ghrelin among other GI hormones)
 RYGB also has an effect on beta cell function independent of weight loss
(thought to be secondary to increased incretin stimulation that occurs from
bypassing the duodenum, incretin increases beta cell proliferation and
insulin secretion)
 Alteration of gut microbiome after RYGB might also lead to long-lasting
metabolic benefits
Preoperative Evaluation and Selection
 Eligibility: BMI > 40 or BMI > 35 with associated medical comorbidity, failed
dietary plan, psychiatric stability, knowledgeable about the operation and
motivated individual
 Contraindications to LAGB include cirrhosis, portal HTN, IBD and need for
chronic administration of steroids
Preoperative Preparation
 Preoperative and postoperative use of LMWH is associated with significantly
lower rates of VTE compared to SQH (Michigan Bariatric Surgery
Collaborative)
 Mechanical prophylaxis with early ambulation and SCDs should also
employed
 Level 1 evidence shown in accumulated RCTs shows that bariatric surgery is
superior to medical therapy for treatment of DM2
Operative Procedures
 Vertical banded gastroplasty  historical purposes only, band non-
adjustable
 Laparoscopic adjustable gastric banding  posterolateral aspect of
fundus most likely to hernia through the band
  Roux-en-Y gastric bypass  small gastric pouch, jejunum is divided 30 to
40cm distal to the ligament of treitz with a roux limb of at least 75cm (longer
roux limb used in patients with greater BMI), internal hernia incidence
reduced by an antecolic Roux limb and closure of the mesenteric defect in the
jejunojejunostomy
 Bilipancreatic diversion  proximal end of the ileum is anastomsed to the
stomach after a distal hemigastrectomy is performed, ileum proximal to the
end that is anastamosed to the stomach is in turn anastomosed to the
terminal ileum within 50 cm from the ileocecal valve (common channel)
 Duodenal switch  developed to lessen the high incidence of marginal
ulcers seen after BPD, common channel is 100cm, sleeve gastrectomy
performed (vs hemigastrectomy in BPD), duodenum is divided 2 cm beyond
the pylorus and duodenoileostomy is performed, a two-staged DS can be
performed in patients with extremely high BMI to decrease morbidity (sleeve
gastrectomy = 1st stage)
RYGB BPD DS

 Laparoscopic sleeve gastrectomy  greater curvature taken down leaving

intact tissue within 3cm of the pylorus up to the angle of His, vitally
important to preserve left gastric vessels for lesser curve blood supply
Post operative care and follow-up
 Post operative leak  tachycardia is often the only manifestation, CT scan
with PO contrast can be used for diagnosis
 After RYGB, the risk for iron, folate, vitamin A, vitamin D or vitamin B12
deficiency exists for life
Results
 EWL of 70% after BPD/DS is the highest of the bariatric operations
 LSG with lower EWL vs. RYGB (65% vs. 60%) but fewer serious
complications
Complications
 Laparoscopic adjustable gastric banding  slipped band is most common
(decreased incidence with the pars flaccida technique) associated with an
increased phi angle on x ray (normal between 4-58°), erosion of the band is
less frequent but also requires operative intervention
 Roux-en-Y gastric bypass  leaks from GJ most common (however leak rate
is low, 0.5% of patients), patients with SBO after RYGB require reoperation
 (internal hernia), GJ stenosis can manifest 4-6 weeks postop (rx w/ balloon
dilatation), marginal ulcers (rx w/ PPI), iron deficiency occurs more
commonly than B12 deficiency
 Laparoscopic sleeve gastrectomy  malabsorption of vitamins is much less
common compared to RYGB or DS, however leaks are more common than
RYGB and are more difficult to treat (1% of patients)
 BPD  most signigicant and specific long-term complication is protein
malnutrition (12% of patients) sometimes requires lengthening of common
channel, diarrhea is common, fat soluble vitamin deficiency, marginal ulcers
which has been addressed with DS modifcation preserving the pylorus
Investigational bariatric procedures
 Gastric stimulation devices, vagal blockade, endoscopic incisionless surgery
(specifically in patients after RYGB with dilated GJ) and endoscopic
placement of plastic sleeve to prevent nutrient exposure to the duodenum
(decrease the anti-secretin effect)
 RYGB, LSG and LAGB as surgical treatment for diabetes in patients with a
BMI of 30 to 35

Biliary System
Anatomy
 Gallbladder  w/ neck / infundibulum / body / fundus, blood supply via
cystic artery (branch of R hepatic)
 Cystic duct  drains GB into CBD, w/ spiral valves of Heister
 CBD  originates from common hepatic duct after takeoff of cystic duct and
extends to ampulla of Vater, bloody supply via 3- & 9-o’clock positions from
pancreaticoduodenal / gastroduodenal / R hepatic / cystic arteries
 Foramen of Winslow  CBD anterolateral, hepatic artery anteromedial,
portal vein posteriorly
 Variations in biliary anatomy present in 30% of patients
Physiology
 GB stores & concentrates bile via active resorption of NaCl and passive
resorption of H20, GB contraction mediated by CCK & vagal inputs (fed state)
/ motilin (fasted state) / sphincter of Oddi relaxation mediated by CCK,
secretion of bile mediated by secretin
Calculous Biliary Disease
 Cholelithiaisis  cholesterol stone formation assoc. w/ increased
cholesterol / decreased lecithin / decreased bile salt, pigment stone
formation assoc. w/ breakdown of hemoglobin
 Biliary colic  due to resolved blockage of cystic duct
 Acute cholecystitis  due to unresolved blockage of cystic duct w/
resultant stasis and infection, Dx w/ US / HIDA, Rx w/ laparoscopic
cholecystectomy vs. PCT in non-surgical candidates
 Chronic cholecystitis  assoc. w/ Rokitansky-Aschoff sinuses
  Emphysematous cholecystitis  due to C. perfiringens, p/w gas within GB
wall, Rx w/ percutaneous cholecystostomy
 Choledocholithiasis  primary stones (brown stones due to bacterial
infection of CBD) vs. secondary stones (cholesterol stones from GB, more
common), Dx w/ US / MRCP, Rx w/ ERCP (complication rate of 10%) +
cholecystectomy, if ERCP fails  laparoscopic (flushing w/ transcystic 
choledochotomy  transduodenal) / open CBD exploration w/ T-tube
placement
 Acute cholangitis  ascending bacterial infection (E. coli > Klebsiella), p/w
Charcot triad (RUQ / jaundice / fevers) & Reynolds’ pentad (Charcot triad +
AMS / hypotension), Rx w/ Abx + ERCP
 Gallstone pancreatitis  Rx w/ supportive therapy ± ERCP, w/
cholecystectomy during same admission
 Biliary dyskinesia  Dx w/ CCK-stimulated HIDA  EF < 30% @ 20
minutes, Rx w/ cholecystectomy
 Mirizzi syndrome  stone in GB neck compresses common hepatic duct,
can cause cholecystocholedochal fistula, Rx w/ cholecystectomy
 Gallstone ileus  GB fistualizes to duodenum, p/w SBO due to stone
impaction in distal ileum w/ pneumobilia, Rx w/ proximal enterotomy w/
stone removal w/ future operation for cholecystectomy
 Recurrent pyogenic cholangitis  due to intrahepatic obstructing brown
stones w/recurrent infection /cholangitis & eventual cirrhosis, occurs in
Asian population, Rx w/ stone removal & Roux-en-Y hepaticojejunostomy
 Hydrops of gallbladder  due to stone impacted in cystic duct, leads to
accumulation of mucus, Rx w/ cholecystectomy
 Cholesterolosis  due to accumulation of cholesterol in macrophages of GB
mucosa, p/w strawberry gross appearance
 Adenomyomatosis  hypertrophy of GB smooth muscle & mucosa
Noncalculous Biliary Disease
 Acute acalculous cholecystitis  due to biliary stasis, assoc. w/ critical
illness / TPN, Rx w/ PCT
 Primary sclerosing cholangitis  men > women, assoc. w/ UC / p-ANCA,
p/w dilations / strictures of intra- & extrahepatic biliary tree, risk of
cholangiocarcinoma (check CA 19-9), Rx w/ liver TXP
 Primary biliary sclerosis  w/ anti-mitochondrial antibodies
 Choledochal cysts  assoc. w/ long common channel resulting in efflux of
pancreatic secretions into biliary tree, Todani classification (type I = fusiform
dilatation, type II = diverticulum, type III = choledochocele, type IV = intra- &
extrahepatic dilatation, type IV = Caroli disease), w/ increased risk of
cholangiocarcinoma, Rx w/ surgical excision and reconstruction
 Gallbladder polyps  dx w/ US, cholesterol polyps are multiple & < 1 cm,
adenoma polyps are singular & > 1 cm, size > 10mm = RF for
adenocarcinoma / indication for cholecystectomy
Postcholecystectomy Complications
  Bile duct injury  due to visual misinterpretation of biliary anatomy, IOC
does not decrease incidence of BDI but increases early recognition, Rx
injuries <50% w/ T-tube vs. >50% w/ biliary-enteric anastomosis
(hepaticojejunostomy)
 Biliary leak  due to cystic or duct of Luschka leak, Dx w/ US / CT
demonstrating biloma, Rx w/ percutaneous drainage & ERCP w/ stenting
 Lost stone  cause chronic abscesses, Rx w/ laparoscopic stone retrieval
 Retained stone  secondary CBD stones can be identified up to 2 years
after cholecystectomy, Rx w/ ERCP
Malignant Biliary Disease
 Gallbladder carcinoma  assoc. w/ gallstones > 3cm, occurs in women >
men during 7th decade, papillary subtype = best prognosis, Rx w/
cholecystectomy (T1a lesions w/ no muscle involvement), extended
cholecystectomy w/ drainage of lymph node basins (T1b lesions),
cholecystectomy w/ segment IVB & V liver resection (T2/3 lesions), ± port
site excision, R0 resection is most important prognostic factor
 Cholangiocarcinoma  assoc. w/ UC / PSC / choledochal cysts / recurrent
pyogenic cholangitis / OCPs / cigarette use, occurs in men > women during
5th decade, nodular subtype = most common / papillary = best prognosis,
p/w painless jaundice, Rx distal cholangiocarcinoma w/
pancreaticoduodenectomy vs. proximal cholangiocarcinoma (Bismuth
classification) w/ common duct resection / cholecystectomy / hepatic
resection & reconstruction w/ Roux-en-Y hepaticojejunostomy vs. locally
unresectable disease without lymph node involvement w/ liver TXP, R0
resection is most important prognostic factor
Hemobilia
 Due to iatrogenic injury during laparoscopic cholecystectomy / trauma, p/w
UGI bleed / RUQ pain / jaundice, assoc. w/ arterial pseudoaneurysm, Rx w/
angiographic embolization

Breast
Anatomy / Physiology
 Breast lies between subdermal adipose tissue & superficial pectoral fascia
and is composed of glandular epithelium / fibrous stroma / adipose tissue
 Vascular supply via internal / lateral thoracic, intercostal & thoracoacromial
arteries
 Lymphatic flow directed to axillary nodes w/ three levels defined by
relationship to pectoralis minor  level 1 = lateral, level II = posterior, level
III = medial
 Long thoracic n. innervates serratus anterior, thoracodorsal n. innervates
latissimus dorsi, intercostal brachial n. provides sensation to medial arm
(most commonly injured during SLNB/ ALND)
 Suspensory ligaments of Copper provide structural support (infiltration by
CA results in skin retraction)
  Prolactin (anterior pituitary) triggers lactation, oxytocin (posterior pituitary)
triggers expulsion of milk
 Batson plexus  valveless veins, implicated
Abnormal Anatomy / Physiology
 Mastodynia  Rx w/ danzol (evidence based) / primrose oil / caffeine
cessation
 Accessory breast tissue  can occur from axilla (most common location) to
groin
 Fibrocystic change due to exaggerated response of breast epithelium /
stroma to hormones, p/w cyclic breast pain / nodularity / nonspontaneous
bilateral “greenish” discharge, not a risk factor for breast CA
 Gynecomastia  pubertal hypertrophy = teenage boys vs. senescent
hypertrophy = adults w/ medications (e.g. digoxin / thiazides / estrogens) or
underlying disease (e.g. cirrhosis / renal failure), w/ elevated estrogens /
decreased androgens, Rx w/ observation
 Galactocele  milk-filled cyst, occurs after cessation of lactation, Rx w/
needle aspiration, can be complicated by milk fistula  Rx w/ observation /
surgical excision
Gail Model
 Multivariate analysis that incorporates age / age at menarche / age at 1st live
birth / family history of breast cancer / number of breast biopsies to
estimate breast cancer risk
Breast Imaging
 Mammography  annual screening recommended for women older than
40, BI-RADS classification determines degree of suspicion for mammographic
abnormalities
 MRI  annual screening recommended for women age 30 w/ lifetime risk
for breast CA >25% or age 25 in patients w/ hereditary breast cancer
syndromes (e.g. BRCA)
 US  can aid in the diagnosis of a palpable mass in young patient (>30 years)
Breast Biopsy
 Fine needle aspiration  mostly historical, provides cytologic information
but cannot differentiate noninvasive from invasive lesions
 Core needle  can be performed w/ mammographic (stereotactic) / US /
MRI guidance
 Excisional  indicated when core needle biopsy is inconclusive or
disconcordant w/ imaging studies / w/ ADH / ALH / radial scar seen on core
(20% chance of upstage on excisional biopsy) / w/ cellular fibroadenoma on
core (risk of phyllodes tumor)
Benign Breast Disease
 Breast cysts  Dx / Rx w/ US aspiration (straw–colored fluid), no malignant
potential
 Fibroadenoma  most common breast mass in patients < 30, benign, p/w
mobile / rubbery mass that fluctuates w/ menstrual cycle, Dx w/ US /
 mammogram, Rx w/ reassurance or enucleation / excision if large /
symptomatic (giant fibroadenoma > 5cm)
 Lactational mastitis  due to Staph. aureus, Rx w/ frequent breast feeding
± Abx, can develop abscess requiring aspiration or operative drainage
 Periductal mastitis  occurs in women who are not lactating, due to mixed
infection, assoc. w/ DM & smoking, Rx w/ warm soaks / Abx, can develop
abscess Rx w/ aspiration / operative drainage, Rx repeat infections w/
excision of subareolar duct complex
 Intraductal papilloma  assoc. w/ bloody nipple discharge, Dx w/
ductogram, Rx w/ excision
 Sclerosing adenosis  proliferation of stromal tissue w/ Ca2+ deposition,
mammogram findings indistinguishable from microcalcifications of
intraductal carcinoma, benign finding
 Radial scar  w/ central sclerosis & spiculations, Rx w/ excisional biopsy to
r/o CA
 Fat necrosis  palpable mass w/ calcifications from trauma to breast,
benign finding
 Mondor's disease  superficial vein thrombophlebitis of breast (lateral
thoracic vein), p/w acute onset painful palpable cords, Rx w/ NSAIDs
Breast Cancer Risk Factors
 Increasing age, personal or family history of breast CA, histologic
abnormalities (e.g. DCIS / LCIS / ADH / ALH), BRCA1/2 mutation (approx.
50% lifetime risk), reproductive factors (e.g. early menarche / late
menopause), exogenous hormone use (e.g. OCPs / HRT)
 BRCA1 vs. BRCA2  AD w/ incomplete penetrance, BRCA1 w/ increased
risk of breast & ovarian malignancy / ER- tumors, BRCA2 w/ increased risk
of male breast CA / pancreatic & prostate CA / ER+ tumors; Rx w/
prophylactic mastectomy & BLSO in women
Breast Cancer Staging
 T  Tis = carcinoma in situ, T1 = <2 cm, T2 = 2-5 cm, T3 = > 5cm, T4 =
extension to chest wall
 N  N1 = 1-3 axillary nodes, N2 = 4-9 axillary noes, N3 = >10 axillary nodes
or single infraclavicular node
 M  M1 = distant detectable metastases (bone > lung > liver)
Noninvasive Epithelial Cancer
 LCIS  RF for the development of CA in either breast (20%), without
findings on mammogram, Rx w/ close observation / excisional biopsy (does
not require margins) / chemoprevention w/ tamoxifen / bilateral
mastectomies, pleomorphic LCIS = aggressive subtype  Rx w/ excision w/
1 mm margin (similar to DCIS)
 DCIS  risk of malignant transformation, pathologic subtypes = papillary /
cribriform / solid / comedo, Dx w/ microcalfications on mammogram, Rx w/
excision w/ 1mm margin + postop XRT, SLNB only in patients undergoing
mastectomy (indicated in patients w/ extensive DCIS), tamoxifen in young
patient’s w/ ER+ / comedo subtype DCIS
Invasive Epithelial Cancer
 Invasive lobular  less common form of breast CA, increase risk of bilateral
/ multifocal disease, Rx w/ BCT vs. mastectomy
 Invasive ductal  most common form of breast CA, Rx w/ BCT vs.
mastectomy
Mixed Epithelial & Connective Cancer
 Phyllodes tumor  benign vs. malignant determined by mitoses per HPF,
Rx w/ surgical excision w/ 1 cm margin, metastasis via hematogenous
spread (no need for lymph node evaluation), most common site of spread =
lung
 Lymphangiosarcoma  due to chronic lymphedema after ALND (Stewart-
Treves syndrome), p/w painless / purple nodule 5-10 years postop
Surgical Treatment of Breast Cancer
 Halsted radical mastectomy  historical procedure, includes removal of
breast, overlying skin, pectoralis muscle and ALND
 Modified radical mastectomy  removal of breast, overlying skin and
ALND but preservation of pectoralis major
 Total mastectomy  removal of breast & overlying skin
 Breast conserving therapy (BCT)  lumpectomy & SLNB + postop XRT,
eligibility = clear margins & good cosmesis regardless of tumor size (margin
for CA = “no ink on tumor”), multicentric disease / history of previous
irradiation are contraindications to BCT
 BCT during pregnancy  Rx w/ resection, chemotherapy during 2nd/3rd
trimester & postpartum XRT
 Sentinel lymph node biopsy (SLNB)  99mTc-labeled sulfur colloid (safe
during pregnancy) & isosulfan blue (not safe during pregnancy, <1% risk of
anaphylactic reaction) injected to localize sentinel node, if SLN not localized
 ALND indicated
 Axillary lymph node dissection (ALND)  boundaries = axillary vein
superiorly / latissimus dorsi muscle laterally / chest wall medially, level I/II
dissection indicated in patients w/ clinically positive axillary nodes, 20%
chance of lymphedema / risk of n. injury (intercostal brachial >
thoracodorsal / long thoracic)
 Postmastectomy breast reconstruction  immediate vs. delayed (patients
who require postop XRT), options include TE / implants / autologous tissue
flaps (e.g. TRAM / latissimus / DIEP)
 Postmastectomy radiation  decreases local recurrence, indicated in
patients w/ tumors T3 (>5cm) / N2 (≥4 nodes) / inflammatory breast CA /
aggressive histology / extranodal extension
Systemic Treatment of Breast Cancer
 ER / PR status determines endocrine therapy, HER2 status (receptor tyrosine
kinase from erb-B2 gene) determines trastuzumab therapy, multigene assays
(e.g. Oncotype DX) determine chemotherapy regimen
  Tamoxifen  assoc. w/ 50% reduced risk for recurrence in patient’s w/ ER-
positive CA, useful for chemoprevention in high risk patients (e.g DCIS / LCIS
/ BRCA), assoc. w/ increased risk of uterine CA & VTE (vs. Raloxifene)
 Aromatase inhibitors  assoc. w/ reduction of invasive breast CA in post-
menopausal women, not useful for chemoprevention
 Chemotherapy  decreases systemic recurrence, doxorubicin
(topoisomerase inhibitor, side effect = cardiomyopathy), taxane (microtubule
inhibitor, side effect = peripheral neuropathy), Rx triple-negative /
inflammatory breast CA w/ neoadjuvant chemotherapy, Rx pre-menopausal
women w/ ≥3 positive nodes w/ adjuvant chemotherapy
 Trastuzumab  binds to HER2/neu, side effect = systolic cardiac toxicity
Paget disease
 P/w excoriation of the superficial epidermis w/ underlying DCIS or ductal CA
(rarely w/ a palpable mass), Dx w/ full-thickness biopsy of NAC, Rx w/
mastectomy + SLNB
Inflammatory carcinoma
 P/w Peau d’orange due to obstruction of dermal lymphatics by CA cells, Rx
w/ preop chemotherapy / modified radical mastectomy / postop XRT
Male Breast Cancer
 Risk factors include age / radiation / obesity / cirrhosis / Klinefelter
syndrome / BRCA2, 90% invasive ductal / 10% DCIS, prognosis is similar
stage for stage to women, Rx w/ mastectomy + tamoxifen if ER+
Cowden Syndrome
 AD, PTEN mutation, p/w breast / thyroid / female GU CA & mucocutaneous
lesions
Poland Syndrome
 Unilateral hypoplasia of breast / perctoralis / chest wall
Breast Lymphoma
 B cell origin, primary = secondary, Rx w/ CHOP, recurrence = CNS

Cardiac
Anatomy
 RCA  emerges from R coronary sinus, supplies RV, gives off PDA
 LCA  emerges from L coronary sinus, supplies LV, gives off LAD /
circumflex
Embryology
 Ductus arteriosus  shunts blood away from developing lungs
 Ductus venosum  shunts blood away from developing liver
 Circulation to/from placenta  2 umbilical arteries (become medial
ligaments in adults) / 1 umbilical vein (becomes ligamentum teres in adults)
Congenital Disease
 R  L shunts  cause cyanosis, squatting increases SVR to decrease shunt,
sequlae = polycythemia / strokes, example = tetralogy of Fallot (Pulmonic
stenosis / RV hypertrophy / Overriding aorta / VSD, Rx at 6 months)
  L  R shunts  do not cause cyanosis, sequlae = CHF w/ hepatomegaly,
examples = VSD (most common / 80% close spontaneously / FTT =
indication to repair) / ASD (assoc. w/ DS) / PDA (close w/ indomethacin)
 Eisenmenger’s syndrome  shift from LR to RL shunt due to
progressive pulmonary HTN
Coronary Artery Disease
 Assoc. w/ male / smoking / HTN / HLD / DM, Rx w/ smoking cessation /
nitrates / ASA / statin, Surgical Rx w/ CABG if significant L main / 3 vessel
disease present (internal mammary artery), mediastinitis is devastating
complication (RF = obesity / poor glycemic control / use of bilateral internal
mammary arteries, Rx w/ aggressive debridement)
Valvular Disease
 Aortic stenosis  due to calcification, p/w syncope / angina / dyspnea, Rx
w/ AVR if symptomatic / peak gradient > 50 mmHg / valve area < 1 cm
 Mitral regurgitation  p/w atrial fibrillation / pulmonary congestion, Rx if
symptomatic
 Mitral stenosis  grossly historical due to rheumatic fever
Endocarditis
 P/w fevers / chills, aortic valve = site of prosthetic valve infection vs. mitral
valve = site of native valve infection, most commonly due to Staph. Aureus,
Rx w/ ABX
Cardiac Tumors
 Myxoma  most common benign tumor, LA > RA
 Angiosarcoma  most common malignant tumor
 Metastatic disease  most commonly due to lung CA

Coagulation
Physiology
 Intrinsic pathway  VIII  XI  XI  common pathway (measured by
PTT, affected by heparin)
 Extrinsic pathway  factor VII + TF  common pathway (measured by PT
/ INR, affected by warfarin)
 Common pathway  X  V  II (thrombin)  I (fibrinogen)
Chemical Prophylaxis
 Unfractionated heparin  binds to antithrombin III, targets intrinsic
pathway (monitor PTT)
 LMWH  binds to factor Xa, undergoes renal excretion, superior in oncology
/ trauma patients
Bleeding Disorders
 Hemophilia A  X-linked, due to deficiency in factor VIII, Dx w/ increased
PTT, p/w hemoarthrosis / persistent bleeding after surgical procedures, Rx
w/ recombinant factor VIII, replete levels to 30% prior to dental procedure /
50% if hemoarthrosis is present / 100% prior to major surgery
 Hemophilia B  due to deficiency in factor IX
Coagulation Disorders
 Factor V Leiden  most common inherited coagulation condition, p/w
venous thromboembolism
 Von Wilbebrand disease  due to failure of platelets to adhere to injured
vessel wall, Dx w/ increased BT / normal PTT, Rx w/ cryoprecipitate /
DDAVP
 Glanzmann thrombasthenia  AR, due to deficiency in glycoprotein
IIb/IIIa/ p/w defect in platelet aggregation
 Protein C deficiency  assoc. w/ risk of warfarin-induced skin necrosis
 Antithrombin III deficiency  heparin resistance due to congenital or
acquired causes (DIC / pregnancy), p/w venous thrombosis, Rx w/ FFP
(replete AT-III) followed by readministration of heparin
 Homocystinuria  AR disease, p/w arterial thrombosis / MR / seizures /
skeletal abnormalities, Rx w/ B6
 Heparin-induced thrombocytopenia  due IgG antibodies against PF4-
heparin complex, p/w thrombocytopenia (platelet count drop by >50%) /
thrombosis 5-10 days after initiation of heparin, Rx w/ heparin
discontinuation / initiation of direct thrombin inhibitor
Platelet Disorders
 Bernard-Soulier disease  GpIb receptor deficiency, prevents cross linking
with vWF
 Glanzmann’s thrombocytopenia  GpIIb/IIIa receptor deficiency
Antiplatelet Medications
 Aspirin  COX blocker, continue throughout perioperative period
 Clopidogrel  irreversibly inhibits platelet aggregation via ADP receptor
thus preventing activation of IIb/IIIa complex, works within 2 hours & lasts 5
days, hold five days prior to major operation

Colon and Rectum

Embryology
 Midgut  2nd portion of duodenum to distal 3rd of transverse colon
 Hindgut  distal 3rd of transverse colon to descending colon / rectum
 Distal rectal  cloaca separates into anterior urogenital / posterior rectal
tracts
Colon Anatomy
 Approx. 150cm in length w/ four layers (mucosa / submucosa / muscularis
propria / serosa), ascending / descending colon w/ posterior surface fixed to
retroperitoneum / transverse colon fixed to liver via nephrocolic & spleen
via phrenocolic ligaments, colon w/ taenia coli that form haustra
 Vascular supply  midgut via SMA (jejunal / ileal / ileocolic / R colic / M
colic branches), hindgut via IMA (L colic), marginal artery = collateral
between SMA & IMA @ splenic flexure, Arc of Riolan = connects proximal
SMA & IMA, IMA terminates w/ SRA
  Venous drainage  IMV empties into splenic vein, SMV + splenic vein =
portal vein
 Innervation  parasympathetic (vagus) / sympathetic / enteric (Meissner’s
= submucosal & Auerbach’s = muscularis)
Rectal anatomy
 3 valves of Houston (no taenia coli), anterior rectum w/ peritonealized space
(Pouch of Douglas = site of drop metastasis from visceral tumors), posterior
rectum w/ Waldeyer’s fascia
 Vascular supply  SRA from IMA, MRA from ILA, IRA from pudendal artery,
Sudek’s point @ junction of SRA & MRA (watershed area)
 Venous drainage  SRV drains into IMV, MRV & IRV drain into ILV
 Pelvic floor musculature  levator ani = pubococcygeus / iliococcygeus /
puborectalis
Physiology
 SCFAs (butyrate > acetate / propriate) produced by microbial fermentation
are primary fuel for colonocytes (bacteroides = main microbe), sodium
absorbed actively via Na+/ K+-ATPase w/ H2O following passively
Colorectal Surgery Management
 Preoperative  mechanical bowel prep w/ polyethylene glycol in
conjunction w/ PO Abx prep (erythromycin & neomycin) & parenteral Abx
30 minutes before incision (e.g. cefotetan) / no longer than 24 hours postop
have both been shown to reduce SSI
 Postoperative  ERAS w/ fluid restriction / limitation of opiates w/
alternative multimodal pain strategies / early enteral feeding, alvimopan is
opioid antagonist that decreases post-operative ileus
Intestinal Stomas
 Ideal placement  through the rectus w/ 2cm aperture
 Colostomy  descending colon is preferred, does not need to be elevated
above skin level due to noncorrosive effluent
 Ileostomy  approx. 900mL of ileal effluent expected over 24-hr period,
does need to be elevated above skin level due to corrosive effluent (Brooke
configuration)
Diverticular Disease
 Diverticulosis  protrusion of mucosa / submucosa at areas of weakness
(sites of penetration of vasa recta), sigmoid > descending colon, assoc. w/
increased age / LFD, false diverticula
 Diverticulitis  due perforation of diverticulum, uncomplicated vs.
complicated (abscess / obstruction / perforation / fistula), Rx uncomplicated
diverticulitis w/ outpatient PO Abx ± elective resection, Rx complicated
diverticulitis based on Hinchey classification (I = pericolonic abscess, II =
pelvic abscess, III = purulent peritonitis, IV = feculent peritonitis), I/II = IV
Abx & percutaneous drainage + eventual sigmoid resection vs. III/IV =
Hartmann’s (sigmoid resection w/ end colostomy), colonoscopy should be
performed 4-6 weeks after an episode of diverticulitis to rule out malignancy
Colonic Volvulus
  Sigmoid volvulus  more common, assoc. w/ chronic constipation / high
fiber diet / psychotropic drugs, radiograph w/ bent tube towards RUQ, Rx w/
endoscopic detorsion followed by resection (70% recurrence rate) vs.
emergent resection w/ end colostomy in patients w/ peritonitis
 Cecal volvulus  less common, assoc. w/ previous surgery / pregnancy /
malrotation, radiograph w/ comma shape towards LUQ, Rx w/ R
hemicolectomy, w/ end ileostomy in patients w/ peritonitis
Large Bowel Obstruction
 Most commonly due to CRC, p/w abdominal pain / distension, closed-loop
obstructions occur in setting of competent ileocecal valve, site of perforation
= cecum (law of Laplace), Rx w/ decompression via transverse loop
colostomy
Colonic Pseudo-Obstruction
 Ogilvie syndrome  assoc. w/ medications (e.g. neuroleptics / opiods) &
medical illness (e.g. uremia / DM), pathophysiology = sympathetic override,
Rx w/ NGT / correction of electrolyte abnormalities / cessation of narcotics /
colonoscopic decompression / IV neostigmine (in a monitored unit to assess
for bradycardia) / laparotomy (if concern for perforation)
Ulcerative Colitis
 Epidemiology  most commonly affects patients < 30, men / women
affected equally, smoking w/ protective effect, strong familial assoc.
 Etiology  infectious agents (C. diff / campylobacter), environmental
factors, genetic (HLA Class II), autoimmune
 Pathology  continuous disease, involves mucosa / submucosal but spares
muscularis, assoc. w/ mucosal edema (earliest manifestation) / rectal
involvement / pseudopolyps / crypt abscesses / P-ANCA
 Presentation  bloody diarrhea / increased urgency (distal proctitis) /
perianal disease is uncommon / backwash ileitis w/ proximal disease /
extraintestinal manifestations = erythema nodosum /pyroderma
gangrenosum / PSC / AS (the latter two do not improve after colectomy)
 Carcinoma  risk proportional to duration of UC, colonoscopy screening 8
years after diagnosis at 1-2 year intervals w/ 30 biopsy specimens
 Medical Therapy  aminosalicylates (maintenance therapy),
corticosteroids (active UC), azathioprine (maintenance in steroid-dependent
patients), tacrolimus / cyclosporine (active UC resistant to steroids),
imfliximab (anti-TNF-alpha), cipro / flagyl (toxic colitis)
 Surgical Therapy  Rx fulminant colitis w/ total abdominal colectomy w/
end ileostomy, Rx dysplasia / carcinoma w/ proctocolectomy w/ IPAA in
young patients (complicated by pouchitis, Rx w/ metronidazole) vs. total
proctocolectomy w/ end ileostomy in patients w/ incontinence
(contraindication to ileal J-pouch anastomosis)
Crohn’s Colitis
 15% of Crohn’s patients p/w disease limited to the colon
 Medical Therapy  medical > surgical is mainstay in treatment of Crohn’s;
aminosalicylates, corticosteroids, immunomodulators & biologics
  Surgical Therapy  proctocolectomy w/ end ileostomy in patients w/
disease involving entire colon / rectum & incontinence or total abdominal
colectomy w/ ileorectal anastomosis in patients w/ rectal sparing
Pseudomembranous Colitis
 Due to infection w/ clostridium difficile, assoc. w/ Abx use, p/w diffuse
watery diarrhea, Rx mild disease w/ PO vancomycin, Rx severe disease w/
PO / rectal vancomycin + IV metronidazole, Rx recurrent disease w/ FMT,
surgical Rx w/ loop ileostomy w/ antegrade colonic lavage vs. total
abdominal colectomy w/ ileostomy
Ischemic Colitis
 Occurs at watershed areas (Griffith point = splenic flexure / Sudeck point =
sigmoid / rectum junction), P/w abdominal pain / fever / hematochezia, Dx
w/ CT ± colonoscopy, Rx w/ supportive care
Screening Options for CRC
 Colonoscopy at age 50 w/ repeat every 10 years for normal risk vs. 10 years
before youngest case of CRC in 1st degree family w/ repeat every 5 years vs.
FOBT every 3 years + flex sig every 5 years vs. FOBT every year
Colorectal Polyps
 Hyperplastic polyps are most common & do not have malignancy risk, polyps
classified by gross appearance (pedunculated / sessile) and histologic
appearance (tubular < tubovillous < villous), 5% incidence of carcinoma in
adenomatous polyp < 1cm vs. 50% incidence of carcinoma in villous
adenoma > 2 cm, Rx pedunculated polyp w/ snare polypectomy vs. sessile
polyp may require segmental colectomy (e.g. those w/ ulcerated centers)
 Haggitt’s criteria  level 0 (carcinoma in situ), level I (carcinoma limited to
the head of the polyp), level II (carcinoma limited to the neck of the polyp),
level III (carcinoma limited to the stalk of the polyp), level IV (carcinoma
invades into the submucosa of the bowel wall), all sessile polyps = level IV
 Adenoma to Carcinoma Sequence  APC  K-RAS  DCC  p53
Colorectal Cancer Staging
 T  Tis = carcinoma in situ, T1 = invades submucosa, T2 = invades
muscularis propria, T3 = invades through muscularis propria into
pericolorectal tissue, T4 = penetrates visceral peritoneum
 N  N0 = no nodes, N1 = 1-3 regional nodes, N2 = >4 regional nodes
 M  M0 = no distant metastasis, M1 = distant metastasis
Management of Colon Cancer
 Rx lesions involving the cecum / ascending colon w/ R hemicolectomy,
transverse colon w/ extended R hemicolectomy (division of R and M colic
arteries) & descending colon w/ L hemicolectomy
 Rx isolated lung / hepatic metastases w/ resection
 Rx stage I / II w/ resection, stage III w/ resection + adjuvant FOLFOX, stage
IV w/ chemotherapy ± cetuximab (anti-EGF) / bevacizumab (anti-VEGF)
Management of Rectal Cancer
 Stage T&N w/ endorectal US / MRI
  Rx w/ T1 lesions / < 3 cm / involving < 30% of rectal wall circumference /
located in the distal rectum w/ transanal local excision vs. > T1 w/ AR
(requires 2 cm margin from proximal anal canal) / APR
 Rx ≥ stage II w/ neoadjuvant chemoradiation + resection
Hereditary Colon Cancer Syndromes
 Familial adenomatous polyposis (FAP)  APC gene mutation, AD
inheritance, p/w numerous colonic polyps that will develop cancer if left
untreated, extracolonic manifestations = epidermoid cysts / desmoid tumors
/ osteomas / brain tumors / gastric (hyperplastic) & duodenal (neoplastic)
polyps, colonoscopy starting at age 12, Rx w/ proctocolectomy w/ IPAA vs
end ileostomy in patients w/ incontinence vs. total abdominal colectomy w/
ileorectal anastomosis (ongoing risk for rectal Ca), EGD screening every 2
years after age 30, Rx desmoid tumors w/ sulindac or tamoxifen
 Lynch syndrome (HNPCC)  MLH1 & MSH1 gene mutation (DNA mismatch
repair), w/ high microsatellite instability, diagnosis via Amsterdam criteria
(CRC in 3 family member, across 2 generations, w/ at least 1 individual
affected < 50 years), Lynch I w/ CRC vs. Lynch II w/ endometrial / ovarian /
gastric / ureteral / renal pelvic Ca, colonoscopy every 2 years starting at age
25, Rx w/ proctocolectomy w/ first cancer operation, prophylactic TAH-BSO
recommended in women w/ no plans for further childbearing
 Peutz-jeghers syndrome  STK11 gene mutation, AD inheritance, p/w
hamartomatous polyps of intestinal tract and hyperpigmentation of buccal
mucosa / lips, assoc. w/ extra colonic Ca including breast / cervical / thyroid
 Juvenile polyposis syndrome  SMAD4 gene mutation, AD inheritance,
polyps are usually hamartomas but may contain adenomatous elements
 Gardner syndrome  AD inheritance, p/w multiple epidermal cysts /
polyposis / adenomas
Rectal Prolapse
 Full-thickness rectal intussusception w/ concentric rings of tissue, assoc. w/
pudendal n. damage, Rx w/ abdominal (resection rectopexy) vs. perineal
(altemeir) approach, no role for conservative measures

Cutaneous Neoplasms
Melanoma
 Risk factors  sun exposure / family history of melanoma / Xeroderma
pigmentosum / precursor lesions (e.g congenital nevi / dysplastic nevi /
Spitz nevi)
 Pathogenesis  activating mutations in BRAF / c-KIT
 Presentation  ABCDE (Asymmetry, irregular Borders, Color changes,
Diameter > 6mm, Evolution)
 Pathology  originates from neural crest cells (stains positive for S-100 /
HMB-45), advances w/ radial growth first followed by vertical growth,
melanoma in situ, superficial spreading = most common, lentigo maligna
 = best prognosis, acral lentiginous occurs on palms / subungual / soles of
African Americans, nodular = worst prognosis
 Diagnosis  excisional full-thickness biopsy w/ 2-mm margins
 Treatment  WLE w/ margins based on Breslow depth (thickness : margin
 in situ : 0.5 cm vs. < 1 mm : 1 cm vs. 1-2 mm : 1-2 cm vs. >2-4 mm : 2 cm),
SLN biopsy performed if lesion > 1 mm or > 0.75 mm w/ high risk factors
(ulceration / >1 mitoses/mm2), identification via lymphoscintigraphy (safe
during pregnancy) & isosulfan blue (<1% risk of anaphylactic reaction), if
SLN is positive  Rx w/ completion lymphadenectomy, if palpable nodal
disease present  Rx w/ therapeutic lymph node dissection, if in-transit
disease present  Rx w/ resection / hyperthermic isolate limb perfusion
(HILP), adjuvant radiation to lymph node bed after lymphadenectomy
 Adjuvant therapy  interferon alfa-2b (high-risk local disease) /
dicarbazine (1st line chemo in metastatic disease) / iplimumab (anti-CTLA-4)
/ brolizumab (anti-PD-1) / vemurafenib (anti-BRAF) = novel therapies in
Squamous Cell Carcinoma (SCC)
 Risk factors  sun exposure / precursor lesions (actinic keratosis) /
smoking / solid organ transplant / immunosuppression / radiation /
Marjolin ulcers (chronic non-healing wounds)
 Diagnosis  punch biopsy
 Presentation  scaling lesions w/ central ulceration
 Treatment  WLE w/ 4-6 mm margin vs. Mohs surgery for high-risk
Basal Cell Carcinoma (BCC)
 Risk factors  sun exposure / no precursor lesions / most common
cutaneous neoplasm (80%)
 Diagnosis  punch biopsy
 Presentation  pearly lesion w/ rolled boarders & slow growth
 Treatment  WLE w/ 3-5 mm margin vs. Mohs surgery for high-risk
Benign Cutaneous Neoplasms
 Actinic Keratoses  precursor to SCC, Rx w/ cryotherapy / topical 5-FU
 Seborrheic Keratoses  most common benign skin neoplasm, p/w raised /
scaly lesions in elderly patient w/ “stuck-on” appearance, no Rx required
Uncommon Cutaneous Malignant Neoplasms
 Cutaneous angiosarcoma  assoc. w/ chronic lymphedema (e.g. Stewart-
Treves syndrome), p/w violaceous growth, Rx w/ complete resection &
radiation
 Dermatofibrosarcoma protuberans (DFSP)  low-grade sarcoma, p/w
flesh-colored nodules & finger-like projections, Rx w/ WLE vs. Mohs,
fibrosarcomatous change w/ worse prognosis / increased risk of metastatic
potential (lungs is most common site)
 Extramammary Paget disease  p/w erythematous plaque in perianal
area, Rx w/ WLE, assoc. w/ underlying GI / GU malignancy
 Kaposi sarcoma  assoc. w/ HIV & HHV-8, Rx w/ intralesional injections /
WLE
  Merkel cell carcinoma (MCC)  aggressive tumor, neural cell origin, assoc.
w/ CLL / polyomavirus, p/w pink nodule that progresses to a violaceous
blue, Rx w/ WLE w/ 2 cm margin / SLN Bx / adjuvant radiation therapy
 Bowen disease  SCC in situ of the perianal region, due to HPV 16 / 18, Rx
w/ imiquimod / topical 5-FU / WLE for refractory pruritus

Endocrine Pancreas
Anatomy
 Islets of Langerhans  organization of endocrine cells w/ α / β / D / F cells
 Alpha cells  located peripherally / secrete glucagon / 10% of islet cell
mass
 Beta cells  located centrally / secrete insulin / 70% of islet cell mass
 D cells  distributed throughout / secrete somatostatin & VIP
 F cells  located peripherally / secrete pancreatic polypeptide (PP)
Physiology
 Insulin  anabolic hormone, synthesized as proinsulin in β cells & cleaved
into insulin / C peptide, decreases blood glucose level, release stimulated by
vagal input / inhibited by somatostatin
 Glucagon  stress hormone, increases blood glucose level, release
stimulated by epinephrine / inhibited by somatostatin
Pancreatic Neuroendocrine Tumors (PNETs)
 Assoc. w/ MEN-1 / VHL, p/w classic syndromes (functional) vs. symptoms of
mass effect (nonfunctional), Dx w/ elevated chromogranin A, localization w/
thin-cut CT / MRI / EUS / somatosatin receptor scintigraphy (will not
localize insulinoma) / portal venous sampling (calcium to stimulate
insulinoma / secretin to stimulate gastrinoma), Rx localized disease w/
pancreatic resection / enucleation, Rx liver metastases w/ liver resection /
hepatic arterial therapy, Rx advance metastatic disease w/ somatostatin
analogue
 Insulinoma  distributed evenly within the pancreas, p/w Whipple triad,
Dx w/ high levels of serum insulin / proinsulin / C peptide in the presence of
hypoglycemia, Rx w/ enucleation (generally benign) / diazoxide given pre-op
 Gastrinoma  distributed in the gastrinoma triangle, p/w Zollinger-Ellison
syndrome (duodenal ulcers), Dx w/ fasting gastrin levels / basal acid output
/ secretin stimulation test, Rx w/ surgical resection vs. enucleation / PPIs
 VIPoma  distributed in pancreatic body / tail, p/w WDHA syndrome
(watery diarrhea / hypokalemia / achlorhydia), Dx w/ elevated VIP levels, Rx
w/ resection (generally malignant)
 Glucagonoma  distributed in pancreatic body / tail, p/w necrolytic
migrating erythematous dermatitis / diabetes / DVTs, Dx w/ elevated
glucagon levels, Rx w/ resection (generally malignant) / amino acids
improve dermatitis
  Somatostatinoma  distributed in pancreatic head, p/w cholelithais /
diabetes / steatorrhea, Dx w/ elevated somatostatin levels, Rx w/ resection
(generally malignant)
MEN-1
 P/w pituitary adenomas / parathyroid adenomas / PNETs (gastrinoma >
insulinoma > glucagonoma > VIPoma), Rx w/ parathyroidectomy first
followed by resection of PNET
Autologous Islet Cell Transplantation
 Used in conjunction w/ total / partial pancreatectomy to prevent diabetes,
islet cells are infused into portal vein & engraft in liver to produce insulin / C
peptide
Pancreatic Transplantation
 Indicated in difficult to manage type-1 DM  results in insulin independence

Esophagus
Anatomy
 Begins at the UES (cricopharyngeus muscle / resting pressure of 60 mmHg),
ends at LES (resting pressure of 25 mmHg), w/ inner circular muscle
(extension of the cricopharyngeus) & outer longitudinal muscle, lacks serosal
layer (prone to perforation)
 Cervical esophagus 15-20 cm from incisors / blood supply = inferior
thyroid artery
 Thoracic esophagus  20 - 30 cm from incisors / blood supply = branches
of aorta
 Abdominal esophagus  30 - 40 cm from incisors / blood supply = left
gastric / phrenic arteries
 Innervation Meissner plexus (submucosal) / Auerbach plexus (between
muscle layers)
 Three anatomic points of constriction = cricopharyngeal muscles / L
mainstem bronchus / diaphragmatic hiatus
Physiology
 Primary contractions → peristaltic & voluntary, occur after swallowing
 Secondary contractions → peristaltic & involuntary, occur w/ food bolus
 Tertiary contractions → non-peristaltic & non-coordinated, assoc. w/ GERD
Hiatal Hernia
 Type I → sliding hernia, due to weakness of phrenoesophageal membrane
 Type II → paraesophageal, due to defect in phrenoesophageal membrane
 Type III → combined type I & II
 Type IV → stomach in the chest + another organ (colon / spleen)
Dysmotility Disorders
 Diffuse esophageal spasm (DES) → p/w chest pain / dysphagia, Dx w/
esophagram w/ corkscrew & HRM w/ simultaneous high amplitude
contractions / decreased distal latent time, Rx w/ nitrates / calcium blockers
 / botulinum / endoscopic dilatation / Heller esophagomyotomy w/
fundoplication / POEM
 Achalasia → due to destruction of neuronal ganglion cells, assoc. w/
trypanosoma cruzi, risk for SCC, p/w progressive dysphagia / regurgitation /
weight loss, Dx w/ esophagram w/ bird’s beak & HRM w/ failure of LES to
relax w/ non-peristaltic low amplitude contractions, Rx w/ nitrates / calcium
blockers / botulinum / endoscopic dilatation / Heller esophagomyotomy w/
fundoplication / esophagectomy (last resort)
 Nutcracker esophagus → p/w chest pain / dysphagia, Dx w/ HRM w/ high
distal contractility w/ normal LES pressure, Rx w/ nitrates / calcium
blockers / antispasmodics
 Hypertensive LES → Dx w/ HRM w/ elevated LES pressure w/ normal
peristaltic contractions, Rx w/ Heller esophagomyotomy w/ fundoplication /
POEM
 Scleroderma  HRM w/ aperistalsis & low LES pressure
Diverticular Disorders
 Paraesophageal (Zenker) diverticulum → false / pulsion diverticulum
through Killian’s triangle (bounded by cricopharyngeus & thyropharyngeus),
p/w halitosis, Dx w/ barium esophagram, Rx w/ diverticulotomy &
cricopharyngomyotomy (surgical > endoscopic repair for diverticula <3 cm
vs. equivalent results for diverticula >3cm)
 Midesophageal diverticulum → true / traction diverticulum, due to
esophageal dysmotility disorders / tuberculosis (historical), usually
asymptomatic, Rx w/ diverticulopexy if symptomatic or >2cm
 Epiphrenic diverticulum → false / pulsion diverticulum located adjacent to
diaphragm, due to esophageal dysmotility disorders, usually asymptomatic,
Rx w/ diverticulopexy & myotomy if symptomatic or >2cm
GERD
 Dx w/ pH test / HRM / esophagography / endoscopy, medical Rx w/ PPIs /
smoking & alcohol cessation, surgical Rx w/ Nissen fundoplication (first step
= division of gastrohepatic ligament) / Toupet (partial posterior wrap) / Dor
(partial anterior wrap) / Collis gastroplasty (creates extra intra-abdominal
esophageal length), surgical Rx improves typical symptoms (regurgitation /
epigastric pain) > atypical symptoms (cough), most common cause for
recurrence of symptoms after surgery = herniated wrap
Esophageal Strictures
 Assoc. w/ GERD, Bx to r/o CA, Rx w/ serial dilatation
Esophageal Perforation
 Due to iatrogenic injuries (e.g. endoscopy, occurs at cricopharyngeus) /
Boerhaave syndrome (occurs on L side of distal esophagus) / trauma /
foreign body / CA, p/w chest pain / neck swelling / crepitus, Dx w/ CXR /
esophagram w/ gastrografin / EGD, Rx w/ Abx / antifungals / Rx high
perforations via left-sided neck incision / mid perforations via right
posterolateral thoracotomy / distal perforations via left anterolateral
thoracotomy, first step in Rx is myotomy to assess extent of mucosal injury,
Rx cervical injuries w/ drain placement & wound closure, Rx small injuries
 w/ two layer closure vs. large injuries w/ controlled fistualization /
esophageal exclusion & reconstruction (e.g. colonic interposition)
Foreign Body Ingestion
 Obstruction occurs at anatomic areas of narrowing (UES / aortic arch /
diaphragmatic hiatus), Dx w/ CXR / Dx /Rx w/ endoscopy, avoid contrast
examinations due to aspiration risk
Caustic Ingestion
 Occurs in young children (consumption of household items) vs. adults
(suicide attempt), alkaline = liquefactive necrosis (more damaging) vs. acidic
= coagulative necrosis, Rx w/ airway control followed by Dx w/ endoscopic
evaluation of extent of injury, late complication = SCC (mandates endoscopic
surveillance starting 10 years after injury)
Tracheoesophageal Fistula
 Occurs in patients w/ tracheostomy, Rx w/ fistula excision / definitive repair
Schatzki ring
 Fibrous thickening of the GEJ (squamous mucosa superiorly / columnar
gastric mucosa inferiorly), assoc. w/ hiatal hernia / GERD, p/w dysphagia, Bx
to r/o CA, Rx w/ balloon dilation (do not resect)
Benign Tumors
 Occur in the submucosa w/ normal appearing mucosa
 Leiomyomas → most common benign tumor, do not Bx, Rx w/ enucleation if
symptomatic vs. > 5 cm Rx w/ excision via VATS / laparoscopy
 Granular cell tumors → stain positive for S100
 Fibrovascular polyps → occur at cricopharyngeus
 Squamous papillomas → assoc. w/ inflammation, excise to r/o CA
Esophageal Neoplasms
 SCC  most common world wide, black men > white men, assoc. w/
tobacco/ alcohol / nitrosamines
 Adenocarcinoma  most common in US, white men > black men, assoc. w/
Barrett esophagus / obesity
 Dx  w/ esophagram w/ apple-core” filling defect / EGD w/ Bx, EUS for
assessment of T & N / PET / CT for assessment of M
 Staging  T1a = muscularis mucosa / T1b = submucosal / T2 = muscularis
propria, T3 = adventitia / T4a = resectable into adj. structures (diaphragm /
pericardium) / T4b = unresectable into adj. structures (trachea / aorta),
nodal spread is via submucosal lymphatics
 Rx low-grade dysplasia / Barrett esophagus w/ surveillance w/ EGD and 4
quadrant Bx every 2 cm every 6 months, Rx high-grade dysplasia w/ RFA, Rx
T1 w/ EMR, T2 / T3 tumors w/ neoadjuvant chemoradiation (cisplatin / 5-
FU) w/ esophagectomy, Rx T4 / metastatic disease w/ palliation

Exocrine Pancreas
Anatomy
 Composed of four portions w/ head w/ uncinate process / neck / body / tail,
w/ acinar (85%) & islet cells (2%), uncinate process is dorsal to SMA/SMV
  Bloody supply  superior (from common hepatic  GDA) / inferior
pancreaticoduodenal (from SMA) arteries supply head, splenic arterial
system supplies neck / body / tail
 Venous drainage portal system via SMV & splenic veins
Embryology
 Dorsal / ventral pancreatic buds arise from duodenal endoderm & fuse @ 8th
week, dorsal = superior head / neck / body / tail w/ accessory duct of
Santorini vs. ventral = inferior head / uncinate process w/ main duct of
Wirsung
 Pancreatic divisum  failure of fusion of dorsal / ventral pancreatic ducts
(duct of Santorini drains majority of pancreas & empties into lesser papilla /
duct of Wirsung drains into major papilla), usually asymptomatic but can
p/w pancreatitis (Rx w/ sphincterotomy of minor papilla)
 Annular pancreas  circumferential pancreatic tissue surrounding
duodenum, assoc. w/ DS, Rx obstruction w/ duodenojejunostomy (avoid
pancreatic resection)
Physiology
 CCK stimulates release of pancreatic enzymes into duodenum including
trypsinogen, chymotrypsinogen, eslastase (endopeptidases) /
carboxypeptidase (exopeptidases) / pancreatic lipase / pancreatic amylase
(secreted in active form)
 Enterokinase from duodenum converts trypsinogen to trypsin which in turn
propagates pancreatic enzymatic activation
 Secretin stimulates HCO3- / Cl- anion exchanger which neutralizes duodenal
lumen for optimal acinar enzyme function
Acute Pancreatitis
 Due to proteolytic enzyme activation within acinar cells w/ subsequent auto-
digestion, RFs include gallstones (#1 cause worldwide) / EtOH /
autoimmune / drugs (e.g. thiazides / antiretroviral) / ERCP /
hypertriglyceridemia, Dx w/ clinical findings + elevated amylase / lipase &
CT scan, clinical severity assessed by Ranson score / BISAP score, imaging
severity assessed by Balthazar score, Rx w/ aggressive fluid resuscitation, Rx
gallstone pancreatitis w/ ERCP & cholecystectomy during same admission
(25% of pancreatitis recurrence if cholecystectomy is not performed)
Chronic Pancreatitis
 Due to irreversible fibrosis & atrophy of pancreatic parenchyma, RFs include
chronic EtOH (induces spasm of sphincter of Oddi & increases pancreatic
permeability) / smoking / hereditary pancreatitis (PRSS1 gene mutation) /
tropical pancreatitis (SPINK1 gene mutation) / autoimmune (elevated IgG4,
Rx w/ steroids), p/w early satiety / abdominal pain / steatorrhea (occurs
after loss of >90% of exocrine function), Dx w/ CT scan w/ parenchymal
atrophy / EUS w/ biopsy demonstrating fibrosis / fecal elastase level, Rx w/
PPI / pancreatic enzyme replacement, surgical Rx w/ Puestow (longitudinal
pancreaticojejunostomy, if pancreatic duct > 6mm, duct opened anteriorly
from GDA medially to tail laterally) / Frey (resection of pancreatic head w/
 longitudinal pancreaticojejunostoy) / Beger (duodenum-preserving
pancreatic head resection) / Whipple / total pancreatectomy (minimal
change disease), most common indication for surgical intervention is chronic
pain
Complications of Pancreatitis
 Pancreatic fistula  Rx w/ conservative management initially (NPO /
ocretotide), follow by ERCP w/ pancreatic duct stent placement, surgical Rx
is last resort
 Pancreatic necrosis w/ subsequent infection  nonviable pancreatic
tissue infected w/ E. coli / Klebsiella, Dx w/ FNA / CT scan w/ air in pockets
of necrosis, Rx w/ carbapenem ± open / endoscopic / retroscopic
necrosectomy
 Pancreatic pseudocyst  matures 4-6 weeks after AP / CP, p/w early
satiety & pain, Dx w/ CT scan / FNA w/ amylase, Rx w/ observation if
asymptomatic / > 6cm vs. endoscopic internal drainage > cystogastrostomy
/ cystoenterotomy if symptomatic vs. external drainage if pseudocyst is
infected (risk of pancreaticocutaneous fistula)
Cystic Neoplasms of Pancreas
 Mucinous cystic  more common in women, occurs in body / tail of
pancrease, Dx w/ FNA w/ mucin & high CEA, Rx w/ resection (risk of
malignant transformation), can have ovarian stroma
 Serous cystic  more common in women, occurs in head of pancreas, Dx w/
FNA w/ glycogen & low CEA, Rx w/ resection if >4 cm
 Intraductal papillary mucinous neoplasm (IPMN)  classified as MD-
IPMN (main duct) vs. BD-IPMN (branch duct) vs. mixed-type, Rx all MD-IPMN
/ mixed-type & BD-IPMN w/ worrisome features (mural nodule) w/ partial
pancreatectomy
 Solid pseudopapillary epithelial neoplasm  exclusively in young
women, low malignant potential, Rx w/ resection
Adenocarcinoma of Pancreas
 Arises from main pancreatic duct, RFs include smoking / chronic pancreatitis
/ PRSS1 / Peutz-Jeghers / CF / BRCA2 / Lynch syndrome / FAP, KRAS
mutation = inciting incident, p/w painless jaundice, dilated non tender gall
bladder (Courvoisier law), laboratory analysis w/ elevated CA 19-9, Dx w/
triple-phase CT / EUS w/ FNA, tumor stage in node negative disease is
determinant of survival, Rx w/ staging laparoscopy (involvement of celiac /
SMA / any evidence of metastasis = contraindications to resection) /
pancreaticoduodenectomy for pancreatic head mass (no difference in short /
long-term outcome in pylorus sparing variation) vs. distal pancreatectomy
w/ en bloc splenectomy for pancreatic tail mass, complications of resection =
delayed gastric emptying / pancreatic fistula / GDA stump leak (Rx w/
angiography & embolization), adjuvant chemotherapy w/ gemcitabine / 5-
FU, ERCP w/ metallic stent for palliation of obstructive jaundice, celiac n.
block for palliation of chronic pain
Pancreatic Lymphoma
  P/w B cell symptoms, Dx w/ CT w/ pancreatic mass / lymphadenopathy,
laboratory analysis w/ elevated LDH, Rx w/ chemotherapy (CHOP)

Hematology
Normal Coagulation
 Response to vascular injury → vasoconstriction, platelet adhesion, thrombin
generation
 Prostacyclin from endothelium promotes vasodilatation and decreases
platelet aggregation by increasing cAMP
 Thromboxane from platelets promotes vasoconstriction and increases
platelet aggregation by increasing calcium
 vWF links GpIb to collagen, fibrin binds GpIIb/IIIa molecules and form
platelet plug
 Intrinsic pathway; exposed collagen + factor XII → XI → IX → VIII → X → V →
prothrombin (II) to thrombin → fibrinogen to fibrin, measured by pTT
 Extrinsic pathway; TF + factor VII → X → V → prothrombin (II) to thrombin
→ fibrinogen to fibrin, measured by PT / INR
 Protein S is cofactor for Protein C which degrades factors V / VIII / fibrinogen
 Antithrombin III binds and inhibits thrombin, activated by heparin
 tPA converts plasminogen to plasmin which degrades fibrinogen / fibrin
 Factors II, VII, IX, X and protein C/S are Vit K dependent factors
 Factor VII w/ shortest half-life
 Factor VIII not synthesized in liver, rather endothelium along w/ vWF

Bleeding Disorders
 Most common cause of surgical bleeding → incomplete hemostasis
 Von Willebrand’s disease → most common congenital bleeding disorder,
vWF links Gp1b receptor on platelets to collagen, assoc. w/ increased
bleeding time, Rx w/ DDAVP / cryoprecipitate, type I most common
 Hemophilia A → factor VIII deficiency, assoc. w/ increased PTT, Rx w/
cryoprecipitate or recombinant human factor VIII, do NOT aspirate
hemophiliac joint bleeding rather ROM and ice
 Hemophilia B → factor IX deficiency, assoc. w/ increased PTT, Rx w/
recombinant human factor IX or FFP
 Thrombolytic overdose → Rx w/ aminocaproic acid
Platelet Disorders
 Acquired thrombocytopenia secondary to H2 blockers / heparin
 Glanzmann’s thrombocytopenia → GpIIb/IIIa receptor deficiency, Rx w/
platelets
 Bernard Soulier → GpIb receptor deficiency, Rx w/ platelets
 Uremia → inhibits release of vWF, Rx w/DDAVP in acute situations vs.
hemodialysis in non-acute situation
 Heparin-induced thrombocytopenia (HIT) → due to anti-heparin
antibodies, Dx w/ ELISA for heparin Ab’s / serotonin release assay, Rx w/
stopping heparin and starting argatroban
  Disseminated intravascular coagulation (DIC) → decreased platelets, low
fibrinogen, high fibrin split products, Rx w/ correction of underlying cause
 Aspirin → inhibits COX and decreases thromboxane
 Clopidogrel → ADP receptor antagonist
Hypercoagulable Disorders
 Factor V leiden mutation → most common congenital hypercoagulability
disorder, resistance to activated protein
 Antithrombin III deficiency → heparin does NOT work in these patient, Rx
w/ recombinant antithrombin III concentrate
 Acquired hypercoagulability → tobacco (most common), malignancy,
inflammatory states, OCPs, pregnancy, etc.
 Warfarin-induced skin necrosis → assoc. w/ protein C deficiency,
hypercoagulable state due to shorter half life of protein C / S

Hernias
Anatomy of the Abdominal Wall
 Blood supply → lateral abdominal wall via intercostal arteries, rectus
abdominis via superior (branch of internal thoracic) / inferior epigastric
arteries (branch of external iliac)
 Innervation → intercostal / lumbar nerves
 External oblique muscle & aponeurosis → most superficial layer of lateral
abdominal wall, fibers run inferiorly and medially
 Internal oblique muscle & aponeurosis → middle layer of the lateral
abdominal wall, fibers run superiorly and laterally
 Transversus abdominis muscle & aponeurosis →deep layer of the lateral
abdominal wall, fibers run horizontally
 Transversalis fascia → underlies the abdominal wall musculature
 Anterior / Posterior rectus sheath → formed by aponeuroses of external
oblique / internal oblique / transversus abdominis
 Arcuate line → located 3-6 cm below umbilicus, below this point the
posterior rectus sheath is composed solely of transversalis fascia
Anatomy of the Groin
 Inguinal ligament (Poupart ligament) → formed by inferior edge of the
external oblique aponeurosis, extends from ASIS to pubic tubercle
 Conjoined tendon → formed by connection of aponeuroses for internal
oblique and transversus abdominis
 Iliopubic tract → formed by aponeurotic band of transversus abdominis and
transversalis fascia, located posterior to inguinal ligament
 Lacunar ligament → formed by fan-shaped medial expansion of inguinal
ligament into pubis
 Pectineal (Cooper) ligament → formed by the periosteum and aponeurotic
tissues along the superior ramus of the pubis, posterior to femoral vessels
 Hasselbach triangle → formed by inferior epigastric vessels (lateral
border), rectus sheath (medial border), inguinal ligament (inferior border)
 Preperitoneal space → contains adipose tissue, lymphatics, blood vessels
and nerves (lateral femoral cutaneous n. and genitofemoral n.)
Anatomy of the Inguinal Canal
 Extends between the internal (deep) and external (superficial) inguinal rings,
contains the spermatic cord in men and round ligament in women
 Spermatic cord → composed of cremaster muscle fibers (arise from fibers of
internal oblique), testicular artery / veins, ilioinguinal n. (anterior), genital
branch of the genitofemoral n. (posterior) and vas deferens (medial)
 Genitobranch branch of genitofemoral n. → innervates cremaster muscle
and skin on lateral aspect of scrotum / labia
 Iliohypogastric / ilioinguinal n. → sensation to upper medial thigh
Anatomy of the Femoral Canal
 Iliopubic tract / inguinal ligament (superior border), cooper ligament
(inferior border), femoral vein (lateral border)
Inguinal Hernias
 Represent 75% of all hernias (indirect > direct, R > L, male > female)
 Direct hernias occur medial to inferior epigastric vessels (Hasslebach
triangle) vs. indirect occur lateral to inferior epigastric vessels
 Management → Rx asymptomatic males w/ watchful waiting vs.
symptomatic males w/ operative repair vs. females (regardless of
symptoms) w/ operative repair (increased risk of strangulation)
 Surgical approach  transverse linear incision above the inguinal ligament
from the ASIS to pubic tubercle → dissection through the subcutaneous tissue
& Scarpa’s fascia → external oblique visualized and incised through the
superficial ring to expose inguinal canal → spermatic cord mobilized and
cremaster muscle incised → hernia sac separated from adjacent cord
structures
 Anterior repair → hernia sac ligated at internal ring which is subsequently
tightened
 Iliopubic tract repair → transversus abdominis arch sutured to iliopubic
tract
 Bassini repair → conjoined tendon sutured to the inguinal ligament
 Shouldice repair → multilayer repair, first suture line approximates
transversus abdominis arch to iliopubic tract, second suture line
approximates conjoint tendon to inguinal ligament
 Cooper (McVay) repair → iliopubic tract sutured to Cooper ligament (Rx for
femoral hernias), w/ relaxing incision in anterior rectus sheath and lateral
transition stitch (closes femoral canal)
 Lichtenstein tension-free repair → mesh sutured to pubic tubercle,
superomedial edge sutured to the conjoined tendon, inferolateral edge
sutured to the inguinal ligament, spermatic cord structures placed overlying
the mesh and external oblique is closed over (lower rate of recurrence then
tissue repairs)
 Preperitoneal open repair → avoids mobilization of spermatic cord
 Laparoscopic repair → Rx for bilateral or recurrent hernias, performed
either via totally extraperitoneal (TEP) or transabdominal preperitoneal
(TAPP) approach, risks = triangle of pain (below the iliopubic tract → risk of
 n. injury) & triangle of doom (below the internal ring → risk of external iliac
a. & v. injury), contraindicated in strangulated hernia
 Inguinal hernia repair in children → high ligation only
 Complications of inguinal hernia repair → SSI (1%, no indication for
perioperative abx use unless ASA > 3), n. injuries (open → ilioinguinal /
genital branch of the genitofemoral /iliohypogastric vs. laparoscopic →
femoral branch of the genitofemoral / lateral femoral cutaneous), chronic
pain syndromes (most common complication, Rx w/ triple neurectomy),
ischemic orchitis (due to venous thrombosis of pampiniform plexus, p/w
testicular atrophy, Rx w/ NSAIDs), scrotal hematoma (Rx w/ reassurance),
hernia recurrence
Femoral Hernias
 P/w bulge below inguinal ligament, Rx w/ operative fixation (20% risk of
strangulation) via Cooper / preperitoneal / laparoscopic approaches, if
incarcerated contents cannot be reduced  divide lacunar ligament
Sliding Hernia
 Internal organ lined by visceral peritoneum comprises portion of hernia sac,
mostly indirect, MC organ in females = ovaries vs. MC organ in males =
cecum, bladder common in both sexes
Ventral Hernias
 P/w anterior abdominal wall bulge, spontaneous vs. acquired (e.g.
incisional), epigastric (from xiphoid to umbilicus) /umbilical / hypogastric
(below the umbilicus)
 Epigastric hernias → small, p/w pain due to incarceration of preperitoneal
fat, Rx w/ primary closure
 Umbilical hernias → women > men, infants = congenital, close
spontaneously by age 2 / those that persists after age 5 should be fixed vs.
adults = acquired, those w/ symptoms / signs of incarceration or
uncontrollable ascites should be fixed, Rx w/ Mayo repair (vest over pants,
historical approach) vs. primary closure (<3 cm) vs. mesh closure (>3 cm)
 Incisional hernias → due to excess tension / inadequate healing of previous
incision, incidence of 10% after laparotomy, assoc. w/ SSI, defects < 2 cm
closed primarily vs. defects > 2 cm closed w/ synthetic or biologic
(contaminated cases) mesh placed in inlay / overlay / underlay
(intraperitoneal) / retrorectus fashions w/ 3-5 cm overlap between mesh &
fascia
 Chevrel repair → mesh placed between subcutaneous tissue and anterior
rectus sheath
 Rives-Stoppa repair → posterior rectus sheath incision w/ retromuscular
mesh placement
 Component separation → anterior component separation involves incision
of external oblique muscle 2 cm lateral to rectus sheath (yields 20 cm of
mobilization), posterior component separation involves incision of posterior
rectus sheath (yields 2-4 cm of mobilization)
 Complications of ventral hernia repair → recurrence, mesh infections,
seromas and enterotomies
Unusual Hernias
 Spigelian hernia → occurs through the Spigelian fascia between rectus
muscle medially and semilunar line laterally, below the arcuate line due to
absence of posterior rectus sheath, Rx w/ elective repair
 Obturator hernia → occurs through the obturator canal (formed by union of
pubic bone and ischium covered by a membrane pierced by obturator n. and
vessels), p/w SBO in elderly female patient, Rx w/ urgent repair via
abdominal approach
 Lumbar hernia → occurs through superior lumbar triangle (bounded by 12th
rib, paraspinal muscles & internal oblique) vs. inferior lumbar triangle
(bounded by latissimus dorsi, iliac crest & external oblique)
 Sciatic hernia → occurs through greater sciatic foramen, p/w sciatic nerve
pain
 Perineal hernia → occurs through weakened pelvic floor, may occur after
APR
 Parastomal hernia → occurs more commonly w/ colostomies, repair
reserved for obstruction, stomal relocation reserved for skin excoriation
Diastasis Recti
 Due to separation of rectus muscles, assoc. w/ obesity / multiparity, p/w
midline bulge but w/ intact fascia, Rx w/ abdominal wall strengthening /
operative repair w/ plication of midline aponeurosis

Liver
Anatomy
 Embryology → fetal umbilical vein becomes the ligamentum teres (located
within falciform ligament)
 Segmental anatomy → eight segments, each supplied by a single portal triad
(portal vein / hepatic vein / bile duct)
 Portal vein → 75% of blood inflow (O2 poor), divides into R & L branches,
no valves, normal pressure is 3 to 5 mm Hg, located posterior in portal triad
 Hepatic artery → 25% of blood inflow (O2 rich), divides into R, M & L
branches (replaced R hepatic artery off SMA, replaced L hepatic artery off L
gastric)
 Hepatic veins → R hepatic vein & confluence of M / L hepatic veins drain
into IVC, veins of caudate lobe drain directly into IVC
 Biliary system → R & L bile ducts form common hepatic duct, which after
takeoff of cystic duct becomes the CBD (blood supply at 3- & 9-o’clock)
 Microscopic anatomy → hepatic lobule w/ terminal portal triads draining
into central vein via zone I / II / III (w/ decreasing O2 concentrations)
Physiology
 Bile acid metabolism → 1° bile acids (cholic / chenodeoxycholic acid) are
produced by hepatocytes & conjugated w/ taurine / glycine, actively secreted
into canaliculi into gut, modified to 2° bile acids (deoxycholic / lithocholic
acid), enterohepatic circulation via passive absorption in jejunum / active
absorption in ileum into portal venous system
  Bilirubin metabolism → product of heme breakdown, conjugated to
glucuronic acid by hepatocytes & actively secreted into canaliculi, enter gut &
deconjugated to urobilinogen, reabsorbed via enterohepatic circulation
 Carbohydrate metabolism → glucose from gut stored as glycogen in the
liver =1° source of fuel in the fasted state (48 hours) then shift to
gluconeogenesis (lactate from muscle converted to pyruvate via Cori cycle)
 Lipid metabolism → lipogenesis → FAs synthesized in liver from glucose
after glycogen storage capacity exceeded & stored in adipocytes, lipolysis →
TGs synthesized in liver from esterification of FAs w/ glycerol undergo β-
oxidation to generate ATP
 Protein metabolism → excess protein oxidized by liver as fuel or converted
into glucose / ketone bodies / fat, BCAAs cannot be catabolized in liver - only
muscle
 Drug metabolism → phase I (cytochrome P450) & phase II (transferase rxn,
creates a less toxic byproduct)
 Coagulation → liver responsible for synthesis of all coagulation factors
(except VIII & vWf), factors II / VII (shortest half-life) / IX / X / protein C & S
= Vit-K dependent, PT is most accurate marker of liver function
Portal Hypertension
 Dx w/ hepatic venous wedge pressure > 10 mm Hg
 Presinudsoidal HTN  w/ normal liver function, due to intra-hepatic
(Schistosomiasis) vs. extra-hepatic (portal / splenic vein thrombosis) causes
 Sinusoidal HTN  w/ abnormal liver function, due to Cirrhosis
 Postsinusoidal HTN  w/ abnormal liver function, due to congenital webs /
Budd-Chiari syndrome = thrombosis of the hepatic veins or IVC w/
postsinusoidal portal HTN / assoc. w/ hypercoagulable state, p/w ascites, Dx
w/ US / CT / elevated liver enzymes, Rx w/ anticoagulation / percutaneous
angioplasty ± stenting)
Esophagogastric Variceal hemorrhage
 Sequela of portal HTN, due to abnormal connection between short gastric &
azygos, prophylactic Rx w/ β-blocker / endoscopic ligation (most effective),
Rx acute bleeding w/ endoscopic ligation / octreotide / Abx / TIPS
(refractory cases), Blakemore tube for life-threatening hemorrhage (90%
control of bleeding but 50% risk of rebleeding), definitive Rx w/ TIPS (useful
in patients w/ refractory ascites & as a bridge to TXP, MCC = stent stenosis >
worsening encephalopathy) / operative shunt (e.g splenorenal = selective vs.
side-to-side portocaval = nonselective)/ hepatic TXP in patients w/ advance
disease (MELD > 19 or Child-Pugh C)
 Other sites of varices  hemorrhoids (middle & inferior hemrrhoidal veins)
/ caput medusa
Cirrhosis
 Mediated by Ito cells, assoc. w/ HCV / EtOH / NASH / Wilson disease /
hemochromatosis
  Child-Pugh Classification → predictor of perioperative mortality in patients
w/ Cirrhosis, uses bilirubin / albumin / PT / ascites / encephalopathy (Class
C = contraindication to surgery)
 MELD Score  predicts 3-month mortality in patients awaiting liver TXP,
uses bilirubin / INR / Cr
 Umbilical hernia  occurs frequently in cirrhosis due to increased intra
abdominal pressure, w/ risk for skin rupture (high mortality), Rx w/ medical
optimization (furosemide / spironolactone / sodium restriction) followed by
elective hernia repair vs. if evidence of skin perforation / infection proceed
w/ emergent hernia repair (do not place mesh if concern for infection)
Hemobilia
 Due to abnormal connection between blood vessel and bile duct, caused by
iatrogenic trauma, p/w triad of abdominal pain / UGI bleed / jaundice, Dx w/
EGD, Rx w/ conservative therapy / transarterial embolization for patients
requiring blood transfusion
Infectious Diseases of the Liver
 Pyogenic abscess → results from infection of biliary tree (E. coli >
Klebsiella), occur on R side of liver, p/w triad of fever / RUQ pain / jaundice,
Rx w/ Abx + percutaneous drainage, high mortality
 Amebic abscess → men > women, R liver predominance, results from E.
histolytica, endemic to Mexico, fecal-oral ingestion w/ 1° colonic infection
that ascends via portal vein, dx w/ circulating antiamebic antibodies, Rx w/
metronidazole
 Hydatid cyst → results from Echinococcus (dogs are definitive host / sheep
& human are intermediate host), forms double-walled cyst w/ calcifications,
Rx w/ pre- & post-op albendazole + surgical excision (risk of anaphylaxis w/
spillage of cyst)
Pyephlebitis
 Infection of the portal system, secondary to diverticulitis / appendicitis, p/w
fevers / elevated LFTs, dx w/ air in the portal system, complication = liver
abscess
Viral Hepatitis
 Hepatitis A → fecal-oral transmission
 Hepatitis B → assoc. w/ HCC, DNA virus integrates into host genome, anti
hepatitis B core Ab indicates previous infection vs. vaccination
 Hepatitis C → chronic infection, Rx w/ Sovaldi
 Hepatitis D → superinfection w/ hepatitis B
 Hepatitis E → fecal-oral transmission, fulminant hepatic failure in pregnancy
Benign Neoplasms of the Liver
 Hepatic adenoma → occurs in young women on OCPs, assoc. w/ risk of
hemorrhage and malignant transformation, p/w pain, Dx w/ CT w/ early
enhancement during arterial phase & no uptake on colloid scan (-Kupffer
cells), Rx w/ resection if symptomatic or >4 cm, complications = rupture
 Focal nodular hyperplasia → due to embryonic disturbance in blood flow,
located peripherally, no risk of malignant transformation, usually
 asymptomatic, Dx w/ central stellate scar & uptake on colloid scan (+Kupffer
cells), no Rx required
 Hemangioma → most common benign hepatic tumor, usually asymptomatic,
can be assoc. w/ Kasabach-Merritt syndrome (hemangioma /
thrombocytopenia / consumptive coagulopathy), Dx w/ CT w/ peripheral
nodular enhancement, Rx w/ resection ± pre-op embolization if symptomatic
(needle biopsy contraindicated)
Malignant Neoplasms of the Liver
 Hepatocellular carcinoma → assoc. w/ male sex / HBV > HCV / EtOH /
smoking / cirrhosis / hemochromatosis / aflatoxin, Dx w/ arterial
enhancement & subsequent washout on CT ± elevated AFP, fibrolamellar =
best prognosis / occurs in younger patients /Hep B negative / assoc. w/
elevated neurotensin levels / normal AFP vs. diffuse nodular = worse
prognosis, most common site of metastasis = lung, Rx w/ resection (1 cm
margin) / preoperative portal vein embolization to increase FLR / orthotopic
liver TXP if cirrhosis present / transarterial chemoembolization for
multifocal disease (blood supply via hepatic artery) / percutaneous ethanol
injection for tumors < 2 cm / thermal ablative therapy (heat sink side effect)
/ Sorafenib (anti Raf-1), Milan Criteria  determines TXP eligibility in
patients w/ cirrhosis / HCC = single lesion < 5cm, up to 3 lesions each < 3cm,
no extra hepatic metastatic, no extrahepatic metastatic disease / major vessel
involvement
 Intrahepatic cholangiocarcinoma → poor prognosis, assoc. w/ PSC, HBV &
HCV / choledochal cysts, Rx w/ resection
 Hepatoblastoma → most common liver mass in children, p/w painless
abdominal mass, Rx w/ chemotherapy & resection
 Angiosarcoma → assoc. w/ vinyl chloride exposure
Metastatic Neoplasms of the Liver
 Metastatic liver tumors are more common than primary liver tumors
 Colorectal metastases → 35% 5-year survival for patients w/ CRC &
resectable disease after surgery (no difference in outcomes between
simultaneous vs. staged resection of CRC w/ liver lesions), hepatic arterial
infusion chemotherapy can convert patients to resection candidates
 Neuroendocrine metastases → gastrinomas / glucagonomas /
somatostatinomas / insulinomas / carcinoid tumors (excellent prognosis),
Rx w/ resection
Cystic Neoplasms of the Liver
 Simple cysts → congenital malformations, Rx w/ observation
 Cystadenoma → > 10 cm, can undergo malignant transformation to
cystadenocarcinoma, Rx w/ excision
 Polycystic liver disease → assoc. w/ autosomal dominant adult polycystic
kidney disease, p/w multiple cysts w/ normal liver function, Rx symptomatic
patients w/ laparoscopic fenestration
 Choledochal cysts → congenital dilatation of biliary tree, risk of malignancy
/ cholangitis, type IV & V involve intrahepatic ducts, Rx type V w/ liver TXP
 Multiple Endocrine Neoplasia Syndromes
MEN 1
 Autosomal dominant inheritance, due to mutation in MEN1 tumor
suppressor gene, p/w hyperparathyroidism due to multiglandular
parathyroid neoplasms / PNETs (gastrinoma > insulinoma > glucagonoma >
VIPoma) / pituitary adenomas (prolactinoma)
 Surveillance in MEN1  yearly pituitary screening w/ prolactin @ age 5,
yearly parathyroid screening w/ Ca2+ / PTH @ age 8, yearly pancreas
screening w/ gastrin / chromogranin A / proinsulin / glucagon / CT @ age
20
 Rx hyperparathyroidism first w/ subtotal parathyroidectomy vs. total
parathyroidectomy w/ autotransplantation, Rx gastrinoma w/ local resection
vs. pancreaticoduodenectomy (frequently occur in submucosal of
duodenum), Rx insulinoma w/ enucleation vs. resection, Rx pituitary
adenoma w/ dopamine antagonists (prolactinoma) vs. trans-sphenoidal
hypophysectomy
 Other associated tumors  bronchial / thymic / type II gastric carcinoids
MEN 2
 MEN 2A  autosomal dominant inheritance, due to mutation in proto-
oncogene RET, p/w MTC / pheochromocytoma / hyperparathyroidism,
assoc. w/ Hirschsprung’s disease (congenital absence of ganglion cells in
distal colon)
 MEN 2B  autosomal dominant inheritance, due to mutation in proto-
oncogene RET, p/w MTC (occurs in infancy / most aggressive form) /
pheochromocytoma / mucosal neuromas / megacolon / Marfanoid-habitus
 Surveillance in MEN2  measurement of calcitonin levels (MTC arises from
C-cells), yearly pheochromocytoma screening w/ 24-hour urine
metanephrines, yearly parathyroid screening w/ Ca2+ / PTH
 Rx MTC w/ total thyroidectomy, central neck dissection ± ipsilateral lateral
neck dissection (MEN 2A should undergo prophylactic total thyroidectomy @
age 5 vs. MEN 2B should under prophylactic total thyroidectomy < age 1), Rx
pheochromocytoma w/ total adrenalectomy, Rx hyperparathyroidism w/
total parathyroidectomy w/ autotransplantation
Familial non-MEN MTC (FMTC)
 Autosomal dominant inheritance, due to mutation in proto-oncogene RET,
p/w MTC in later decades of life
Sporadic MTC
 No inheritance pattern, due to somatic RET mutation, p/w no assoc.
abnormalities

Parathyroid Glands
Embryology
 Endoderm origin, superior parathyroid glands = 4th pharyngeal pouch /
inferior parathyroid glands = 3rd pharyngeal pouch
Anatomy
 Superior parathyroid glands located posteromedial to superior thyroid
lobe, posterolateral to RLN
 Inferior parathyroid glands  located inferior to inferior thyroid lobe,
anteromedial to RLN
 Arterial supply  inferior thyroid artery (branch of thyrocervical trunk)
 Venous drainage  superior / middle / inferior thyroid veins into IJV
Physiology
 Parietal chief cells secrete PTH in response to low Ca2+ which stimulates
osteoblast induced bone resorption / renal Ca2+ resorption in DCT & PO43-
excretion / conversion of 25-hyrdoxyvitamin D to 1,25-hydroxyvitamin D
(calcitriol) which increases absorption of Ca2+ & PO43- in the gut
Calcium physiology
 Most abundant cation, free & active (50%) / bound to albumin & inactive
(45%) / bound to citrate & inactive (5%)
Vitamin D Physiology
 Synthesis begins in keratinocytes, hydroxylation in liver to 25-
hydroxyvitamin D, hydroxylation in liver to 1,25-dihydroxyvitamin D
Hypoparathyroidism
 Postsurgical > congenital (e.g. DiGeorge syndrome), p/w hypocalcaemia &
hyperphosphatemia
Pseudohypoparathyroidism
 Inappropriate response to PTH, p/w hypocalcaemia & hyperphosphatemia in
the setting of a normal PTH (e.g. Albright hereditary osteodystrophy)
Hyperparathyroidism
 Nonparathyroidal hypercalcemia  due to malignancy (most commonly
due to secretion of PTHrP) / endocrine disorders / medications (e.g. lithium
/ thiazide diuretics) / granulomatous disease
 Primary hyperparathyroidism (PHPT)  due to parathyroid adenoma >>
multigland disease >> parathyroid carcinoma, w/ inappropriately elevated
PTH level relative to serum Ca2+ / elevated renal cAMP / elevated urine Ca2+,
p/w polyuria > nephrolithiasis, localize gland w/ 99mTc Sestamibi scan, Rx w/
subtotal parathyroidectomy (adenoma) vs. total parathyroidectomy w/
immediate heterotrophic transplantation of parathyroid tissue (forearm)
 Secondary hyperparathyroidism  due to chronic renal failure, p/w
elevated PTH / normal Ca2+/ hyperphosphatemia / low calcitriol, Rx w/
calcimimetic agents & phosphate binders
 Tertiary hyperparathyroidism  due to hyper functioning parathyroid
tissue in patients w/ chronic renal failure after renal transplantation, Rx w/
subtotal parathyroidectomy
Ectopic Parathyroid Glands
 Inferior parathyroid (most commonly located in thymus) > superior
parathyroid (most commonly located in retro-esophageal groove)
Operative Adjuncts to Parathyroidectomy
  Intraoperative PTH monitoring (cure = 50% drop in PTH levels from baseline
to 10-15 minutes after resection) / gamma probe localization (preoperative
injection of 99mTc Sestamibi) /RLN monitoring (has not been shown to
decrease nerve injury)
Complications of Parathyroid Surgery
 RLN injury (1%) / hungry bone syndrome (postoperative hypocalcemia &
hypophosphatemia, risks include patients w/ 4-gland hyperplasia/ Graves
disease) / hematoma
Indications for Parathyroidectomy in Asymptomatic Patient
 Elevated serum Ca2+(>1 mg/dL above normal) / 30% reduced Cr clearance /
elevated 24 hour urinary Ca2+ excretion (>400) / DEXA T-score < -2.5
Hyperparathyroidism in Pregnancy
 Assoc. w/ a 3.5x increase in miscarriage, Rx w/ parathyroidectomy during 1st
trimester
Parathyroid Carcinoma
 Uncommon, p/w palpable neck mass & markedly elevated serum Ca2+ / PTH,
Rx w/ en bloc resection of the tumor w/ ipsilateral thyroid lobectomy,
mortality due to hypercalcemia
Inherited Parathyroid disease
 MENI  pituitary adenoma / PHPT (multigland disease) / pancreatic
neoplasm, w/ MEN1 gene
 MEN IIA  PHPT (single gland disease) / medullary thyroid carcinoma /
pheochromocytoma, w/ RET proto-oncogene
Familial Hypercalcemic Hypocalciuria (FHH)
 Defect in kidney PTH receptor, p/w increased Ca2+ resorption / high serum
Ca2+ / low urine Ca2+
Parathyromatosis
 Due to low-grade parathyroid malignancy / fracturing of parathyroid
adenoma, p/w recurrent hyperparathyroidism despite multiple surgical
resections, Rx w/ serial debulking
Hypercalcemic crisis
 Elevated Ca2+ assoc. w/ end organ dysfunction, due to malignancy > PHPT, Rx
w/ IV hydration / loop diuretics / glucocorticoids / bisphosphonates /
calcitonin
Calciphylaxis
 Calcific uremic arteriolopathy, assoc. w/ ESRD, p/w chronic nonhealing
wounds, Dx w/ skin biopsy, Rx w/ subtotal parathyroidectomy

Pediatric Surgery
Fetal Physiology
 Cardiovascular  arterial blood from placenta bypasses the liver via ductus
venosus and bypasses the lungs via patent foramen ovale & ductus arteriosus
 Pulmonary  immature lungs w/ decreased type II pneumocytes & lower
surfactant production, infants are obligate nasal breathers
  Immunology  decreased levels of immunoglobulins (IgA = milk, IgG =
placenta)
 Thermoregulation  increased BSA make infants susceptible to
hypothermia
 Maintenance fluids  4-2-1 rule (40 + patient’s weight in Kg)
Extracorporeal Membrane Oxygenation (ECMO)
 Indicated in patients w/ refractory cardiopulmonary failure (e.g. meconium
aspiration = most common, respiratory distress syndrome, PPHN, CDH), VA
bypass (R IJ  CCA) drains desaturated venous blood and returns warm
oxygenated blood, complication = ICH
Chest Wall
 Pectus excavatum  4:1 male predominance, Rx w/ Nuss procedure
(curved metal bar stabilized in retrosternal plane) if width of chest wall :
depth of sternum > 3.2 / abnormal PFTs / MVP (40% resolution after repair)
/ progression of deformity
 Pectus carinatum  Rx w/ bracing
Abdominal Wall
 Omphalocele  p/w abdominal contents protruding through abdominal
ring w/ intact sac covering, assoc. w/ other congenital abnormalities
(Cantrell pentad), Rx w/ primary / mesh closure
 Gastroschisis  p/w abdominal contents protruding to the right of an intact
umbilical cord (site of obliteration of umbilical vein) w/o intact sac covering,
not assoc. w/ other congenital abnormalities (exception = intestinal atresia),
Rx w/ primary / mesh closure, if viscera unable to be reduced into abdomen
 silo placed at bedside
 Inguinal hernia  due to persistent processus vaginalis, indirect / R > L,
boys > girls, Rx w/ high ligation of hernia sac, Rx reducible incarcerated
hernia w/ admission & hernia repair at 24-48 hours, Rx nonreducible
incarcerated hernia w/ urgent repair, routine contralateral inguinal
exploration indicated in infants at time of repair
 Umbilical hernia  due to failure of closure of linea alba, most close
spontaneously by age 2, however if they persist Rx w/ repair at age 5
Head & Neck
 Dermoid / Epidermoid cysts  benign, p/w lesion on scalp w/ hair / teeth
/ skin glands, Rx w/ resection
 Cystic hygroma  due to lymphatic malformation, p/w multiloculated cyst
in posterior neck triangle, risk for infection, Rx w/ resection
 Thyroglossal duct cyst  embryology = thyroglossal duct originates from
foramen cecum at base of tongue and migrates inferiorly w/ thyroid
diverticulum during development before regressing, failure to regress =
thyroglossal duct cyst, p/w midline neck lesion, Rx w/ cyst excision and
resection of central portion of hyoid
 Brachial cleft remnants  p/w cysts / sinuses / fistulas, 1st = angle of
mandible (can involve CN VII), 2nd = anterior SCM (most common, involves
carotid bifurcation), 3rd= lower neck, Rx w/ resection
Brochopulmonary Malformations
 Bronchogenic cyst  commonly occur at carina, usually does not
communicate w/ tracheopulmonary tree, p/w airway compression, risk for
infection, Rx w/ resection regardless of symptoms (malignant potential)
 Congenital pulmonary airway malformation (CPAM)  hamartomatous
lesions, communicates w/ tracheopulmonary tree, p/w respiratory
compromise, risk for infection, Rx w/ resection regardless of symptoms at 6
months (malignant potential)
 Pulmonary sequestration  nonfunctional lung tissue fed by aberrant
artery that does not communicate w/ tracheopulmonary tree, intra-lobar w/
pulmonary venous drainage / within native visceral pleura vs. extra-lobar w/
systemic venous drainage / separate pleura / assoc. w/ CDH, p/w recurrent
infection / hemoptysis, Rx w/ arterial ligation then lobectomy
 Congenital lobar emphysema  failure of cartilage development in
bronchus, p/w air trapping on expiration in LUL, Dx w/ CXR w/ hyperlucent
lobe, Rx w/ lobectomy
Congenital Diaphragmatic Hernia (CHD)
 Due to failure of closure of pleuroperitoneal canal (Bochdalek hernia =
posterolateral, Morgani hernia = anteromedial), occurs on L > R side,
survival = 50% due to pulmonary hypoplasia & pulmonary HTN, Rx w/
ventilatory support / inhaled NO, surgical Rx after medical optimization w/
reduction of viscera & closure of defect ± mesh / hernia sac excision (present
in 10%), novel Rx = fetoscopic occlusion of trachea to promote lung growth
Alimentary Tract
 Tracheoesophageal fistulas (TEF)  type C = proximal esophageal atresia
w/ distal TEF (most common), type A = proximal esophageal atresia w/o
distal TEF (gasless abdomen), assoc. w/ VACTERL (vertebral / anorectal /
cardiac / TEF / renal / limb malformations), Dx w/ inability to place OGT, Rx
w/ right thoracotomy w/ esophageal anastomosis and fistula takedown,
complications of Rx = GERD > stricture > leak > tracheomalacia
 Hypertrophic pyloric stenosis  most common in 1st born male, p/w
projectile nonbilious emesis (hypokalemic hypochloremic metabolic
alkalosis & paradoxical aciduria) ± palpable “olive”, Dx w/ US, Rx w/ fluid
resuscitation (20 mL/Kg NS bolus followed by maintenance w/ D5 ½NS w/
20mEQ KCl) & pyloromyotomy (serosa & muscle divided / submucosa &
mucosa left intact)
 Duodenal atresia  assoc. w/ TS 21 / cardiac (obtain echocardiogram) &
renal abnormalities, due to failure of canalization, p/w bilious emesis, Dx w/
double-bubble sign on AXR, Rx w/ duodenoduodenostomy
 Jejunal atresia  most common intestinal atresia due to intrauterine
vascular accident, p/w bilious emesis, Dx w/ triple-bubble sign on AXR, Rx
w/ resection of dilated bowel and establishment of intestinal continuity
 Malrotation & midgut volvulus  normal intestinal rotation is 270°
counterclockwise around the SMA & failure results in malrotation, midgut
volvulus due to narrow mesenteric stalk, p/w bilious emesis, Dx w/ UGI, Rx
 w/ emergent LADD procedure  counterclockwise detorsion, resection of
necrotic bowel, division of Ladd bands & incidental appendectomy (at
conclusion of operation small bowel loops placed on R side & colon placed on
L side)
 Necrotizing enterocolitis (NEC)  RF = prematurity (#1) / hypoxia /
sepsis, p/w hematochezia after initiation of enteral feeding, assoc. w/ Abx
use, probiotics are protective, Dx w/ pneumatosis intestinalis on AXR, Rx w/
medical mgmt. (IV hydration / Abx / TPN) vs. surgical Rx
(pneumoperitoneum / persistent acidosis) w/resection of necrotic bowel &
ostomy diversion (contrast enema before ostomy takedown), complications
= short gut syndrome / colonic stricture formation
 Short gut syndrome  inadequate bowel length to sustain enteral nutrition,
NEC is most common pediatric etiology, Rx w/ elemental diet / glutamine /
Bianchi intestinal lengthening procedure (jejunum is preferred for intestinal
lengthening)
 Meconium ileus  assoc. w/ CF, p/w abdominal distension / bilious emesis
/ failure to pass meconium, Dx w/ soap-bubble appearance / microcolon on
AXR, Rx w/ gastrografin enema / enterotomy w/ N-cetylcysteine antegrade
enemas
 Hirschsprung’s disease  absence of ganglion cells in Aerbach & Meissner
plexus at the anorectal line, p/w failure to pass meconium, complication =
enterocolitis (most common cause of death, Rx w/ rectal irrigations & Abx),
Dx w/ rectal suction biopsy, Rx w/ diverting colostomy / resection of
aganglionic rectum / eventual coloanal anastomosis
 Imperforate anus  more common in males, assoc. w/ VACTERL, Rx high
lesions (above the levator, w/ increased risk for urological abnormalities) w/
colostomy & eventual posterior sagittal anoplasty vs. low lesions (below the
levator) w/ primary posterior sagittal anoplasty
 Intussusception  due to telescoping of the intestine, occurs at ileocecal
junction, lead point in children = hypertrophied Peyer’s patches > Meckel’s
diverticulum, p/w abdominal pain / currant jelly stool / “sausage” mass, Dx
& Rx w/ air-contrast enema, Rx 2nd recurrence after reduction w/ air enema,
Rx 3rd recurrence after reduction or any patient w/ peritonitis w/ surgery 
retrograde reduction w/o bowel resection
 Meckel’s diverticulum  true diverticulum due to persistence of vitelline
duct, 2% of population / 2% symptomatic / 2 types of tissue (gastric >
pancreatic) / 2 feet of ileocecal valve, p/w painless hematochezia >
obstruction (Littre hernia) > diverticulitis, Dx w/ Meckel’s scan (99mTc-
pertechnetate isotope), Rx w/ diverticulectomy vs. bowel resection if
inflammation / ulceration of base is present
Hepatobiliary Malformations
 Biliary atresia  due to inflammatory obliteration of intra- & extrahepatic
bile ducts, p/w persistent jaundice in neonate past 2 weeks, Dx w/ liver
biopsy, Rx w/ Kasai hepatoportoenterostomy, however patients eventually
require liver TXP
  Choledochal cyst  due to pacreaticobiliary reflux, type I = fusiform
dilatation / type II = diverticulum / type III = choledochocele / type IV =
intra- & extrahepatic / type V = intrahepatic, p/w triad of RUQ pain /
jaundice / mass, risk for malignant transformation / pancreatitis /
cholangitis, Rx w/ excision & biliary enteric reconstruction
Genitourinary Tract
 Cryptorchidism  failure of descent of testes into the scrotum before birth,
most common location is inguinal canal, Rx at 6 months w/ inguinal
orchiopexy, risk for nonseminomatous germ cell tumor is not decreased by
orchiopexy / risk for infertility is decreased by orchiopexy
 Testicular torsion  due to inadequate attachment to tunica vaginalis, p/w
acute onset testicular pain / absence of cremasteric reflex, Dx w/ US, Rx w/
bilateral scrotal orchiopexy
 Testicular tumors  p/w painless scrotal mass, yolk sac tumors w/ AFP,
embryonal carcinomas / mixed teratomas w/ β-hCG, Rx w/ radical inguinal
orchiectomy
Solid Tumors
 Neuroblastoma  most common solid pediatric tumor, arises from neural
crest cells most often in adrenal medulla, p/w painless mass, can have HTN /
secretory diarrhea / raccooon eyes / opsoclonus-myoclonus / blueberry
muffin skin lesions, Dx w/ elevated NSE & urinary VMA / CT, staging = low /
intermediate / high, age < 1 w/ best prognosis vs. >3 copies of N-myc w/
worse prognosis, Rx low w/ resection vs. intermediate / high w/ adjuvant
chemoradiation (doxorubicin) + resection, bone marrow transplant in
patients w/ advance disease improves outcomes
 Wilms tumor (Neuroblastoma)  assoc. w/ WAGR (aniridia /
hemihypertrophy / GU malformations / MR) & BWS, p/w painless mass, can
have hematuria / HTN, Dx w/ US / CT, staging = favorable / unfavorable, Rx
w/ neoadjuvant chemo (actinomycin & vincristine) + nephrectomy, if both
kidneys involved  nephron-sparing Rx, tumor rupture greatly increases
recurrence rates
 Hepatoblastoma  assoc. w/ BWS / fetal alcohol syndrome, p/w painless
mass, Dx w/ elevated AFP / CT, fetal histology = favorable prognosis, Rx w/
neoadjuvant chemo (doxorubicin) + resection
 Sacrococcygeal teratomas  occur in neonates, age <2 months = favorable
prognosis, Rx w/ coccygectomy
 Ovarian neoplasms  50% of all ovarian lesions in children are neoplastic,
germ cell tumors = teratoma, sex cord tumors = granulosa / seritoli-leydig
cell (p/w precocious puberty), epithelial tumors = serious / mucinous

Peripheral Arterial Disease

Arterial Anatomy
  Vascular wall composed of intima (endothelial cells), media (structural
support, blood supply of inner layer via direct diffusion vs. outer layer via
vasa vasorum) & adventitia (strength layer)
Atherosclerosis
 RF = nonwhite / age / smoking / HTN / HLD / DM / CKD, assoc. w/ MI &
stroke, due to endothelial injury w/ smooth muscle proliferation & plaque
deposition, fibrous cap (smooth muscle) & lipid core (LDL), rupture of cap
exposes thrombogenic core, occurs at arterial branch points due to
alterations in laminar flow (e.g. CFA) / points of entrapment (e.g. distal SFA
at Hunter’s canal), >40% stenosis compromises lumen
Chronic Arterial Insufficiency
 Arterial disease is one level above symptomatic muscle group, p/w
claudication (specific muscle groups) / trophic changes / rest pain (distal
aspects of circulation, pain experienced over metacarpal heads) / tissue loss,
Dx w/ ABI (<0.9) / CTA / angiography (diagnostic & therapeutic), Rx w/
walking programs / smoking cessation / cilostazol (increases walking
distance) / ASA / β blocker / statin / endovascular revascularization
procedures (patency for iliac >> femortibial disease/ patency for claudication
> ischemic disease) / open revascularization procedures (GSV > PTFE,
especially for BK bypasses, postop surveillance w/ US biannually, early graft
failure <30 days due to technical failure vs. intermediate graft failure 30 days
to < 2 years due to intimal hyperplasia vs. late graft failure > 2 years due to
atherosclerosis) / debridement / amputation
Acute Arterial Insufficiency
 P/w pain / pallor / pulselessness / parasthesias / paralysis / poikilothermia,
due to embolic (A. fib / recent MI / valvular disease) vs. thrombotic events
(h/o previous interventions), Rx w/ anticoagulation & fibrinolytics in
patients w/ minimal neurologic changes vs. open thrombectomy w/ patch
angioplasty in patients w/ significant deficits, w/ four compartment
fasciotomy if ischemic time > 4 hours (lateral incision releases anterior &
lateral compartments / medial incision releases superficial & deep posterior
compartments)
Atheroembolic Disease
 Due to aortoiliac disease, microemboli lodge in distal small vessels (e.g. blue
toe syndrome), p/w palpable pulses, Rx w/ surgical removal of embolic
source
Amputations
 BKA  assoc. w/ 5% perioperative mortality / poor wound healing w/ high
revision rate, anterior incision 10cm below tibial tuberosity, posterior–flap
technique w/ soleus & gastrocnemius, guillotine BKA in severe infection
 AKA  assoc. w/ 15% preioperative mortality / improved wound healing /
increased energy expenditure, fish-mouth incision
Carotid Artery Disease
 Carotid bifurcation common location for atherosclerosis, p/w TIAs /
ischemic strokes (perform surgery within 2 weeks of stroke) / amaurosis
fugax (transient unilateral loss of vision due to embolus to ophthalmic
artery), Dx w/ US (increased velocity correlates w/ severity of disease), Rx
w/ CEA in patients w/ high-grade stenosis regardless of symptoms or in
patients w/ moderate-grade stenosis who are symptomatic, no benefit in
completely occluded ICA, benefit in men > women, complications = stroke /
vagal n. (paralysis of vocal cord) > hypoglossal n. (tongue deviation to
ipsilateral side) > glossopharyngeal n., Rx new neurologic deficits w/
operation (due to thromboempolic phenomena), hyper perfusion syndrome
due to impairment in auto regulation / p/w ipsilateral frontal headache /Rx
w/ β blockers
 Carotid angioplasty w/ stenting (CAS)  indicated for high risk patients
w/ significant disease, CAS w/ higher perioperative stroke risk vs. lower
perioperative cardiac risk when compared to CEA
Peripheral Artery Aneurysms
 Popliteal > femoral, assoc. w/ aortoiliac aneurysms, often bilateral, Dx w/ CT,
Rx regardless of size due to risk of thromboembolic events, Rx femoral
aneurysms w/ excision + interposition graft, Rx popliteal aneurysms w/
bypass vs. covered stents
Splanchnic Artery Aneurysms
 Splenic artery aneurysms  most common, women > men, increased risk
of rupture w/ pregnancy w/ high maternal & infant mortality, p/w double
rupture phenomena (initial bleeding within lesser sac followed by free
hemorrhage into peritoneal cavity), Rx if > 2 cm or in pregnant patient
regardless of size w/ proximal & distal ligation of aneurysm vs. covered stent
 Hepatic aneurysms  second most common, Rx if > 2 cm or symptomatic
w/ ligation of CHA vs. covered stent
Nonatherosclerotic Arteriopathies
 Raynaud syndrome  affects women < 40, p/w episodic digital ischemia
due to vasospasm in the presence of cold / stress, primary vs. secondary
(assoc. w/ scleroderma / SLE), Rx w/ Ca2+ channel blocker
 Buerger disease  thromboangiitis obliterans, affects male smokers in 30s,
p/w digital gangrene, Rx w/ smoking cessation / amputation as indicated
Vasculitis
 GCA (temporal arteritis)  large vessels, affects patients > 55 years /
branches of the ECA, Dx w/ temporal artery biopsy, Rx w/ high dose steroids,
complication = blindness
 Takayasu  large vessels, affects young patients / major branches of aorta
 Polyarteritis nodosa  medium vessels of kidney / liver / heart / GI tract,
risk for multiple visceral aneurysms, Rx w/ immunosuppressive therapy
  Kawaski disease  medium vessels, p/w coronary aneursyms in children
<5, Rx w/ASA
 Bechet disease  medium vessels, p/w genital mucocutaneous ulcerations
 Wegner granulomatosis  small vessels of kidney and respiratory tract
 Churg-Strauss  small vessels, p/w allergic rhinitis / asthma due to
eosinophilic infiltrative disease
Cystic Medial Necrosis
 Assoc. w/ Ehlers-Danlos / Marfans, p/w aortic dissection w/ propagation to
aortic leaflets, Rx w/ aortic arch repair + valve replacement
Popliteal Entrapment Syndrome
 Occurs in men < 40, p/w mild claudication, Dx w/ MRI (demonstration of
medially placed popliteal artery relative to normal placed medial head of the
gastrocnemius), Rx w/ resection of medial head of gastrocnemius
Renal artery disease
 Renovascular HTN due to elevated renin w/ activation of RAAS, due to
atherosclerosis > fibrodysplasia, Dx w/ US, Rx w/ PTA w/ covered stent for
atherosclerosis vs. PTA w/o stent for fibrodysplasia
Dialysis Access
 Autologous radiocephalic fistula > autologous brachiocephalic fistula >
transposed basilic-basilic fistula > brachial-cephalic graft, AVF requires
>3mm vein & >2mm artery w/ end of vein to side of artery anastomosis, rule
of 6 determines accessibility of AV fistula for HD cannulation (6 weeks
maturation, vein diameter of 6 mm, access depth of 6 mm, access flow of 600
mL / min), complications = intimal hyperplasia of the venous anastomosis
(most likely cause of late access failure, Rx w/ surgical thrombectomy or
endovascular thrombolysis) / aneurysmal degeneration / steal syndrome

Plastic Surgery
Reconstructive Ladder
 Secondary intention  primary closure  skin graft  local / regional tissue
transfer  free flap
Primary Wound Closure
 Minimizing tension results in minimal scaring
Skin Grafts
 Autograft / allograft / homograft / heterograft
 STSG  w/ epidermis & part of dermis, harvested via a dermatome,
advantages = takes readily to the recipient site / donor site reepitheliazes
quickly, disadvantages = secondary contraction / abnormal pigmentation
and poor durability, meshed STSG allows for increased coverage & drainage
of hematoma / seroma
 FTSG  w/ epidermis and entire dermis w/ portions of sweat glands /
sebaceous glands / hair follicles, harvested via a scalpel, advantages =
durable, disadvantages = less predictable because more tissue must be re
 vascularized from the recipient bed / primary contraction, used in areas w/
sensitive cosmesis (e.g. face)
 Three phases of skin graft take  plasmatic circulation (serum imbibition)
during first 48 hours, revascularization via neovascularization and
inosculation (graft and host form anastomoses), organization starting with a
fibrin layer that is replaced by fibroblasts by post graft day 7
 Most common cause of skin graft failure is hematoma / seroma, other less
common causes include infection / poor wound bed / shearing forces
Skin Flap
 Flap refers to the tongue, pedicle refers to the base
 Failure of a skin flap usually involves necrosis of the most distal portion of
the transferred tissue
 Local flaps rely on inherent elasticity of the skin, examples include rotation,
transposition, advancement, V-Y, rhomboid and Z-plasty
 Muscles flaps  type I single pedicle, type II dominant pedicle w/ minor
pedicles, type III dual dominant pedicles, type IV segmental pedicles, type V
dominant pedicle w/ secondary segmental pedicles (I, III and V most useful)
 Musculocutaneous flaps  muscle flap with an attached skin paddle,
supplied via musculocutaneous perforators
 Fasciocutaneous flaps  skin flap including deep fascia, supplied via
septocutaneous perforators
 Perforator flaps  neither a passive muscle carrier nor the underlying
fascia is necessary for flap survival if the musculocutaneous or
septocutaneous vessel is carefully dissected, advantages  preservation of
muscle / fascia at donor site, disadvantages  difficult dissection and longer
operating time; direct vs. indirect perforators

Small Intestine
Embryology
 Endodermal origin, derived from midgut (except the duodenum)
 Midgut herniates through umbilicus at week 4 → rotates 270° CCW → returns
to abdominal cavity at week 10
Anatomy
 Consists of four layers = serosa / muscularis propria / submucosa (tensile
strength) / mucosa, measures up to 300 cm
 Blood supply  proximal duodenum via celiac axis, remainder of small
bowel via SMA
 Venous drainage  SMV (joins splenic vein to form portal vein)
 Innervation  vagus (parasympathetic) & three splanchnic nerves
(sympathetic)
 Lymphatics  Peyer’s patches (ileum)  cisterna chyli  thoracic ducts
Physiology
 Carbohydrates → brush border enzymes split disaccharides into
monosaccharides, glucose / galactose absorbed via active transport, fructose
absorbed via facilitated diffusion
  Protein → digestion initiated in the stomach by gastric acid, continued in
small bowel by trypsin, di- / tripeptides absorbed via active transport in
jejunum & digested further to amino acids at brush border
 Fats → emulsification w/ bile salts & lecithin promotes lipolysis of TG into
FFA and 2-monoglycerides via pancreatic lipase, these products are dissolved
by micelles & absorbed at brush border, TG are resynthesized & combined
with cholesterol / apoproteins / phospholipids to form chylomicrons which
travel via thoracic duct into venous system
 Short- / medium-chain fatty acids may be absorbed directly into portal blood
without undergoing lipolysis
 Water  absorbed via simple diffusion
 Electrolytes  absorbed via active transport
 Vitamins  Fat soluble (ADEK) vs. water soluble (vitamin C, biotin, folic
acid, B1/2/6/12)
 MMC (migrating myoelectric complexes) stimulated by parasympathetic /
inhibited by sympathetic, also affected by motilin
 Immune function  secretory IgA inhibits adherence of bacteria to
epithelial cells & prevents absorption / neutralizes bacterial toxins
 Fuel source for enterocytes = glutamine
Obstruction
 Etiology  adhesions > neoplasms > hernias > IBD
 Pathophysiology  early increase in bowel peristalsis (can p/w diarrhea)
followed by late fatigue and dilatation w/ third-space fluid loss and bacterial
translocation, closed loop obstruction assoc. w/ arterial occlusion and
subsequent ischemia
 Rx  fluid resuscitation / NGT decompression / operative management in
select patients (e.g. LOA / reduction of incarcerated hernias / intestinal
bypass in malignancy / strictureplasty in Crohn’s disease)
 Rx malignant SBO w/ octreotide / reglan / erythromycin
 Hyaluronate-based bioresorbable membranes have been show to reduce the
incidence of postoperative adhesion formation
Ileus
 Intestinal slowing without mechanical obstruction
 Etiology  metabolic / electrolyte derangements / pharmacologic agents /
post operative / infections
 Rx  fluid resuscitation / NGT decompression / correction of underlying
condition
Crohn’s Disease
 Epidemiology  bimodal distribution (2nd / 3rd decade > 6th decade), men /
women affected equally, increased risk in smokers, strong familial assoc.
 Etiology  infections agents (enteroadherent E. Coli) / autoimmune
processes / genetic factors (NOD2, CARD15, FHIT)
 Pathology  disease is discontinuous and segmental, most commonly
affects small intestine and colon, usually rectal sparing, assoc. w/ creeping fat
 / skip lesions / aphthous ulcers (earliest lesion) / cobblestone appearance /
transmural inflammation / noncaseating granulomas
 Presentation  insidious onset, p/w intermittent abdominal pain (most
common symptom), intestinal manifestations = obstruction / perforation /
fistulas / strictures / abscesses / toxic megacolon / malignancy (CRC > small
bowel), perianal manifestations = fissure / fistula, extraintestional
manifestations = pyoderma gangrenosum / erythema nodosum / uveitis / AS
/ PSC (the latter two do not improve after bowel resection), screening
colonoscopy every 1-3 years starting at age 30
 Medical therapy  sulfasalazine / mesalamine = maintenance therapy,
budesonide > prednisone = flare therapy, AZT / MTX / 6-MP / cyclosporine /
FK-506 = steroid-dependent and refractory disease, infliximab (anti TNF-α =
fistulous disease, antibiotics = perianal disease
 Surgical therapy  bowel preservation = key, surgical margins to grossly
normal tissue
 Acute ileitis  presentation similar to acute appendicitis, perform
appendectomy at index procedure if base of cecum is not involved
 Stricturing disease  p/w obstruction, Rx w/ strictureplasty (longitudinal
incision closed transversely) w/ Heineke-Mikulicz for short segments /
Finney for long segments vs. resection (for isolated lesions, w/ lower rate of
post op complications compared to strictureplasty), gastrojejunostomy for
gastroduodenal disease + highly-selective vagotomy to avoid marginal ulcers
 Fistulous disease  Rx w/ fistula takedown & segmental resection, if fistula
involves adj. organ  close defect but do not resect adj. organ
 Perianal disease  Rx abscesses w/ drainage, Rx fistulas w/ noncutting
setons, Rx fissures (usually lateral) w/ medical mgmt.
 Malignancy  same mgmt., however assoc. w/ worse outcomes
Thyphoid Enteritis
 Due to Salmonella typhi (ingestion of contaminated water), Rx w/
fluroquinolones / third-generation cephalosporin, complications = intestinal
perforation / hemorrhage
Enteritis in the Immunocompromised
 Porotozoa = cryptosporidium, bacteria = salmonella / shigella /
campylobacter, mycobacteria = MAC / Tb, viruses = CMV, fungi =
histoplasmosis
Neoplasms
 Epidemiology  rare, 6th decade of life, men / women affected equally, RF =
FAP / HNPCC / Peutz-Jeghers / Crohn’s disease / celiac spruce / PUD / CF
 Benign neoplasms  usually asymptomatic; adenomas (most common in
ileum, malignant potential), stromal tumors (arise from interstitial cells of
Cajal, express CD117), lipomas, hamartomas (pigmented lesions assoc. w/
Peutz-Jeghers), hemangiomas (assoc. w/ Osler-Weber-Rendu disease)
 Malignant neoplasms  usually symptomatic; adenocarcinoma most
common
  Neuroendocrine tumors (Carcinoid)  good prognosis, arise from
enterochromaffin cells (Kulchitsky cells), occur in submucosa, located in
appendix > rectum > ileum (most likely to metastasize to liver) /
bronchopulmonary tree, p/w carcinoid syndrome due to serotonin release =
flushing / diarrhea / hepatomegaly / right-sided heart valvular disease /
asthma (due to Kallikrein) / pellagra, Dx w/ increased urinary 5-HIAA /
Dotatate scan, medical Rx w/ somatostatin analogues (Rx for carcinoid crisis)
/ surgical Rx w/ resection (w/ mesentery if > 1cm), metastectomy for liver
lesions, serum chromogranin A = best assessment of Rx
 Adenocarcinomas  poor prognosis, located in duodenum > jejunum, can
be found in ileum in patients w/ Crohn’s disease, assoc. w/ FAP / HNPCC /
Celiac, surgical Rx w/ segmental resection w/ lymphadenectomy ± adjuvant
chemotherapy (FOLFOX) for lesions in 3rd / 4th portion of duodenum /
pancreaticoduodenectomy for lesions in 1st / 2nd portion of duodenum
 Lymphoma  located in ileum (greatest concentration of Peyer’s patches),
B-cell > T-cell, assoc. w/ AIDS / H. Pylori (B-cell MALT) / celiac disease (T-
cell), Rx w/ chemotherapy
 GISTs  located in jejunum, arise from interstitial cells of Cajal, grow
extramurally, C-kit / CD117/ CD34 positive, malignant potential based on
mitotic index (>5 mitotic rates per 50 HPF), Rx w/ resection w/ grossly
normal margins & no lymphadenectomy + adjuvant imatinib (tyrosine kinase
inhibitor) for three years if >5 cm or >5 mitoses per HPF, small GISTs (<2 cm)
found incidentally can be observed
 Metastatic neoplasms  more common than primary small bowel
neoplasms, primary sites = uterine / colon / pancreas / stomach / melanoma
/ breast and lung, Rx w/ palliative measures
Diverticular Disease
 Duodenal / jejunal / ileal diverticula  false / acquired, occur on
mesenteric border, usually asymptomatic & no Rx required, duodenal =
single, jejunal / ileal = multiple, if symptoms occur Rx w/ resection
 Meckel’s diverticulum  true / congenital, occur on antimesenteric border,
in 2% of population, located on antimesenteric border of the ileum within 2
feet of the ileocecal valve, due to incomplete closure of the vitilline duct,
contains gastric > pancreatic mucosa, p/w hemorrhage in children < 2 years
from adjacent ulcer or intestinal obstruction, diagnosis via 99mT c-
pertechnetate scan (Meckel’s scan), surgical Rx w/ removal of incidental
lesions in children but not in adults / segmental resection in symptomatic
patients regardless of age
Small Bowel Fistulas
 85% iatrogenic, 15% assoc. w/ Crohn’s / malignancy / diverticulitis /
trauma, proximal fistulas p/w high output (>500 mL/day) vs. distal fistulas
p/w low output (<200 mL/day), factors preventing spontaneous closure =
FRIEND  foreign body / radiation / infection / epithelialization / neoplasm
/ distal obstruction, Rx w/ fluid resuscitation / electrolyte replacement /
 TPN / octreotide, allow 6 week period for spontaneous closure  if this fails
surgical Rx w/ fistula takedown & segmental resection
Pneumatosis Intestinalis
 Most common in jejunum, assoc. w/ NEC / COPD / immunocompromised, Rx
directed at underlying disease
Blind Loop Syndrome
 Bacterial overgrowth in stagnant areas of small bowel (e.g enteroenteric
fistula) results in steatorrhea / megaloblastic anemia / deficiencies of fat-
soluble vitamins / hypocalcemia (Ca2+ binds to ubabsorbed FA), Rx w/ B12
therapy & antibiotics (e.g. tetracycline) w/ surgical correction
Radiation Enteritis
 Risk proportional to exposure, damage directly to DNA & via generation of
oxygen free radicals, mucosal layer = most sensitive, acute vs. chronic
(obliterative arteritis), gray / opaque gross appearance, ACE inhibitors /
statins = reduce GI symptoms, amifostine = radioprotectant agent
Short Bowel Syndrome
 Due to a bowel length inadequate to support nutrition, assoc. w/ multiple
segmental resections (NEC / Crohn’s), Rx w/ nutritional support (TPN) / H2
blockers / PPI (increased gastrin output) / octreotide / tincture of opium /
teduglutide (GLP-2 analogue) / intestinal TXP
SMA Syndrome
 Compression of third portion of the duodenum by the SMA, p/w nausea /
vomiting / weight loss, Rx w/ weight regain, surgical Rx w/
duodenojejunostomy
Intussusception
 Assoc. w/ pathologic lead point in 90% of adults, Rx w/ resection &
lymphadenectomy

Soft Tissue Sarcoma (STS)

Epidemiology
 STS is a diverse group of more than 60 neoplasms that arise from skeletal
muscle, adipose cells, blood and lymphatic vessels and connective tissue
 STS accounts for 1% of cancer incidence and 2% of cancer-related deaths
Risk Factors
 Radiation  dose dependent risk, assoc. w/ angiosarcoma /
leiomyosarcoma / fibrosarcoma
 Carcinogens  PVC / arsenic, assoc. w/ hepatic angiosarcoma
 Neurofibromatosis type I  AD Ras mutation, p/w multiple cutaneous
neurofibromas, peripheral n. sheath tumors / schwannomas / gliomas
 Li-Fraumeni syndrome  AD P53 mutation, p/w breast cancer, STS
(especially rhabdomyosarcoma), adrenocortical carcinoma, osteosarcoma
and hematologic malignancies
 Familial adenomatous polyposis and Gardner syndrome  AD APC
mutation, presents w/ innumerable colonic polyps, also w/ extracolonic
manifestations including epidermoid cysts, osteomas and desmoid tumors
Diagnosis
 FNA is unsatisfactory, diagnosis made via excisional biopsy if < 3 cm vs
incisional biopsy if > 3 cm through a longitudinal incision
Staging
 Tumor grade  most important prognostic factor, based on tumor
differentiation / rate of mitoses / amount of tumor necrosis
 Lymph node involvement  uncommon in STS, exceptions include clear
cell carcinoma / angiosarcoma / liposarcoma / rhabdomyosarcoma;
important prognosticator of survival
 Metastasis  STS spreads hematogenously, principally to the lungs but also
liver / bones
Follow-up
 High recurrence risk; physical exam every 3 to 6 months for 2 to 3 years,
then every 6 months for next 2 years, then annually; radiographic
surveillance of chest / abdomen / pelvis at regular intervals also
recommended
Trunk and Extremity Sarcoma
 Malignant peripheral nerve sheath tumors (MPNST)  malignant form
of schwannoma, occur equally sporadically / part of NF1, prognosis
determined by tumor size / grade, treatment w/ microscopic margin-
negative resection
 Desmoid tumor  fibroblastic tumor, 85% occur sporadically vs. 15%
related to FAP, 2:1 female to male ratio, treatment w/ active surveillance vs.
resection depending on symptoms
 Angiosarcoma  arise from endothelial lining of blood vessels, 40% occur
in assoc. w/ radiation, higher frequency of involved regional lymph nodes
compared to other STS, treatment w/ microscopic margin-negative resection
 Dermatofibrosarcoma protuberans  presents as firm / indurated
nodules, often mistaken for hypertrophic scar, histological appearance is
finger-like projections of spindle cells
Retroperitoneal Sarcoma
 Average tumor size at presentation is 15cm, subtypes include liposarcoma,
leiomyosarcoma and MFH, diagnosis made via imaging and biopsy not
necessary given sampling error and potential for tumor seeding, treatment
w/ complete gross resection ± adjuvant radiation / novel agents (e.g.
tyrosine kinase inhibitors, CDK4 antagonists)
Visceral Sarcoma
 GIST  submucosal spindle cell neoplasms that arise from interstitial cells of
Cajal throughout alimentary tract (stomach > small bowel > rectum), assoc.
w/ c-KIT (70%) and PDGFRA (7%) mutations and CD117 expression,
treatment w/ complete gross resection but lymphadenectomy is not
mandatory / imatinib (tyrosine kinase inhibitor)
 Leiomyosarcoma  second most frequent form of STS, affects the RP and
peritoneal cavity (e.g. uterus), stains positive for desmin and smooth muscle
 actin, treatment w/ complete gross resection but does not require adjuvant
therapy
Lipomatous Tumors
 Lipomas  benign neoplasms encapsulated and devoid of nodularity, can
occur anywhere in body and treatment is excision beyond the capsule
 Liposarcoma  most frequent form of STS, well-differentiated and
dedifferentiated subtypes arise more commonly in RP  treatment is
resection w/ adequate gross margins vs. complete compartmental resection
(dedifferentiated subtype may benefit from adjuvant radiation therapy);
pleomorphic liposarcoma and myxoid/round cell subtypes arise more
commonly in extremities  treatment is limb-sparing resection ±
neo/adjuvant chemoradiation (favored over traditional amputation)

Spleen
Anatomy
 Ligaments  splenophrenic / gastrosplenic (w/ short gastrics & L
gastroepiploic) / splenorenal (w/ splenic artery & vein) / splenocolic
ligaments
 Wandering spleen  laxity of peritoneal attachments, p/w intermittent
abdominal pain / splenomegaly, assoc. w gastric volvulus
Physiology
 85% red pulp (filters damaged RBCs via pitting / culling) / 15% white pulp
(Ag trapping / complement activation / lymphocyte stimulation /Ab
generation [IgM] / production of opsonins tuftsin & properdin)
Hypersplenism
 P/w hypotension / abdominal tenderness / splenomegaly
ITP
 Women > men, due to IgG autoantibodies produced by the spleen against
platelets, p/w purpura / epistaxis / gingival bleeding, Dx of exclusion, Rx w/
glucocorticoids / immunoglobulins / splenectomy (removes source of
antiplatelet antibodies), persistent thrombocytopenia after splenectomy =
accessory spleen / Dx w/ radio nucleotide imaging / blood smear, most
common location is the splenic hilum / Rx w/ excision / Rituximab
TTP
 Due to loss of platelet inhibition, p/w pentad of fever / AMS / hemolytic
anemia / renal failure / purpura, Rx w/ plasmapheresis, rarely splenectomy,
cause of death = ICH
Hemolytic Anemias w/ Membrane Defects
 Hereditary spherocytosis →AD inheritance, due to decreased spectrin
(deformed RBC shape & increased osmotic fragility), p/w anemia / jaundice /
splenomegaly / leg ulcers, Rx w/ splenectomy / cholecystectomy (assoc. w/
pigment stones) after age 5
 Elliptocytosis → due to spectrin & protein 4.1 deficit (less common)
Hemolytic Anemias w/ Non-Membrane Defects
  Pyruvate kinase deficiency → AR inheritance, Rx w/ splenectomy after age
5
 G6PD → X-linked inheritance, p/w hemolysis precipitated by infection /
foods (e.g.fava beans) / medications (e.g. sulfa drugs), Rx w/ avoidance of
stressors, rarely splenectomy
 Sickle cell anemia → HgS formed due to AA substitution (valine  glutamic
acid), p/w sequestration crisis / hyposplenism, Rx w/ supportive care,
spleen usually infarcts therefore splenectomy not required
 Beta thalassemia → AD inheritance, due to defect in hemoglobin synthesis
w/ persistent HgbF (major - both chains vs. minor - one chain), Rx w/ blood
transfusions & deferoxamine, +/- splenectomy if splenomegaly present
Splenic Cysts
 True cysts  parasitic (endemic hydatid disease) > nonparasitic (congenital
/secrete Ca 19-9 / no malignant potential), Rx w/ splenectomy
 Pseudocysts  assoc. w/ trauma, Rx w/splenectomy
Splenic Abscesses
 Due to hematogenous spread from another location (e.g endocarditis /
osteomyelitis), salmonella / enterobacter, p/w fevers / tender splenomegaly,
Rx w/ percutaneous drainage (unilocular) vs. splenectomy (multilocular)
Splenic Neoplasms
 Hemangioma  most common benign splenic tumor, Rx w/ splenectomy if
symptomatic
 Non-Hodgkin’s Lymphoma  most common malignant blood cell splenic
tumor
 Angiosarcoma  most common malignant non-blood cell splenic tumor
Post Splenectomy Complications
 Thrombocytosis  Rx w/ ASA if platelets > 1x10^6, can p/w PVT
 OPSI  1-5% risk but high mortality, risk greatest in younger patients w/
hematologic (thalassemia major >) / malignant disorders & within 2 years of
splenectomy, due to S. pneumoniae, Rx w/ 3rd generation cephalosporin if
suspected
Prophylactic Treatment of Splenectomized Patients
 Immunization for N. meningitides / S. pneumonia / H. influenzae 2 weeks
pre-operatively for elective splecetomy or 2 weeks post-operatively for
emergent splenectomy / follow-up Ab titers at 3 - 5 years / daily penicillin in
children / immunocompromised patients for 2 years / annual influenza
vaccination

Stomach
Anatomy
 Blood supply  lesser curvature (via R & L gastric arteries), greater
curvature (via R & L gastroepiploic arteries)
 Venous drainage  R & L gastrics drain into portal vein, R gastroepiploic
drains into SMV, L gastroepiploic drains into splenic
  Lymphatic drainage  celiac nodes to thoracic duct
 Innervation  parasympathetic (vagus  L = anterior, gives off hepatic
branch / R = posterior, gives off celiac branch), sympathetic (celiac plexus 
T5-T10) & intrinsic (Auerbach and Meissner plexuses)
Gastric Cell Types
 Mucus secreting cells  located in the cardia
 Parietal cells  located in the body, secrete H+ (stimulated by gastrin /
histamine / Ach) & IF (absorption of B12 in terminal ileum)
 Chief cells  located in the body, secrete pepsinogen (converted to pepsin in
acidic environment)
 G cells  located in the antrum, secrete gastrin, stimulated by AcH /
inhibited by adenosine & luminal acid
 D cells  located in the antrum, secrete somatostatin, inhibits insulin /
glucagon / bicarbonate / gastrin secretion
Physiology
 Phases of acid secretion  cephalic phase (sight / smell of food stimulates
vagal release of ACh), gastric phase (distention of gastric lumen by food
stimulates vasovagal reflex & G cells), intestinal phase (chyme in small
intestine stimulates final phase)
 Pathways of acid secretion by parietal cell  histamine  cAMP 
protein kinase A  H+/K+-ATPase vs. ACh / gastrin  phospholipase C 
Ca2+  phosphorylase kinase  H+/K+-ATPase
Gastric Motility
 Fasting  MMC (myoelectric migrating complex), lasts 90 – 120 minutes,
 Postprandial  receptive relaxation and gastric accommodation, mediated
by vagal innervation
Gastric Dysmotility
 Assoc. w/ vagotomy (p/w rapid emptying of liquids / delayed emptying of
solids) / diabetes / H. pylori, Dx w/ EGD (to r/o organic cause) followed by
radiolabeled emptying studies, Rx w/ diet modification / medication
cessation / glycemic control, medical Rx w/ reglan (dopamine) /
erythromycin (motilin), surgical Rx w/ pyloroplasty / gastric pacemaker
Peptic Ulcer Disease
 Assoc. w/ H. Pylori (duodenum > stomach, w/ active gastritis) vs. NSAID use
(stomach > duodenum, w/o active gastritis)
 Gastric ulcers  p/w abdominal pain exacerbated by food, type I (low on
lesser curve at incisura = normal acid), type II (body & duodenum = increase
acid), type III (prepyloric = increased acid), type IV (high on lesser curve =
normal acid), type V (anywhere = NSAID-induced), all gastric ulcers must be
biopsied to r/o malignancy (>2 cm w/ high risk), Rx w/ resection of ulcer /
partial gastrectomy + vagotomy (type II / III), complications = perforation
 Duodenal ulcers  p/w abdominal pain relieved by food, Dx w/ EGD
(biopsy to r/o malignancy) & H. Pylori testing (invasive  urease assay /
histological examination of biopsy tissue vs. noninvasive  serology / urea
breath test [test for H. Pylori eradication] / stool antigen), Rx w/ antacids /
 sucralfate / H2 receptor antagonists / PPI / H. Pylori eradication (triple
therapy w/ PPI + clarithromycin/ metronidazole), complications = bleeding
(Rx w/ EGD w/ epinephrine & clipping vs. oversewing of GDA), perforation
(<1 cm = primary closure / graham patch vs. >3 cm = jejunoal serosal patch
w/ pyloric exclusion & BRII), GOO (endoscopic dilatation vs. BR II)
 Kissing duodenal ulcers  anterior ulcer perforates into peritoneum &
posterior ulcer perforates into GDA, Rx w/ closure of perforation / graham
patch / duodenotomy w/ oversewing of posterior ulcer
Surgical Procedures for Ulcer Disease
 All forms of vagotomy increase serum gastrin levels
 Truncal vagotomy  division of R & L vagus proximal to hepatic / celiac
branches + drainage procedure (truncal vagotomy & antrectomy = lowest
risk of ulcer recurrence)
 Selective vagotomy  division of R & L vagus distal to hepatic / celiac
branches + drainage procedure
 Highly selective (proximal) vagotomy  division of vagus supplying
gastric body but preservation of vagus supplying antrum / pylorus (no need
for drainage procedure)
 Complications  post vagotomy diarrhea = Rx w/ dietary modifications
/ oral cholestyramine / loperamide / reversal of jejunal segment, recurrent
ulcer disease = occurs s/p high selective vagotomy due to intact criminal
nerve of Grassi (branch of posterior vagus), gastric atony
Forest Classification
 Stratifies risk of bleeding in patients w/ ulcer disease based on EGD findings,
actively bleeding > visible vessel > adherent clot > flat pigment spot > clean
base
Stress Gastritis
 Assoc. w/ prolonged ventilation / coagulopathy > head truma (Cushing
ulcer) / burn (Curling ulcer) / h/o PUD, occurs in antrum 3-10 days after
insult, p/w painless UGI bleeding, Dx w/ EGD, Rx w/ PPI / surgery if severe
hemorrhage
Zollinger-Ellison Syndrome
 P/w triad of gastric acid hypersecretion / PUD / non-β islet cell tumor of
pancreas, assoc. w/ MEN type I, Dx w/ secretin-stimulated gastrin level w/
paradoxical increase, occurs in gastrinoma triangle, Rx w/ resection, Rx
metastatic disease w/ streptozotocin
Postgastrectomy Syndromes
 Dumping syndrome  early (hyperosmotic load causes fluid shift into
bowel) vs. late (hypoglycemia secondary to increased insulin release), Rx w/
dietary measures / octreotide
 Blind-loop syndrome  bacterial overgrowth in static limb, p/w
megaloblastic anemia & steatorrhea, Rx w/ tetracycline / metronidazole
 Afferent loop syndrome  mechanical obstruction of afferent limb, assoc.
w/ long limb in BRII / Roux-en-Y, Rx w/ limb-shortening procedure
  Efferent loop syndrome mechanical obstruction of efferent limb, occurs
within first postoperative month, Rx w/ operative relief of obstruction
 Alkaline reflux gastritis  bile reflux into stomach w/ subsequent gastritis,
Dx w/ EGD / HIDA, Rx w/ conversion of BRII to Roux-en-Y w/ >40cm Roux
limb
 Marginal ulcer  located at GJ anastomosis, due to lack of Brunner’s glands
(alkaline secreting) in the jejunum, Rx w/ smoking cessation / PPI, surgery
rarely required
Gastric Cancer
 Gastric adenocarcinoma  assoc. w/ male sex / H. Pylori / nitrates /
tobacco / hereditary diffuse gastric cancer (mutation in E-cadherin) /
pernicious anemia / adenomatous polyps, Dx w/ EGD w/ multiple biopsies,
intestinal-type  well differentiated & occurs in high risk populations vs.
diffuse-type  poorly differentiated w/ signet ring cells & occurs in low risk
populations, EUS (T & N stage) / staging laparoscopy > PET-CT (M stage), Rx
w/ EMR (T1 / < 2 cm) vs. gastrectomy (total gastrectomy for proximal
lesions vs. subtotal gastrectomy w/ 5 cm margins for distal lesions) w/
D1/D2 lymphadenectomy (15 lymph nodes) w/ neoadjuvant chemo-XRT
(≥T3 = serosa, or N+ disease), palliation in M+ disease w/ chemo or total
gastrectomy, Sister Mary Joseph node = umbilical mestastasis, Virchow
node = L subclavian lymph node
 Gastric lymphoma  diffuse B cell type most common, occurs in
submucosa, rarely p/w B symptoms, Rx w/ chemo (CHOP)
 MALT  assoc. w/ H. Pylori, Rx w/ triple therapy & EGD surveillance, t11;18
predicts poor responsiveness to Abx & may require chemo-XRT
 GIST  arise from interstitial cells of Cajal, submucosal, CD117+ (c-kit),
malignancy = >5 mitoses / 50 HPF or > 10 cm, Rx w/ resection + imatinib
(tyrosine kinase inhibitor) if malignant, metastasize to liver via
hematogenous spread (no role for lymphadenectomy)
 Carcinoid  type I (assoc. w/ atrophic gastritis w/ atrophic gastric mucosa),
type II (assoc. w/ ZES w/ hypertrophic gastric mucosa), type III (sporadic,
worst prognosis), Rx tumors assoc. w/ hypergastrinemia, (type I & II) w/
antrectomy + local excision of dominant tumor
Dieulfoy Lesion
 Vascular malformation, results in large / tortuous artery in submucosa of
gastric fundus, p/w painless / recurrent hematemesis, Dx and Rx w/ EGD
Gastric Varices
 Occur in setting of portal hypertension along w/ esophageal varices (Rx w/
banding / sclerotherapy / TIPS) or isolated secondary to splenic vein
thrombosis from pancreatitis w/ retrograde flow through short gastric (Rx
w/ splenectomy)
Gastric Volvulus
 Assoc. w/ type II paraesophageal hernia in adults / CDH in children /
wondering spleen, p/w Borchardt triad (abdominal pain, retching w/ little
 vomitus & inability to pass NGT), Rx w/ surgical reduction and
diaphragmatic repair
Bezoars
 Phytobezoar (fiber) occur in patients w/ DM or h/o gastric surgery, Rx w/
enzymatic degradation & EGD lavage
 Trichobezoar (hair)  occur in patients w/ psychiatric disorders, Rx w/
gastrostomy & removal
Menetrier Disease
 Acquired disease, assoc. w/ giant rugal folds / hypochlorhydia / CMV in
children vs. H. Pylori in adults, risk for gastric Ca, Rx w/ medical therapy /
gastric resection for severe hypoproteinemia

Surgical Critical Care

Neurologic System
 Dysfunction  spectrum of disease from confusion to delirium (active vs.
hypoactive, assoc. w/ benzodiazepines, Rx w/ haloperidol) to
encephalopathy (due to organic vs. nonorganic causes) & brain death
 Analgesia  Rx w/ fentanyl (rapid onset / no active metabolites / lipophilic
/ large doses = RF for muscle rigidity syndromes) / morphine (slower onset /
active metabolite therefore contraindicated in renal failure / may worsen
hypotension) / hydromorphone (no active metabolites) / NSAIDS (inhibit
prostaglandin production, RF = GI bleeding / renal failure) / acetaminophen
(reduces opioid-related complications)
 Sedation  titration w/ RASS scale, midazolam (benzodiazepine / GABA
agonist / short half life / metabolized by liver & cleared renally / RF for
delirium) / propofol (GABA agonist / rapid onset & clearance / assoc. w/
hypotension / RF for hypertriglyceridemia, pancreatitis, propofol infusion
syndrome) / dexmedetomidine (α2-adrenergic agonist / does not cause
delirium or respiratory depression / assoc. w/ reduced ventilator times)
 Neuromuscular blocking agents  depolarizing (succinylcholine for rapid
sequence intubation / assoc. w/ hyperkalemia) / nondepolarizing
(cisatracurium & atracurium used in patients w/ renal / hepatic failure,
metabolized via Hoffman elimination)
Cardiovascular System
 Dysfunction  perioperative abnormalities include arrhythmias / MI / non-
fatal & fatal cardiac arrest
 Risk mitigation  β-blockers & HMG-CoA reductase inhibitors improve
perioperative cardiac outcomes in non-cardiac surgery
 Shock  condition in which tissue perfusion fails to meet oxygen needs,
hypovolemic shock (most common etiology, due to decreased circulating
volume) / cardiogenic shock (due to acute MI, p/w volume overload from
decreased CI) / distributive shock (septic or neurogenic, p/w loss of
vasomotor tone)
  Hemodynamic monitoring  CVC measures CVP (end-diastolic pressure in
RV, w/ immediate technical complications = HTX / PTX / air embolus /
dysrhythmia & late complications = thrombosis [lowest in subclavian] /
infection [highest in femoral]), PAC measures RA pressure / pulmonary
arterial pressure / pulmonary artery wedge pressure (limited data to
support routine use, complications = dysrhythmias / PA rupture / infection)
 Resuscitation  crystalloid (lactated ringers can potentiate metabolic
alkalosis vs. normal saline can potentiate hyperchloremic metabolic acidosis)
/ colloids / blood products (1st line in bleeding patients)
 Hemodynamic support  phenylephrine (α1 agonist, used in neurogenic
shock) / norepinephrine (α1 & β1 agonist, used in septic shock) /
epinephrine (β1 >> α1, used in cardiogenic shock) / vasopressin (not an
adrenergic agents, works via G protein-coupled receptor) / dobutamine (β1
& β2, used in cardiogenic shock) / dopamine (D1/D2 agonist at low doses /
β agonist at moderate doses / α agonist at high doses)
Respiratory System
 Dysfunction  Rx respiratory failure in ICU w/ RSI (preoxygenation w/
100% FiO2 / hypnotic agents w/ etomidate or ketamine / paralytic agent w/
succinylcholine or rocuronium when depolarizing agent contraindicated)
 Oxygenation  determined by PEEP & FiO2, assessed by O2 saturation)
 Ventilation  determined by RR & TV, assessed by CO2 levels
 Tidal volume  calculated by IBW (men = 50 ± 2.3 kg for each inch over 5
feet, women = 45.5 ± 2.3 kg for each inch over 5 feet)
 Noninvasive ventilation  CPAP (continuous level of positive pressure to
augment FRC, aids in oxygenation but not ventilation) / BiPAP (continuous
level of positive pressure to augment FRC but aids in both oxygenation &
ventilation) / HFNC (aids in oxygenation)
 Invasive ventilation  volume control / pressure control ventilation,
pressure regulated volume control targets specific TV without exceeding set
peak pressure, assist modes augment patient-initiated breaths,
 Weaning & extubation  low P:F ratio (partial pressure of O2 : FiO2) w/
decreased likelihood for successful extubation, SBTs improve likelihood for
successful extubation
 VAP  high rate in SICU, bundle of HOB elevation to 30° / chlorohexidine /
sedation holidays / SBTs decreases incidence, Rx w/ broad spectrum ABX
 ARDS  due to protein-rich exudate w/ subsequent fibroproliferation &
decreased pulmonary compliance, Dx w/ P:F ratio < 300 / CXR w/ 3
quadrant infiltrates / non cardiogenic pulmonary edema / onset within 7
days of clinical insult, Rx w/ PEEP (increases FRC) / TV w/ 6 mL/Kg of IBW /
conservative fluid mgmt. / inhaled NO / cisatracurium x 48 hours (mortality
benefit) / prone positioning / permissive hypercapnia (duration of
mechanical ventilation increased but survival improved) / ECMO
 Tracheostomy  assoc. w/ decreased dead space ventilation & WOB /
improved clearance of secretions, early tracheostomy w/ improved
outcomes
Gastrointestinal System
 Catabolism  critical illness assoc. w/ catabolic state due to tissue injury /
pain / immune-inflammatory activation, w/ negative N2 balance
 Malnutrition  albumin (half-life of 21 days) / pre-albumin (half-life of 2
days)
 Energy requirements  25 kcal/kg/day & 1-2 g/kg of protein
 Enteral feeding  assoc. w/ increased intestinal immunoglobulin
production / decreased infection rates, GRV < 500 mL tolerated & w/o risk of
aspiration, 24-hour total nutritional goal overcomes disruptions in feeding
schedule
 Parenteral Nutrition  w/ more reliability in meeting nutritional needs but
increased infectious complications when compared to enteral feeding
 Refeeding syndrome  due to intracellular shift of electrolytes after
reintroduction of nutrition (phosphorous > magnesium / potassium), p/w
arrhythmias / respiratory failures / neurologic dysfunction
Renal System
 AKI  defined as oliguria or increase in serum Cr, due to prerenal (e.g
diminished renal perfusion, w/ FeNa <1%) / intrinsic (e.g. ATN, w/ FeNa
>3%) / postrenal causes, Rx w/ avoidance of hypoperfusion & nephrotoxic
agents, RRT (intermittent vs. continuous)
Hepatic System
 Cirrhosis  PT is preferred marker for liver synthetic function, worsening
of liver function postoperatively due to ischemic injury to hepatocytes, p/w
ascites (low oncotic pressure, Rx w/ diuretics/ paracentesis / TIPS) /
encephalopathy (impaired clearance of ammonia, Rx w/ lactulose /
rifaximin), primary liver failure occurs in patients w/ preexisting liver
disease vs. secondary liver function in patients w/ normal liver
Hematologic System
 Intrinsic & extrinsic pathways, converge at common pathway w/ thrombin
(factor II) which activates fibrinogen to fibrin, factor C inhibits cascade,
plamin degrades fibrin
 Coagulopathy  due to nutritional deficiencies / liver dysfunction /
congenital diseases, worsened by hypothermia
 Thrombosis  due to endothelial injury / venous stasis / hypercoagulable
state, p/w DVT / PE
 HIT  due to exposure to unfractionated heparin, type I (less serious / non-
immune-mediated) vs. type II (more serious / immune-mediated), p/w
thrombocytopenia (reduction of platelets by >50%) / thromboembolism, Dx
w/ ELISA / SRA, Rx w/ cessation of hepranoids / initiation of direct thrombin
inhibitor (e.g. Argatroban)
 Anemia / transfusions  due to decreased erythropoiesis / increased iron
sequestration / frequent phlebotomy in ICU setting, conservative transfusion
mgmt. w/ Hgb goal >7 mg/dL assoc. w/ improved outcomes (exception is
active bleeding / coronary ischemia)
  PCC  contains vitamin-K dependent factors, useful in reversing
hemorrhage in patient on warfarin / novel anticoagulants
 TXA  inhibits thrombolysis by binding to plasminogen, useful in trauma
Endocrine System
 Hyperglycemia  due to increased glucose production (catabolic state) &
insulin resistance, glucose goal of <180 mg/dL in critically ill patients
 Adrenal insufficiency  steroid therapy indicated in patients w/ shock
refractory to pressure / fluids, results in reduction of vasopressor
requirements but no change in mortality
Prophylaxis
 Stress ulcer PPX  bleeding episodes due to loss of mucosal defense, RF =
mechanical ventilation, PPX w/ PPI > H2 receptor antagonists, complications
= increased PNA / C. diff
 VTE PPX  mechanical PPX w/ SCDs / chemical PPX w/ UH / LMWH, IVC
filters in patients at high risk for VTE w/ contraindications to AC
Sepsis Definitions
 Sepsis  life threatening organ dysfunction due to dysregulated response to
infection
 Septic shock  hypotension w/ requirement for vasopressors to maintain
MAP > 65 & lactate > 2 mmol/L
 qSOFA  hypotension / tachypnea / AMS

Thoracic
Anatomy
 Right lobe  three segments = RUL / RML / RLL, major fissure separates
RUL & RML from RLL / minor fissure separates RUL from RML
 Left lobe  two segments = LUL / LLL & lingula (extension of upper lobe)
 Thoracic duct  carries long-chained fatty acids, crosses midline from R to
L at T4-5, enters chest via aortic hiatus, empties into junction of L subclavian
& L IJV veins
 Azygous vein  runs along the right side & drains into SVC
 Vagus nerve  posterior to lung hilum, more susceptible to injury on L side
 Phrenic nerve  anterior to lung hilum, originates from C3-5, innervates
diaphragm
 Trachea  blood supply via inferior thyroid & bronchial arteries
Physiology
 Type I pneumocytes  squamous cells, sites of gas exchange
 Type II pneumocytes  cuboidal shape, produce surfactant to maintain
alveolar stability and decrease surface tension
 Pores of Kohn  located between alveoli, allow for direct O2 exchange
Pulmonary Function Tests (PFTs)
 Lobectomy requires FEV1 > 0.8 (best predictor of pulmonary complications,
if close perform V/Q scan to determine contribution of target segment) &
DLCO > 10
Lung Cancer
 Hamartoma  most common benign lung tumor, Dx w/ peripheral popcorn
lesion, Rx w/ observation
 Non-small cell carcinoma  80% of lung CA, SCC (central, can produce
paraneoplastic syndrome via PTH-rp) / adenocarcinoma (peripheral / most
common type), T1 = <3 cm / T2 = >3 cm / T3 = invasion of chest wall / T4 =
invasion of mediastinum or malignant effusion, N1 = ipsilateral hilum nodes
/ N2 = ipsilateral mediastinal nodes (borderline resectable) / N3 =
contralateral nodes (unresectable), M = distant metastasis (brain is most
common site), malignant pleural effusion = stage IV disease, Dx w/ CT (T&N
stage) & PET scan (M stage), Rx w/ lobectomy (MCC = persistent air leak) /
pneumonectomy (MCC = arrhythmia), atelectasis is MCC overall after lung
resection, w/ adjuvant chemo-XRT (carboplatin / taxol) for ≥ stage II (any N+
disease), Rx unresectable disease w/ chemo-XRT, screening CT in patients
age 55-80 w/ ≥ 30 pack-year smoking history
 Small cell carcinoma  20% of lung CA, neuroendocrine in origin (can
produce paraneoplastic syndrome via ACTH > ADH / Lambert-Eaton
myasthenic syndrome), poor survival / usually unresectable, Rx w/ chemo-
XRT (cisplatin / etoposide) / no role for surgery
 Mesothelioma most aggressive lung CA, assoc. w/ asbestos exposure, Rx
w/ chemo-XRT / rarely extrapleural pneumonectomy, poor prognosis
 Bronchoalveolar cancer  involves alveolar walls, can resemble PNA
 Carcinoids  neuroendocrine / central, prognosis for typical > atypical, Rx
w/ resection w/ lymph node sampling
 Pulmonary blastoma  most common primary pediatric lung tumor
 Metastasectomy  sarcoma / germ cell tumors often metastasize to the
lung, if primary tumor is controlled these patients are candidates for
resection even in presence of multiple lung lesion
Compressive Sequlae of Lung Cancer
 Pancoast tumor  apical lung tumor, invades sympathetic trunk & p/w
Horner’s syndrome (ptosis / anhidrosis / miosis) / ulnar n. symptoms
 SVC syndrome  obstruction of SVC, p/w abrupt onset of swelling of head /
neck / upper extremities, Rx w/ endovascular stenting > emergent XRT
Lung Abscess
 Due to aspiration into RLL, most often Staph. Aureus, Rx w/ ABX / operative
drainage if persistence > 8 weeks / hemoptysis
Empyema
 Due to PNA w/ parapneumonic effusion, w/ exudative / fibro-proliferative
phases, Rx w/ tube thoracostomy w/ ABX, if that fails Rx w/ VATS
decordication ± tPA
Chylothorax
 Due to iatrogenic injury of thoracic duct > lymphoma, p/w pleural effusion,
Dx w/ sudan fat stain, Rx w/ medium-chain fatty acids / TPN / octreotide, if
>1L/day after 5 days Rx w/ R VATS w/ ligation of thoracic duct
Massive Hemoptysis
  Due to bronchial arteries, defined as >600 cc in 24 hours, Rx w/ rigid
bronchoscopy w/ airway packing / bronchial artery embolization
(devastating complication = paraparesis due to common origin of ASA)
Spontaneous Pneumothorax
 Occur in young / tall males, R>L, due to rupture of apical bleb, Rx w/ tube
thoracostomy (60% recurrence in patients treated nonoperatively), Rx
repeat episode w/ VATS blebectomy
Trachea
 Adult tumors  papilloma (benign) / SCC (malignant), Rx w/ resection +
XRT
 Pediatric tumors  hemangioma (benign) / carcinoid (malignant)
 Tracheal stenosis  occurs at tracheostomy site, RF = tracheostomy site
through 1st tracheal ring, Rx w/ serial dilatations if <1 cm/ resection w/
anastomosis for >1 cm or circumferential scar formation (up to 6cm of
trachea can be safely resected)
 Tracheo-innominate artery fistula  occurs if tracheostomy site is below
4th tracheal ring, p/w herald bleed followed by rapid exsanguation, Rx w/
median sternotomy / fistula takedown
 Tracheo-esophageal fistula  occurs w/ prolonged intubation / NGT
decpmpression, high cuff pressure = #1 RF, Rx w/ tracheal resection / fistula
takedown / may require sternohyoid flap for esophagus, perform repair only
after patient has been weaned from ventilator
Bronchial Tumors
 Bronchogenic cysts  located posterior to carina, Rx w/ resection
 Bronchogenic malignancy  carcinoid > mucoepidermoid / mucous gland
/ adenoid cystic, good prognosis / slow growing, Rx w/ resection
Mediastinal Tumors
 Thymoma  most common anterior mediastinal tumor / adult mediastinal
tumor, assoc. w/ myasthenia gravis (ABs to ACh receptors, Rx w/
neostigmine), Rx w/ resection
 Teratoma  most common germ cell tumor, Rx w/ resection
 Seminoma  most common malignant germ cell tumor, normal AFP / beta-
HCG, Rx w/ XRT
 Nonseminoma  elevated AFP / betaHCG, Rx w/ chemotherapy
 Neurogenic tumors  most common posterior mediastinal tumor /
pediatric mediastinal tumor, usually schwannoma / paraganglioma, Rx w/
resection
Chest Wall
 Osteochondroma  most common benign lesion
 Chondrosarcoma  most common malignant lesion, Rx w/ wide excision

Thyroid Gland
Embryology
  Enoderm origin from 1st & 2nd pharyngeal arch, exception is C cells (4th
pharyngeal pouch / neural crest), originates at foramen cecum at base of
tongue (failure of descent = lingual thyroid, Dx w/ RAI uptake scan, Rx w/
excision), descends into neck via the thyroglosal duct (failure of resorption =
thyroglosal duct cyst, Rx w/ surgical excision of duct & central portion of
hyoid bone)
Anatomy
 Vascular supply  superior thyroid artery (first branch of ECA) / inferior
thyroid artery (from thyrocervical trunk) / thyroidea ima artery
(anatomic variant in 3-10% of patients / supplies inferior thyroid / from
brachiocephalic trunk or aortic arch)
 Venous drainage  superior / middle / inferior thyroid veins
 Superior laryngeal n.  branch of vagus / internal = sensory to larynx vs.
external = motor to cricothyroid / injury p/w mild voice damage
 Recurrent laryngeal n.  branch of vagus / medial = motor vs. sensory =
lateral, innervation to all intrinsic laryngeal muscles (except cricothyroid) &
true vocal cords / injury p/w severe voice damage & cord paralysis (cords
remain in a paramedian position)
 Nonrecurrent right laryngeal n.  anatomic variant in 0.5% of patients,
arises directly from the vagus n. and courses medially to innervate the
larynx, assoc. w/ aberrant R subclavian artery
Physiology
 TRH / low T3 levels stimulate release of TSH which increases iodine uptake
in follicular cells, oxidized iodine couples w/ thyroglobulin to form MIT / DIT
via thyroid peroxidase, MIT / DIT couple to form T3 / T4 which is stored in
thyroid colloid, most thyroid hormone released is T4 which is deiodinated in
the plasma & liver to form T3 (significantly more bioactive, conversion
inhibited by corticosteroids), 80% of circulating T3 and T4 is bound to TBG,
free T3 interacts w/ the nuclear thyroid hormone receptor
 Calcitonin  produced by C cells, inhibits osteoclast induced Ca2+
absorption
Hypothyroidism
 Due to endemic goiter (chronic iodine deficiency) / postradiation
hypothyroidism (after Rx w/ 131I) / postsurgical hypothyroidism /
pharmacological hypothyroidism (e.g. methimazole / PTU / amlodipine /
lithium), Rx w/ levothyroxine (monitor Rx w/ TSH)
Thyroiditis
 Hashimoto thyroiditis  autoimmune mediated destruction of thyrocytes,
due to antithyroid peroxidase Abs, assoc. w/ thyroid lymphoma
 Acute suppurative thyroiditis  assoc. w/ bacterial infection, Rx w/ Abx +
abscess drainage if necessary
 Subacute thyroiditis  assoc. w/ viral infection, Rx w/ NSAIDs /
corticosteroids
 Riedel struma  replacement of colloid w/ dense fibrous tissue, Rx w/
corticosteroids / tamoxifen
Hyperthyroidism
 Graves disease  due to TSH-R Abs, p/w increased adrenergic activity /
exophthalmos, Dx w/ RAI scan (diffuse uptake), Rx w/ medical therapy >>
surgical Rx w/ total thyroidectomy
 Toxic nodular goiter & toxic adenoma  increased thyroid hormone
production independent of TSH, p/w increased adrenergic activity, Dx w/
RAI scan (isolated uptake, may worsen exophthalmos)
Treatment of Thyrotoxicosis
 Beta-blockers  mitigate increased adrenergic effects
 Thionamide medications (PTU and methimazole)  inhibit
organification of iodine / coupling of MIT & DIT (side effect =
agranulocytosis)
 Large dose iodine  alters organic binding process (Wolff-Chaikoff effect)
 Radioactive ablation  w/ 131I
 Surgical resection  total vs. near-total thyroidectomy
 Thyroid storm is a serious complication of medical / surgical Rx of
thyrotoxicosis, Rx w/ IV hydration / corticosteroids / beta blockers
Evaluation of a Thyroid Nodule
 Low TSH & a thyroid nodule  radioisotope scan (99Tc or 131I) determines
“hot” vs. “cold” (cold nodules are more likely to be cancer)
 Normal or high TSH & a thyroid nodule  US ± FNA (concerning US findings
include irregular margins / punctuate calcifications / hypoechoic /
incomplete halo / size > 1cm)
 FNA biopsy results reported using the Bethesda Criteria (1-6), Rx
nondiagnostic FNA w/ repeat FNA, Rx atypia of undetermined significance /
follicular lesion of undetermined significant w/ lobectomy
Differentiated Thyroid Carcinoma
 Papillary Thyroid Carcinoma (PTC)  most common thyroid Ca, RF =
radiation exposure, pathology w/ psammoma bodies, spreads via lymphatics,
age at time of diagnosis is the most important prognostic factor, BRAF = poor
prognosis, lateral aberrant thyroid = metastatic papillary cancer
 Follicular Thyroid Carcinoma (FTC)  pathology w/ follicular cells w/
capsular invasion, spreads via hematogenous, age at time of diagnosis is the
most important prognostic factor, Hürthle cell carcinoma = aggressive
variant
 Rx PTC & FTC  lobectomy or total thyroidectomy (>1 cm / h/o previous
neck radiation requires total thyroidectomy), neck dissection in node
positive disease, radioactive 131I (large tumors /extra thyroidal involvement
/ adverse histologic subtypes), TSH suppression
 Surveillance PTC & FTC  serum thyroglobulin
Medullary Thyroid Carcinoma
 From C cells, occurs sporadically (80%) or in assoc. w/ MEN IIA / IIB
carcinoma (MEN II w/ multifocal bilateral disease) / familial medullary
thyroid, pathology w/ amyloid deposits, p/w elevated calcitonin, spreads via
lymphatics, Rx w/ total thyroidectomy w/ central neck dissection
 (radioactive 131I is not effective), monitor recurrence w/ pentagastrin-
stimulated calcitonin levels
Anaplastic Thyroid Carcinoma
 Poor prognosis (mortality = 100%), pathology w/ poorly differentiated cells,
Rx w/ palliative
Thyroid Lymphoma
 NHL type, assoc. w/ Hashimoto thyroiditis, Dx w/ US w/ pseudocystic
appearance / flow cytometry, Rx w/ CHOP & radiation
Metastases to the Thyroid
 RCC >> lung / breast / colon
Thyroidectomy
 Platysma encountered first followed sternohyoid and then stenothyroid,
superior laryngeal n. at risk during dissection of superior thyroid artery vs.
recurrent laryngeal n. at risk during dissection of inferior thyroid artery
 Substernal goiters are usually amenable to resection by cervical incision
 Intraoperative neuromonitoring  assists in RLN identification but does not
necessarily reduce injury rates
Complications of Thyroid Surgery
 Transient hypocalcemia (reduced by postoperative use of Ca2+ & vitamin D) /
hypoparathyroidism secondary to devascularization of parathyroid glands /
nerve injury (1% of patients) / wound hematoma
Thyroid Disease in Pregnancy
 Increased TBG  therefore increased levels of total T3 and T4 are required
to maintain appropriate free levels of hormone
 Hypothyroidism  assoc. w/ placental abruption / preterm labor, Rx w/
thyroid supplementation
 Hyperthyroidism  assoc. w/ IUGR, Rx w/ PTU (1st trimester) /
methimazole (2nd and 3rd trimester) / thyroidectomy if refractory, RAI is
contraindicated in pregnancy
Postpartum Thyroiditis
 P/w thyrotoxicosis followed by hypothyroidism, Rx w/ beta blockers

Transfusion
Blood Products
 PRBC  stored at 4°C w/ ½ life of 35 days, increased age assoc. w/
increased potassium / decreased 2,3-DPG (left-shift), one unit increases Hgb
by 1 g/dL / hematocrit by 3%, transfusion trigger of Hg 7 g/dL in patients
w/o cardiac history
 FFP  stored at -18°C for up to 1 year, shelf life of 5 days after thawing,
contains all coagulation factos / fibrinogen / vWF / AT-III, indicated for the
reversal of either acquired / congenital coagulation defects & reversal of
warfarin
  Platelets  stored at room temperature, discarded after 5 days due to
bacterial contamination (most commonly contaminated blood source), one
six-pack increases platelet count by 50,000, transfusion trigger of 50,000
 Cryoprecipitate  stored at 18°C / thawed to room temperature & must be
transfused within 6 hours, contains fibrinogen / factors VIII / XIII / vWF,
indicated for fibrinogen deficiency / factor XIII deficiency / uremic platelet
dysfunction (second line after DDAVP)
 Massive transfusion protocol  1:1:1 ratio of PRBC / FFP / platelets, assoc.
w/ hypocalcemia / hyperkalemia / metabolic alkalosis
 Prothrombin Concentrate (PCC)  inactivated concentrate of protein C / S
& factors II / VII / IX / X, rapidly reverses INR of bleeding patient on
Coumadin, does not require thawing & w/ less volume compared to FFP
Hemolytic Reactions
 Acute hemolysis  due to Ab-mediated ABO incompatibility (type II
hypersensitivity reaction), p/w tachycardia / fevers / back pain, Dx w/
decreased haptoglobin / increased free hemoglobin / unconjugated bilirubin
/ LDH, Rx w/ fluid resuscitation / diuretics / HCO3-
 Delayed hemolysis  due to Ab-mediated minor Ag incompatibility, Rx w/
observation
Nonhemolytic Reactions
 Febrile nonhemolytic transfusion reaction  most common transfusion
reaction, due to recipient Abs against donor leukocytes w/ subsequent
cytokine release, Rx w/ transfusion discontinuation / filtration of future
transfusions
 Urticaria / anaphylaxis  occurs in IgA-deficient patient, due to recipient
Abs against donor proteins, Rx w/ histamine blockers / epinephrine
 Transfusion-related acute lung injury (TRALI)  due to donor Abs
against recipient WBCs, p/w pulmonary clots / ARDS, Rx w/ supportive care,
MCC of transfusion related death
 Transfusion-associated sepsis  due to bacterial contamination (E. coli >
Staph Epidermidis), MCC of infectious-related death
 Viral transmission  risk of HIV / HCV / HBV / HTLV-1 / CMV w/ all blood
products except albumin
 Post transfusion purpura  due to alloimmunization from previous
platelet transfusions / pregnancies, Rx w/ immunoglobulin / plasmapharesis
/ no further platelet transfusions
 Hypocalcemia  Ca2+ binds to citrate in stored blood
 Dilutional thrombocytopenia  occurs w/ massive transfusion

Transplantation
Determination of Organ Allocation
 Time on list / HLA compatibility (HLA-DR >> A / B) / PR, h/o previous TXP is
not a factor
Screening for TXP
  Cross match  detects preformed recipient ABs to donor lymphocytes
 Panel reactivity antibody  detects % of cells that recipients’ serum reacts
w/, high PRA = highly sensitized = higher likelihood of rejection
Type of Rejection
 Hyperacute rejection  occurs within hours, due to preformed IgG AB
(ABO > HLA), type II hypersensitivity reaction, Rx w/ emergent re-transplant
 Acute rejection  occurs within one month, due to T cells to donor HLA
antigens, Rx w/ increasing immunosuppression / pulse steroids / AB Rx
 Chronic rejection  occurs within months to years, major cause of graft
failure, due to type IV hypersensitivity reaction w/ AB formation (MCC = HLA
incompatibility), Rx w/ increasing immunosuppression / possible re-TXP
Immunosuppressive Therapy
 Mycophenolate  used for maintenance Rx, MOA = inhibits de novo purine
synthesis (growth of T cells), side effects = GI intolerance > pancytopenia
 Steroids  used for induction & acute rejection episodes, MOA = inhibits
inflammatory cells & IL-2
 Cyclosporin  used for maintenance Rx, MOA = binds to cyclophilin &
inhibits calcineurin which inhibits IL-2 synthesis, side effects =
nephrotoxicity / hepatotoxicity, pharmacokinetics = hepatic metabolism &
biliary excretion, trough = 200 - 300
 FK-506 (Tacrolimus)  most effective in kidney TXP, MOA = FK-binding
protein which inhibits IL-2 synthesis, side effects = nephrotoxicity /
neurotoxicity (mood changes / headache / seizure) / DM, trough = 10-15
 Sirolimus  used for maintenance Rx, MOA = inhibits m-TOR, side effects =
poor wound healing / interstitial lung disease, no nephrotoxicity, also w/
decreased risk of de novo malignancies
 Anti-thymocyte Globulin (ATG)  used for induction & acute rejection
episodes, MOA = polyclonal antibodies / cytotoxic, side effects = cytokine
release syndrome (pretreat w/ steroids & Benadryl) / PTLD
Kidney TXP
 Can store for 48 hours, GFR < 80mL/min (CKD stage II) / h/o melanoma in
donor are contraindications to TXP, HIV / elevated Cr / UTI / CNS tumors in
donor are not contraindications to TXP, anastomosis to external iliac vessels
w/ ureteroneocystostomy, kidney problems post-op = Dx w/ US w/ biopsy,
complications = urine leak (Rx w/ ureteral stent) > renal artery stenosis (Rx
w/ PTA w/ stent) / renal vein thrombosis (p/w hematuria) > renal artery
thrombosis / lymphocele (due to extensive iliac vessel mobilization / failure
to ligate lymphatics, Rx w/ percutaneous drainage, may require peritoneal
window), postoperative oliguria due to ATN (ischemia-reperfusion injury, Rx
w/ fluid resuscitation), acute rejection w/ tubilitis vs. chronic rejection w/
interstitial fibrosis & tubular atrophy, MCC mortality in recipient = MI vs.
donor = PE, COPD assoc. w/ death while awaiting TXP & poor graft function
after TXP, MCC for donor = wound infection
Liver TXP
  Can store for 24 hours, ETOH / acute UC / severe pulmonary HTN in
recipient are contraindications to TXP, hepatitis C in donor / recipient is not
a contraindication to TXP, MELD score (Cr / INR / bilirubin) predicts patients
who would benefit from TXP, duct-to-duct anastomosis in adults vs.
hepaticojejunostomy in children, liver problems post-op = Dx w/ US w/
biopsy, complications = biliary leak (Rx w/ drain / ERCP w/ stent) > hepatic
artery stenosis (Rx w/ stent, intact hepatic artery = major determinant
biliary anastomosis healing) / hepatic artery thrombosis (acute setting p/w
fulminant hepatic failure mandating emergent re- TXP vs. chronic setting
p/w biliary stricture, also RF hepatic abscess formation) > hepatic vein /
portal vein / IVC thrombosis / cholangitis , acute rejection w/ portal triad
lymphocytosis vs. chronic rejection w/ disappearing bile ducts (liver
rejection less prevalent then other solid organs), MCC mortality = infection
Pancreas TXP
 Indicated for brittle diabetics / hypoglycemia unawareness, improves
neuropathy & nephropathy / stabilize retinopathy / does not reverse
vascular disease, complications = venous thrombosis > rejection,
Simultaneous Pancreas-Kidney TXP (SPK)
 Most common indication is DM w/ ESRD, assoc. w/ better quality of life,
biliary (assoc. w/ high infection rate) > bladder drainage (assoc. w/
metabolic acidosis due to loss of HCO3- from pancreatic secretions)
Lung TXP
 Can be stored for 6 hours, need ABO compatibility, acute rejection w/
perivascular lymphocytes vs. chronic rejection w/ bronchiolitis obliterans,
MCC of early mortality = reperfusion injury vs. late mortality = bronchiolitis
obliterans, median survival = 5 years
Cardiac TXP
 Can be stored for 6 hours, need ABO compatibility, acute rejection w/
perivascular lymphocytes vs. chronic rejection w/ progressive coronary
atherosclerosis, MCC of early mortality = infection vs. late mortality =
coronary atherosclerosis, median survival = 10 years
Infection After TXP
 CMV  p/w fever / leucopenia / myalgia / graft dysfunction / GI upset, Dx
w/ inclusion bodies, Rx w/ gangciclovir
 Polyomavirus (BK)  chronic allograft nephropathy after kidney TXP
Malignancy After TXP
 Skin cancer  most common malignancy following organ TXP (SCC > BCC)
 Post-transplant Lympho-proliferative Disorder (PTLD)  second most
common malignancy following organ TXP, occurs during first year in children
> adults, due to proliferation of B cells assoc. w/ EBV / CMV / cytolytic Rx,
p/w SBO / mass / adenopathy, Rx w/ withdrawal of immunosuppression /
rituximab (anti-CD20) / acyclovir or ganciclovir
Milan Criteria
  Determines eligibility for liver TXP in patients w/ HCC, single tumor < 5cm /
up to 3 tumors with none larger then 3 cm / no evidence of lymphovascular
invasion or distant metastasis

Trauma
Injury Scoring Systems
 AIS (Abbreviated Injury Scale)  first described scoring system, includes
body region / anatomic structure & detail of injury
 ISS (Injury Severity Score)  calculated by summing the AIS score for the
three most injured body regions, ranges from 1 – 75, severe injury > 25
 GCS (Glasgow Coma Scale)  eye opening (spontaneous = 4, to voice = 3,
to pain = 2, none = 1), verbal response (oriented = 5, confused = 4,
inappropriate = 3, incomprehensible = 2, none = 1), motor response (obeys
commands = 6, localizes pain = 5, withdraws to pain = 4, flexion = 3,
extension = 2, none = 1), ranges from 3-15, < 8 = intubation
 RTS (Revised Trauma Score)  includes GCS / systolic BP / RR
Primary Survey
 ABCDE  each must be addressed before moving on
 Airway  eliciting a verbal response indicates adequate airway protection, if
airway is deemed inadequate a definitive airway must be established via ET
intubation through a rapid-sequence technique, if this fails a surgical airway
should be obtained via a cricothyroidotomy (transverse incision through the
cricothyroid membrane w/ placement of 6 ET tube)
 Breathing  visualizing chest movement / auscultating breath sounds /
measuring O2 saturation
 Circulation  determining if patient is in shock (e.g. tachycardia /
tachypnea / hypotension / diaphoresis / decreased UOP / AMS), often due to
hemorrhage (exsanguination can occur via external blood loss from the chest
/ abdomen / RP / femur fractures), Rx w/ 2L IV crystalloid resuscitation
followed by 1:1:1 ratio of PRBC : FFP : platelets if needed (goals of
resuscitation = lactate <2.5 / UOP >0.5-1 mL/Kg/Hr / SBP >90 mmHg)
 Disability and Exposure  assess GCS / remove all clothing
Secondary Survey
 Head to toe physical / detailed neurologic exam / prone evaluation of spine
Damage Control Principles
 Objectives include controlling bleeding / preventing ischemia / limiting GI
spillage, abdomen is left open w/ vac, return to OR for definitive treatment
upon correction of lethal triad (coagulopathy / acidosis / hypothermia), TXA
improves outcomes if given within 3 hours
Causes of Death in Trauma
 Hemorrhagic shock = most common cause of death in first hour vs. TBI =
most common cause of death in patients who reach hospital alive
Injuries to the Brain
  Head injury is the leading cause of death in trauma patients who reach
hospital alive
 Epidural hematoma  due to middle meningeal artery, p/w initial loss of
consciousness followed by lucid interval, underlying brain tissue is normally
intact, Rx w/ craniotomy
 Subdural hematoma  due to sheering of bridging veins between the dura
mater and cerebral cortex, underlying brain tissue is normally injured
 Subarachnoid hemorrhage  due to diffuse bleeding from brain tissue,
complication = cerebral edema
 Diffuse axonal injury  due to disruption of axons by rotational forces
 CPP  MAP – ICP, Rx intracranial hypertension w/ HOB elevation /
hyperventilation (goal PCO2 between 30 – 35) / mannitol / hypertonic saline
Injuries to the Spinal Cord and the Vertebral Column
 SCIs  due to blunt / penetrating trauma, assoc. w/ low mortality / high
morbidity, p/w neurogenic shock due to loss of sympathetic tone
(hypotension w/ warm extremities, Rx w/ IV resuscitation ± vasopressor
agents), Rx incomplete lesions w/ operative decompression
 Vertebral column injuries  Rx lesions w/ instability w/ operative fixation
vs. those without instability w/ immobilization, Odontoid fracture  type I
= tip of odontoid (Rx w/ hard collar), type II = through base / unstable (Rx
w/ surgery), type III = involves C2 (Rx w/ halo vest), Chance fracture 
avulsion of posterior lumbar vertebrae, due to MVA & high seatbelt use
(assoc. w/ hollow viscus abdominal injury)
Injury to the Maxillofacial Region
 Rx of facial fractures in acute setting is rarely necessary, exception is severely
depressed fractures (Rx w/ operative decompression)
 Le Fort classification  I = horizontal, II = pyramidal, III = transverse
(craniofacial dissociation)
 Mandibular fractures  Rx w/ maxillary-mandibular fixation
 Epistaxis  Rx anterior w/ packing vs. posterior w/ foley control & rarely
angioembolization
Injuries to the Neck
 Penetrating injury > blunt injury (assoc. w/ cerebrovascular injury w/ risk
for thromboembolism, Rx w/ anticoagulation), anterior triangle (anterior to
SCM & divided into three zones) Zone 1  thoracic inlet to cricoid cartilage,
Zone 2  cricoid cartilage to angle of the mandible, Zone 3  angle of the
mandible to base of skull, Rx stable neck injuries (regardless of zone) w/
observation & CXR / CT angiography / esophagography, Rx unstable patients
/crepitus / pulsatile bleeding / expanding hematoma (regardless of zone)
w/ operative exploration, posterior triangle (posterior to SCM / anterior to
trapezius / superior to clavicle), tracheostomy = surgical airway of choice in
patients w/ upper airway injuries
Injuries to the Chest
 Penetrating thoracic box injuries  defined by sternal notch superiorly /
costal margin inferiorly / nipples laterally, assoc. w/ high risk to
 cardiovascular / aerodigestive structures, mandates assessment for bleeding
/ perforation of at risk structures
 Tracheobronchial injuries p/w persistent PTX w/ continuous air leak
despite tube thoracostomy, Dx w/ bronchoscopy, Rx injuries of < ⅓
bronchial circumference w/ nonoperative care, Rx injuries > ⅓ w/ operative
repair via right posterolateral thoracotomy, surgical airway via tracheotomy
 Esophageal injuries  Dx w/ contrast esophagography / esophagoscopy,
Rx upper esophagus via L neck incision / middle esophagus via right
posterolateral thoracotomy / lower esophagus via left anterolateral
thoracotomy / GE junction via laparotomy, repair performed w/ two layers &
w/ wide drainage of mediastinum, esophagectomy w/ delayed
reconstruction may be required
 Sternal fractures  degree of fracture correlates w/ risk of assoc. thoracic
injury, Dx w/ CXR / CT, Rx w/ conservative mgmt.
 Rib fractures  p/w pain, complication = PNA, Rx w/ pain control, may
require epidurals > intercostal nerve blocks
 Flail chest  ≥2 adj. ribs fractured ≥2 locations, p/w paradoxical motion,
assoc. w/ pulmonary contusion, Rx w/ conservative mgmt. vs. rib plating
 Pulmonary contusion  Rx w/ supportive care, may require mechanical
ventilation w/ PEEP
 Tension pneumothorax  p/w deviation of trachea / unilateral breath
sounds / hypotension, Rx w/ urgent needle thoracostomy at 2nd intercostal
space in midclavicular line
 Massive hemothorax  due to intercostal artery, Rx w/ tube thoracostomy
at 4th / 5th intercostal space in midaxillary line, if >1500 mL of blood drained
on insertion or >250 mL/hr drainage for 3-4 hours Rx w/ thoracotomy, Rx
retained hemothorax w/ VATS
 Penetrating cardiac injuries  Dx w/ US / if equivocal Dx w/ subxiphoid
pericardial window, Rx positive pericardial window w/ median sternotomy,
Rx penetrating cardiac injuries w/ cardiac arrest w/ left anterolateral
thoracotomy through 4th / 5th intercostal space, Rx ventricular injuries w/
horizontal mattress w/ pledget, Rx atrial injuries w/ running non-absorbable
 Blunt cardiac injuries  affects RV (anterior-most chamber), p/w
arrhythmias (PVSs), Dx w/ screening ECG / ECHO if abnormalities present on
ECG or hemodynamically unstable, Rx w/ telemetry observation for 48 hours
 Thoracic aortic injuries  blunt aortic injuries due to rapid deceleration /
occurs at tethering point of ligamentum arteriosum, Dx w/ CXR (widened
mediastinum), Rx w/ endovascular vs. open repair via median sternotomy
(ascending aorta) / left posterolateral thoracotomy (descending aorta)
 Diaphragmatic injuries  left > right (protected by liver), penetrating >
blunt, CXR not reliable, Rx w/ debridement of nonviable tissue / closure of
defect via laparotomy (acute setting) vs. thoracotomy (chronic setting) w/
permanent interrupted sutures & mesh for larg defects
Injuries to the Abdomen
  Blunt abdominal trauma  Rx +FAST / + DPL (> 500 WBC/mm3 / > 10,000
RBC/mm3 / amylase / bilirubin / particulate matter) / unstable patients /
peritonitis w/ emergent laparotomy, Dx w/ CT in all other patients
 Penetrating abdominal trauma  Rx GSW w/ laparotomy, Rx stab wound
w/o shock / peritonitis w/ LWE
 Splenic injuries  organ most commonly requiring intervention following
blunt trauma, Rx grade I – III injuries in a stable patient w/ nonoperative
mgmt. ±angioembolization, Rx grade IV – V injuries (hilar vascular injury /
completely shattered spleen) in an unstable patient w/ splenectomy
 Hepatic injuries  most commonly injured organ following blunt trauma,
physiologic stability > injury grade predicts success of nonoperative mgmt.,
Rx active extravasation w/ angiography, Rx unstable patients w/ operative
intervention w/ argon beam vs. severe bleeding w/ Pringle maneuver
(clamping of hepatoduodenal ligament = liver inflow) / total hepatic venous
occlusion (clamping of infra- & supra-hepatic IVC = liver outflow), Rx w/
resection of devitalized tissue (not formal anatomic resection), repeat CT in 8
weeks, complications = biloma (Rx w/ percutaneous drain placement)
 Biliary duct injuries  Rx w/ primary repair over stent (incomplete
injuries) vs. choledochojejunostomy (low injuries) vs. hepaticojejunostomy
(high injuries)
 Gallbladder injuries  Rx w/ cholecystectomy
 Gastric injuries  Rx hematomas within gastric wall w/ evacuation &
closure of seromuscular layer, Rx full thickness injuries w/ two layer repair,
Rx tissue loss w/ partial gastrectomy w/ BRI / BR II, Rx extensive tissue loss
w/ total gastrectomy w/ Roux-en-Y esophagojejunostomy
 Duodenal injuries  p/w indeterminate physical exam findings, Rx
hematomas of duodenal wall w/ observation (complication = GOO), Rx
duodenal wall perforations w/ primarily repair, Rx duodenal transection w/
resection & primary anastomosis if ampulla is not involved, Kocher
maneuver mobilizes duodenum for tension free repair, contaminant
pancreatic injury = RF for leak after repair
 Pancreatic injuries  assoc. w/ duodenal injuries, Rx small ductal injuries
w/ drainage, Rx major ductal injuries to the left of the superior mesenteric
vessels w/ distal pancreatectomy (spleen-sparing in stable patients vs.
splenectomy in unstable patients), Rx major ductal injuries within pancreatic
head w/ trauma Whipple, complication = pancreatic fistula
 Small bowel injuries  Rx injuries < 50% w/ primarily repair vs. injuries
>50% w/ resection & primary anastomosis
 Colon injuries  assoc. w/ penetrating trauma, Rx injuries < 50% w/
primarily repair vs. injuries >50% w/ resection & primary anastomosis
 Rectal injuries  assoc. w/ penetrating trauma, intraperitoneal vs.
extraperitoneal, Rx intraperitoneal rectal injuries <50% w/ primary repair
vs. injuries >50% w/ resection of the rectum & end colostomy, Rx
extraperitoneal rectal injuries w/ fecal diversion ± presacreal drainage
Abdominal Compartment Syndrome
  Due to IP or RP hemorrhage / aggressive fluid resuscitation, Dx w/ bladder
pressure >20 mmHg w/ new onset organ failure, Rx w/ decompressive
laparotomy
Genitourinary Injuries
 Renal trauma  Rx penetrating renal trauma / evidence of expanding
hematoma / pedicle avulsion / hemodynamic instability w/ operative
exploration vs. blunt renal trauma w/ observation, most urinary
extravasation resolves nonoperatively
 Ureter injury  Dx w/ retrograde pyelogram, Rx distal ureter injury w/
ureteroneocystostomy w/ psoas hitch / Boari flap
 Bladder trauma  assoc. w/ pelvic injuries (obturator ring / pubic
diastasis), Dx w/ CT cystography, Rx intraperitoneal bladder injury w/
primary repair vs. extraperitoneal bladder injury w/ Foley catheter & re-
imaging in 10 days
 Ureteral injury  due to injury at prostatic urethra, assoc. w/ pubic rami
fracture, p/w high riding prostate / blood at external meatus, Dx w/
retrograde urethrogram, Rx w/ surapubic cystostomy
Zones of Retroperitoneum
 Zone 1  central vascular structures at risk including aorta and IVC, Rx
hematoma w/ operative exploration regardless if blunt / penetrating trauma
 Zone 2  kidneys / adrenal glands, Rx hematoma w/ operative exploration
(penetrating trauma) vs. observation (blunt trauma)
 Zone 3  pelvic vasculature, Rx hematoma w/ observation regardless if
blunt / penetrating trauma
Exposure Maneuvers
 Mattox maneuver  left medial visceral rotation, exposure to left
retroperitoneum & abdominal aorta
 Cattell-Braasch  right medial visceral rotation, exposure to right
retroperitoneum & infra-hepatic IVC
Injury to the Pelvis and Extremities
 Rx unstable pelvic fractures w/ binder, if bleeding persists Rx w/
angiography / embolization
Trauma in a Pregnant Patient
 Primary and secondary survey focus on mother, pregnancy assoc. w/ 30%
increase in CO, left lateral decubitius can improve venous return, Rh-immune
globulin given to Rh- pregnant patients w/ pelvic trauma