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Surgery > Chapter 13, part 2 > Flashcards

Chapter 13, part 2 Flashcards

1
Q

What may cause amebic liver abscesses?

A

Entamoeba histolytica

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2
Q

Who is at highest risk for amebic liver abscesses?

A

Alcoholic pts

Homosexuals

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3
Q

Tx of amebic liver abscess

A

Medical management
10-14 day course of metronidazole
No role for surgical management

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4
Q

Tx of hydatid liver dz

A

Surgical resection of the hydatid cyst constitutes definitive therapy

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5
Q

In hydatid liver dz, what may result in anaphylactic shock?

A

Cyst rupture

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6
Q

Cirrhosis of the liver

A

Characterized by the replacement of nl functioning hepatocytes with fibrous connective tissue and regenerative hepatic nodules

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7
Q

Common causes of cirrhosis

A 
Chronic HBV or HCV infection
Exposure to hepatotoxins such as alcohol
A1-antitrypsin deficiency
Hemochromatosis
Wilson's dz
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8
Q

How are surgeons asked to manage cirrhosis?

A

Liver transplantation, the only curative and definitive therapy for end-stage cirrhosis
Manage complications of portal HTN
Any other surgical diseases that affect the rest of the population

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9
Q

Presentation of cirrhosis

A 
Varies
May be relatively well compensated or asymptomatic
Encephalopathy
Jaundice
Coagulopathy
Complications of portal HTN:
-Gastroesophageal varices
-Ascites
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10
Q

What is the best option in pts with isolated gastric variceal bleeding secondary to splenic vein thrombosis?

A

Splenectomy

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11
Q

What is the best option in pts with gastric varices secondary to portal HTN?

A

Insertion of a transjugular intrahepatic portosystemic shunt (TIPS)

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12
Q

Contraindications to TIPS procedure

A 
Right-sided heart failure with increased central venous pressure
Severe hepatic failure
Portal vein thrombosis
Severe hepatic encephalopathy
Active local or systemic infection
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13
Q

Tx of gastroesophageal variceal bleeding

A

Endoscopic band ligation

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14
Q

For gastroesophageal variceal bleeding, what should be done if endoscopic band ligation fails?

A

TIPS procedure

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15
Q

What may be required with massive gastroesophageal variceal bleeding?

A

Control with a Sengstaken-Blakemore tube prior to the initiation of more definitive therapy

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16
Q

When TIPS fails to stop gastroesophageal variceal bleeding or is unavailable, what may be required?

A

Surgical portosystemic shunts

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17
Q

Which surgical portosystemic shunt is the shunt of choice for gastroesophageal variceal bleeding?

A

Portacaval shunt

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18
Q

What is an alternative to shunt surgery for gastroesophageal variceal bleeding?

A

Esophageal devascularization and transection procedures

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19
Q

How can refractory ascites be treated?

A

Surgical placement of a LeVeen shunt

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20
Q

Complications of a LeVeen shunt

A

Infection of the shunt

Coagulopathy secondary to systemic fibrinolysis

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21
Q

When is a LaVeen shunt not recommended?

A

Cirrhotic pts with ascites

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22
Q

What are the two measures of severity of liver dz in the cirrhotic pt?

A 
Child
MELD (Model for End-stage Liver Dz) score
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23
Q

In terms of Child’s classification or MELD score, what is associated with the worst perioperative survival?

A

An emergent operation in a pt with a Child’s C classification or a MELD score >25

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24
Q

When elective surgery is performed in a cirrhotic pt, what needs to be done?

A

A preoperative evaluation for liver transplantation should be considered.

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25
Q

What are the most common benign solid tumors of the liver?

A

Hemangiomas

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26
Q

Presentation of hemangiomas

A

Abdominal pain or discomfort only after the hemangioma has grown to over 10 cm

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27
Q

Tx of hemangiomas

A

The great majority of hemangiomas should be observed and not resected unless there are significant sx
When surgical intervention is warranted, the hemangioma can be enucleated

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28
Q

What is an additional indication for hemangioma resection?

A

Kasabach-Merritt syndrome

29
Q

Tx of hepatic cysts

A

Require no intervention but must be distinguished from cystadenomas, which can undergo malignant degeneration.

30
Q

What two neoplasms both affect young women of reproductive age and are associated with similar CT scan findings?

A

Focal nodular hyperplasia (FNH) and hepatic adenoma (HA)

31
Q

What is the difference in tx between FNH and HA?

A

HA requires surgical resection, while FNH is treated nonsurgically

32
Q

What most reliably distinguishes between FNH and HA?

A

MRI

33
Q

What should be done if a definitive dx can’t be made through imaging between FNH and HA?

A

Resection or core bx

34
Q

What is the difference in presentation between FNA and HA

A

FNH nodules do not hemorrhage
40% of HA tumors contain intraparenchymal hemorrhage
HA usually causes more sx than does FNH and may enlarge upon exposure to higher levels of circulating hormone

35
Q

What sometimes results in regression of HA tumor size and improvement of sx?

A

Cessation of OCPs

36
Q

What are the most common malignant hepatic neoplasms?

A

Metastatic tumors to the liver from the GI tract, breast, or lung

37
Q

Tx of metastatic liver disease

A

Precludes surgical intervention, EXCEPT liver metastases from colorectal cancer

38
Q

How have approaches to resectable synchronous lesions changed over the years?

A

Traditionally, staged resection
Then, Simultaneous hepatic and colon resection- combined approach
Recently, reverse approach- resecting liver metastases prior to the colorectal primary

39
Q

When is a reverse approach indicated?

A

Pts with more extensive liver metastases and an asymptomatic colorectal primary

40
Q

What is a more prevalent dz worldwide than in the USS in terms of liver tumors?

A

Hepatocellular carcinoma (HCC)

41
Q

In the United States, what is hepatocellular carcinoma usually associated with?

A

Chronic hep C infection

Alcoholic cirrhosis

42
Q

What is the primary risk factor for the development of hepatocellular carcinoma?

A

Cirrhosis of the liver of any etiology

43
Q

Who is at highest risk for developing hepatocellular carcinoma?

A

Men over that age of 40 with HCV cirrhosis

44
Q

How does hepatocellular carcinoma present?

A

May present as a RUQ mass, or more commonly, is discovered incidentally on cross-sectional imaging performed for another indication

45
Q

Dx of hepatocellular carcinoma

A

Can be made without bx if the pt has a liver mass an an elevated alpha-fetoprotein level
CT and MRI have become increasingly sensitive and specific for the dx of HCC

46
Q

Screening for hepatocellular carcinoma

A

The NCI does not recommend a standard screening protocol in any population for this dz

47
Q

What is the name of the criteria to screen HCC pts for liver transplant?

A

Milan

48
Q

5-year disease-free survival is superior in HCC pts who undergo ______ compared to ________.

A

Transplantation; resection

49
Q

Tx for noncirrhotic pt with HCC

A

Aggressive anatomic resection should be performed so long as the liver remnant will provide adequate hepatic mass to physiologically support the pt

50
Q

In what category are the vast majority of pts with HCC?

A

> 80% of pts are neither transplant candidates nor do they have resectable dz

51
Q

Tx for unresectable HCC pts

A 
Locally ablative therapies such as:
Radiofrequency ablation (RFA)
Percutaneous ethanol injection (PEI)
Cryotherapy
Transarterial chemoembolization
52
Q

Risk factors for cholangiocarcinoma

A

Congenital choledochal cysts
Primary sclerosing cholangitis
Infection with the liver fluke Clonorchis sinensis

53
Q

How can cholangiocarcinoma be further divided?

A

Intrahepatic or extrahepatic dz

54
Q

Presentation of intrahepatic cholangiocarcinoma

A

Frequently confused with HCC

Usually present late in the dz

55
Q

Tx of intrahepatic cholangiocarcinoma

A

Resection

56
Q

Presentation of extrahepatic cholangiocarcinoma

A

Presents earlier than intrahepatic cholangiocarcinoma with obstructive jaundice

57
Q

Tx of extrahepatic cholangiocarcinoma

A

Resection is the only curative modality

58
Q

What has been done for certain pts with small, unresectable cholangiocarcinoma?

A

Orthotopic liver transplantation

59
Q

What is the most common cancer of the biliary tree?

A

Gallbladder adenocarcinoma

60
Q

Primary risk factors of gallbladder adenocarcinoma

A

Female gender

Gallstones

61
Q

Who should undergo cholecystectomy due to polyp size being correlated with neoplastic transformation?

A

Any pt with a gallbladder polyp >1 cm

62
Q

In gallbladder adenocarcinoma, what is associated with a high cure rate?

A

Resection of very early-stage tumors

63
Q

What is recommended for any pt with T2 or resectable T3 gallbladder adenocarcinoma?

A

An extensive hepatic en bloc resection in addition to regional lymphadenectomy

64
Q

Tx for angiosarcomas

A

Surgical resection

65
Q

What are the most common primary malignant liver tumors afflicting children?

A

Hepatoblastomas

66
Q

Presentation of hepatoblastomas

A 
Abd pain
Mass
Bloating
Nausea
Vomiting
Jaundice is rare
67
Q

Initial tx of hepatoblastomas

A

Chemo

However, resection or transplantation remains the primary modality of therapy

68
Q

What is useful for dx and f/u for hepatoblastomas?

A

Serum AFP

Surgery (30 decks)

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