Oncology

• True/False: Pharmacologic treatment is first line for FAP

Oncology

• False.

• No effective pharmacologic treatment• Autosomal dominant• Hundreds to thousands of polyps

Oncology

• Bcl-2 regulates what aspect of cell biology?

• Apoptosis• Anti-apoptotic through stabilization of

mitochodrial membranes• Chromosome 18

Nutrition and electrolytes

• 80 kg male pt with sodium =124. How much sodium should be replaced over the next 24 hours?

• Correct Na no more than 0.5/hr and 0.5/hr =12 /24 hours so over 24 hours want to correct Na only by 12

• Na required = (desired Na – measured Na) x total body water

• Here, desired Na = 124+12=136• (136-124)( 60%x80kg)= 576mEq• TBW= 60% men, 50%women 80% infant,

subtract 10% if obsese

Oncology

• True/false: radiation therapy works best under conditions of low oxygen tension

• False• Radiation works best with high oxygen

tension and forms oxidative free radicals which damage dna and cell membranes

• High energy = smaller wavelength= better more focused skin penetration= less skin damage

Oncology word association

• Ret• C-myc• p53

• Small cell lung ca• Li Fraumeni syndrome

(chromosome 17)• Medullary thyroid ca,

MEN

Oncology word association

• Ret• C-myc• p53

• Medullary thyroid ca, MEN

• Small cell lung ca• Li Fraumeni syndrome

(chromosome 17)

nutrition

• How many calories in 1L of D5 NS?

• 1L D5 = 5% dextrose = 50g dextrose• 50g dextrose x 3.4 kcal/g = 170 kcal

• Protein = 4 kcal/g• Fat = 9 kcal/g

• True/false: A patient with a respiratory quotient of 0.72 is consuming primarily lipid rather than carbohydrate

• True• Respiratory quotient is ratio of CO2

produced to O2 consumed• 0.7 = fat used• 1.0 = glucose used

Wound healing

• true/false: newly arrived fibroblasts recruit macrophages to a wound during the inflammatory phase

• False• Order: platelets-pmns-macrophages-

fibroblasts

Wound Healing

• True/False: albumin, CRP, and transferrinincrease in levels during the acute phase response

• False• Albumin and transferrin decrease during the

acute phase response• CRP, seruloplasmin, a-1 antitrypsin, and

fibrinogen levels increase during the acute phase response

Medicines

• True /false: halothane should not be used in burn victims due to its association with hyperkalemia

• False• Succinylcholine is associated with

hyperkalemia in burn patients• Halothane is hepatotoxic and can

additionally cause cardiac depression and dysrhythmias

Meds

• True/false: ketamine causes increased cardiac work and O2 consumption

• True

• True/false: Ehlers-Danlos patients are deficient in type IV collagen and have defects in the structure of basement membranes

• False• Ehlers-Danlos is a deficiency in which

there are low levels of type III collagen• Type IV collagen is found in basement

membranes

Wound healing

• True/false: TNF-α is a critical anti-inflammatory cytokine produced by TH2 T cells to promote wound healing

• False• The major source of TNF-a are

monocytes/macrophages• TNF-a is pro-inflammatory• It is pro-coagulant• It recruits and activates neutrophils

Nutrition

• True/false: Substance P is a sensory neurotansmitter of the enteric nervous system that signals mechanical and chemical stimulation of the colon

• True• Substance P is a sensory neurotansmitter of

the enteric nervous system that signals mechanical and chemical stimulation of the colon

Nutrition

• How many moles of ATP are produced per mole of glucose consumed under anerobic conditions?

• With krebs cycle and oxidative phosphorylation?

• 2 under anerobic glycolysis

• 38 with oxidative phosphorylation

Oncology

• True/false: midgut carcinoid tumors tend to produce flushing symptoms more often than those of the hindgut

• True• Hindgut carcinoids are generally hormonally inert• Foregut tumors (bronchial tree, stomach, pancreas,

first part of duodenum) often produce vasoactive substances that result in prolonged flushing

• Midgut tumor (2nd part of duodenum to transverse colon tend to give the classic carcinoid syndrome

• Highest carcinoid prevalence is at the appendix, 2nd highest is distal small bowel

Oncology

• True/False: there are 2 types of HNPCC

• True• Type I-right-sided colon ca• Type II- increased risk also of endometrial,

ovarian, stomach, and urinary tract tumors

• Together account for 5% of colorectal ca overall• Young age of ca onset• Multiple tumors• Multiple family members, autosomal dominant

• Silver sulfadiazine is associated with what side-effect?

• Transient leukopenia 2-3 days after initial treatment

• Poor eschar penetration• Good activity against S. aureas, E coli,

klebsiella, proteus, enterobacter, psuedomonas aeruginosa, C. albicans

• Can create a “psuedo-eschar”

Nutrition

• An alcoholic pt with hypocalcemia not explained by reduced serum albumin should be treated with what?

• Magesium replacement• Hypomagnesemia seen in 30% of cases of alcohol

abuse and 85% of delerium tremens cases• Low magnesium inhibits PTH secretion and end-

organ responsiveness to PTH• Hypocalcemia from magnesium depletion is often

corrected by giving magnesium, and in fact often does not respond to calcium replacement

Cytokines

• True/false: interferon-alpha and IL-13 are important cytokines produced by T cells during acute inflammation

• False• IL-1, IL-6, TNF-alpha, and Interferon –

alpha are primarily produced by monocyte/macrophages

• IL-2, IL-3, IL-4, IL-13 are produced by T cells

• IL-7, IL-11 produced by stromal cells for lymphoid homeostasis

Breast

While performing a modified radical mastectomy you injure the long

thoracic nerve. Postop this patient is most likely to have:

Breast

• Winged Scapula• The long thoracic nerve innervates the serratus

anterior muscle.

Breast

Describe the anatomic borders of an axillary lymph node dissection

Breast

• Superior Border: Axillary vein• Medial Border: Chest wall (watch for long

thoracic nerve)• Lateral Border: Skin Flap• Anterior Border: Pectoralis minor muscle• Posterior Border: Latissimus dorsi muscle

Breast

What is the most commonly injured nerve after modified radical

mastectomy?

Breast

• Intercostal brachiocutaneous– Injury to this nerve causes numbness in the

axillary area

Breast

True/False: Paget’s disease is the most common cause of bloody nipple

discharge

Breast

• False• Intraductal Papilloma is the most common

cause of bloody nipple discharge• Usually small, nonpalpable, and close to

nipple• NOT premalignant• Order ductogram to localize papilloma• Treat by subareolar resection (curative)

Breast

A 51yo Woman presents with scaling and dermatitis of the nipple. What is

the most likely diagnosis?

Breast

• Paget’s Disease• Scaly skin lesion on nipple• 1st symptom is often burning or itching• Biopsy shows Paget’s cells• Patients have DCIS or ductal carcinoma• Rx: Modified Radical Mastectomy if Ca

present, otherwise simple mastectomy

Breast

True/False: Postmenopausal womenwith breast Ca show an

overwhelming propensity for ER-PR-tumors

Breast

• False• 63%of postmenopausal women showed

ER+PR+ receptor status• Better response to hormones,

chemotherapy, surgery, and better overall prognosis

• PR+ tumors have a better prognosis than ER+ tumors

Breast

Discuss the treatment options for Lobular Carcinoma in situ.

Breast

• Nothing, Tamoxifen, or Bilateral SimpleMastectomy

• 40% get Cancer (either breast)• Marker for breast ca, not premalignant lesion itself• No calcifications, Not palpable• Pts that develop breast Ca are more likely to

develop ductal Ca• Multifocal disease is common

Breast

What is the most common breast mass in women under 30years old?

Breast

• Fibroadenoma• Painless, slow growing, round, well

circumscribed, firm, rubbery• Can change in size with menstral cycle• <30yo: clinically benign, US or mammogram

consistent with fibroadenoma, FNA or core needle biopsy

• >30yo: excisional biopsy to ensure diagnosis

Breast

A 40yo woman presents with breast pain. She has a palpable, tender,

erythematous 5cm long cord radiating from breast to inframammary fold. What is the appropriate treatment?

Breast

• Mondor’s disease is superficial thrombophlebitis of the veins overlying the breast

• Usually lower, outer quadrant• Associated with trauma and strenuous exercise• Self limiting condition, usually resolves over

weeks• NSAIDS and warm compresses

Breast

What percentage of screening mammograms are false positive?

Breast

• In a patient with a palpable, obvious breast mass a false negative mammogram is seen approximately 50% of the time if <45yo

• In woman >45yo there is only a 10% false negative mammogram rate

• “Triad of Error”-Factors in dealy of diagnosis of Breast Ca– <45yo, self found breast mass, negative mammogram

Breast

Risk Factors for Breast Ca include all of the following except: age, family history, multiparity, obesity, benign

breast disease

Breast

• Multiparity• Risk Factors for developing Breast Ca

Age Family Historyearly menarche late age-birth of first childlate menopause benign breast diseaseobesity OCP, ERTalcohol prior personal h/o breastCa

Breast

What is the most common organism in breast abscesses?

Breast

• S. aureus• Usually associated with breast feeding• Treament: I&D, antibiotics, ice/heat,

discontinue breast feeding, breast pump

Breast

A 46yo Woman undergoes breast biopsy which shows cystosarcoma phyllodes. There is no evidence of

metastatic disease. What is the most appropriate management?

Breast

• Cystosarcoma phyllodes is a sarcoma• Sarcomas rarely have mets to the LNs• Treatment consists of wide local excision or

simple mastectomy (NO ALND)• Only 10% malignant

Breast

What is the standard treatment for DCIS?

Breast

• Lumpectomy and XRT– Need 2-3mm margin with excision

• Simple Mastectomy if high grade (comedo type, multicentric, multifocal), large tumor not amenable to lumpectomy, unable to get good margins, or patient preference

• Usually not palpable, calcifications on mammogram

• Premalignant lesion, malignant cells of dictal epithelium without invasion of basement membrane

Breast

True/False: Lymph nodes are the most important prognostic staging

factor

Breast

• Survival is directly related to the number of positive LNs

• Large tumors are more likely to have +LNs• 0 LNs positive 75% 5yr survival• 1-3 LNs positive 60% 5yr survival• 4-10 LNs positive 40% 5yr survival

Breast

True/False: BRCA II is associated with increased risk of male breast Ca.

Breast

• True• BRCA I-associated with ovarian and

endometrial Ca• BRCA II-associated with male breast Ca• Consider TAH/BSO in BRCA I patients• BRCA gene + family history = 80-90%

chance of breast Ca by age 70yo

Breast

A 56yo Woman has a 2cm ductal Ca on core needle biopsy and clinically

(-) nodes. You decide to perform SLN biopsy. After lumpectomy, you are unable to identify any blue LNs.

What is the next step?

Breast

• Axillary LN Dissection• If you cannot find any blue or radioactive

LNs you cannot accurately stage the patient

Breast

True/False: Every Breast Ca patient with positive nodes should undergo

chemotherapy.

Breast

• True• Positive nodes: All get chemotherapy, except post

menopausal women with ER+ tumors-tamoxifen• >1cm and negative nodes: All get chemotherapy

except women with ER+ receptors-tamoxifen• <1cm and negative nodes: no further treatment• Tamoxifen:

1% risk of blood clots1% risk of endometrial Ca

Esophagus

How is Achalasia diagnosed?

Esophagus

• ManometryIncreased LES pressureIncomplete LES relaxationNO peristalsis

Esophagus

What are the treatment options forAchalasia?

Esophagus

• First line treatment is pneumatic dilatation– 60-70% success rate, 5-6% perforation rate

• C. botulinum toxin, safe, long term effects unknown

• Heller Myotomy and fundoplicaiton– Laparoscopic– Thoracoscopic

Esophagus

True/False: The esophagus lacks serosa

Esophagus

• True

Esophagus

Describe the surgical approaches to the cervical, upper thoracic, and

lower thoracic esophagus

Esophagus

• Cervical: Left neck• Upper thoracic: Right thoracotomy• Lower thoracic: Left thoracotomy

Esophagus

True/False: The arterial blood supply to the mobilized stomach used during

an esophagectomy is based on the Left Gastric Artery

Esophagus

• False• Right Gastroepiploic Artery • The Left Gastric, Left Gastroepiploic, and

Short Gastrics are divided to allow appropriate mobilization

Esophagus

Leiomyoma is the most commonbenign tumor of the esophagus, how

is it diagnosed and treated?

Esophagus

• Leiomyoma• Pts present with dysphagia and pain in lower

esophagus• Dx with UGI swallow and EGD to rule out Ca• DO NOT biopsy, can form scar and make

subsequent resection more difficult• If >5cm or symptomatic, ENUCLEATE via

thoracotomy

Esophagus

Describe the arterial supply to the esophagus

Esophagus

• Arterial supply:– Inferior thyroid artery provides the main blood

supply to the cervical esophagus– Bronchial arteries and branches directly off of

the aorta provide the main blood supply to the thoracic esophagus

• Venous drainage:– Venous plexus in the submucosa-->Left gastric

v-->azygous v

Esophagus

True/False: The incidence of esophageal Ca metastasis

significantly increases with tumor invasion of the submucosa

Esophagus

• True• Lymphatics of the esophagus form a rich

submucosal network. • Drainage from the upper 2/3 esophagus is

cephalad and from the lower 1/3 is in both directions

• Because of the rich lymphatic network, once Ca is in the submucosa there is a 60% INCIDENCE OF METASTASIS

Esophagus

A 58yo Man with h/o Etoh abuse presents to the ED with chest pain

after forceful vomiting. You order a gastrograffin swallow and discover

free perforation of esophagus. Describe the operative approach.

Esophagus

• Perforation most commonly in Left lateral wall at T8 level, 3-5cm above GE junction

• If free perforation has occurred and the diagnose is made acutely (within 24hrs):attempt primary repair: Left thoracotomy, longitudinal myotomy to see extent of injury (mucosal injury is usually longer than muscular injury), primary repair, leave CTs

• If delay in dx or “sick” pt: cervical esophagostomy for diversion and reestablish continuity later

Esophagus

A 50yo Woman presents to your office with chief complaint of dysphagia. What is the most

appropriate 1st diagnostic test?

Esophagus

• Barium Swallow• The best initial test for dysphagia or

odynophagia is a barium swallow.• EGD and CT scan are not as sensitive in

picking up abnormalities

Esophagus

True/False: All true paraesophageal hernias should be repaired

Esophagus

• False• Hiatal Hernia:

– Type I: sliding hernia– Type II: paraesophagaeal, hole in diaphragm alongside

esophagus– Type III: combined– Type IV: entire stomach in chest plus another organ

• Paraesophageal hernia (type II)– ONLY symptomatic patients

Esophagus

True/False: Manometry is the best test for diagnosis of GERD

Esophagus

• False• 24hr pH study• No PPIs for 2wks• Indications for Surgical Rx of GERD:

– failure of medical Rx– complications of GERD (stricture, Ca)

Esophagus

True/False: Zenker’s diverticula are treated via LES myotomy

Esophagus

• False• False diverticula-located posteriorly at UES

(cricopharyngeus m)• Diagnose with barium swallow study• Cricopharngeal myotomy

– Resection– Pexy– Left Cervical Incision, leave drains

Thoracic

What are the necessary predicted post op values for FEV1, DLCO, ABG

Thoracic

• FEV1>0.8 (or at least 40% predicted value)– V/Q scan if close

• DLCO at least 50% predicted value• NO RESECTION if preop pCO2>45 or

pO2<50 at rest

Thoracic

True/False: Nodal involvement in Lung Ca has the strongest influence

on survival

Thoracic

• True• Lung Ca is the most common cause of Ca

related death in the the US• Brain is the single most common site of

metastasis• Recurrence most commonly presents as

disseminated mets (brain most common)

Thoracic

True/False: Only stage I NSCLC is resectable

Thoracic

• False• Stage I and II disease are resectable• Stage IIIa (T3, N1, M0) possibly resectable

Thoracic

True/False: All thymomas require resection

Thoracic

• True• 50% of thymomas are malignant• 50% of patients with thymomas have

symptoms• 50% of patients with thymomas have

myasthenia gravis (10% of patients with myasthenia gravis have thymomas)

Thoracic

A 35yo Woman has progressive symptoms of myasthenia gravis

despite maximal medical Rx. No thymoma seen on CT, do you resect

the thymus anyway?

Thoracic

• Yes• In some patients with myasthenia gravis

that is refractory to medical therapy, removal of a normal thymus can result in improvement of symptoms

Thoracic

True/False: The most common structure involved in thoracic outlet

syndrome is the subclavian vein.

Thoracic

• False• The brachial plexus is the most common

structure involved in thoracic outlet syndrome-most common distribution C8-T1

• 1st Rib Resection and any cervical ribs• Only 60% of patients have complete

resolution of symptoms after repair

Thoracic

Alveolar macrophages originate from which cell type?

Thoracic

• Monocytes• Type I pneumocytes: gas exchange• Type II pneumocytes: surfactant production

Thoracic

A 65yo Man with a 30 pack year smoking history and apical lung Ca

presents with swollen arms, face, and hands. What is the best treatment for

this patient?

Thoracic

• Radiation Therapy• This patient most likely has Superior Vena

Cava Syndrome• Invasion of SVC is considered a T4 tumor

(stage IIIb) unresectable• Malignant tumors are the cause of caval

obstruction in 80-90% of cases

Thoracic

A 67yo Man with 50pack yr smoking history presents with a solitary 2cm

spiculated RUL nodule and a palpable supraclavicular LN. What stage is his disease? Is it resectable?

Thoracic

• Stage IIIb NSCLC, unresectable, Rx with XRT or chemoXRT

Thoracic-NSCLC staging

STAGE TNM Status

I T1-2, NO, MO

II T1-2, N1, MO or T3, NO, MO

IIIA T1-3, N2, MO or T3, N1, MO

IIIB Any T4, or N3

IV M1

Thoracic-NSCLC Staging

• T1: <3cm• T2: >2cm but >2cm away from carina• T3: invasion of chest wall, pericardium,

diaphragm or <2cm away from carina• T4: mediastinum, esophagus, trachea,

vertebra, heart, great vessels, malignant effusion (all indicate unresectability)

Thoracic-NSCLC Staging

• N1: ipsilateral, intrapulmonary and hilar LNs

• N2: ipsilateral mediastinal LNs (unresectable)

• N3: contralateral mediatinal LNs or supraclavicular LNs (unresectable)

• M1: distant metastasis

Thoracic

What is the most common cause of spontaneous pneumothorax?

Thoracic

• Rupture of subpleural bleb• Tall, healthy, thin, young men• Recurrence risk after 1st PTX 20%, after 2nd PTX

60%, after 3rd PTX 80%• Tx: chest tube• Surgery for recurrence, large blebs on CT scan, air

leak >7d, nonreexpansion• Surgery: thoracoscopy, apical blebectomy,

mechanical pleurodesis

Thoracic

What is the most common benign lung tumor? What is the radiographic

appearance?

Thoracic

• Hamartoma• Consists of an unusual arrangement of normally

occurring cells, most frequent component is cartilage

• Solitary pulmonary nodule with slow growth• Well circumscribed nodule with calcifications,

Popcorn lesion on CT (diagnose by chest CT)• DO NOT require resection, repeat chest CT in

6mos to confirm diagnosis

Thoracic

True/False: N-myc is the most frequently activated oncogene in

NSCLC

Thoracic

• False• K-ras is the most freqeuntly activated oncogene in

NSCLC• K-ras point mutations are linked to smoking• Associated with poor survival• About 1/3 of adenoCa, have the K-ras oncogene• SMALL CELL LUNG CA associated with myc

oncogenes

Thoracic

A 55yo M developed Right pleural effusion POD#3 s/p Ivor-Lewis esophagectomy. CT placed andoutput is 500cc/day. What is the

single most useful lab parameter to diagnose the nature of the fluid?

Thoracic

• Triglyceride level• Disruption of thoracic duct results in chylothorax

which is usually persistent• TG level is the most sensitive test for diagnosis of

chylothorax• Tx: chest tube, TPN• If chylothorax persists despite these measures,

thoracotomy and ligation of thoracic duct

Thoracic

True/False: Stage I and II NSCLC are best treated with surgical resection. Wedge resection is

associated with a higher rate of local recurrence and poorer survival then

lobectomy.

Thoracic

• True• The standard of care for surgical resection

of Stage I and II NSCLC is LOBECTOMY• Mortality rate lobectomy <3% and wedge

resection <1%

Thoracic

True/False: Thymoma is the mostcommon mediatinal tumor in adults.

Thoracic

• False• Neurogenic tumors are the most common-usually

in posterior mediastinum• Anterior: thymoma (#1 anterior), thyroid

Ca/goiter, T cell Lymphoma, Teratoma, PTH adenomas

• Middle: Bronchogenic cysts, Pericardial cysts, Enteric cysts, Lymphoma

• Posterior: NEUROGENIC TUMORs, Enteric cysts, Lymphoma

Thoracic

Which lung Ca is most likely to beassociated with a paraneoplastic

syndrome? Small cell Ca, AdenoCa, Squamous Cell Ca, Large Cell Ca

Thoracic

• Small Cell Ca-ACTH and ADH• Squamous cell Ca is associated with PTH-

rp release

Head and Neck

Which of the following is the most effective technique for safely identifying the facial nerve trunk during a total parotidectomy?

a) Identify the temporal branches of the nerve and perform a retrograde dissection

b) Use the midpoint between the fascial covering of the parotid gland and the earlobe as a landmark

c) Use the plane between the superficial and deep lobes of the parotid gland as a landmark

d) Use the tympanomastoid suture as a landmarke) Use a nerve stimulator

Head and Neck

• Use the tympanomastoid suture.• Retrograde dissection is difficult and

dangerous.• Because the earlobe is not a fixed point, it

cannot be used as a landmark. • Nerve stimulators are used as aids and are

not the primary means for identifying the nerve trunk.

Head and Neck• 68 y/o presents w/ a 3mm deep melanoma on her right temple as well as

palpable right neck nodes. An FNA reveals metastatic melanoma. Ideal local and regional management includes:

• A) Excision with 0.5 cm margins only.• B) Excision with 1.0 cm margins and neck dissection only.• C) Excision with 2.0 cm margins and a neck dissection only. • D) Excision with 2.0 cm margins, neck dissection and superficial

parotidectomy. • E) Excision with 1.0 cm margins, neck dissection and total parotidectomy.

Head and Neck• Melanomas above the lip tend to drain into the parotid gland as well as

cervical nodes. Therefore, in this patient, a superficial parotidectomy as well as a neck dissection should be performed.

• For lesions between 1 and 4 mm deep, margins should be 2cm. In the head and neck, this often means full thickness skin grafts or flap reconstruction is necessary.

Head and Neck• 58 year old female has biopsy proven squamous cell carcinoma located

in the medial canthus of the eye. She does not have lymphadenopathy. Treatment of choice is?

• A) Surgery alone w/ immediate local flap reconstruction• B) Surgery, reconstruction, followed by radiation therapy• C) Topical 5 FU• D) Photodynamic therapy• E) Radiation therapy alone

Head and Neck• Radiation therapy is the best choice for treatment of squamous or basal

cell skin cancers located on the nose, eye, lip, eyelid and inner or outer canthi.

• Cure rates approach 96% for basal cell and 92% for squamous cell carcinoma.

Head and Neck• Which of the following is not true regarding the surgical management

of a new-born with a unilateral cleft lip?• A) Surgery should be preformed around 6 months to one year of age• B) Surgery should be done when the baby is at least 10 lbs• C) Surgery should be done when the baby has a hemoglobin level of at

least 10 gm/dl• D) One of the surgical goals is to reconstitute the orbicularis muscle

sling• E) One of the surgical goals is to provide an inconspicuos scar.

Head and Neck• Rule of 10’s for cleft lip repair

– At least 10 weeks of age– A weight of 10 lbs– Hgb of at least 10gm/dl

• Surgical principles include– Reconstituting the orbicularis sling– Reconstruction of the horizontal “cupids bow”– An inconspicuous scar

Hepatobiliary• A 57-year-old man with alcoholic cirrhosis is referred for evaluation of

an umbilical hernia. The patient has ascites and takes spironolactone, 25 mg/day. On physical examination, he has a 3-cm facial defect containing intestine. The hernia cannot be reduced and is associated with a small skin ulcer.

• Appropriate management for this patient would be• a) nonoperative therapy• b) increasing the dose of spironolactone to 75 mg/day, adding

furosemide, and continued nonoperatiive therapy• c) repair of the hernia at the time of liver transplant• d) immediate operation• e) transjugular intrahepatic portosystemic shunt (TIPS)

Hepatobiliary• This patient has an incarcerated hernia. Because bowel strangulation is

possible in this situation, delaying operation while attempting to control the ascites is precluded.

• The best management strategy for a patient with ascites and an uncomplicated umbilical hernia generally begins with medical control of the ascites. Patients should be started on doses of spironolactone (up to 100 mg/day) in combination with furosemide. Umbilical hernia repair in the setting of uncontrolled ascites is associated with high morbidity and mortality rates (30% and 5%, respectively) and a high recurrence rate.

• If such a patient will be undergoing liver transplantation in the future, hernia repair can be accomplished at the time of the transplantation. T

• Transjugular intrahepatic portosystemic shunt (TIPS), portal-systemic, or peritoneo-jugular shunt procedures should be considered prior to umbilical hernia repair only for patients with ascites refractory to medical therapy

Hepatobiliary

• During laparoscopic cholecystectomy, a 40-year-old woman has a 6-mm common duct stone on intraoperative flluoroscopic cholangiogram. The next step in management should be

• a) Open bile duct exploration• b) postoperative lithotripsy• c) laparoscopic transcystic common bile duct

exploration• d) laparoscopic common bile duct exploration• e) observation

Hepatobiliary• Most common bile duct stones can be washed or retrieved using a

laparoscopic transcystic approach. • Laparoscopic common bile duct exploration is occasionally necessary

to clear the duct. This is most commonly done through the cystic duct.• ERCP is a viable alternative, although it does add cost and is not

without its own set of complications. ERCP complications may include bleeding, perforation, pancreatitis, sepsis and duct stenosis in approximately 10% of patients.

• A third option is to convert the procedure to an open CBD exploration. This conversion prolongs recuperation and should be reserved for large impacted stones that are not amendable to other approaches. Observation may be acceptable for stones less than 3 mm.

Hepatobiliary• The organism Clonorchis sinensis causes:

• A) Acute pancreatitis• B) Chronic pancreatitis• C) Cholangiohepatitis with recurrent cholangitis• D) Chronic cholecystitis• E) Pre-sinusoidal portal hypertension

Hepatobiliary• Clonorchis causes cholangiohepatitis. The infection is most common in

Asia and presents w/ recurrent episodes of cholangitis.• Cholangiogram shows multiple strictures in the intra and extra hepatic

biliary tree. • Surgical management includes biliary drainage with either roux en y

choledochojejunostomy or choledochoduodenostomy.• No special medical management is avialable for this condition.

Hepatobiliary• The spincter of Oddi:

• A) Contracts with CCK stimulation• B) Contracts with parasympathetic stimulation• C) Is more important in the regulation of bile flow than the

surrounding smooth muscle of the duodenum• D) Has a resting pressure of about 25 mmHg above

duodenal pressure• E) Is extremely short (<1mm)

Hepatobiliary• The sphincter is 4-6 mm long and has a resting pressure of 13mmHg

above duodenal pressure. • Sphincter exhibits phasic contractions at a frequency of 4/min and a

duration of 8 sec• Bile flow is primarily regulated by the sphincter and not by the

surrounding duodenal muscle• CCK and parasympathetic stimulation leads to relaxation of the

sphincter.

OrthopedicsA 28-yr-old man sustained a dog bite to his right arm. His physical

examination revealed a large, open wound at his forearm and loss of motor function and sensation at the radial nerve distribution. Exploring the wound at bedside, you notice total transection of the radial nerve. Radiographs showed no fractured bones. What is the most appropriate treatment for this patient ?

a) Exploration of the wound in the operating room with primary repair of the transected nerve

b) Immediate local wound care, antibiotic administration, and delayed repair of the nerve

c) Immediate cleansing of the wound, antibiotic administratoin, and no repair of the nerve

d) Immediate cleansing of the wound, antibiotic administration, observation for 24 hrs, and then exploration and repair in the operating room

e) Exploration of the wound in the operating room, with a transposition muscle flap over the injured nerve

Orthopedics• In clean, sharp, totally transected nerves, repair can be done

immediately. • Delayed repair is preferred by most surgeons for many reasons,

especially in dirty, macerated wounds. The delayed repair turns the scenario into a benign and elective case, allows the wound to heal, and decreases the chances of infection. The scarred ends of the nerve are better visualized, and there is a clear-cut edge between injured and non-injured nerve. Delayed repair of a totally transected nerve should not be postponed more than 1 month.

• Gunshot wounds, crushing blows, traction, and fractures can be explored by 2 months if signs of recovery are absent. If the injury to the nerve is within 2 to 3 inches of the first recoverable muscle, which at 2 months may be at the verge of reinnervation, an additional delay of 1 more month may be justified. If there is no improvement by 3 months, exploration and repair should be performed.

• The brachial plexus is an exception. For stretches or contusions, patients can be observed for 4 months.

Orthopedics• Regarding compartment syndrome, which one of the

following statements is correct?• a) The leg is divided into two compartments: anterior and

posterior.• b) The most common affected compartment is the

posterior.• c) The earliest manifestation of acute compartment

syndrome is elevated tissue pressure.• d) The peak time of the symptoms appears to be 6 to 8

hours after the insult.• e) Patients with compartment pressures greater than 15

mmHg should undergo fasciotomy.

Orthopedics• The earliest manifestation of acute compartment syndrome is elevated tissue

pressure. Signs and symptoms occur after tissue pressure has been elevated beyond a critical period. The first clinical symptom is pain, followed by decreased passive range of motion due to pain, paresthesias, and absence of pulse.

• The decision to perform a fasciotomy should be based on clinical signs and symptoms. Extremities are quick to develop compartment syndrome because of their confined environment, especially lower extremities.

• The leg is divided into three compartments: anterior, which is the most susceptible to compartment syndrome; posterior, which is subdivided into superficial and deep compartments; and lateral.

Orthopedics• Regarding fractures of the upper extremities, which one of the

following statements is true?

• a) Open reduction of clavicle fractures usually has a better outcome than non-operative treatment.

• b) Most fractures of the sfaft of the humerus are treated by open reduction and fixation.

• c) Olecranon fractures rarely require open reduction and fixation.• d) Monteggia fractures can be fixed by closed reduction of the radial

head and internal fixation of the fractured ulna.• e) Fractures of the shaft of the ulna and radius in children frequently

require surgical intervention.

Orthopedics• The treatment of a Monteggia fracture (dislocation of the head of the radius

and fracture of of the proximal ulna) remains controversial. Most authors recommend closed reduction of the radial head and internal fixation of the fractured ulna.

• Most fractures of the clavicle can be treated conservatively. Nonunion occurs in less than 1% of the patients, whereas it occurs in 4% of patients who undergo surgery.

• Most fractures of the shaft of the humerus can be treated non-operatively. Non-surgical treatment results in a higher incidence of union and fewer complications than does open reduction and internal fixation.

• Conversely, in fractures of the olecranon in adults, when the fragments are separated, open reduction and internal fixation are necessary.

• Fractures of the radius and ulna most likely do not require open reduction in children. Because of the high impact and subsequent displacement of the radius and ulna, this fracture is treated with open reduction and fixation in adults.

Orthopedics• Regarding radial nerve injuries, which of the following is false?• A) Injuries associated with closed fractures of the humerous or radius

generally recover spontaneously• B) Most spontaneous recovery will show evidence within eight weeks• C) Palsy associated with open fractures should be explored within 2

weeks• D) An advancing Tinels sign along the superficial radial nerve may not

be accompanied by succesful motor function recovery• E) Early tendon transfers for functional substitution are favored

Orthopedics• Radial nerve injury associated with closed fractures generally recovers

spontaneously.• Prompt exploration is recommended for open fractures, in particular

spiral oblique humerous fractures involving the lower third• If evidence of recovery is not found in 8-10 weeks after injury,

exploration should be considered.• Advancing Tinels sign along the course of the superficial radial nerve

may not be accompanied by succcessful motor function recovery.

Neurosurgery• Regarding neurogenic shock, which of the following is false?• A) It is caused by sympathetic denervation. • B) Hypotension and bradycardia are classic signs• C) The extremities are warm• D) The mainstay of treatment is alpha-adrenergic agonists• E) There is loss of both arteriolar and venous tone

Neurosurgery• Neurogenic shock occurs when sympathetic denervation produces

impairment in vasomotor tone.• Loss of tone in both arteriolar and venous systems leads to decrease in

systemic vascular resistance, increase in venous capacitance, decreased venous return to the heart and decreased cardiac output. Hypotension and bradycardia are frequently observed.

• Mainstay of treatment is to improve cardiac filling by IV volume administration. Use of alpha-adrenergic agonists are rarely indicated if adequate volume is given.

Neurosurgery• Regarding astrocytomas, which of the following is false?

• A) It is the most common primary brain tumor• B) It infiltrates the brain and has indistinct boundaries• C) It is more cellular than the normal brain• D) The most malignant form is the anaplastic astrocytoma• E) Unlike most astrocytomas, those in the cerebellum have a high

probability of cure

Neurosurgery• Astrocytic neoplasms are the most common primary brain tumor.• The infiltrate the brain and have indistinct borders.• Astrocytomas are more cellular than normal brain and they grow

slowly with the exception of the anaplastic variety. • Most malignant form is glioblastoma multiforme, which exhibit

necrosis, neovascularity, polymorphism and hemorrhage.• Prognosis for disease in the cerebral hemisphere is poor. In contrast,

cerebellar or optic nerve tumors are amenable to surgical removal and have a high probability of cure.

Neurosurgery• Regarding cerebral arterial spasm, which of the following is false?

• A) It is the leading cause of death in patients with ruptured intracranial aneurysms

• B) Is is seen in angiograms of 40% of patients with SAH from ruptures aneurysms

• C) It almos always occurs within the first 2 days after the bleeding episode

• D) The risk is proportional to the amount of subarachnoid blood on CT• E) It lasts for days to weeks

Neurosurgery• Vasospasm is the leading cause of death and morbidity in patients with

ruptured intracranial aneurysms.• It is seen on at least 40% of angiograms of patients with SAH• It almost never happens until the third day of bleeding and almost

never happens after the 10th day• It can last days to weeks• Likelyhood of vasospasms correlate to the amount of subarachnoid

blood on CT• Volume expansion and arterial hypertension are the most important

therapies• Nimodipine may protect against stroke following subarachnoid

hemorrhage

Neurosurgery• A 50 y/o presents w/ complaint of a severe headache and weaknes in

his right lower extremity. A CT of the head shows a low attenuating lesion with minimal contrast enhancement in left cerebral hemisphere. The most likely type of intracranial tumor is:

• A) Meningioma• B) Glioblastoma multiforme• C) Schwannoma• D) Ependymoma• E) Astrocytoma, grade 1

Neurosurgery• Gliomas make up about 50% present of all brain tumors, which

includes astrocytomas, medulloblastomas and oligodendrogliomas and ependymomas.

• Astrocytomas are low attenuating lesions on CT with minimal enhancement. Pts are symptomatic for about a year.

• Glioblastoma are also low attenuating lesions, but they have marked peritumoral edema and mass effect. Typically has a short history of symptoms.

• Meningiomas grwom from the arachnoid layer of the meninges. • Ependymomas grow from cells that line the ventricular system. On CT

these lesions enhance.

Colorectal

Describe the arterial supply, venous drainage, and lymphatic drainage of

the colon and rectum.

Colorectal

• Arterial supply– SMA (ileocolic, right colic, middle colic): ascending

and 2/3 transverse colon– IMA (left colic, sigmoid branches, superior recttal): 1/3

transverse colon, descending, sigmoid, and upper rectum

– Marginal artery: runs along colon margin, connecting SMA to IMA

– Superior rectal a: branch of IMA– Middle rectal a: branch of internal iliac a– Inferior rectal a: branch of internal pudendal a

Colorectal

• Venous drainage– Follows arterial, except IMV which goes to

splenic vein– Splenic vein joins SMV to form portal vein– Superior and middle rectal veins drain into

IMV and eventually into portal vein– Inferior rectal vains drain into the internal iliac

veins and eventually into the caval system

Colorectal

• Lymphatic drainage– Superior and middle rectum drain to IMA nodal

lymphatics– Lower rectum drains primarily to IMA

lymphatics, but also to internal iliac lymphatics

Colorectal

True/False: The external sphincter is innervated by the inferior rectal

branch of the internal pudendal n and perineal branch S4.

Colorectal

• True• External sphincter (puborectalis m) is under

voluntary control and is a continuation of the levator ani m (striated m)

• Internal sphincter is under involuntary control, is the continuation of the circulr band of colon m (smooth m), and is normally contracted

Colorectal

A 60yo Man presents with squamous cell Ca of the anal canal, discuss the

appropriate treatment.

Colorectal

• Squamous cell Ca of anal canal– Symptoms: pruritis, bleeding, palpable mass– Tx: NIGRO protocol, chemo-5-FU and

mitomycin, and XRT (NOT SURGERY)– Cures 80%– APR for persistent or recurrent Ca

Colorectal

A 55yo Woman undergoes colonoscopy with polypectomy. Path shows a T1 lesion. Is she adequately

treated?

Colorectal

• Polypectomy is adequate if:– Polyp is penduculated and the level of invasion is not

below Hagitt’s level 3• If submucosa beyond the neck of the polyp is involved or if the

polyp is sessile, it is a level 4 and requires formal resection

– Margins are clear (2mm)– Well differentiated– No vascular/lymphatic invasion

• Otherwise need formal colon resection

Colorectal

A 57yo Man underwent transanal excision of a rectal polyp. Discuss

the treatment strategies if path reveals a T1 lesion or T2 lesion.

Colorectal

• T1 lesion after transanal polypectomy– Transanal excision adequate if:

• Margins clear (2mm)• Well differentiated• No vascular/lymphatic invasion

• T2 lesion after transanal polypectomy– APR or LAR

Colorectal

STAGE TMN StatusI T1-T2, NO, MO

II T3-T4, NO, MO

III Any N1 disease

IV Any M1 disease

Colorectal

• T1: into submucosa• T2: into muscularis propria• T3: into serosa or through muscularis

propria if no serosa present• T4: through serosa or into adjacent

structures/organs of no serosa present• N0: no nodes, N1: 1-3 LNs, N2: >4 LNs• M1: distant metastasis

Colorectal

True/False: Nodal status is the most important prognostic factor in

colorectal Ca.

Colorectal

• True• Liver: #1 site of mets/Lung: #2 site of metss• Isolated liver an lung mets should be

resected

Colorectal

A 65yo Woman with Stage III colon Ca undergoes Right hemicolectomy,

is her treatment complete?

Colorectal

• No, she needs to undergo postop chemo• Chemotherapy:

– Stage III and IV COLON Ca (positive LNs or distant mets)-PostOp chemo

– Stage II and III RECTAL Ca-PreOp or PostOp chemo and XRT

– Stage IV RECTAL Ca-chemo and XRT, +/- surgery• Stage II (rectal) and III (colon or rectal)-5FU and

levamisole• Stage IV (colon or rectal)-5FU and leucovorin

Colorectal

True/False: All patients with FAP need prophylactic total colectomy by

age 20yrs.

Colorectal

• True• Autosomal dominant, all have Ca by age 40• APC gene-chromosome 5• Also get duodenal polyps-need to check

duodenum for Ca with EGD every 2yrs• Surgery: proctocolectomy, rectal mucosectomy,

and ileoanal puch (proctocolectomy with end ileostomy also an option)

• Need lifetime surveillance of residual rectal mucosa

Colorectal

True/False: Lynch syndromes (HNPCC) are associated with absent

p53.

Colorectal

• False, Lynch syndromes associated with DNA mismatch repair gene

• Lynch I: colon Ca• Lynch II: Incr risk ovarian, endometrial, bladder,

gastric Ca• Amsterdam criteria (3,2,1):

– At least 3 1st degree relatives– Over 2 generations– 1 with Ca before age 50yo

• Surveillance colonoscopy at age 25yrs or 10yrs before relative got Ca

Colorectal

True/False: The preferred fuel of the colonic epithelium is short chain fatty

acids.

Colorectal

• True• N-butyrate is one of the short chain fatty

acids produced by bacterial fermentation and is the preferred fuel of the colonic epithelium

Colorectal

Your patient, in prone jack-knifeposition, has an external opening of a

perianal fistula at the 2 o’clock position. Where is the internal

opening?

Colorectal

• 12 o’clock• Goodsall’s rule-

– Fistulas with secondary openings located anterior to a line bisecting the anus (9 o’clock to 3 o’clock) in a prone patient converge to the posterior midline

Colorectal

A 28yo Woman underwent an appy for perforated appendicitis. Path reveals a 0.5cm carcinoid at tip of

appendix. What is most appropriate next step?

Colorectal

• Observation• Small (<2cm) incidental carcinoid tumors of

the appendix have extremely low likelihood of metastatic spread, therefore no further therapy is needed.

• If >2cm, Right hemicolectomy

Colorectal

In a patient with Crohn’s disease, what is the most appropriate mgmt of

multiple short strictures with total obstruction of ileum without evidence

of ileitis?

Colorectal

• Stricturoplasty• Intestinal obstruction is the most common

indication for surgery

Colorectal

Which of the following agents act as a sensory neurotransmitter for the colon? Somatostatin, Substance P,

Bradykinin, Gastrin, Cholecystokinin

Colorectal

• Substance P and calcitonin related peptide act as sensory neurotransmitters. Their role is unknown, but the sensory neurons which they stimulate transmit information to both motor neurons and prevertebral ganglia.

What are the indications for AAA repair?

• Greater than 5cm• Rapidly expanding• Symptomatic• Ruptured

True or False: popliteal artery aneurysms should be surgically

treated as they have a high risk of rupture.

• False. Popliteal artery aneruysms have high risk of thombosis or embolization. They should be treated surgically with bypass.

• Make sure to look on other leg since 50% of patinents with one pop. aneurysm will have another…

True or False: In a woman of child bearing age, an asymptomatic splenic artery aneurysm does not need repair since it is unlikely to rupture.

• False. Splenic artery aneurysm rupture in pregnancy carries very high maternal and fetal mortality (75%) and therefore should be repaired.

• Splenic artery aneurysm is the most common splanchnic artery aneurysm (60%). Symptomatic ones and those >2cm should be repaired because they may rupture and rupture carries mortality of 25%.

• Women: men = 4:1

Name a large vessel giant cell arteritis….

Name another….

Large vessel vasculitis

• TEMPORAL arteritis

• TAKAYASU’S disease

How do they compare and contrast?

What is Buerger’s disease and how to you treat it?

Hint: 1-800-NO-BUTTS

Buerger’s disease AKA thromboangitis obliterans

• Segmental inflammation and thrombotic occlusion of small and medium arteries

• Occurs in young, male, HEAVY smokers• 50% isolated to lowever extremites, 40%

both lower and upper, 10% only UEs• Tx: quit smoking• Px: normal life expectancy

• True or False: The SAPPHIRE trial showed that Carotid Artery Angioplasty and Stenting is not inferior to CEA in all vascular patients.

• False. SAPPHIRE did conclude that Carotid stenting and plasty was not inferior to CEA…. but this was only tested in HIGH RISK patients.

By HIGH RISK, they mean bad CAD, old (age >80), bad pulm dz, recurrent stenosis after CEA, contralateral carotid occlusion…

• What is the workup for a young man with a testicular mass and normal biochemistries?

• All testicular masses are treated with orchiectomy VIA an INGUINAL incision.

• True or False: an elevated AFP in a man with a diagnosis of seminoma should call into question the diagnosis.

• TRUE. Seminomas do not secrete AFP. Only 10% secrete bHCG.

Seminomas are the most common testicular tumor, don’t secrete markers, are very radiosensitive, and survival is good after radiation and just one ball.

A gyn patient in the OR sustains a ureteral injury….

They call you to fix it. What do you do?

Ureteral injury

• Almost always iatrogenic• Tx: avoid ureteral dissection since that

compromises the blood supply. Repair primarily if possible over a stent. Use absorbable suture (so no nidus for stone formation) and place a drain (to ensure no urine leak post op)

• Are varicoceles more common on the Left or the Right side?

• Varicoceles are more common on the LEFT side because the LEFT gonadal vein enters the LEFT renal vein which can get compressed by the SMA, causing a varicocele, varicose veins of the pampiniform plexus. This causes a varicocele and can cause testicular atrophy and even infertility. Must rule out RCC.

• An obese woman presents with N/V, abdominal distention, fever, WBC=16, and a tender mass at her right groin inferior to the inguinal ligament.

What is the best treatment option?

Incarcerated Femoral hernia

• When and femoral hernia is incarcerated and bowel ischemia suspected, treatment is an open transabdominal reduction of hernia (so you can examine the bowel) in addition to femoral hernia repair.

What is the diagnosis in a healthy young women with HTN?

How do you treat it?

Dx: fibromuscular dysplasia

• Most often involves Right renal artery, followed by carotid, then iliacs

• Dx: see “string of beads” on angiogram, usually affects the distal third of the artery

• Tx: angioplasty, bypass if fails

A patient h/o CAD, HTN presents with:-Weight loss-Postprandial abdominal aching-Food fear (avoidance of eating)

What study will to order? What is the diagnosis?

Dx: Chronic mesenteric ischemia• The classic triad for viseral angina is:-weight loss-postprandial abdominal aching-food fear

Dx: angiogram with A/P & LATERAL viewsTx: revascularization (angioplasty/stent or

bypass)

What is the treatment for mesenteric venous thrombosis?

This is rare but LETHAL so must make the diagnosis quickly and start treatment quickly!!!

Mesenteric venous thrombosis

• Is the cause of 5-10% of all mesenteric ischemia

• 90% of patients have an underlying hypercoagulable state

• Tx: IV heparin gtt. Not TPA, not coumadin, not surgical thrombectomy

• True or False: the Unna boot is the treatment of choice for venous stasis ulcers.

• True. Unna boot is a moist bandage that contains zinc and calamine which dries and hardens that is wrapped up with an ACE wrap. This dressing compression combo is #1, beats duoderm, JOBST, foam, etc.

The macula densa senses low NaCL, and produces which converts angiotensinogen to which is converted to angiotensin II in the lung by .

RENIN

ACE

ANGIOTENSIN I

WHAT ADRENAL HORMONE IS INCREASED AS A RESULT?

General

ALDOSTERONEACE INHIBITORS

Increases absorption of sodium in the collecting duct in exchange for K+ and H+

A prospective cohort trial is one form of randomized controlled trial

TRUEFALSE

General

FALSE

• A cohort trial is a group of patient that is NOT randomized.

• Can be studied retrospectively or prospectively.

How many molecules of ATP are produced per glucose molecule by the Krebs Cycle?

How many by anaerobic glycolysis?

38

2

General

True or false?

A type 2 error occurs when the null hypothesis is incorrectly discarded

(i.e., a difference is “shown” to exist when it actually does not).

General

FALSEType 1 error: null hypothesis rejectedincorrectly (a difference is “shown” to

exist when it acutally does not).

Type 2 error: the null hypothesis is accepted incorrectly (a difference exists, but was not demonstrated.) Usually from

the study being under-powered (too small).

Name three major actions of CCK

1. Constrict gallbladder2. Relax Sphincter of Oddi3. Stimulate pancreatic enzyme secretion

Gut Physio

CHOLECYSTIKININ

• Release stimulated by fat/protein in duodenum• Also inhibits gastric emptying and acid secretion

chole = bilecysto = sac kinin = move

“mover of the the bile-sac”

Gut Physio

The most important stimulant of gastrin is which of the following?

A. MealB. Low pHC. SecretinD. Ach releaseE. Cholecystokinin

Gut Physio

A meal stimulates gastric release

• Especially small peptides and amino acids• pH places a lesser role in gastrin release• Vagus nerves seems to stimulate AND inhibit

gastrin release (increased gastrin after vagotomy)

Gut Physio

Most patient with early dumping syndrome require which of the

following to control their syndrome?

A. SomatostatinB. Reversed jejunal loop at gastro-jC. Dietary modification and postural

measures

Gut Physio

Early dumping syndrome (post vagotomy)

• Most patients can be treated with small frequent meals high in protein and low in sugar salt and fluids, as well as lying supine after meals to slow gastric emptying.

Gut Physio

In what phase of the MMC does the gallbladder contract?

PHASE II

Gut Physio

MMC

• 90 minute cycles to the TI– PHASE I: quiescence– PHASE II: gallbladder contracts– PHASE III: peristalsis– PHASE IV: subsiding electric activity

• KEY hormone is MOTILIN; the motilin receptor is stimulated by Erythromycin.

Gut Physio

Regarding mast cells, which of the following is FALSE?

A. They are very similar to basophilsB. They are the major source of

histamine in most tissuesC. They mature in the circulation

and then populate the tissues. D. They release histamine when

injured

Immuno

Mast cells

• Do not enter the circulation• Are the major source of histamine in most tissues

Immuno

Three hours post-op your patient has a high fever. You remove the

dressing and see thin gray fluid oozing from the incision and dusky wound edges. What two organisms

are the most likely culprits?

Immuno

Answer

• Beta hemolytic strep (pyogenes)• Clostridium

• Abx and return to OR for debridement

Immuno

Which immunoglobulin is the “early” one?

IgM

Immuno

What is the mechanism quinolones?

INHIBITION OF DNA GYRASE

Immuno

Which staph is coagulasepositive?

A. Staph aureusB. Staph epidermidis

Immuno

What are the vitamin K dependent factors?

2, 7, 9, 10

Hemostasis

Warfarin

• Blocks the vitamin K dependent factors• Remember: 1972• Also inhibits Protein C and S can lead to

thombosis initially (therefore may want to bridge with heparin).

Hemostasis

Is banked blood shifted left or right on the dissociation curve?

Why?

Hemostasis

Shifted to the LEFTBecause it has less DPG

The affinity for oxygen is INCREASED, which results in decreased tissue oxygenation. (Oxygen held more tightly)

Decreased pH, increased temp, DPG or CO2 causes a right shift, and un-loading of O2

Hemostasis

What is the mechanism of heparin?

BINDS ANTI-THROMBIN III, INACTIVATINGS FACTOR 9-12

Hemostasis

What does thromboxane do?

• Vasoconstriction• Increased platelet aggregation

– Opposite of Prostacyclin

Hemostasis

Question #1

• While performing an EGD you find a small ulcer located in the body of the stomach as well as one in the duodenum. This is most consistent with what type of ulcer (I, II, III, IV, V)?

Type II

Gastric ulcer classification

• Type I: Lesser curve– Acid hyposecretion, ? Type A blood

• Type II: Lesser curve & duodenal– Type O blood

• Type III: Pre-pyloric• Type IV: High on lesser curve (GE jxn)

– Acid hyposecretion, similar to Type I• Type V: Anywhere

– NSAID use

Question #2

• True/False– Most patients with early dumping after an

antiulcer operation require somatostatin analogue treatment to control their syndrome.

False

Treatment of early dumping syndrome

• Most patients (99%) require only dietary/behavioral modifications– Lying down for 30 minutes– Low carb, high fat/protein diet + fluid restriction

• Octreotide– May reduce symptoms for some patients

• Surgery– <10cm reversed jejunal segment placed at gastric outlet– Reserved for medical treatment failures

Question #3

• During a celiotomy for an o/w healthy patient with Crohn’s disease, you note severe inflammation at the ileocecal region, a 2cm stricture in the jejunum, and an 8cm stricture in the jejunum. The strictures are separated by 15cm of normal bowel. What is the optimal management for this patient?

Resection of the inflamed ileocecal region and two

stricturoplasties

SB complications of Crohn’s

• Inflammation not responding to medical therapy, strictures, fistulae

• Minimal resection recommended– Resect healthy bowel only if <5cm separation

btwn diseased segments– Stricturoplasties for multiple short strictures

• Heinecke-Mikulicz vs Finney

Question #4

• True/False:– Cholecystokinin is the most important stimulant

of gastrin release.

False

Stimulants of gastrin release

• Gastrin produced by G cells in antrum• Major stimulant:

– Small peptide fragments/amino acids from ameal

• Other stimulants:– Vagus, high pH

• Inhibitors:– Somatostatin, low pH, ? vagus

Question #5

• True/False:– Hindgut carcinoids are generally hormonally

inactive.

True

Carcinoid syndrome

• Release of serotonin from argentaffin staining cells– Tryptophan --> serotonin --> 5-HIAA (urine)

• Flushing, bronchospasm/asthma, diarrhea, vasomotor collapse, R heart valvular dz

• Only seen in 9% of pts with METS• Most hormonally active carcinoids are in foregut

and midgut, hindgut tumors rarely active

Question #6

• True/False:– Total thyroidectomy facilitates the

postoperative detection and treatment of metastases with iodine-131 in most cases of medullary thyroid carcinoma.

False

Postoperative radioiodine for thyroid cancer

• Typically used as adjuvant therapy after total thyroidectomy– Uptakes and ablates residual functional thyroid tissue– Can diagnose and treat residual or metastatic dz

• Only useful for well-differentiated cancers (retain ability to take up iodine)– Classically only papillary and follicular– Also reported to be used in papillary variants, Hurthle

cell, and insular– No use in medullary or anaplastic cancers

Question #7

• During a routine neck exploration for a patient with hyperparathyroidism, only 3 normal parathyroids are found. What is the next step in management?

Mobilize the thymus

The “missing” parathyroid

• Steps to take in the OR:– Mobilize thymus– Look for intrathyroidal location (intraop US helpful)– Look posterior to esophagus– Open carotid sheath– Close, repeat localizing studies

Question #8

• After performing a thyroidectomy on a 23 yo woman, she returns to the clinic complaining of difficulty shouting and singing. What is the most likely cause of this symptom?

Injury to the external branch of the superior laryngeal nerve

Complications of thyroidectomy

• Hypocalcemia• Permanent hypoPTH• Transient/permanent RLN injury

– Hoarseness if unilateral, stridor/airway occlusion if bilateral

• Injury to external branch of superior LN– Motor to cricothyroid muscle, injury leads to inability

to project and hit high notes• Hematoma

– Airway emergency, open incision at bedside

Question #9

• True/False:– The RET oncogene has been associated with

both medullary and papillary thyroid carcinomas.

True

Genes associated with thyroid cancer

• RET– RET point mutation in MEN2 and familial MTC– RET/PTC rearrangements in radiation-induced PTC

• Trk• RAS

– More common in FTC

• BRAF• p53

Question #10

• True/False:– The inferior parathyroids are derived from the

3rd pharyngeal pouch.

True

Parathyroid anatomy

• Superior glands:– Derived from 4th pharyngeal pouch

• Inferior glands:– Derived from 3rd pharyngeal pouch– Descend greater distance than superior glands,

leading to more variable positions• Blood supply to all parathyroids primarily

from inferior thyroid artery

Question #11

• True/False:– Hyperacute rejection is mediated by preformed

antibodies to donor allograft antigens.

True

Post-transplant rejection

• Hyperacute (minutes/hours)– Preformed antibodies against donor antigens– Complement activation --> hemorrhagic graft necrosis– Tests to prevent: PRA, crossmatch

• Acute (weeks/months/years)– Generally mediated by T cells (cellular)– Humoral rejection can involve IgG Abs

• Chronic (months/years)– Chronic fibrosis– Main cause of late graft failures

Question #12

• True/False:– Mycophenolate mofetil exerts its

immunosuppressive action via inhibition of IL-2 production.

False

Mechanisms of immunosuppression meds

• Steroids: impair DNA/RNA inhibits cytokine production

• Calcineurin inhibitors: prevents NFAT transcription inhibits IL-2 expression

• Sirolimus: cell cycle inhibitor• Mycophenolate mofetil: inhibits guanine synthesis• Azathioprine: purine analogue, inhibits DNA

replication/RNA transcription• Thymoglobulin: polyclonal antithymocyte Ab• OKT3: monoclonal Ab against TCR-CD3

Question #13

• What is the most common cause of post-kidney transplant oliguria?

Preservation injury resulting in ATN

Question #14

• True/False:– Nonspecific cholestasis develops in the vast

majority of liver transplants and is thought to be a result of ischemic injury during harvest/preservation.

False

Cholestasis post-liver transplant

• Only occurs in 15% of transplants• Causes:

– Primary/delayed nonfunction– Rejection– Nonspecific (functional) cholestasis– Hepatic artery thrombosis (ABSITE answer)

• Dx using cholangiograms (US not sensitive in the early post-op period)

• Donor bile duct blood supply solely through HA

Question #15

• What malignancy is a 45 yo patient who underwent successful kidney transplant 6 years ago most likely to develop as a consequence of long-standing immunosuppressive therapy?

Skin cancer

Malignancies related to immunosuppression

• Mechanism often linked to chronic viral infection• Skin cancer (HPV, most common)• T-cell lymphoma (HTLV-1)• PTLD/B-cell lymphoma (EBV)

– Treatment: decrease immunosuppression (unless it has progressed to B-cell lymphoma)

• Cervical cancer (HPV)• Kaposi sarcoma (EBV)• Vulvar/perineal cancer (HSV)

Question #16

• A 50 kg patient with 2nd and 3rd degree burns to her entire left lower extremity and right thigh should receive how much fluid over 24 hours?

5600 mL

Burn management

• Parkland formula:– mL IVF in first 24 hrs

= 4 × (weight in kg) ×(% TBSA burned)

– Give half in first 8 hours

– Only count 2nd, 3rd degree burns

– “Rule of nines”

• Criteria for txf to burn center:– TBSA>20% in 10 - 50 yo

patients– TBSA>10% in <10 or >50

yo patients– 3rd degree burns >5%– Burns on face, hands, feet,

eyes, ears, perineum– Significant chemical,

electrical burns– Inhalation injury– Significant other trauma,

comorbidities

Question #17

• True/False:– In a stable patient with a Zone III penetrating

neck injury one can make the argument to explore without any further work-up since the area can be explored safely.

False

Management of stable penetrating neck trauma

• I and III: angio, tracheobronchoscopy,esophagram/EGD

• II: “traditionally”operative (easy access)– Nonoperative

management now used in select patients

• CTA invaluable as a triage tool

Question #18

• True/False:– The affinity of hemoglobin for oxygen in the

periphery can be increased by elevation of pH in the blood.

TRUE

Oxygen dissociation curve

Question #19

• A 45 yo man is brought to the ED after sustaining a head-on MVA in which he was the passenger. During your initial assessment he opens his eyes to voice, is mumbling inappropriate words and withdraws his extremities to pain. What is his GCS?

10

GCS

• Motor response most important predictor of severity of injury

• Coma generallyregarded as GCS≤8– Survival 40%

Question #20

• True/False:– The Rapid Shallow Breathing Index should not

be measured until the patient is about 10 breaths per minute above the ventilator set rate.

False

Match the clinical presentation with the type of functional endocrine tumor of the pancreas.

Insulinoma watery diarrhea, hypokalemia, acholorhydria

Gastrinoma diabetes, stomatitis, migratory necrolytic erythema

VIPoma diabetes, gallstones, steatorrhea, hypochlorhydria

Glucagonoma refractory ulcer disease, diarrhea

Somatostatinoma hypoglycemia, episodic syncope

Question 1:

Question 2:

Order the following periampullary tumors from worse to better prognosis: ampullary, duodenal, pancreatic, distal CBD

Answer:

5 year survival:Pancreatic (10-25%)Distal CBD (15-40%)Ampullary (15-55%)Duodenal (30-60%)

Question 3:

True or False

Gastrinoma is the most common type of islet pancreatic tumor seen in MEN I.

Answer:

True

MEN I: Pituitary (prolactinoma) Pancreatic tumors hyperParathyroidism (hyperplasia)

Question 4:

True or False

Secretin stimulates pancreatic enzyme secretion and CCK stimulates pancreatic bicarbonate secretion.

Answer:

False

Origin Response

CCK Duodenum Stimulates:K cells GB contraction

Relaxation of OddiPancreatic enzyme

Secretin Duodenum Stimulates:S cells Pancreatic bicarbonate

Bile flowInhibits:HCl releasegastrin release

Both hormones stimulated by low pH in duodenum

Question 5:

True or False

Treatment for pancreatic divisum is Whipple procedure.

Answer:

False

Treatment: sphincterotomy of both lesser and greater ducts and cholecystectomy

Question 1:

True or FalseMale infant is admitted for postprandial

projective vomiting. There is a palpable olive on abdominal examination and laboratory workup shows hypokalemia and hypochloridemic metabolic alkalosis. Treatment includes immediate surgical exploration.

Answer:

False

Hypertrophic pyloric stenosis

• Treatment: IVF resuscitation (IVB 20cc/kg) to

correct alkalosisRamstedt pyloromyotomy

Question 2:

True or FalseMale infant is admitted for bilious vomiting

and on examination is lethargic. KUB shows dilated stomach, but otherwise, paucity of gas-filled bowel. Treatment includes immediate surgical exploration.

Answer:

True

If patient is clinically stable, UGI can be obtained.

Midgut Volvulus: Malrotation

• Ladd’s procedure- reduce volvulus

(counterclockwise)- release Ladd’s bands- widen mesenteric base- appendectomy

Question 3:

True or False

Term infant does not pass meconium within the first 24 hours of life. Barium enema is normal and does not show a transition zone. The patient does not have Hirshsprung’s disease.

Answer:

False

Hirshsprung’s disease is diagnosed by absence of ganglion cells on rectal biopsy.

Question 4:

True or False

Poor prognostic factors for neuroblastoma includes age < 1 year, N-myc amplication, high HVA (homovanillic acid) levels

Answer:

False

Children age < 1 year: best prognosis

Question 5:

13 month old baby boy presents with increased fussiness and passage of bloody, mucoid stool. Contrast enema shows:

True or FalseAfter successful radiographic

reduction, the patient should be taken immediately to OR because over 50% of patients will have a lead point.

Answer:

False

Only 10% of cases in children < 4 years will have lead point. Surgical exploration is necessary for perforation, incomplete radiographic reduction.

Question 1:

34-year old man has 4 cm adrenal lesion on abdominal CT scan. Urinary VMA, metanephrines, and catecholamines are all positive. What preoperation preparation is necessary?

Answer:

Volume replacement and alpha-blockade (phenoxybenzamine)

* B-blockade only if tachycardicwith alpha-blockade

Pheochromocytoma

10% rule:Malignant, bilateral, extra-adenal,

children, familial

Question 2:

In Conn’s syndrome, how do you preoperatively distinguish hyperplasia from adenoma or cancer?

Answer:

Postural stimulation test:Adenoma: no change in renin or

aldosterone levelsHyperplasia: slight ↑ aldosterone

and renin levels

Salt Sweet Sex

Glomerulosa Fasiculata Reticularis

Aldosterone Cortisol Androgen Estrogen

Question 3:

True or False

Patient presents with truncal obesity, hypertension, and diabetes. Laboratory results show ↑ 24-hr urinary cortisol, ↑serum ACTH, and positive overnight low-dose dexamethasone suppression test. Treatment includes bilateral adrenalectomy.

Answer:

False

Diagnosis: Pituitary adenoma (Cushing’s disease), Head MRI to help localize lesion, Treatment: trans-sphenoidal resection

Cushing’s syndrome

• Pituitary adenoma: ↑ ACTH, suppressed by either low or high-dose dexamethasonetest

• Ectopic ACTH (most common: small cell lung CA): ↑ ACTH, not suppressed by either dexamethasone test

• Adrenal adenoma/hyperplasia: ↓ ACTH

Question 4:

56 year old woman with history of modified radical mastectomy for breast cancer is found to have a 2-cm right adrenal mass on abdominal CT scan. What is the most likely diagnosis?

Answer:

Breast cancer metastasis

Mets to adrenal: breast (most common), renal, melanoma,lung cancer

Question 5:

True or False

Risk factors for melanoma include dysplastic nevi, congenital nevi, and BK Mole syndrome.

Answer:

True

Question 1:

True or False

The most common cause of musculocutaneous flap necrosis is arterial insufficiency.

Answer:

False

Venous thrombosis

Question 2:

56 year old man with 2 cm melonoma on his back. No evidence of axillary or cervical lymphadenopathy. Core biopsy shows a depth of 3 mm. What is the treatment?

Answer:

Resection with 2 cm margins and sentinel lymph node biopsy.

Question 3:

True or False20 year old man has bilateral

lung lesions 2 years after limb-sparing surgery for left leg sarcoma. Only treatment option is chemotherapy.

Answer:

False

Wedge resection of lung lesions if primary disease is adequately controlled.

Question 4:

True or False

Patients with melanoma on the face can be adequately treated with Mohs surgery.

Answer:

False

Mohs surgery

• Margin mapping using conservative slices: minimize area of resection

• For basal or squamous cell skin carcinoma.

• NEVER for melanoma

Question 5:

Order the type of melanoma based on worse to better prognosis: nodular, lentigo maligna, superficial spreading, acral lentigus

Answer:

Acral lentigusNodularSuperficial spreading (most

common)Lentigo maligna