Old Exam Questions 2 Flashcards

Question

A pt, 3 wks after an alcoholic binge, arrives in the ER with intense upper abdo and back pain. Vital signs are N. He is tolerating a regular diet and is not experiencing diarrhea. A CT scan is obtained in ER and shows a large pseudocyst. Which of the following represents the best surgical care at this time? ``` A. Stapled cyst gastrostomy plus bx B. Perc aspiration and drain placement C. Endoscopic cyst gastrostomy D. Octreotide and NPO E. Multivitamins and pain meds ```

Answer 1

E By hx, pseudocyst is just forming. Most pseudocysts, even large ones, will resolve without invasive procedures. Best approach is to provide pain control and replace B vitamins from pt's diet. Octreotide does not improve the resolution rates of panc pseudocysts and should be used very selectively, if at all, for high output panc fistulae. The invasive options are competitive and complementary and should be reserved for mature pseudocysts (>6 wks old) that are symp and large. Cysts < 6 cm usually resolve without invasive procedures. Cysts > 6 cm also usually resolve without invasive procedures but these cysts are more likely to remain symptomatic and large. Complications of unresolved, large panc pseudocyts include chronic pain, compression of surrounding structures, bleeding, pseudocyst infection, and other life threatening problems. When it comes time to intervene, a cyst gastrostomy with bx of the cyst wall to r/o malignancy is the gold standard option, especially if the etiology of the cyst is in question. This procedure can be accomplished through an open or a lap approach. Endoscopic cyst gastrostomy can be accomplished with the placement of drainage stents into the cyst. Percutaneous aspiration or drain placement can be achieved although the results are not as good as surgical drainage.

Answer 2

B Panc necrosis occurs in ~10% of pts with pancreatitis and put pt at risk for multiple organ failure, infection of necrotic tissue, or both. Risk of death is estimated 20-30% for pts with these complications. Dx is best made with CT to determine which areas of the pancreas are perfused. Nonperfused areas are considered necrotic. Definitive dx of infected panc necrosis is more difficult and can be made with a FNA and gram stain/cultures of the aspirate or visualization of the presence of gas within the fluid collection on CT. Pts with sterile necrosis can still have multiple organ failure. Decreasing mortality as low as 4% due to better ICU, avoidance of early open intervention to allow for stabilization, and demarcation of peripanc fluid collections and liquefied necrosis. Intervention should be delayed until ~4 wks after onset of pancreatitis to allow this walling off and demarcation, as well as liquefaction. Classical tx of infected necrosis is laparotomy and panc debridement; however, this approach is being challenged. MIS panc necrosectomy is described as endoscopic debridement performed via transgastric, laparoscopic, or RP routes. Study prospectively compared open necrosectomy with a step up approach in which the first step was perc drain, followed, if necessary by VARDs with end points of major complications or death. Patients tx with step up had a lower incidence of multiple organ failure and systemic complications but not difference in rate of death. 35% required only perc drain and did not need to go on to necrosectomy Tx with abx alone is not described. Effectiveness of abx used ppx to prevent infection in cases of nec panc is hotly debated and a 2010 Cochrane review stated "although we cannot confirm benefit from the use of ppx abx, consistent trend towards a beneficial effect nonetheless remain". Somatostatin analogs such as octreotide are used to tx panc fistula, although they are not thought to be of benefit. Octreotide is not effective as a preventive measure for panc fistula Enteral nutrition, compared with TPN, reduces mortlaity, multiple organ failure, systemic infections and the need for operative interventions in pts with acute pancreatitis.

Answer 3

D Acute appy occurs in approx 1 in 1500 pregnancies and is 1 of the most common indications for sx in pregnancy. During pregnancy, physiologic incr in WBC and upward migration of appendix makes dx of acute appy more difficult. Delay in dx ca be assoc with serious complications. Uncomplicated appy results in a 2% rate of fetal loss and 4% rate of early delivery. Perf appy can result in fetal loss rates between 6-30% with an 11% rate of early delivery. B/c of the difficulties in dx, failure to use preop imaging resulted in a neg appy rate of 23-33% US avoids use of ionizing radiation and assists in identification of gyne dx and is the initial imaging for suspected appy in preg pts. Sensitivity of US in the dx of appy is as low as 20%. If the dx cannot be ascertained via US, MRI avoids ionizing radiation and has a high sensitivity and specificity for appy and alternative dx in pregnant women. Although the cost of MRI is greater than CT or US, it is a minor expense compared with that incurred during a neg appy.

Answer 4

A This pt has a mesh infection based on purulence draining from his abdo wall in the setting of an implanted mesh Definitive dx of a mesh infection relies on postive deep cultures of fluid surrounding the mesh or mesh cultures. Mesh infections occur with a reported incidence of 6-10% in open repairs and 0-3.6% in laparoscopic ventral incisional hernia repair. Mesh infections in the early post op period are more likely to be assoc with an enterocutaneous fistula. They are the 3rd leading cause of mesh explantation. Staph aureus is the organism most implicated in mesh infections, although other organisms, such as staph epi, strep pyogenes and gram negs are implicated. Tx of mesh infections depends on the pt's clinical status. Pts who may be septic require abx and explantation. Concomitant procedures performed via the same incision as hernia repair, enterotomy, surgical site infection and ECF are assoc with higher rates of of mesh explantation. Expanded PTFE mesh used in open ventral incisional hernia repairs is significantly more likely (4x) to need explantation than prolene or expanded PTFE mesh used in lap repairs. Well incorporated mesh does not need to be removed during an explantation procedure

Answer 5

A Leaks from the subvesical ducts of Luschka are next in freq to those from the cystic duct. Luschka ducts are accessory, not aberrant, biliary ducts that drain subsegmental areas of liver into the extrahepatic bile ducts. Ducts of Luschka are estimated to occur in up to 50% of pts. Aberrant hepatocystic ducts are the only source of drainage from their assoc liver parenchyma, whereas accessory ducts are not. The hepatocystic duct may drain into the gallbladder or cystic duct. Luschka ducts do not. Injuries to Luschka ducts are not predicted by the presence of acute chole or by the elective or urgent nature of a chole. Tx of a Luschka duct leak not recognized at the time of chole is often successfully accomplished by sphincterotomy and transampullary stenting to decr the pressure in the biliary tree. Enteric drainage is not usually required.

Answer 6

B Mechanical SBO in elderly pt who have not undergone prior sx suggest the dx of malignancy or internal hernia. Obturator hernia are rare but thay are identified typically in such patients, particularly multiparous women. Ipsilateral thigh and knee pain (the Howship Romberhg sign) is caused by obturator nerve compression. Sign occurs in approx half of pts. CT have improved the dx accuracy of obturator hernias. 1/3 of pts have evidence of intestinal ischemia at the time of sx and hernia reduction. B/c many elderly pts have degenerative joint disease, nonspecific nature of pain in patients with obturator hernias may suggest a more common finding of hip and lumbar spine disease. However, mechanical SBO confirmed by CT should raise suspicion for an obturator hernia. Early dx of this disease is assoc with a mortality of only 5% in a group of pts with a mean age of 80.

Answer 7

C May present without significant abdo wall bulges b/c they are generally interparietal, penetrating the transversus abdominis and internal oblique muscles, but lying posterior to the external oblique aponeurosis. Pts present most freq in 5th and 6th decades of life. Hernias occur anywhere along the Spigelian fascia that runs between the lateral edge of the rectus abdominis and the semilunar line. Most freq develop at or inferior to the arcuate line. Often cannot be dx on hx and px alone. Physical exam false neg in 36% of pts and false positive in half of pts. CT improves dx accuracy but false neg scans in 1/3 of pts. RCT of open vs las repairs found that both techniques were effective inn preventing recurrences. Advantages of laparoscopic; these were greater number of pts having outpt sx and shorter hosp stays

Answer 8

D Meta analysis of 10 RCTs involving 880 patients, there was no statistical difference between recurrence rates for lap or open repair of ventral hernias, although follow up was limited. In the 4 trials in which early post op pain was recorded, there was no difference in pain intensity between the two techniques Seroma formation was relatively common with both techniques. Most consistent finding across all studies was a significant decr in incidence of surgical site infections (3% vs 13%). Enterotomy was uncommon in both groups. Laparoscopic abdominal wall hernia repair had a significantly lower likelihood of developing morbidity but there was no effect on mortality

Answer 9

E Initially there was concern that lap chole at the time of acute inflam would result in higher open conversion rate and a higher incidence of serious bile duct injuries. Despite growing evidence with lap chole, some surgeons still cool the pt off with abx and delay OR for 6 wks. In a meta analysis (5 trials of 451 pts) of RCTs comparing early (<1 week after onset of symp) vs delayed lap chole (>6 wks after onset of symp) for acute chole, there was no difference in rates of conversion to open, bile duct injury or bile leakage. No mortality in either group. Early lap chole results in a 4 day reduction in total hospital LOS

Answer 10

C Option for preop ERCP if CBD stone is suspected. Deciding factor to pursue preop eval of CBD depends on probability a CBD stone would be present based on clinical findings, findings on preop labs and US. Very strong = CBD stone on US, Clinical ascending cholangitis, Bili >40; Strong = dil CBD on US >6 mm with gb in situ and bili 1.8-4; Moderate = AbN liver tests other than bili, Age >55, Clinical gallstone panc If low probability of choledocholithiasis--> surgery. High probability of choledocholithiasis--> ERCP. Intermediate probability--> Surgery + IOC or preop imaging HIDA is reasonable if acute chole is being considered but limitations in evaluation of CBD. MRCP sensitivity is greater than 90% and specificty >95% which is better than CT of US. ERCP and EUS are invasive. EUS has sensitivity and specificity similar to MRCP. More sensitive for stones <5 mm. ERCP typically reserved for pts with very high probability of CBD stones. B/c incr risk of complications includ pancreatitis, hemorrhage and perf. Pt has 1 strong risk factor present (elevated bili). Make her intermediate probability . 2 options are MRCP or EUS.

Answer 11

D Liver is one of the most commonly injured organs after blunt trauma. Range from minor to severe, most are managed without surgical intervention. As grade of liver injury incr, likelihood that the pt will require some sort of intervention incr. With intro of angio evaluation of liver injuries, arterial abN that otherwise would have gone unnoticed are now being identified and tx. Most common tx is embolization. After significant liver injury, complications are assoc with the injury itself as well as the perc intervention. Complications broken down into early and late. Most significant early complciation is ongoing or recurrent bleeding. Typically seen within first 48 hrs after injury. Presentation may include incr abdo pain, distension, peritonitis, hemodynamic instability, abd dec hct. Late complications incl hepatic necrosis, abscess, and biloma. Differentiated on CT by their appearance. Enhancement is more characteristic of hepatic abscess. Another test to differentiate is the measurement of serum bilrubin. If this is elevated, dx is more consistent with biloma Hemobilia is a late bleeding complication assoc with liver injury. It presents with a sudden drop in Hct sometimes assoc with hemodynamic instability. Bc the CBD is filled with blood, an elevation of serum bili also occurs.

Answer 12

C Panc debridement with either open packing or drainage is assoc with significant complications. Open technique with packing of peripanc space and RP gave reasonable control of infectious and necrotic processes but led to significant complications assoc with fistula formation and prolonged inflamm response. With debridement and drainage there was the ned for multiple procedure to ensure that a complete debridement was undertaken. Injury to the intraabdominal viscera was not uncommon with the many procedures. In addition, b/c the operative procedures, there was a continued generation of inflam response. Minimal access technique for panc necrosectomy. Placement of drain into the RP space and then serial dilation of the drain tract until a RP endoscopic approach can be undertaken. Area is debrided and irrigated, and drain catheters left at the completion of the procedure. Significant decr in complications assoc with nec panc. Decr rates of postop organ failure, ICU support and complications (e.g. multisystem organ ffailure, bleeding, visceral perf, and death) 2010 study compared open mgmt vs step up approach and found the step up approach has statistically significant decr in number of complications. New onset multisystem failure also occurred less freq. No difference in the number of deaths in each group. Step up with perc drain and advancement to endoscopic drainage appears to provide best outcome for these complicated pts.

Answer 13

A Use of screening US often leads to incidentalomas. With regard to gb, most common incidental findings include gallstones and gb wall polyps. Cholelithiasis is an asymp pt is a relatively straightforward dx. If a pt is not having symptoms from gallstones, chole is not indicated. A gb polyp, conversely, has the potential to be neoplastic. For this reason, in the past, it was recommended that gb poylps, even if asymp, necessitated cholecystectomy Most recent data have providede guidelines to the val and mgmt of gb poylps. Recommendations divided into gb assoc sympts, assoc conditions, polyp size, and polyp morphology. Pt with sympts attributed to gb who has a polyp on US should undergo chole. Chole is indicated in the asymp pt if the polyp is >6 mm or sessile, or if the pt has PSC. If the pt is asymp, polyp is pedunculated and 6 mm or smaller, follow up US is indicated. If on repeat US, polyp incr to more than 6 mm or beings to develop sessile features, chole is indicated. In this pt with an asymp 3 mm polyp, a follow up US 6 months would be the correct recommendation. No further eval is required if the polyp is stable and the pt remains asymp.

Answer 14

A Ppx mesh placement at the time of stoma formation has conclusively been shown to reduce the incidence of parastomal hernia. Two systematic reviews of mesh vs no mesh stoma formation did not identify any incr morbidity or mortality with the use of mesh. Analysis included biologic and synthetic mesh Mesh placement is used in the repair of established parastomal hernias, b/c primary direct suture fascial repair leads to unacceptable recurrence rates (46-100%). Type of mesh used may affect the rate of complication; synthetic mesh repair is assoc with a higher rate of complications than biologic mesh, often leading to the need for mesh explantation. Mesh infection, extrusion or erosion, chronic pain, bowel obstruction, seroma formation, and intestinal fistulization occur more often synthetic mesh. Sufficient robust long term data are not currently available to conclude that lap mesh placement is superior to open mesh placement

Answer 15

B In RCT comparing watchful waiting and early surgical repair with open tension free techniques, only 2 of 364 watchful waiting pts experienced acute incarceration and non experiences strangulation during the 4.5 yr follow up. 23% converted from watchful waiting to surgical repair during this time and hernia related pain was the most common reason providede. Surgical outcomes from pts initially assigned to surgical repair and those who crosed over to repair were similar. Chronic pain after surgery is also an important outcome to consider. In randomized multicenter study analysing outcomes after lap TEP or open Lichtenstein hernia repair, authors folowed 1370 pts and found the total incidence of chronic pain to be 9.4% vs 18.5%. This finding includs pts reproting mildpain, defd as occ discomfort or pain not limiting daily activities. By contrast, moderate or severe pain, defined as occ or daily interference with daily activities was noted in only 1.9% and 3.5% after 5 yrs. Long term follow up of RCT reported that testicular pain was more common finding in pts who underwent a TEP compared with open mesh repair.

Answer 16

A Ureter injuries are relatively rare, but missed injuries lead to significant morbidity adn mortality. Injuries to the ureter are classified and managed based on the degree and location of injury. Divided into upper, middle and lwoer thirds. Upper extends from UPJ to the area where it crosses the SI joint. Middle ureter courses the bony pelvis to the iliac vessels. Lower portion extends from the iliac vessels to the bladder. Blood supply to the ureter (utreteral artery) is tenous and runs longitudinally along the ureter without collateral flow in 80%. Reconstruction options for the upper 1/3 include ureteroureterostomy or ureteropyelostomy. Recon options of the middle 1/3 include ureteroureterostomy, transureteroureterostomy or anterior wall bladder flap (Boari). Recon options for the lower 1/3 include ureteruneocystostomy with direct reimplantation and ureteruoneocystostomy with a psoas hitch. Early identification and surgical repair improves overall morbidity; therefore drainage and delayed operative repair is not a preferred mgmt strategy

Answer 17

C Pt presents with pyogenic liver abscess. As tx of appy, diverticulitis and other intra abdominal infections has improved, incidence has decr. Biliary obstruction, stenting or instrumentation is now a more common primary source than seeding through portal blood flow. Tx is primarily abx and perc drain. Needle aspiration of small <5 cm, simple abscesses may suffice but large multiloculated abscesses freq require multiple catheters and interventions to resolve the abscess. In the presence of yeast in the abscess or demonstration of communication with the biliary tree may predict failure of perc tx strategy. Perc drain found to produce statistically significant improvements in morbidity, LOS, and hospital costs. Preferred to open or lap drainage or liver resection

Answer 18

B Pt presents with strangulated femoral hernia after prev open inguinal hernia repair. Fem hernias comprise 2-8% of all groin hernias in adults and are extremely rare in children. Most are found in adults age 40-70 and are 4-5x more common in women. In contast to inguinal hernias, 30-50% of femoral present as emergencies due to incarceration or strangulation. B/c of higher risk of incarceration or strangulation, once dx, femoral hernias should be repaired in pts of suitable surgical risk. Some physicians now recommend lap repair of all inguinal hernias in women b/c of higher risk of clinically undetectable femoral hernias (37%). If a strangulated hernia is encountered during open groin exploration, the bowel may be freed by dividing the inguinal ligament and then assessing for viability. If a bowel resection is necessary, this can most often be accomplished through the groin incision without converting to laparotomy. Repair of the hernia will depend on the level of suspected contamination of the surgical field. If the bowel is incarcerated but viable, standard tension free techniques can be used. If there i contamination, mesh should be avoided and either a tissue repair or implantation of a bioprosthetic should be considered

Answer 19

D Pt has Mirizzi syndrome. Obstructive jaundice due to extrinsic compression of the CHD caused by a stone impacted in the neck of the gb or cystic duct. Depending on degree of impairment and chronicity of condition, may be a cholecystocholedochal fistula. Rare complication of gallstones occurs in approx 0.1-0.7% of pts who have gallstones and this condition is distinct from gallstone ileus. Up to 25% of pts have incr risk of gallbladder cancer 4 factors contribute to development: 1) cystic duct must be anatomically parallel to CHD, 2) stone must become impacted in cystic duct or gallbladder neck, 3) CHD must be obstructed by the stone or by the secondary inflammatory response, 4) longstanding obstruction must cause intermittent or constant jaundice with occasional cholangitis B/c stone is characteristically in either the neck of the gb or cystic duct, prev chole does not rule it out as a possible dx. Csendes I - Pressure on CHD due to an extrinsic stone in cystic duct II- A cholecystobiliary fistula <1/3 circumference of duct wall III- A cholecystobiliary fistula involving 2/3 circumference of the ductal wall IV- A cholecystobiliary fistula involved the entire circumference of the ductal wall Lap chole can be successful with Type I Mirizzi syndrome or external compression of the CHD by a stone impacted by the cystic duct or Hartmann pouch but the authors cautioned that open chole is the method of choice for type 2 Mirizzi syndrome, a fistula between the gb and common duct from inflam and erosion. Another retrospective study indicated that of 14 pts who underwent laparoscopic sx, 11 required conversion to an open procedure.

Answer 20

A Gastrin is secreted by G cells in the gastric Antrum. Acts on parietal cells to stimulate HCL after ingestion of food. Gastrin production is inhibited by somatostatin secreted by D cells in response to gastric acid. Hypergastrinemia can can occur secondary to uninhibited gastric production or in response to decr acid secretion. Pts who have a gastrinoma as their source of uninhibited gastrin secretion usually present with peptic ulcers secondary to acid hypersecretion. By contrast, unopposed gastrin secretion in response to achlorhydria typically occurs in pts with atrophic gastritis or who take PPI. Hypergastrinemia occurring with gastritis related to H pylori infection is caused by the decr somatostatin release by D cells due to incr pH and circulating cytokines around D cells. Gastric carcinoid also termed NETs are rare in US, comprising 4.1% of all carcinoid tumors. Subclassified into 3 distinct groups: those assoc with chronic atrophic gastritis/pernicious anemia (Type 1 70-80%), those assoc with MEN type 1 ZES (type 2 2.5%) and sporadic NETs of the stomach (type 3 15-20%). Both type 1 and 2 NETS of the stomach are assoc with hypergastrinemia. Type 3 develop in the absence of hypergastrinemia and tend to pursue an aggressive clinical course B/c type 1 and 2 pursue an indolent course, tumors <2 cm (up to 6 in number) should be resected endoscopically, with subsequent interval follow up. Pts with tumors >2 cm, those with recurrent tumors or those with >6 tumors generally require more aggressive mgmt and local sx resection is recommended. In Type I NET arising in the setting of chronic atrophic gastritis, antrectomy may be performed to eliminate source of gastric production. Antrectomy results in tumor regression. In Type 2 NET of the stomach secondary to ZES/MEN I syndrome, tx with somatostatin analogs may be initiated and result in tumor regression. The surgical mgmt of type 3 isolated sporadic NETs of the stomach require more aggressive surgery, generally with partial gastrectomy and LN dissection This pt has anemia, hypergastrinemia, and atrophic gastritis consistent with Type I gastric carcinoid. Tumors in pts with type 1 gastric carcinoid are caused by gastric stimulation of ECL cells proliferation which can progress to ECL cell hyperplasia and type 1 gastric carcinoid. This progression occurs in approx 5% of pts with pernicious anemia, an autoimmune condition in which antibodies are directed against parietal cells. Destruction of parietal cell mass results in atrophic gastritis, loss of acid production, hypergastrinemia, and macrocytic anemia from loss of intrinsic factor and vit b12 absorption. Risk of LN mets in this pt is low. Reduction in gastrin from Antrum through antrectomy alone should result in regression of the tumors without resection of the tumors themselves

Answer 21

C RYGB combines gastric resection with a minor malabsorptive state to achieve wt loss. Affects gut hormone, such as gherkin, glucagon like peptide 1 and peptide YY that influence eating behaviours and body wt. Change in eating habits combined with the malabsorptive state can result in significant nutritional consequences. Major physiologic consequence of RYGB involves lipid absorption. Under physiologic conditions, fat passes into duodenum and stimulated CCK. CCK stimulates gb and pancreas to release bile and lipolytic enzymes. After RYGB, secretion of bile and lipolytic enzymes is reduced, b/c lipids never pass through the duodenum. Lipids including triglycerides, phospholipids and cholesterol travel through the Roux conduit as intact structures until they reach the jejunojejunostomy. Delayed breakdown of dietary fats and the delayed formation of micelles limits the amt of fat available for absorption. Undigested fat passes into the colon, producing fat malabsorption and steatorrhea. Intolerance of protein rich foods, such as meat and dairy products, is common. Many pts fail to meet the recommended protein intake, which should avg 60-120 g/day. Meat and dairy products also contain sever critical moicronutrients; therefore routine supplementation and monitoring for deficiencies in iron, vit b12, calcium, vit D, folate (vit B9), and thiamine (vit B1) is recommended. In addition, iron, calcium, and thiamine are absorbed primarily in the duodenum, which is precluded in RYGB. Iron stores decline after gastric bypass, making iron deficient microcytic anemia very common. Orally administered ferrous sulphate, fumarate or gluconate may be needed to prevent iron deficiency. Vit C should be added to incr iron absorption and ferritin levels. Oral iron supplements can decr absorption of ca, mg, and zn, so these should be taken at different times of day. RYGB alters the absorption of vit B12 by isolating the source if intrinsic factor, the distal stomach, from the alimentary system. However, substantial deficiencies in vit B12 do not occur until at least 1 yet after surgery. Deficiency can result in macrocytic anemia and neuropathy. Wt loss that occurs after RYGB is commonly accompanied by calcium deficiency and bone loss. Loss of fat absorption is believed to contribute to vit D def b/c it is a fat soluble vitamin. This is believed to incr bone turnover and to decr bone mass. However, calcium deficiency and loss of bone density can occur in the presence of normal vit D and PTH levels. For. This reason, monitoring of bone density and serum levels of calcium, vit D and PTH is recommended. An incr in serum PTH is indicative of neg calcium balance or vit D deficiency. If deficient vit D can be supplemented with ergocalciferol or cholecalciferol.

Answer 22

D Division of IMA at its origin from the aorta (high ligation) is often performed to remove the LN basin at risk for mets and provide adequate mobilization of the proximal bowel for a tension free anastomosis. In this case, arterial flow occurs through collateral vessels. Anatomic variations and postsurgical alterations in arterial anatomy can greatly alter the collateral arterial flow necessary to provide oxygenized blood to the proximal bowel necessary for healing a low colorectal or coloanal anast and prevent leak or stricture. Line of division describes in the questions is at the Sudeck point and the IMA is divided at its origin Ischemia of the proximal bowel would not occur if the L colic were divided instead of IMA, b/c superior hemorrhoidal branches arising from IMA trunk provide arterial flow. Arc of Riolan is an inconstant artery that connects proximal SMA or 1 of its primary branches to the proximal IMA of 1 of its primary branches. It is classically described as connecting the middle colic branch of the SMA with the L colic branch of the IMA. Forms a short loop that runs close to the root of the mesentery. An important connection between SMA and IMA in the setting of arterial occlusion or significant stenosis such as proximal SMA occlusion. In this event, high ligation of proximal IMA would result in ischemia within the SMA distribution (sm bowel and R colon) as well as the transected distal colon Marginal artery of Drummond is the anastomoses of the terminal branches of the ileocolic, R colic and middle colic arteries of SMA and of the L colic and sigmoid branches of the IMA. Form a continuous arterial circle or arcade along the inner border of the colon known as the marginal artery of Drummond. Important connection between SMA and IMA and provides collateral flow in the even of occlusion or significant stenosis. Jcn of SMA and IMA territories is at the splenic flexure. Vascular anast here are often weak or absent, hence the marginal artery at this point, known as Griffiths point, is often vocally small or discontinuous. Poor arterial flow across this point is most likely to produce ischemia at the point of transection of the distal colon. The aorta and its iliac branches are within the systemic arterial circulation; therefore occlusive or aneurysmal disease of these vessels is unlikely to cause ischemia at the point of bowel transection. AAA can occlude the origin of IMA, resulting in collaterals that should be carefully preserved

Answer 23

C Barrett's is a pathologic change in the squamous epithelium of the esophagus to intestinal metaplasia. Places pts at high risk for esophageal adenoca. Risk of progression of Barrett esophagus to adenoca is dependent on the pathologic grade of its dysplasia. When no dysplasia is present, risk of 0.7% per year. High grade dysplasia carries highest risk, with 15-30% of resected esophagectomy specimens already harbouring carcinoma and a detection rate of approx 14.6% per yrs. This group of pts require intervention to reduce the risk of adenoca Observation with PPI is accepted mgmt strategy. Requires endoscopy with bx q3-6 months. Strategy does not actually address carcinoma risk, but rather relies on early detection of carcinoma. This strategy is inferior to RFA. Antireflux operations, although good for treating the symptoms of GERD, have not been conclusively demonstrated to reduce the cancer risk. Photodynamic therapy, usually with light sensitizing agen such as porfirmer sodium, has fallen out of favour due to issues related to buried glands (i.e. Islands of Barrett's under a layer of seemingly normal squamous epithelium) and stricture formation. Esophagectomy was considered an acceptable option b/c of the high rate of occupation carcinoma with high grade dysplasia. However, given the efficacy of RFA, esophagectomy is reserved for pts in whom the high grade dysplasia cannot be completely eradicated or in whom other signs incr the suspicion of carcinoma presence. A randomized, sham controlled trial showed that endoscopic RFA can eradicate Barrett metaplasia and dysplasia and reduce the progression to carcinoma. Now considered the primary tx for Barrett's esophagus with high grade dysplasia in pts without other signs of carcinoma, such as ulceration or nodularity.

Answer 24

A Small bowel diverticula are categorized by location and type. Location categories include duodenal and jejunoileal. Type categories include true and false (pulsion) diverticula. Duodenal and Meckel's diverticula are true diverticula and are the most common, with duodenal diverticula accounting for 15% of all small bowel diverticula. These are generally found in the periampullary region and are asymp, although occasionally can cause biliary obstruction. Diverticula of the jejunum and ileum are pulsion diverticula similar to that of the colon. Although the exact incidence of ileojejunal diverticulosis is unknown, b/c most of these pts are asymp, it is generally considered far less common than colonic diverticulosis. Prevalence of jejunoileal diverticula at approx 2% or less. Jejunum is a more common site of diverticula than ileum. Diverticula occur on the mesenteric side of bowel where the blood vessels enter the bowel from the mesentery. Perforation, bleeding and obstruction are the most common urgent presentations. Perforation accounts for >20% of emergency surgical interventions for jejunoileal diverticula compared with hemorrhage, which accounts for <2%. Recurrent abdo pain is rarely assoc with jejunoileal diverticulosis and wt loss is not likely related to jejunal diverticula.

Answer 25

A Repair of PEH has several areas of controversy. First is whether they should be repaired at all. Repair of symptomatic PEH in pts who are acceptable surgical risk is indicated; however, many surgeons now chooses to observe asymp pts b/c the risk of catastrophic incarceration, and gastric necrosis is rarely the first presenting symptom. Other areas of controversy are open vs lap repair, need for an esophageal lengthening procedure, and routine use of mesh. Primary suture repair has recurrence rates of 20-30%, although some reports as high as 50% exist. Recurrences are usually identified radiographically, and most are asymp sliding hiatal hernias. Only a minority of radiographically identified recurrences are symptomatic No difference in rates of symptomatic improvement between primary and mesh repair, as long as complications do not occur. If mesh is used, the next area of controversy is whether a prosthetic mesh or a biologic mesh should be used. Meta analyses comparing biologic with prosthetic meshes have generally shown that prosthetic meshes have a lower recurrence rate. However, there is no standardization as to the type of mesh, its configuration or fixation. In addition, studies have varied as to type and length of follow up. One of the most devastating complications of mesh use, especially prosthetic mesh, is erosion and stricture formation. Although data for the rate of these occurrences are limited, erosions and strictures appear to occur in more than 2% of pts. If this occurs, the only tx is esophagectomy, gastrectomy or some combo of both.

Answer 26

C Colon cancer may be dx by routine screening before symptoms develop, but when symptoms are the reason the pt seeks medical attention, those symptoms are usually LGIB, change in bowel habits (incl stool caliber), abdo pain, or obstruction. Bleeding as the presenting symptom is not assoc with worse prognosis, and there is no assoc between duration of symptoms and survival in pts with colon ca. Patients with intestinal obstruction as their presenting sign of colon cancer form a subgroup that tends to have a short duration of symptoms with a poorer prognosis. Both a famhx of colon cancer and Peutz Jeghers syndrome incr the risk of colon ca with approx 40% of pts with Peutz Jeghers developing colon ca. However, these pts are subjected to incr screening compared with the general population. Thus, their cancer is often detected at an earlier stage, resulting in a good prognosis and improved survival

Answer 27

B Significant more morbidity in pts with panc adenoca undergoing palliative resection compared with those undergoing bypass procedures without a significant incr in the length of survival: 8.2 mos for palliative resection and 6.7 mos for bypass. 2009 meta-analysis of chemo for locally advanced and met panc ca showed improved progression free survival in pts receiving gemcitabine based combo therapy, but that improvement was offset by toxicity in those pts Survival for pts with unresectable tumors by preop imaging is reported to be essentially the same, whether they were given neoadj chemo or were resected followed by adj chemo. It is uncommon for neoadj chemo and radiation to convert unresectable tumors into resectable ones. In pts with resectable tumors, medial survival is <2 yrs in most reports.

Answer 28

D Pt has an 8 cm solitary isolated focus of HCC in R hepatic lobe and evidence of well compensated cirrhosis. HCC is one of the most freq encountered malignancies worldwide. Degree of underlying cirrhosis directly influences choice of therapy and its efficacy. Surgical resection is reserved for non cirrhotic pts or those with well preserved liver function and relatively limited tumor burden (ideally a single lesion). Bili values >11 and evidence of portal HTN (esophageal varices, ascites, thrombocytopenia, portal vein pressure >10mmHg) are predictors of post op hepatic failure and preclude resection RFA and alcohol injection are therapies usually reserved for pts who are not primary surgical resection candidates due to # or distn of lesions. Both are most effective for masses <3 cm. TACE involves injection of chemo agent such as doxorubicin or cisplatin, in conjunction with occlusion of hepatic artery supplying the liver lobe containing the tumor. Generally used in pts with sufficiently high tumor burden or more advanced cirrhosis to obviate either resection or ablation. B/c recurrence and progression of malignancy can be very rapid under immunosuppresion, strict pt selection criteria if liver transplant is considered. Milan criteria limit selection to a pt with a single tumor 6.5 cm or smaller or 2-3 lesions 4.5 cm or smaller, totalling 8 cm or less, who shows no evidence of vascular invasion or extrahepatic spread. Ideal transplant candidates may benefit from bridging ablative or TACE while awaiting an organ. Interferon alpha has no role in tx of HCC but is used in mgmt of active hep C. Despite high risk of multicentric recurrence (70% at 5 yrs), primary resection offers best therapeutic option for this pt, with potential for a 50% survival rate at 5 yrs.

Answer 29

B Incidence of post op pancreas fistula after Whipple ranges from 10-40%. Several studies have documented small duct size, residual soft panc parenchyma, BMI, poor nutritional status, and malignancy as factors contributing to increased risk of postop fistula development. Although somatostatin analogues such as octreotide do decr fistula output, a cochrane review of 17 RCTs concluded that its use does not affect the development of perioperative pancreatitis, post op mortality, reoperation rates, or the ICU length of stay. Preop use of octreotide has not been shown to prevent fistula development, even in high risk pts.

Answer 30

C Pilonidal sinus disease is widely attributed to hair follicle in growth and subsequent fb reaction. Local hair control with shaving or laser epilation, coupled with improved hygiene, has been demonstrated to decr total hospital admission days and the necessity for surgical procedures, even in obese pts. Pilonidal disease presenting as an abscess should be tx with simple incision and drainage; approx 60% of such pts will heal without further surgical intervention after this initial episode. Formal surgical mgmt should be reserved for chronic or recurrent disease. Preop IV abx before excision of a chronic sinus has not been shown to decr wound complications, improve healing or affect recurrence. Surgical options include complete sinus excision with primary closure or healing by secondary intention, with or without marsupialization of the wound edges. Success of primary closure requires a narrow field of excision and care to avoid sitting in the immediate post op period. Sinus recurrence, however, is more freq after primary closure compared with healing by secondary intention. Carcinoma arising in a pilonidal sinus is rare, accounting for approx 0.1% of pts with chronic untx or recurrent pilonidal disease. These tumors classically present as an ulcer with rapidly progressing, fungating margins, and show an aggressive biology.

Answer 31

Pts with esophageal ca often present with progressive dysphagia. Along with tumor induced cachexia, this progressive dysphagia can lead to malnutrition, manifested as depressed levels of serum albumin and transferrin on lab testing. Predicts incr risk of morbidity and mortality at the time of esophageal resection. Neoadjuvant chemorads presents an additional burden on these pts, further compromising their nutritional parameters. Radiation induced esophagitis develops in 15-28% of tx pts, further worsening dysphagia. Side effects of 5 FU and cisplatin, the most common chemo regimen include N/V and diarrhea. Malnutrition reduces the response of the tumor to chemorads and impairs the pt's ability to tolerate full course of tx. Nutritional deficiencies may also contribute to the trend of incr period morbidity and mortality among esophageal ca patients receiving neoadj therapy compared with pts undergoing esophageal resection alone. For esophageal ca pts with dysphagia receiving neoadj therapy, relief of symptoms, maintenance of nutrition and minimization of periop complications are important tx goals. Correction of malnutrition before sx can markedly reduce the morbidity and mortality of esophageal resection. Traditional options for nutritional supplementation during weeks to allow for wound healing and resolution of local inflam and contamination at insertion site. Avoid PEG b/c of potential to render stomach unusable as replacement conduit for the esophagus. NJ tubes freq become dislodged, resulting in an interruption in nutrition support or more serious complications, including aspiration pneumonia. Complications of feeding tube placement can be devastating in esophageal ca pts b/c of their malnourished state and ongoing malignancy. In addition, use of enteral tube feeding does nothing to address dysphagia, typically the dominant symptom. Preop esophageal stenting has emerged as an alternative approach to promote nutritional repletion in pts undergoing neoadj chemorads before esophageal resection. Options include uncovered bare metal stents or covered silicone stents. Uncovered metal stents are best suited for palliation of pts with inoperable esophageal cancer, b/c they become incorporated into the wall of the esophagus and are not removable. Covered silicone stents offer more effective relief of dysphagia and can be removed later, either endoscopically or at the time of surgery. Compared with enteral feeding, oral alimentation after placement of a covered silicone stent results in better relief of dysphagia, higher performance status, better tolerance of chemorads and better mean improvement in albumin. Reduces incidence of major operative complications by >50% compared with enteral feeds. Incidences of stent related complications are <5%. No difficulties with stent removal or intraop dissection at time of sx are reported. Oral alimentation after placement of a covered silicone stent is a safe and effective means to relieve dysphagia and promote nutritional repletion in pts undergoing neoadj chemorads followed by surgical resection for esophageal ca

Answer 32

A Acute onset of chest and upper abdo pain after an episode of vomiting suggests a spontaneous perf of esophagus. Spont perf of esophagus known as Boerhaave syndrome, is a full thickness longitudinal tear in the esophageal wall as a result of vomiting. Perf typically occurs in the intrathoracic esophagus just above the GE jcn. Significant delay in dx and continued PO intake result in mediastinal contamination are common. Of the factors that critically influence prognosis in these pts, including pre existing comorbidities and esophageal disease, the most significant is delay in dx Successful mgmt of an esophageal leak requires prompt control of sepsis and elimination of ongoing contamination of the mediastinum. Traditional therapy had been urgent operative repair, including primary surgical repair when possible, exclusion and diversion or esophagectomy. Despite advances in critical care, antimicrobial therapy, diagnostic imaging, and surgical technique, spontaneous esophegeal perf continue to be assoc with excessive rates of morbidity and mortality. When tx is performed within the first 24 hrs, mortality rates are between 16 and 24%. When tx is delayed and performed after >24 hrs, mortality rates incr rapidly up to 50%. B/c of these high mortality rates, some surgeons have advocated nonop mgmt, with cessation of PO intake and iv abx until healing is confirmed. Approach is also assoc with long hospital stay in many pts and it often requires enteral or parenteral nutrition support. With the improvement in endoscopic techniques and ICU mgmt, additional of endoluminal stent placement to nonop mgmt has emerged as a feasible and safe alternative for the tx. Stent placement closes the site of perf, stops ongoing contamination of the mediastinum, preserves esophagogastric continuity, avoids potential morbidity and mortality of open sx and allows for earlier oral intake and a decr in hosp stay. Plastic stents are mainly using for the tx of leaks and strictures of benign disease b/c of their ability to be removed more easilty with less damage to the esophageal wall. To ensure complete occlusion, it is important to allow adequate stent coverage on either side of the leak and the stent length chosen should be at least 3-4 cm longer than the leak. Easily performed under direct endoscopic control with an occlusion rate of 94%. Stent migration occurs in <5% of cases. Stent removal is typically 4-6 wks after implantation Pt's delayed presentation and hx of cirrhosis and ascites markedly incr the risk of surgical intervention to repair the site of perf. At 48 hurts after spontaneous perf, both direct esophageal repair and esophageal exclusion are assoc with mortality rates approaching 50%. Creation of a side esophagocutaneous fistula in the neck and placement of a PEG tube does not close the site of perf and allows ongoing contamination of the mediastinum. Under these circumstances, a less invasive approach that seals the site of perf is a safer option. Placement of a chest tube will drain infected material from the involved hemithorax.

Answer 33

D GISTs are the most common mesentery all tumors of the GI tract. Most are found incidentally at the time of endoscopy or radiologic imaging. Symptoms may include abdo pain, GI bleed, or obstruction, depending on the size and location of the tumor. Most commonly found in stomach (60%) and small bowel (35%). GISTs originate from interstitial cells of cajal which express cd117 (c-kit), present in 95% of tumors. Complete surgical resection to grossly neg margins is tx of choice. Lymphadenectomy is not required for GISTs b/c these tumors spread hematogenously. Lap vs open depending on tumor size, location and extent of invasion. EMR suggested for smaller tumors. Resection offers potential for cure, disease recurs in 40-90% of surgically tx pts. Prognostic indicators include tumor size, mitotic index, tumor location and tumor rupture during sx. Adjuvant therapy with imatinib, which targets the tyrosine kinase c kit receptor, is recommended for intermediate to high risk GISTs and may have a role in cytoreduction and organ preserving sx but it is not indicated. Epirubicin, cisplatin, and 5FU are the chemo agents used for gastric adenoca.

Answer 34

C Achalasia or impaired relaxation of LES, is the most common d/o of esophageal dysmotility. Symptoms incl dysphagia and CP. Dx eval includes barium swallow, endoscopy and manometry. Classic radiologic findings incl a dilated esophagus with narrowing and the GE jcn (bird's beak). Endoscopy is used to exclude malignancy, b/c pt with achalasia are at incr risk of both SCC and adenoca of the esophagus. Manometric findings of achalasia incl elevated resting LES pressure and a peristalsis of the body with secondary and tertiary contractions. Tx options include medical mgmt, Botox, pneumatic dilation and surgical myotomy. Medical mgmt consists of CCB and nitrates, which are reserved primarily for pts who are not candidates for more invasive therapies. Effects of these meds are short lived with variable symptom relief and significant side effects. Botox inhibits the release of acetylcholine, resulting in reduction in LES pressure. Efficacious in reducing CP and dysphagia in pts with achalasia; however its effects are time limited with relapse of symptoms in >50% after 3 months. Repeated injections in initial responders may confer some long term benefit up to 2 yrs. Endoscopic pneumatic diln is considered a good 1st line option. Compared with Botox, pneumatic diln has much higher long term response rates, with low complication rates. Age and successful disruption of LES fibres, as measured manometrically, are predictors of symptom relief with pneumatic diln. Surgical myotomy results in complete disruption of the LES fibres from the stomach to the esophagus, thus reducing resting LES pressure. A partial funds may be performed with the myotomy, depending on the presence of reflux symptoms preop. Most consistent preop predictors of successful surgical myotomy is elevated resting LES pressures >30 mmHg. Failure of surgical myotomy is assoc with megaesophagus and lengthy, high amplitude esophageal contractions. Prior pneumatic dilation and tx with Botox have not been shown to significantly affected surgical outcomes in pts with achalasia

Answer 35

D Biliary enteric fistula (gallstone ileus) is a recognized complication of cholelithiasis. Presentation may be intestinal obstruction when the gallstone lodges in the distal ileum. Classic radiographic findings comprise a triad of gastric or small bowel diln with pneumobiliar and intraintestinal gallstone on CT. B/c the cholecystenteric fistula is usually large, recurrent symptoms are rare and choelcystostomy and fistula mgmt are not mandatory. Abdo exploration will involve an enterotomy proximal to the site of obstruction to remove the stone. Operative intervention should include manual exam of the entire small intestine, b/c a second stone may be present. Drainage of gab has occurred by means of the fistula, thus cholecystostomy is unnecessary. Enteroscopy is not recommended in this setting.

Answer 36

D Choledochal cyst disease may present as diln in a variety of locations within the biliary tree. Type I fusiform dilation of extrahepatic duct Type II DIverticulum of the extrahepatic duct Type III Intraduodenal (choledochocele proper) Type IVa Intra and extra hep diln of the bile duct Type IVb Multiple diln of extrahepatic bile duct Type V Multiple intrahepatic biliary cysts (Caroli disease) Incidence of carcinoma in bile duct cysts is estimated to be 2.5-15%, compared with an incidence of 0.012-0.48% in pts without bile duct cysts. Classical triad of jaundice, RUQ pain, and abdo mass, occurs in <20% of all pts with biliary cysts. Choledochal cysts should be surgically resected when possible to avoid long term consequences of cholangitis, liver cirrhosis, pancreatitis and malignant transformation MRCP provides a noninvasive test to image the biliary tree and assess feasibility of surgical resection. Such imaging should supersede ERCP, brushings, tumor markers or FNA

Answer 37

E Stapling device for hemorrhoidectomy has less pain at the cost of higher recurrence rates. Comparison trials have shown that patient satisfaction is similar between procedures--possible due to patient self selection, that is, one is often likely to be happy with the chosen option. Less pain results in a quicker return to N activities in controlled studies. Infection rates are similar. Conventional hemorrhoidectomy may be used more often in pts with prominent external skin tags, and this is the source of the incr pain scores. Randomization of subjects removes this selection bias but pts in the conventional hemorrhoidectomy group may suffer the pain of skin tag removal. With these differences between stapled and open hemorrhoidectomy, it is clear that patient selection and a good preop discussion of options is relevant

Answer 38

C Adhesive SBO is less common after LRYGB than open, the overall rate of bowel obstruction remains approx equal between 2 approaches and is possibly even higher with lap. Due to incr incidence of bowel obstruction caused by internal hernia, which occurs at a rate of approx 2-5% after LRYGB. 3 potential spaces of internal herniation are created during the procedure. First is Peterson defect between the Roux limb mesentery and the mesocolon. Second is jejunojejunostomy meseteric defect. Third occurs only in retrocolic RYGB. Overall incidence of SBO in retrocolic cohort is 5.1%. Internal hernia causes half of these bowel obstructions and approx half were adhesive disease, scarring at the mesocolic space, port site hernia and jejunojejunostomy stenosis. 3/4 of internal hernias were at the defect in the transverse mesocolon, a space that is not created in the anetocolic technique. In antecolic LRYGB, overall incidence of SBO was 1.7% and obstructions were caused by stenosis at the jejunojejunostomy, adhesive disease, internal hernia and port site hernia, in desc order of freq. When evaluation a pt with bowel obstruction after LRYG, important to note the route of Roux limb and timing of the obstruction. Early obstruction (within 30 days) are more likely caused by technical error causing obstruction at the jejunojejunostomy. Late obstruction is more likely due to internal hernia or adhesive disease. Internal hernia is thought to be a late complication b/c the pt's wt loss causes a decr in intraperitoneal fat and subsequent enlarging of mesenteric defects. Dx can be difficult. Valuable diagnostic tool is lap reexploration and may SBO after LRYGB can be tx laparoscopically. Stricture at gastrojej causes a GOO rather than SBO. Pts are intolerant of even small amts of food and generally do not have bloating and abdo distension.

Answer 39

B Hinchey I Pericolic or mesenteric abscess Hinchey II Walled off Pelvic abscess Hinchey III Generalized purulent peritonitis Hinchey IV Generalized feculent peritonitis Tx of sigmoid diverticulitis continues to evolve. Significant morbidity and mortality assoc with Hartmann's and subsequent colostomy take down. This OR is commonly considered for Hinchey III or IV. However in clinically stable pts with favourable anatomy, it is possible and perhaps better to perform resection with colorectal anastomosis with or without diverting loop ileostomy. Subsequent ileostomy takedown is easier. Other approaches for Hinchey III and IV include damage control sigmoid resection with a delayed anastomosis as well as irrigation and drainage alone. Thus, all pts do not need a Hartmann. Applying elective resection after a first attack of uncomplicated diverticulitis has little effect on the incidence of pts requiring emergency procedures, b/c the type of presentation tends to be similar to their first attack and not necessarily more sever. The ASCRS now recommends "the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in defining the appropriateness of sx". Studies based on decision analysis models suggest that life expectancy will be optimized if elective sx is performed after the 3rd or 4th attack of uncomplicated diverticulitis. This finding is particularly relevant b/c elective diverticular disease resection has a significant rate of morbidity and mortality--higher than that of elective CRC resection Colonoscopy is recommended after nonop tx and before operative tx of sigmoid diverticulitis in pts of all ages.

Answer 40

B Polyps of go are typically incidental findings detected during radiologic imaging of the abdo. Significance is related to their potential for malignancy. Polyps <0.5 cm are usually benign and most freq represent cholesterolosis. Asymp pts with cholesterol polyps do not need tx. However, a repeat US exam at 6 and 12 months may be appropriate. FU exam are not necessary if polyp is unchanged. Polyps at least 1 cm in diameter may represent cholesterol polyps, adenomas, or carcinomas. Multiple polyps, pedunculated polyps, and those that are hyperechoic compared with the liver are usually cholesterol polyps, whereas solitary and sessile polyps are isoechoic with the liver are more likely to be neoplasticism and a lap chole should be performed Lesions >1.8 cm are usually malignant. B/c these lesions may represent advanced cancer, pts should undergo preop staging with CT scan and EUS. If malignancy is proven, an extended cholecystectomy with LN dissection and partial hepatic resection of the gb bed is required.

Answer 41

B Meckel diverticulum is a true diverticulum, containing all 3 layers of the intestinal wall. Neoplasms within Meckel are exceedingly rare, but of such neoplasms, carcinoid is most common. In a population based study 77% were carcinoid. A hernia containing a Meckels is a Littre hernia. These hernias can be inguinal (50% in 1 series), umbilical or femoral. A grynfeltt-lesshaft hernia refers to a hernia of abdo contents through the superior lumbar triangle (formed by quadratus lumborum, 12th rib and internal oblique). Acid producing heterotrophic gastric tissue within a Meckel's can result in ulceration of adjacent N small bowel mucosa, resulting in GI bleed. An adequate resection needs to include both the diverticulum and the ulcerated intestinal mucosa. A diverticulectomy alone is insufficienct mgmt of a bleeding Meckel diverticulum if it does not resect the ulcerated intestinal mucosa. In the elective setting, a technetium 99 pertechnetate scan is the study of choice to detect heterotrophic tissue within a Meckel's. Capsule endscopy is often used in the WU of small intestinal bleeds but it is not the preferred study if a Meckels is suspected

Answer 42

E Controversy remains regarding the need for elective colectomy in pts who are successfully managed nonop during an acute diverticulitis episode. After a single episode of uncomplicated sigmoid diverticulitis, risk for recurrent diverticulitis is low; however, with the second episode, the risk for a third episode becomes substantial. Data indicate that although the risk of subsequent episodes of acute diverticulitis is high, risk of complicated diverticulitis remains low. IT is currently recommended that the decision to proceed should be made on a case by case basis and that the number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in determining the appropriateness of sx. For pts who experience diverticulitis complicated by abscess formation requiring perc drain, sigmoid resection is recommended even if otherwise full recovery from the episode of diverticulitis with conservative mgmt is achieved. When performing elective sigmoid resection for diverticular diseases, not all diverticula bearing colon must be removed. Distal margin of resection should extend to where the taenia coli diverge into the upper rectum, b/c diverticulum formation below this level is very uncommon. Proximal margin should be an area of pliable colon without hypertrophy or inflammation.

Answer 43

D Anast leaks after Whipple are a significant source of morbidity and mortality from this procedure. Anast leaks occur in 15-25% of cases. Fortunately, most leaks heal with conservative mgmt and do not give risk to chronic panc fistulas. When a chronic fistula does occur, early operative intervention should be avoided, b/c most of these fistulas will close spontaneously with observation. Although the use of octreotide can decr the output from a panc fistula, octreotide therapy dose not aid in the healing of a fistula. Meta analysis of RCTs has not shown a significant difference between pancreaticojejunostomy and pancreaticogastrostomy with regard to panc anast leak or fistula formation

Answer 44

C Preop work up should include full inspection of colonic mucosa, preferably by colonoscopy, CBC, chem, CEA and CT scan of Chest/Abdo/Pelvis. PET CT is not routinely indicated as part of preop work up. If CT scan demonstrates potentially curable met disease, further evaluation with PET-CT is warranted. Under such circumstances, purpose is to evaluate unrecognized mets that would prevent possibility of surgical cure. Pts with clearly unresectable mets (>5 met lesions in liver) should not have a baseline PET CT b/c the results will not affect the clinical mgmt. Should not be used to assess the response to chemo, b.c the scans can provide a transient falsely neg result after the use of chemo. False positive PET can occur in presence of tissue inflam such as in active UC

Answer 45

A Rectal inhibitory reflex (RAIR) is normal reflex that occurs in response to distension of the distal rectum. With the RAIR, there is a relaxation of the internal anal sphincter. RAIR allows rectal contents to be "sampled" by the sensory area of the proximal anal canal, thus providing a means to determine stool from gas. RAIR is absent in Hirschsprungs, b/c the aganglionic segment prevents the relaxation of the internal sphincter. Patients with other forms of chronic constipation, including colonic inertia and pelvic floor dysfunction, will typically have a detectable RAIR. The RAIR is best measured with anal manometry. RAIR does not result in relaxation of the external anal sphincter. In fact, transient contraction of the external sphincter is often seen with the reflex

Answer 46

E Hirschsprung is a functional obstruction that results from aperistalsis due to congenital loss of ganglion cells within the distal colon and rectum. Occurs in 1 in 5000 births, with the majority being dx and tx in neonatal period. Rare cases, remain undx in adulthood. Adult Hirschsprung is same entity as in peds, differing only in its degree of severity and timing of dx. Clinical course of adults is characterized by chronic debilitating constipation since birth. Most pts are dx before age 40. Oldest person dx was 69 yrs. Almost always involves a short segment of distal rectum and thus gives rise to less severe symptoms. Dx is suggested by abscence of rectoanal inhibitory reflex as measured by anal manometry. RAIR is a normal reflexive response where distension of the distal rectum results in decr in internal anal sphincter tone. Appropriate tx consists of proctectomy and removal of aganglionic segment and anal mucosectomy with coloanal anastomosis. Anorectal myomectomy provides varying success. Simple anal dilation is not likely to affect the clinical course of Hirschsprung disease

Answer 47

D PSC is characterized by inflam and fibrosis of the intrahepatic and extrahepatic bile ducts. PSC is immune mediated progressive disorder than can progress to the development of cirrhosis, portal HTN, and hepatic decompensation. Occurs in ~5% of pts with UC. IN a majority of such cases, dx of UC precedes dx of PSC by several yrs. Colectomy for UC does not appear to improve or prevent PSC. In fact, PSC may develop several yrs after colectomy. Patients with idiopathic UC are at an incr risk for development of CRC. Risk of cancer is related to the duration of colitis. B/c of this risk, all pts suffering from UC should undergo annual surveillance colonoscopy, with multiple bx beginning 8-10 yrs after dx of colitis. Pts who suffer from both UC and PSC are known to be at incr risk for development of dysplasia and CRC compared with other pts with UC. Given this incr risk, UC pts with PSC should undergo annual surveillance colonoscopies beginning at the time of dx of PSC.

Answer 48

A Cochrane analysis of RCTs found that early chole after endoscopic choledocholithotomy decr the risk of mortality by 78% compared with wait and see approach. In ASA IV or V groups, mortality was decr from 13% in wait and see to 7% in early chole. Significant decr in incidence of biliary pain and cholangitis. In pts managed by wait and see, 5.4% developed recurrent jaundice or cholangitis, but only 0.9% developed pancreatitis. In a prospective RCT, 47% managed nonop developed greater than 1 biliary related event during 2 yrs of follow up compared with 2% of pts who underwent lap chole after initial endoscopic choledocholithotomies. Significant incr in conversion to open in wait and see pts who underwent choles after symptomatic recurrence (55%) compared with early chole pts (20%). Early removal of gb after clinical presentation with choledocholithiasis decr risk of death and complications and this improvement is seen even in pts at high operative risk

Answer 49

C ~15% of pts with CRC present with obstruction. Mgmt must include decompression to avoid subsequent perf. Accomplished by either a palliative stoma or Hartmann procedure in 25% of pts. However in up to 40% of Hartmann's are never reversed. Morbidity of operation for acute obstructing CRC is high and mortality rates are 9-27%. Self expandable metal stents are advocated as an alternative to operation. For pts with mets, self expandable metal stents may allow palliation without operation or stoma formation. For pts with potentially curable CRC, these stents may serve as bridge to sx by allowing for decompression and subsequent 1 stage surgery without stoma formation. Approx 50-60% of pts with acute obstructing CRC are candidates for self expandable metal stents. Technical success rate, defined as the ability to deploy stent and relieve obstruction is high (88-100%). Results in a shortened hosp stay by up to 5-8 days, as well as decr need for ICU admission. With relief of obstruction, need for emergency OR and stoma formation at any point in tx is reduced. Use of stents as a bridge to subsequent resection in colon ca is not assoc with worse oncologic outcome or higher mortality, although better long term data are needed. Patients with short segment obstruction and distal obstructions are the best candidates for self expandable metal stents. Overall complication rate is ~20% with migration betting the most common problem (10%). Perf from stent placement occurs in up to 4%. Most important risk factor for perf is the use of balloon dilation

Answer 50

E Intussusception is an uncommon cause of adult bowel obstruction (<5%). Ped intussusception is benign and idiopathic in 80% of pts anc can be tx with reduction (air or barium). However, adult intussusception has a pathologic lead in up to 90% of pts. Approx 65% of colonic intusussception has a malignant lead point. In the small bowel, up to 30% of these lead points are malignant. Benign causes include polyps, Meckels, strictures or benign neoplasms. Thus, up to 90% of adult intussusception cases require definitive tx with surgical resection. In select cases, when a benign etiology is firmly established, the intusussception may be milked out to limit the extent of bowel resection. CT Abdo is considered to be the best diagnostic imaging modality, with an accuracy of 60-100%. Classic finding is the "target sign" which is caused by bowel within bowel. Mesenteric vessels within a bowel lumen may be seen as well. In this pt, CT has established the dx, and given her past hx of GIST, she is very likely to have a pathologic lead point. Thus, ongoing medical mgmt is not appropriate.

Answer 51

D Patient has cecal volvulus. Volvulus occurs when a large, mobile loop of intestin and its mesentery twist on a fixed point. This torsion leads to a closed loop obstruction with bowel distension. Depending on degree and duration of torsion, ischemia, gangrene and perf can occur. Volvulus occurs most commonly in sigmoid colon, followed by cecum Cecal volvulus occurs in 2 types: axial ileocolic volvulus (90%) and cecal bascule (10%). In axial ileocolic volvulus, cecum and TI rotate up and over to the LUQ. Cecal bascule occurs when cecum flips upward and anterior in a horizontal plane. Both types require a highly mobile cecum, which is though to occur from failure of mesentery to fuse to the posterior parietal peritoneum in the R parabolic gutter. Preferred tx of cecal volvulus is operative, which is generally a R hemi. Non viable bowel should be resected without detorsion, b/c this may lead to septic shock. Majority of pts can be reanastomosed after resection even with gangrene and obstruction. however, ileostomy with or without a mucus fistula, remains an option if there is peritonitis or severe bowel distension. Radiologic guided hydrostatic enema with a water soluble contrast can be used to reduce sigmoid volvulus but is less successful in cecal volvulus. In addition, barium would not be used in this pt b/c of risk of perf. Similarly, colonoscopy can decompress a sigmoid volvulus but has a high failure rate for cecal volvulus (put to 70%). Detorsion of volvulus accompanied with fixation, either cecopexy or cecostomy, is assoc with high complication and failure rates

Answer 52

C Postop adhesions are freq after abdo and pelvic sx and occur in 50-95% of pts who undergo subsequent laparotomy. Adhesion related SBO occurs in nearly 5% of pts who have undergone prior abdo or, of which 3-8% required operative intervention. Although risk factors are difficult to identify, type of sx and method of operation play important roles in development of adhesive SBO. Open chole and hyst are assoc with higher rates of SBO compared with laparoscopy; however, with appy, the rates are similar. Open adnexal OR have the highest rate of adhesion related readmission (23%), mostly due to SBO, followed by ileal pouch anal anast (19%), TAH (15%) and colectomy (9%). Age, gender and presence of cancer do not appear to affect post op adhesion formation, readmission, or SBO. Closure of peritoneum as a separate layer appears to incr adhesion related readmission and SBO

Answer 53

D UGIB has an incidence of 1/1000 pts and has a substantial mortality of approx 10%. Initial mgmt is focused on ABCs, correction of coagulopathy and risk assessment, followed by early endoscopy (within 24 hrs of presentation) focused on hemostasis. Upper endoscopy should not be delayed until correction of coagulopathy. At upper scope, hemostatic therapy (clips, thermocoagulation, or sclerosant injection) is indicated for all lesions with high stigmata of recent bleeding (active bleeding or visible vessel in an ulcer bed). Epi injection alone is not sufficient. Second look endoscopy not recommended unless bleeding recurs. If upper endoscopy reveals findings of low risk stigmata (clean based ulcer or clot in an ulcer bed), hemostatic therapy is not indicated and pts can be fed within 24 hrs and d/c'ed early with oral PPI. Pts deemed as high risk should be hospitalized for >72 hrs and should received IV PPI. Percutaneous embolization or surgery can be considered when endoscopic therapy has failed.

Answer 54

B Incidence of cancer in pts with UC corresponds to cumulative probabilities of 2% by 10 yrs, 8% by 20 yrs and 18% by 30 yrs. In patients with use of 5 ASA, lower risk of CRC. Mucosectomy does not confer benefit in terms of disease control and there is no significant improvement in cancer risk with mucosectomy Consensus that CRC is highest in this pts with long duration of disease (adult compared with child) and extent of disease

Answer 55

E TEM provides a minimally invasive technique for excising a wide variety of beings and malignant rectal lesion. Large diameter operating proctoscope is inserted into the anal canal. With an airtight seal, rectum can be distended with CO2, providing clear visualization of rectum was a small calibre videoscope. Precise dissection for both full thickness and partial thickness excision. Better imaging and access facilitate control of hemostasis. Accurate dissection within the proper planes and with appropriate margins can be achieved. Polyps above the peritoneal reflection of the rectum (>15 cm), polyps > than 8 cm in diameter, and polyps occupying >50% of rectal circumference are amenable to TEMS resection. TEMS is applied to a variety of anorectal diseases. Other benign rectal and extrarectal masses such as carcinoids, and some retrorectal cysts, can also be excised with TEMS. TEMS does not allow for visualization of the anal canal. It used is limited to lesion located above the anal canal.

Answer 56

1. C 2. A 3. B 4. A RYGB is most commonly performed bariatric procedure. 60 mL proximal gastric pouch is created and anastomosed to Roux limb. Creating a Roux limb 150 cm long enhances wt loss by means of malabsorption of ingested foods. Small gastric pouch restricts volume of food intake, and pts must dramatically reduce meal size to avoid complications. Mean excess wt loss approaches 60% at 1 yr and is somewhat less at 3 yrs. 30 day operative mortality ranges from 0.1-0.5% in large series BPD includes a sleeve gastrectomy by stapling along a 60 Fr Bougie placed along the lesser curve of the stomach. Duodenum is divided 2 cm distal to pylorus, preserving blood supply and vagal innervation of antrum. Roux limb is created by dividing small intestine 250 cm proximal to IC valve and anastomosing this to the postpyloric duodenal cuff. Bypassed biliopancreatic lumb is sewn to Roux limb 100 cm proximal to IC valve. Technically more challenging than RYGB. Clearly a restrictive procedure, pt acceptance is higher b/c gastric capacity is larger and there is less dumping than RYGB. More effective in reversing premorbid metabolic conditions such as DM, dyslipidemia, and HTN in super obese. 30 day operative mortality 0.5-1.1%. For super obese pt, BPD results in significantly superior sustained wt loss than RYGB at 3 yrs postop

Answer 57

1. B 2. D 3. C 4. B Lap Nissen involves a 360 degree wrap of esophagus with or without division of short gastric vessels. Division of short gastric vessels is rarely necessary to acheive adequate mobilization of the fundus for either Nissen or Toupet. Results are the same without dividing the short gastric vessels and division of short gastric vessels may actually incr postop bloating. Lap Toupet requires a similar posterior esophageal dissection. However, the fundus is sutured to the R diaphragmatic crura, creating a 270 degree wrap, as opposed to a 360 degree wrap. Toupet is assoc with less postop dysphagia and markedly less need for esophageal dilation in the early post op period. Nissen and Toupet are equivalent in terms of symptom resolution at 5 and 10 yrs follow up. IN prospective RCT, 85% have clinical success at 5 yrs

Answer 58

1. C 2. A 3. C 4. D Combining oral meslamine with mesalamine enemas is better than oral monotherapy for pts with mild to mod active, extensive UC. Combo induces 64% remission within 8 weeks, compared with 43% with oral monotherapy. Combo is appropriate for initial therapy. For pts who need escalation in therapy, moving straight from mesalamine to infliximab is an effective option that can avoid steroids; 33% acheived remission after 8 weeks of therapy with infliximab Mesalamine cannot be recommended for Crohn's disease b/c results are inconsistent. Cochrane review found no benefit In meta analysis, infliximab maintained remission in more pts than placebo and incr response and spared pts from corticosteroir therapy. No significantly incr postop complications after ileostomy closure in pts who received infliximab or other immunosuppresive meds compared with pts who did not. Both 6 MP and azathioprine are successful in managing disease for pts who are steroid responsive ileal disease or UC.

Answer 59

1. D 2. B 3. B Obesity exceeds 30%. 3 major procedures are LRYGB, lap gastric band, and lap sleeve gastrectomy All 3 reverse insulin resistance in msot pts. Ghrelin levels are dec with lap sleeve gastrectomy. This finding has theoretical importance in that lowered levels should decr appetite. 30 day mortality is low in all 3 procedures, wich the highest being in LRYGB (0.4%). Incidence of early reoperation with LRYGB is approx 2% with the other 2 procedures, early reoperation is necessary in approx 1% 30 day complication rate is highest in LRYGB group (4%) but the 1 year complication rate is the same for all 3 (8%). At 1 year, the % of excess wt loss is 60% for LRYGB and lap sleeve gastrectomy and 40% for the lap gastric band.

Answer 60

1. C 2. A 3. B 4. B 5. C 6. D 7. A Intusussception and anomalies of intestinal rotation are usually assoc with the peds population, commonly in the neonatal period, particularly with respect to malrotation. Both conditions are also identified in the adult population and some have suggested that these conditions occur with equal incidence to the peds population. These 2 entities should be kept in ddx for adult pts who present with vague or nonspecific abdo complaints. Acute symptoms do occur in adults but not as commonly as they do in children. Classic findings of intusussception in children--palpable sausage shaped abdo mass, currant jelly stools or an acute abdo catastrophe--are not seen in adults. When identified in the adult population, assoc congenital abN are not common. Intusussception in adults may present without a lead point, in contrast to children, and may occur without symptoms as an incidental finding on CT performed for other reasons. Finding of bowel within bowel or target sign is pathognomonic. Presentation in adults with a lead point may manifest with atypical clinical findings, b/c may are related to neoplastic processes, commonly disseminated carcinomatosis. Some intususscpetions may present with acute bowel obstruction. En bloc resection is recommended and attempts at hydrostatic reduction should not be undertaken Intestinal rotational anomalies in adults can be complete or incomplete. Often, like in intussusception, they are found during work up for vague abdo complaints or incidentally at the time of sx for other reasons. Contrast intestinal imaging may identify R sided small bowel, a L sided cecum, and inverse relationship between the SMA and SMV or aplasia of the uncinate process of the pancreas. A whirlpool sign, wrapping of the SMV around the SMA with dilation of SMV, is a common CT finding. Cecal volvulus occurs with malrotation, and partial SBO is common with both malrotation and intusussception in adults

Answer 61

1. A 2. A 3. D Classic histopathologic classification used for gastric cancer describes 2 distinct adenocas: intestinal and diffuse. Diffuse gastric adenoca has an approx equal male:female ratio, with an infiltrative submucosal growth pattern, resulting in classic thickened, non distensible stomach known as linitis plastica. It tends to being in the corpus or proximal fundus of the stomach and generall mets directly into peritonum The intestinal types tends to occur in the older population with a higher male: female ratio. It is somewhat assoc with atrophic gastritis and mets often by hematologic spread to the liver. Assoc with environmental factors such as a diet high in salted, smoked and preserved foods. Surgical resection is the only realiztic modality for cure of the pt. IN large clinical studies, there has been no benefit to ppx splenectomy for curative resection in gastric ca, unless there is macrocystic disease involving the spleen or parasplenic LNs

Answer 62

1. D 2. C 3. D 4. C 5. B Rubber band ligation and stapled hemorrhoidectomy are used in the mgmt of internal hemorrhoids. Neither can be used in the tx of external hemorrhoids. Internal hemorrhoids originate above the dentate line and have visceral innervation but lack somatic innervation. As a result, internal hemorrhoids may be managed with relatively minimal discomfort to the patient. External and mixed internal-external hemorrhoids are covered by anoderm, a modified squamous epithelium that contains pain fibers. Rubber band ligation of external hemorrhoids would be pain ful and stapled hemorrhoidectomy does not remove external hemorroids Rubber band ligation is office based procedure, performed withou anesthesia or bowel prep. Redundant hemorrhoid tissues is grasped above dentate line through an anoscope and a double rubber band is applied at the base of the sensation free hemorrhoid effectively cinching the redundant tissue. Depending on pt tolerance, multiple site may be tx in a single visit. Stapled hemorrhoidectomy is an operative procedure. Circumferential purse string suture is placed above the dentate line through a specialized anoscope and the redundant hemorrhoid tissue excised with a hemorrhoid stapler. 1 to 3 cm ring of mucosa and submucosa is excised. Care taken not to include the sphincter muscle or vagina in the staple line. Fecal incontinence and rectovaginal fistula may result from inaccurate stapler placement Pelvic sepsis may occur after both rubber band ligation and stapled hemorrhoidectomy. This complication is rare yet may be lethal if not recognized. Pelvic sepsis is usually manifested by pelvic pain, fever, and urinary retention. Initial mgmt consists of EUA, debridement of any compromised tissue and broad spectrum Abx.

Answer 63

1. A 2. C 3. D Both presentations are representative of hemorrhoid crisis. Patients present with acute pain and nonreducible prolapse, and they may experience urinary retention with either presentation Gangrene, necrosis and ulceration are absolute indications for a emergency hemorrhoidectomy. There is no role for office based mgmt. All devitalized tissue must be debrided. Wounds should be left open to prevent post op sepsis. Best done under GA. Visible strangulated prolapsing hemorrhoids may be tx with formal surgical hemorrhoidectomy or may be tx more conservatively in the office with a perianal block, gentle reduction and multiple rubber band ligation. Rubber band ligation can be done either at the time of initial reduction or after edema is resolved. Perianal block is obrained with 0.25% bupivicaine with 1:100,000 epinephrine and hyaluronidase. This approaches is particularly useful in late pregnancy. Stapled hemorrhoidectomy is used in the mgmt of uncomplicated second and thrid degree internal hemorrhoids. It does not address the external hemorrhoid component and is contraindicated in the face of tissue necrosis.

Answer 64

B in answer key D is also wrong Most common congenital Gi malformation. Anomaly results from an incomplete obliteration of the omphalomesenteric duct during gestation. Only 4-6% of pts develop symptoms. When discovered incidentally at exp lap, routine resection is not recommended, regardless of age GI bleeding is the major clinical finding in children and occurs in up to 50% of cases. Cause of GI bleed is assoc with ectopic gastric tissue in the diverticulum. Symp of intestinal obstruction are most commonly seen in adults and this presentation is second most common clinical finding in children. <50% of pts present with symptoms before 2 yrs of age.

Answer 65

D Intestinal transplan is a viable surgical option for pts with irreversible chronic intestinal failure who cannot toelrate or be maintained on TPN. Hepatic injury is the most common reason for pts with intestinal failure symptoms (short gut syndrome) not to be able to toelrate PTN. Most common indication for transplant. Complciations related to venous access such as catheter thrombosis and line sepsis can make TPN impractical. Accepted indications include impending or over liver failure, central venous catheter related thrombosis in at least 2 central veins, or at least 2 episodes per year of systemic sepsis secondary to line infections.. Indicated when freq hosp are required for the mgmt of complications related to intestinal failure such as episodes of volume depletion or repeated episodes of pseudo obstruction. In general, the absolute length of residual small bowel alone is no an indication for transplant, except in those situations where ultrashort bowel exits (<20 cm in adults) and where unmanageable complications of volume depletion and electrolyte imbalances are certain to occur.

Answer 66

C Anastomotic leak can occur after any colorectal sx, especailly after sphincter sparing surgeries with low anast for rectal ca. Leak is assoc with longer hospital stay, incr morbidity, and incr mortality and is reported to occur in 2-15% of cases. RF for leak after LAR are large tumors size (esp >5 cm), low serum albumin (<3.5), low anast, higher ASA score and intraop soilage. Temp DLI remains somewhat controversial given the need for an additional operation with potential morbidity, yet when they are used, they are assoc with lower anast leak rates, rates of pelvic sepsis and reoperation. Most experts believe than diversion is appropriate for pts who are at high risk fo anast leak, such as the pts with a large and low tumor. Neoadj chemorads does not appear to influence rate of anast leak.

Answer 67

B Anal margin is WLE Anal canal is Nigro

Answer 68

C T2; doesn’t need NACRT, shouldn’t change operation based on NACRT. Internal = T2 Intersphincteric = T3 External = T4

Answer 69

A Dentate line is within anal canal. 1cm proximal would put distal margin at the anorectal ring. Possible could do a coloanal, but APR is safer.

Answer 70

A Adeno? SCC? Adenosquamous? Path needs clarification.

Answer 71

A Perianal skin cancer behaves as skin cancer, not anal canal SCC. Treatment of choice is WLE. ASCRS text indicates WLE with 1 cm margins, accepting that APR may be necessary if large or involves sphincter. Up to Date is incorrect when it says that perianal SCC should be treated as anal canal SCC. ASCRS: Local excision is an appropriate consideration only for small superficial lesions outside the anal canal at the anal margin in most instances

Answer 72

D NPWT is Canada consensus; SCC in scar is aggressive with high risk of local recurrence, so covering with a flap is controversial as may hide a recurrence. Ideally need to know margin status before closing; VAC as temporizing measure while waiting for path then followed by flap closure once margins confirmed clear.

Answer 73

D Chemoradiation is the treatment of choice for inguinal lymph node disease. Similar to management of the primary anal lesion, the mainstay of treatment for concomitant disease of the perirectal or inguinal nodes is chemoradiation. A complete response has been reported in 79% to 92%. With the identification of any positive inguinal lymph node, bilateral inguinal basins should be incorporated into the radiation fields with the addition of a boost technique. Metachronous lymph nodes are seen in 10% to 20% of patients, normally within 6 months of completing treatment of the primary lesion. These metachronous nodes should also be treated with CRT, and typically respond well. Elective prophylactic lymphadenectomy is generally not warranted and is associated with high wound complication rates as well as lower-extremity complications. Selective inguinal node dissection may be considered for persistent disease following CRT. In small case series, long-term survival has been reported after successful removal of disease.

Answer 74

F T1N0 Need margins >1mm

Answer 75

A ASCRS manual: small leaks can be managed with anastomitic drainage +/- repair and diversion. If managed with Hartmann’s, probably will never be able to reconnect as anast is so low already. * Patients with a free leak should be taken to the operating room after fluid resuscitation and intravenous antibiotics are administered. * After a thorough washout, the treatment is dictated by the findings. * Most colorectal anastomosis will require anastomotic takedown and an end colostomy. * To minimize the effects of a friable rectal stump (that cannot be closed with staples or sutures nor brought to the skin surface as a mucous fi stula), placement of transabdominal and transanal drains is indicated. * Selective small bowel or ileocolic anastomotic defects can be repaired. However, resection of the anastomosis with creation of a new anastomosis or stoma is the most conservative option. Placement of the repaired anastomosis under the surgical incision will result in an enterocutaneous fistula instead of a second bout of peritonitis should a second leak occur. * Any concern regarding viability of the bowel ends necessitates takedown of the anastomosis and creation of a stoma. * Small defects in a colorectal anastomosis, in select circumstances, may be repaired and a proximal ileostomy created. This should be avoided when there is a large fecal load between the ileostomy and the repaired anastomosis. * A contained anastomotic leak is walled off and typically located in the pelvis presenting as an abscess. * If the abscess is small and contrast flows freely into the bowel, the patient can be treated with intravenous antibiotics, bowel rest, and observation. * Larger abscesses or those removed from the site of the anastomosis may require radiologically guided drainage. * A contained leak rarely requires immediate operative intervention, but surgery may eventually be required if the patient develops a cutaneous fistula, anastomotic stricture, or chronic presacral cavity.

Answer 76

C Sounds like the best candidate for CRS; long interval, young, limited disease. Despite HIPEC/CRS not yet being standard of care, it is supported by RCTs.

Answer 77

A (this is an old answer) New ESMO guidelines July 2017 The European Society for Medical Oncology (ESMO) has updated their guidelines for treatment of rectal cancer [1]. Among the many changes from the 2013 guidelines, they suggest a selective approach to postoperative chemoradiotherapy in patients with resected stage II and III disease (table 1), recommending it only for patients with certain high-risk features identified at the time of surgery (table 2). ``` Sufficient and necessary CRM ≤1 mm pT4b pN2 extracapsular spread close to MRF Extranodal deposits (N1c) pN2 if poor mesorectal quality/defects ``` Sufficient pN2 low tumors within 4 cm of anal verge (risk of involved LPLN) Extensive extramural vascular invasion/perineural invasion close to MRF Borderline sufficient pN2 in mid/upper rectum if good mesorectal quality CRM 1 to 2 mm Circumferential obstructing tumours ``` Insufficient and unnecessary pT1/pT2 pT3 CRM >2 mm pT4a above peritoneal reflection pN1 If good-quality smooth intact mesorectum ```

Answer 78

B T2, >2cm means radical resection required. As 1cm above anal verge, APR. Rectal NET: <1cm, confined to mucosa or submucosa, endoscopic resection adequate. >2cm need radical resection (APR/LAR) Intermediate tumours (1-1.9cm) controversial. Generally, if <1.5cm and no high risk features (LVI, mitotic rate, etc), local excision adequate. If high risk, formal resection.

Answer 79

C Small NET 1cm, positive margins, requires local excision NOT radical resection. If >2cm or high-risk features, then formal resection.

Answer 80

D Observation of rectal cancer with complete clinical response is investigational and should not be done outside of a clinical trial. For exam purposes, need to obtain a 2cm distal margin; in this case 2cm would be below dentate so not feasible.

Answer 81

C (most wrong answer) Uptodate: Local excision should be limited to the following groups -Superficial T1 cancer, limited to the submucosa -No radiographic evidence of metastatic disease to the regional nodes -Tumor <3 cm in diameter -Well-differentiated histology, no lymphovascular or perineural invasion -Mobile, non-fixed -Margin clear (>3 mm) -Involving <30 percent of the bowel lumen circumference -Patient is able to comply with frequent postoperative surveillance

Answer 82

B in answer key Neodymium-YAG laser therapy. Used mainly for palliation or in patients who are not surgical candidates Endoscopic Nd:YAG laser treatment of inoperable lower gastrointestinal cancer. "It requires no anaesthesia and is the only non-surgical procedure that can be safely carried out above the peritoneal reflection. " Local control of rectal cancer with the Nd-YAG laser. - NCBI Three patients with locally recurrent rectal cancer were treated using the Neodymium YAG laser to palliate the symptoms of tenesmus, discharge and bleeding.

Answer 83

C Basaloid, epidermoid, mucoepidermoid are all subtypes of SCC, but do not influence treatment choice.

Answer 84

D Most common cause is pelvic recurrence, followed by radiation. FOLFOX –neurotoxicity is common, but is sensory only.

Answer 85

A Need to discuss at multidisciplinary case conference Nigro is treatment for all anal SCC

Answer 86

B Bowen’s or HSIL. <10% will progress to invasive in immunocompetent patients, but can’t predict so treatment favoured. Standard treatment is WLE, although topical therapy (imiquimod) may used in unfit patients OR when surgery would leave a difficult wound Neoplasms of Anal Canal and Perianal Skin. Clinics in Colon and Rectal Surgery, 2010. The standard treatment is wide surgical excision.6 To ensure clear resection margins, a systematic four-quadrant biopsy technique, with intraoperative frozen sections has been advocated. The frozen sections should include intra-anal biopsies. Despite use of this technique, recurrence rates up to 30% have been reported. The major disadvantage of wide local excision is the difficulty to primarily close the wound and skin flaps may be necessary. The rotational v-y skin flap has been most frequently described in this setting.When surgery is not feasible or refused, other options are available such as topical chemotherapy (5-FU), immunomodulation (imiquimod), and phototherapy, although the latest guidelines favor radiotherapy.

Answer 87

A Band applied below dentate line.

Answer 88

C Treat underlying CD

Answer 89

A I&D of thrombosed external hemorrhoid is inadequate; excision is required. Excise up to 72 hours.

Answer 90

C Schwartz: urinary retention is most common complication, limit perioperative fluids to reduce.

Answer 91

D Atypical fissure should be biopsed or excised. Muscle relaxing treatments not effective in atypical lateral fissures.

Answer 92

A Conservative measures first line for acute fissures.

Answer 93

C Complex fistula as likely in high location (near/at cervix) and radiation-related; should be diverted first as poor tissue quality. ``` Surgical Clinics (radiation-related RVF) In the absence of recurrent cancer, radiation-induced fistulas can be approached abdominally, locally, or with diversion. There are several variants of each, with little evidence to support 1 method over the next, but the location and extent of radiation injury usually determine the most prudent approach. Before surgery, the extent of radiation injury, including the compliance of the rectum, needs to be addressed. Compliance can be addressed with manometry and subjectively with attempted insulation during endoscopy. Considering the poor quality of the rectum and concomitant inflammation and edema of tissue planes, these repairs are typically performed in conjunction with a diverting stoma. The diverting stoma can be performed simultaneously or several months before the repair, depending on the amount of contamination and tissue integrity. If the vaginal mucosa is uninvolved with radiation and if the fistula is not higher than the apex of the vaginal vault, a vaginal flap can be raised. ``` Cameron, John L.; Cameron, Andrew M (2013-11-20). Current Surgical Therapy: Expert Consult - Online (Current Therapy) With the increased use of both brachytherapy and external-beam radiation in the treatment of pelvic malignancies, radiation-induced complications are likely to increase. The first step in management of radiation-induced rectovaginal fistulas is to rule out the presence of residual or recurrent malignancy. This requires detailed imaging and an examination with the patient under anesthesia with multiple biopsies of areas of irregularity or random biopsies if no irregularity exists. Once the presence of malignancy has been ruled out, the condition of the rectum, vagina, and surrounding perineal tissues needs to be evaluated. It is mandatory to wait at least 6 months after the completion of radiation treatment before any repair is attempted. This allows for the full effect of radiation to be realized and for the surrounding tissue to recover. If the local tissues are healthy, a rectal or vaginal advancement flap can be attempted. However, it should be appreciated that because the repair is being performed with radiated tissue, it is less likely to succeed. If one attempt at local repair fails, subsequent attempts will most likely be futile. Interposition flaps with nonradiated tissue (e.g., gracilis flap) or a resection of the involved rectum with a coloanal anastomosis and omental interposition then remains the best available option and is preferable to the classic Bricker procedure.

Answer 94

C The diagnosis is made on the basis of histologic finding of fibromuscular obliteration of the lamina propria. We suggest observation alone or treatment with bulk laxatives and biofeedback in patients who are asymptomatic or minimally symptomatic (Grade 2B). We suggest surgery (typically abdominal rectopexy) in symptomatic patients with rectal prolapse rather than conservative therapy (Grade 2C). Surgery may also help relieve symptoms in patients with severe symptoms that are unresponsive to conservative management.

Answer 95

C Primary repair up to 48 hours; if longer delay, wait for 6 months

Answer 96

B Uptodate: Urinary retention following hemorrhoidectomy is observed in as many as 30 percent of patients [56]. Spinal anesthesia tends to be associated with higher rates of urinary retention [5]. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study) [57]. Warm sitz baths and pain medication also may lessen the incidence of urinary retention and reduce the need for catheterization. Some patients will require urinary catheterization, although some remain relatively asymptomatic.

Answer 97

B Occurs in 58-100%

Answer 98

A Adult diagnosis of Hirschsprungs disease. The rectoanal inhibitory reflex (RAIR) is an involuntary IAS relaxation in response to rectal distension, allowing some rectal contents to descend into the anal canal where it is brought into contact with specialized sensory mucosa to detect consistency Cameron: Presence of this reflex effectively rules out Hirschsprung's disease.

Answer 99

C From Sabiston – Cochrane review showed that posterior sphincterotomy less effective and more incontinence

Answer 100

C ``` Presacral nerves (sympathetic: shoot) (hypogastric plexus): ejaculatory difficulties/ retrograde ejaculation. Nervi erigenti (parasympathetic: point) at the lateral stalks, injured if dissection too wide: erectile dysfunction Prostatic plexus – mixed urinary and sexual dysfcn ``` The nervi erigentes are located in the posterolateral aspect of the pelvis and at the point of fusion with the sympathetic nerves are closely related to the middle hemorrhoidal artery. Injury to these nerves will completely abolish erectile function. Finally, dissection near the seminal vesicles and prostate may damage the periprostatic plexus, leading to a mixed parasympathetic and sympathetic injury. This can result in erectile impotence as well as a fl accid, neurogenic bladder.

Answer 101

A Incidence of rectal varices in Childs C is up to 70%; endoscopic therapy (banding/sclerotherapy) is 1st line. 2nd line is retrograde balloon occlusion or TIPS. Surgical therapy is last-resort, can include surgical shunts, IMV ligation, or transanal oversewing of varix. Bleeding ectopic varices – TIPS is useful for acute hemorrhage (Up to Date). This patient is stable and TIPS/embolization seems like too much, although might be getting at prophylaxis. APC is not described anywhere, sclerotherapy is. Hemorrhoidectomy is not necessary for grade I disease. TIPS/embolization is described, so of these options is probably the best.

Answer 102

B Delorme and pexy are not options as does not resect the strangulates bowel. Even gangrenous prolapse can be managed with perineal procedures. Surgical Management of Rectal Prolapse. JAMA Surgery, Jan1 2005. Wexner, S. Perineal rectosigmoidectomy is well suited for male patients; patients with incarcerated, strangulated, or even gangrenous prolapsed rectal segment; and patients who have had recurrence after another transperineal repair.

Answer 103

A Up to Date: Empiric therapy for both chlamydia and gonorrhea is indicated for the treatment of patients with acute proctitis. An empiric regimen of doxycycline (100 mg twice daily) plus a single intramuscular dose of ceftriaxone (250 mg) is active against both [3]. The duration of doxycycline therapy will depend on the severity of symptoms. For patients with mild proctitis, seven days of therapy is adequate. Patients with severe proctitis may have lymphogranuloma venereum infection, which requires a full three-week course of doxycycline. Chlamydial proctitis, defined as inflammation of the distal rectal mucosa that can cause anorectal pain, rectal discharge, or tenesmus [19], is relatively uncommon and occurs almost exclusively in men who have sex with men (MSM) who have had receptive rectal intercourse [20,21]. However, anal intercourse is not uncommon among heterosexuals [22], and symptomatic proctitis has been reported in women [23]. Chlamydial proctitis may be caused by either the common genital strains of C. trachomatis (serovars D-K) that typically cause uncomplicated genital infection in men and women or the lymphogranuloma venereum (LGV) strains (serovars L1, L2, L3), which can cause severe disease (eg, abundant bloody or mucopurulent discharge, severe pain with defecation, fever) Untreated can progress to rectal ulceration and stricturing.

Answer 104

A 1st line is FNA of fat pad; 2nd line rectal biopsy since 1964. And in Up to Date. Kidney or liver has highest overall sensitivity if those organs are involved.

Answer 105

A Real life would attempt endoscopic control 1st; too high for transanal and wouldn’t embolize an anastomosis. This patient is unstable and anast is high enough to revise. Plan: take to OR, attempt endoscopic, revise if fails. SCNA – Complications of Colorectal Anastomoses In most cases, the patient remains hemodynamically stable, and no intervention is required. The rate of transfusion requirement is routinely less than 5%. In the review by Martinez-Serrano and colleagues, bleeding in 6 of the 7 patients resolved with conservative treatment including endoscopy. Only 1 patient required surgical treatment, and there was no mortality and no anastomotic leaks in these 7 patients. Cirocco and Golub reported nonoperative therapy to be successful in 14 of 17 patients (82%), using endoscopic electrocoagulation in 6 patients (43%) and blood transfusion alone in another 6 patients (43%). The investigators concluded that endoscopic electrocoagulation can be safely and effectively used on a newly created anastomosis to control unremitting anastomotic hemorrhage. Alternative endoscopic techniques include the use of submucosal injection of 10 mL adrenaline (1:200 000) in saline at the bleeding point, with good results. The use of the endoscopic hemoclip has been well described in upper gastrointestinal procedures and in colonic diverticular bleeding; however, its application in postoperative anastomotic bleeding for colon or rectal anastomosis is lacking. Anecdotally, the author (DR) has successfully used the endoscopic hemoclip to control bleeding at a colorectal anastomosis in the postoperative period. Finally, although rarely required, surgical exploration with oversewing of the anastomosis or resection may be needed for select recalcitrant cases. Bleeding is a rare event after intestinal anastomosis, and endoscopic techniques have largely replaced the need for laparotomy or other surgical interventions. It is advisable that the operative surgeon performs or be present when endoscopic manipulation of a newly created anastomosis is required.

Answer 106

A Bowel will be dilated, with fecal contamination, so no anastomosis. If can devolved and decompress to achieve better calibre match, primary anastomosis ok.

Answer 107

D in answer key World J Gastroenterol. 2009 Apr 28; 15(16): 1921–1928. Surgical treatment of anal stenosis The causes of anal stenosis include surgery of the anal canal, trauma, inflammatory bowel disease, radiation therapy, venereal disease, tubercolosis, and chronic laxative abuse. LGV causes rectal stricture

Answer 108

B Sabiston – drain when the diagnosis is made

Answer 109

C Most fistulas are thought to arise as a result of cryptoglandular infection with resultant perirectal abscess.

Answer 110

C Central fracture to the acetabulum – this is actually possible but less likely

Answer 111

B Inflammation of mucosa (cuff remnant mucositis)

Answer 112

B ASCRS Textbook: Presacral tumours: 2/3 congenital, 2/3 benign. Can be categorized by congenital, neurogenic, osseous, or miscellaneous categories. Usually present late. More common in females (cystic), solid tumours (chordoma) more common in males. Dermoid or epidermoid cysts, enteric duplication cysts. Teratomas are neoplastic, derived from all 3 germ layers. Malignant degeneration in 40-50%. (and in Schwartz) Neurogenic: meningoceles, chordoma, neurogenic tumours. Osseous tumours: chondroma, osteochondroma, Ewings, myeloma

Answer 113

A Damage to pelvic autonomic/hypogastric plexus, nervi erigentes results in flaccid retention

Answer 114

C Rectum is overall most common, TI most common portion of SB Ileum most commonly involved – 73% Many authors argue for always doing an ileocecal resection when operating for CRE as it has lower anastomotic complications and less reoperation in future. Operative and long term results after surgery for chronic radiation enteritis. Am J Surg, Sept 2001. Small bowel was involved in 93 (85%) patients: ileum in 68, jejunum and ileum in 23, and jejunum in 2 patients.

Answer 115

C ``` Up to Date: Abscess: 50% Fistula: 20-30% Fissure: 20% Skin tag: not mentioned ``` Schwartz 1038: most common is anal skin tag AGA technical review on perianal Crohn’s disease. Nov 2003. Skin tag: 37% Fistula: 26% Abscess: 16% Fissure: 19% Very high overall incidence of skin tags; the sources that compare directly all have anal skin tag incidence the highest.

Answer 116

C Boundaries of ischiorectal fossa Anterior : Perineal membrane (and superficial transverse perineal muscle) Lateral : Obturator internus muscle (& fascia) on ischial tuberosity Supero-medial : Levator ani muscle Posterior :Gluteus maximus (& sacrotuberous ligament)

Answer 117

B Can worsen constipation, incontinence improves only 50% of time

Answer 118

C Botox and topical nitro are effective (50-60%) Sx tx is lateral internal sphincterotomy

Answer 119

C Pouchitis 23-59%

Answer 120

A Desperately try to avoid hemorrhoidectomy in CD: high rate of wound failure. AGA technical review on perianal Crohn’s disease. Nov 2003. Simple hemorrhoidectomy, the newer procedures for prolapsing hemorrhoids, and banding of hemorrhoids in patients with Crohn’s disease are usually contraindicated due to the frequent occurrence of postoperative complications, including poor wound healing, anorectal stenosis, and a high rate of proctectomy,12, 151 and 152 notwithstanding one recent report suggesting that simple hemorrhoidectomy can be safely performed in selected patients.153 When symptomatic prolapsing or bleeding hemorrhoids fail to respond to conservative measures, in the absence of active anorectal Crohn’s disease, elastic band ligation may be used with great effect (Victor Fazio, unpublished experience, May 2003). It should also be noted that in patients without a preceding history/diagnosis of Crohn’s disease who have a nonhealed hemorrhoidectomy wound 2–3 months postoperatively, investigation including colonoscopy is warranted to rule out occult Crohn’s disease.

Answer 121

A Surgery is not indicated for every patient with a perforation of the esophagus and management is dependent on several variables—stability of the patient, extent of contamination, degree of inflammation, underlying esophageal disease, and location of perforation.

Answer 122

A Gastrograffin followed by thin barium if no leak seen.

Answer 123

B Likley benign esophageal leiomyoma Biopsy not required. Diagnosis best on barium swallow. Resect if symptoms, >2cm, or cannot r/o GIST. EUS is recommended by some, biopsy is useful but makes eventual surgery more difficult. Sabiston Leiomyomas are slow-growing tumors with rare malignant potential that continue to grow and become progressively symptomatic over time. Although observation is acceptable in patients with small (<2 cm) asymptomatic tumors or other significant comorbid conditions, surgical resection is advocated for most leiomyomas; however, imatinib (a tyrosine kinase inhibitor), as targeted therapy used on other GIST tumors, may have some benefit for esophageal leiomyomas. Surgical enucleation of the tumor remains the standard of care and is performed through a thoracotomy or with video or robotic assistance. Lesions of the proximal and midesophagus are removed through the right chest; those of distal origin are removed through the left chest. Pearson's Thoracic and Esophageal Surgery: However, biopsy of intramural tumors (e.g., leiomyoma) is contraindicated because adequate pathologic material to exclude malignancy is impossible to obtain and violation of the mucosal layer may complicate subsequent surgical resection. Esophageal endoscopic ultrasonography (EUS) may further help in the diagnosis, planning of surgery, and follow-up of these tumors.

Answer 124

C Requires source control and control of contamination (stent and drain is a potential option)

Answer 125

A in answer key but that's crazy D according to Botkin but C would provide some coverage. Dor 180-200° anterior fundoplication. Thal 270° anterior fundoplication.

Answer 126

A Effect of preserving the hepatic vagal nerve during laparoscopic Nissen fundoplication on postoperative biliary functions. Ozdogan M et al The patients (n = 40) were prospectively randomized into two groups. The HB-AVn was preserved during the dissection of the lesser omentum in the first group. The nerve was cut in the second group. Postoperative fasting gallbladder volumes were calculated by ultrasonography. Postoperative gallbladder ejection fraction (GEF) and gallbladder emptying time (GET) were determined by calculating intestinal transit time scintigraphically. Sacrificing the hepatic branch causes prolongation in the GET. This change in the motor functions of the gallbladder does not cause any symptomatic effect during the early postoperative period. However, the delay in the GET may increase the risk of gallbladder stone formation in the long term.

Answer 127

A Commonly used treatments include: - Elimination and elemental diets to decrease allergen exposure. - Acid suppression to treat gastroesophageal reflux disease, which may mimic or contribute to eosinophilic esophagitis. In addition, a subset of patients respond clinically and histologically to proton pump inhibitors. Such patients have been referred to as having proton pump inhibitor responsive esophageal eosinophilia. - Topical glucocorticoids to decrease esophageal inflammation. (Fluticasone, budesonide, ciciesonide) - Esophageal dilation to treat strictures.

Answer 128

C Sabiston All strictures should be biopsied to rule out malignant processes and can frequently be managed with dilation if they are benign. Metaplastic changes (Barrett esophagus) should be biopsied in four quadrants every centimeter to evaluate for dysplasia and cancer. Fundoplication procedures can still be performed in this setting, but surveillance must continue at regular intervals because regression is rare

Answer 129

D Enucleate. Don’t biopsy, makes eventual surgery much more difficult.

Answer 130

B Should do some sort of imaging to localize perforation, assess for collections, and plan management. Contrast swallow or CT with oral contrast should be done.

Answer 131

C Patient has Diffuse esophageal spasm Long esophagomyotomy with Dor if fails medical management.

Answer 132

B in answer key In the Ivor Lewis esphagectomy, the esophageal tumor is removed through an abdominal incision and a right thoracotomy (a surgical incision of the chest wall). The esophagogastric anastomosis (reconnection between the stomach and remaining esophagus) is located in the upper chest. For this reason, the Ivor Lewis esophagectomy is suitable for patients with resectable tumor of the middle to lower third of the esophagus and gastroesophageal junction. Uptodate: Thoracic anastomotic leaks are more likely to require re-exploration for appropriate control [61], although endoscopic stenting or transluminal vacuum therapy may provide acceptable outcomes in selected circumstances [62]. As an example, 49 patients were treated endoscopically for esophageal anastomotic leaks after cancer surgery [63]. Thirty-one patients had a covered stent placed across the leaks; three patients had the leaks closed with clips. After a median follow-up of 83 days, 88 percent of patients achieved healing of their leaks. Of the 23 patients who received more than one endoscopic intervention, 96 percent healed their leaks. However, stent migration remains a challenge, especially in the thoracic anastomotic position. Furthermore, there remains concern that the radial forces exerted by expandable stents could worsen regional ischemia and thus cause more significant tissue loss. Finally, stent erosion into surrounding structures such as the aorta and airway remains a risk with prolonged use of this technology [64].

Answer 133

B EMR for tissue; high likelihood nodule has invasive component, so surveillance is not appropriate. Esophagectomy contraindicated, not fit for surgery. PDT acceptable but contraindicated by nodule. ACG Guidelines BE 2015 In patients with nonnodular BE, the utility of ablative therapy is becoming clearer. In patients with BE and HGD, ablative therapy should be preferred over either esophagectomy or intensive endoscopic surveillance because of its proven efficacy ( 63 ) and a side-effect profile superior to surgery ( 147 ). Recent data demonstrate that in patients with BE and LGD confirmed by a second pathologist, ablative therapy results in a statistically and clinically significant reduction in progression to the combined end point of HGD or EAC, or to EAC alone ( 142 ).

Answer 134

A For acute variceal hemorrhage, pharmacotherapy is indicated at the time of diagnosis while awaiting endoscopy. Octreotide is preferred over vasopressin (higher bleeding control, no side effects). Terlipressin used in Europe as first line. Antibiotic prophylaxis indicated as high rate of septic complications with AVH. Endoscopic BL or sclerotherapy is succesful in 90%., EVL is 1st line Portal decompressive procedures if fails endoscopic/pharmacologic. TIPS 1st, surgical shunt as last resort, very effective but 50% mortality. Hemospray, SEMS, esophageal transection also described

Answer 135

A Must do motility studies before redo.

Answer 136

D Nodule requires resection

Answer 137

C Pearson's Thoracic and Esophageal Surgery: Epiphrenic diverticula comprise approximately 20% of all esophageal body diverticula. They are frequently alluded to as separate pathologic entities from other pulsion diverticula. There is, however, sufficient evidence to show that the same underlying mechanisms as in midthoracic pulsion diverticula are present. Hypertensive lower esophageal sphincter and increased tone within the esophagus create a high-pressure area above the sphincter, resulting in outpouching of the mucosa through what is thought to be a weak area of muscle. Epiphrenic diverticula are often seen in association with achalasiaas well as with diffuse esophageal spasm. The natural history, complications, and principles of treatment are, therefore, the same as for midesophageal diverticula, and a concomitant nonobstructing partial fundoplication is therefore advised. Surgical Treatment of Epiphrenic Diverticula: A 30-Year Experience, The Annals of Thoracic Surgery, Volume 84, Issue 6, December 2007 Traditional transthoracic resection, long esophagomyotomy, and an antireflux procedure provide excellent long-term functional results with relatively low postoperative morbidity in patients with epiphrenic diverticula.

Answer 138

B Lung cancer – Level 2B node too high for lung primary. Salivary cancer – only H&N malignancy that is adenocarcinoma.

Answer 139

B in answer key Neoadjuvant seems more appropriate given enlarged LNs Sabiston For esophageal adenocarcinoma, mostly located in the distal esophagus or GEJ, we consider nodal disease located in the area from the celiac axis up to the paratracheal region to represent regional disease; nodal disease located outside of these boundaries is regarded as distant disease. Surgical resection of the esophagus was the mainstay of esophageal cancer treatment in the past. However, we have learned that even the most radical resections with extensive lymph node dissections are not adequate to cure locoregionally advanced disease in the majority of cases. The most notable and frequently quoted trial that compared chemoradiation followed by surgery with surgery alone for esophageal and EGJ cancer was the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS).57 This trial enrolled an impressive 368 patients during a 4-year period, and 366 patients were included in the final analysis. The surgery-alone group consisted of 188 patients, whereas 178 underwent chemoradiation followed by surgery. The majority (75%) of the patients had adenocarcinoma, and 22% had SCC. The chemoradiation regimen consisted of a 5-week course of carboplatin and paclitaxel administered concurrently with radiation therapy at a dose of 41.4 Gy given in 23 fractions 5 days a week. Esophagectomy was performed within 4 to 6 weeks in the treatment group and immediately after randomization in the control group. The completeness (R0) of resection was higher in the trimodality group than in the surgery-alone group (92% versus 69%; P < .001). Patients with SCC experienced complete pathologic response (ypT0N0M0) significantly more than patients with adenocarcinoma (49% versus 29%; P < .001). Expectedly, nodal positivity was higher in patients with surgery alone compared with the trimodality group (75% versus 31%; P < .001). At a median follow-up duration of 45 months, patients receiving the trimodality therapy had significantly longer median overall survival. duration (49.4 months) than did patients undergoing surgery alone (24 months; hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.49-0.87; P = .003). The estimated 5-year survival rate in the trimodality therapy group was 47% compared with 34% (HR, 0.65; 95% CI, 0.49-0.87; P = .003) in the surgery group. Interestingly, trimodality therapy did not significantly benefit patients with adenocarcinoma histology (HR, 0.74; 95% CI, 0.53-1.02; P = .07), and inexplicably it benefited patients with clinically node-negative disease (HR, 0.42; 95% CI, 0.23- 0.74; P = .003) but not those with node-positive disease (HR, 0.80; 95% CI, 0.57-1.13; P = .21).

Answer 140

B then D after wt improved? SAGES: Early postoperative dysphagia rates are up to 50% and the general recommendation is for slow advancement of diet from liquids to solids. Attention should be paid to adequate caloric and nutritional intake in the postoperative period. Expert opinion suggests that most patients will lose 10-15 pounds (4.5 – 7 kg) with laparoscopic fundoplication and hernia repair followed by a graduated diet from liquids to soft solids. If dysphagia persists or weight loss occurs of 20 or more pounds (9 kg) evaluation and intervention for the dysphagia should be considered. Depends on time. If early (<12 weeks), prokinetic and liquid diet, if >12 weeks, dilation. Uptodate: Patients with dysphagia in whom the 13 mm barium tablet passes slowly through the esophagus and who had normal motility preoperatively should be considered candidates for dilation after 12 weeks. Approximately 6 to 12 percent of patients with fundoplication required dilation in various reports. Patients who have a 360 degree fundoplication may be candidates for revision to a partial fundoplication if dysphagia persists and effective barium tablet passage cannot be established.

Answer 141

B EMR – histology, short segment makes it appropriate – also describes nodule SCNA: PDT is falling out of favour; can have buried glands, and has high (40%) stricture rate. RFA is actually treatment of choice. EMR is most useful when there is a visible nodule or short segment BE. RFA is treatment of choice for HGD and should be considered for LGD.

Answer 142

D Sabiston: Endoscopic mucosal resection (EMR) has gained favor for the treatment of Barrett’s esophagus with low-grade dysplasia. Also, it has been used as a diagnostic tool to rule out cancer in a focus of Barrett’s esophagus with high-grade dysplasia. Because of an increase in stricture rate with larger resections, it is not advocated for long-segment Barrett’s esophagus. It is acceptable for patients with high-grade dysplasia who are not acceptable candidates for esophageal resection and useful for patients who have an isolated focus of Barrett’s esophagus with dysplasia.

Answer 143

``` Gastroesophageal varix (GOV) Type 1: Extension of esophageal varices along lesser Gastroesophageal varix type 2: Extension of esophageal varices along greater curve ``` Isolated gastric varix (IGV) type 1 near fundus of stomach and Isolated gastric varix type 2: Varices in stomach or duodenum. Gastric varices: Classification, endoscopic and ultrasonographic management J Res Med Sci. 2015 Dec; 20(12): 1200–1207. Gastroesophageal varix type 1 is the most common type, accounting for 74% of all GV. However, the incidence of bleeding is highest with IGV type 1, followed by GOV type 2. Overall, the most important predictor of hemorrhage is the size of varices, with the highest risk of first hemorrhage (15%/year) occurring in patients with large varices. Other predictors of hemorrhage are decompensated cirrhosis (Child B or C) and the endoscopic presence of red wale marks The endoscopic sclerotherapy has been less effective in the treatment of gastric variceal bleeding and eradication of GV as against esophageal varices where endoscopic sclerotherapy is one of the effective modes of treatment.[12,18] Because of the high volume of blood flow through GV compared with EV, resulting in rapid flushing away of the sclerosant in the bloodstream. In acute GV bleeding, GVS has been reported to control bleeding in 60-100% of cases[20,21,22] but with unacceptably high rebleeding rates of up to 90%. Mucosal ulcers are also commonly seen, and cause rebleeding. Approximately, 50% of rebleeding is caused by sclerotherapy induced ulcers and is difficult to control, with a success rate between 9% and 44%.GVS appears to be least successful in controlling acute fundal variceal bleeding.[23,24] Tissue adhesive such as N-butyl-2-cyanoacrylate, which is a monomer that rapidly undergoes exothermic polymerization on contact with the hydroxyl ions present in water, has been used for Gastric variceal obturation.

Answer 144

A Acute hemorrhage Forrest I a (Spurting hemorrhage) Forrest I b (Oozing hemorrhage) Signs of recent hemorrhage Forrest II a (Non bleeding Visible vessel) Forrest II b (Adherent clot) Forrest II c (Flat pigmented haematin on ulcer base) ``` Lesions without active bleeding Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base) ``` Uptodate Stigmata of recent hemorrhage are present if anything other than a clean ulcer base is seen. However, only patients with active bleeding (spurting or oozing), a nonbleeding visible vessel, or an adherent clot are generally considered to be at high risk for recurrent bleeding. Most patients with high-risk stigmata require endoscopic therapy to decrease the risk of recurrent bleeding, whereas patients without these high-risk stigmata are considered low-risk and do not require endoscopic therapy. Medscape Endoscopic treatment is reserved for ulcers demonstrating signs of active or recent hemorrhage (i.e., spurting or oozing ulcers [Forrest Ia and Ib, respectively] and nonbleeding ulcers with visible blood vessels [Forrest IIa]). For-rest Ia, Ib, and IIa ulcers are high-risk lesions with a high probability of re-bleeding, despite achievement of initial hemostasis, and necessitate aggressive endoscopic and pharmacologic management. Nonbleeding ulcers with a clean base or dark spot at the base (Forrest III and IIc, respectively) do not require endoscopic therapy because the probability of rebleeding is low.[15] Management of ulcers covered by an adherent clot (Forrest IIb) is controversial. Most authorities believe that overlying clots should be removed and the underlying ulcer carefully examined. Endoscopic therapy is reserved for patients with high-risk lesions (Forrest Ia, Ib, and IIa ulcers) and withheld in the presence of low-risk lesions (Forrest IIc and III ulcers).[7]

Answer 145

A Forrest IIB since there was a clot Acute hemorrhage Forrest I a (Spurting hemorrhage) Forrest I b (Oozing hemorrhage) Signs of recent hemorrhage Forrest II a (Non bleeding Visible vessel) Forrest II b (Adherent clot) Forrest II c (Flat pigmented haematin on ulcer base) ``` Lesions without active bleeding Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base) ``` Uptodate Stigmata of recent hemorrhage are present if anything other than a clean ulcer base is seen. However, only patients with active bleeding (spurting or oozing), a nonbleeding visible vessel, or an adherent clot are generally considered to be at high risk for recurrent bleeding. Most patients with high-risk stigmata require endoscopic therapy to decrease the risk of recurrent bleeding, whereas patients without these high-risk stigmata are considered low-risk and do not require endoscopic therapy. Medscape Endoscopic treatment is reserved for ulcers demonstrating signs of active or recent hemorrhage (i.e., spurting or oozing ulcers [Forrest Ia and Ib, respectively] and nonbleeding ulcers with visible blood vessels [Forrest IIa]). For-rest Ia, Ib, and IIa ulcers are high-risk lesions with a high probability of re-bleeding, despite achievement of initial hemostasis, and necessitate aggressive endoscopic and pharmacologic management. Nonbleeding ulcers with a clean base or dark spot at the base (Forrest III and IIc, respectively) do not require endoscopic therapy because the probability of rebleeding is low.[15] Management of ulcers covered by an adherent clot (Forrest IIb) is controversial. Most authorities believe that overlying clots should be removed and the underlying ulcer carefully examined. Endoscopic therapy is reserved for patients with high-risk lesions (Forrest Ia, Ib, and IIa ulcers) and withheld in the presence of low-risk lesions (Forrest IIc and III ulcers).[7] Am J Gastroenterology Those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion.

Answer 146

A Difficult location, strictureplasty not effective, G-J best (per Kanthan). SCNA: Surgical Management of CD For gastroduodenal Crohn’s disease, bypass is often the optimal treatment. In patients with obstructing duodenal disease, resection has a fourfold increased risk of major morbidity when compared with gastrojejunal bypass. Some investigators advocate for strictureplasty in the case of duodenal disease. To accomplish this, the duodenum must be mobilized, which can be challenging in the setting of inflammatory changes. Gastroduodenal strictureplasty frequently fails, has a high rate of reoperation, and confers little advantage over gastrojejunal bypass. Strictureplasty is best used for selected, proximal duodenal lesions near the pylorus.

Answer 147

A Forrest IIA

Answer 148

C Old, comorbid, uncontained leak, delayed presentation are all indications to operate. UTD: nonoperative management less successful in >70 yrs Patients chosen for nonoperative management are those with contained perforation, gastrointestinal fistula formation, or limited contamination as judged by imaging, in those who have no signs of systemic sepsis . Not surprisingly, since patients chosen for conservative management in contemporary series are generally less ill, conservative management is often associated with lower rates of morbidity and mortality compared with surgical management. A conservative approach including antibiotic therapy combined with drainage (effusion, abscess), provision for nutritional support (eg, gastrostomy, feeding jejunostomy), or stent placement may be an appropriate initial management strategy

Answer 149

C. Type I ulcer; ulcer excision is preferred, particularly to rule out malignancy. If unstable, oversew; if stable, excise. Lesser curve wedge is problematic due to vascular arcades, more likely to deform stomach and cause obstruction.

Answer 150

A GAVE, or watermelon stomach, is an uncommon cause of UGIB that is often confused with Portal HTN Gastropathy, both of which can occur in patients with cirrhosis The term "watermelon stomach" is derived from the characteristic endoscopic appearance of longitudinal rows of flat, reddish stripes radiating from the pylorus into the antrum that resemble the stripes on a watermelon. The red stripes represent ectatic and sacculated mucosal vessels. A punctate form (in which the red stripes are not apparent) has also been described and appears to be more common in patients with underlying cirrhosis. While acute bleeding may occur, low-grade GI bleeding is more common, often with iron deficiency anemia. It is uncommon for patients to present with acute and massive bleeding. GAVE is usually an isolated problem but has been associated with cirrhosis and systemic sclerosis. In one series of 744 consecutive patients with nonvariceal UGIB, bleeding was due to GAVE in 4 percent. Portal hypertension was present in 31 percent of the patients with GAVE in this cohort. The most common clinical profile of a patient with GAVE is an older (>70 years old) woman. In the series described above, for example, the median age was 74 years, and 80 percent of the patients were women. Patients may also present with acute bleeding. The clinical presentation is similar whether portal hypertension is present or not, except that those with portal hypertension may have diffuse antral angiomas rather than the classic linear pattern. The diagnosis is based on the classic endoscopic appearance. It may be confirmed with endoscopic biopsy, endoscopic ultrasound, tagged red blood cell scan, or computed tomography (CT) scan [66]. Histopathologically, GAVE is characterized by vascular ectasia, spindle cell proliferation, and fibrohyalinosis (picture 8) [63]. Episodic transfusions are required in some patients. Endoscopic coagulation with a heater probe, bipolar probe, argon plasma coagulator, laser therapy, or radiofrequency ablation obliterates the vascular ectasia and decreases the degree of bleeding. Endoscopic band ligation has also been used successfully [68]. (See "Argon plasma coagulation in the management of gastrointestinal hemorrhage".) Portal decompression with TIPS does not reliably reduce bleeding, underscoring the uncertain relationship of GAVE to portal hypertension [69,70]. Antrectomy prevents recurrent bleeding but is usually reserved for patients who fail endoscopic therapies. Combination estrogen/progesterone therapy may decrease bleeding, although the ectatic vessels appear to persist [71].

Answer 151

A Afferent limb syndrome is an intermittent partial or complete mechanical obstruction of the afferent limb of a gastrojejunostomy. The syndrome classically refers to obstruction of the upstream limb of a side-to-side gastrojejunostomy, but has also been used to refer to the biliopancreatic limb of a Roux-en-Y gastrojejunostomy. Afferent loop syndrome is not an uncommon postoperative complication, and one study has estimated that it occurs in 13% of post-pancreaticoduodenectomy patients. Patients usually present with epigastric pain, abdominal distention, nausea, and potentially bilious vomiting. It has been classified as acute (<7 days postoperative) or chronic (>7 days postoperative). Bilious vomiting is presumed to occur from regurgitation of bilious contents in the afferent limb into the stomach after release from intermittent obstruction.

Answer 152

D? Although C may be reasonable if lot of pain Uptodate Subcutaneous air has also been described after PEG tube placement. It occurs from air being introduced between the cutaneous and subcutaneous tissues [35]. In the absence of other findings, it is inconsequential and should not preclude feeding [35].

Answer 153

B in answer key but A more likely the answer But gas in RUQ makes it suspicious for Petersen's hernia CT showing whorling of small bowel mesentery, presence of cecum and TI in RUQ and existence of majority of small bowel loops on one side of the abdo cavity as triad of CT findings pathognomonic for internal hernia In RYGB, there is an assoc between SBO and an elevated amylase or lipase. Acute obstruction of biliopancreatic limb can be difficult to dx and in these pts, sensitivity of elevated amylase or lipase is high. It is important to recognize that an elevation of these enzymes is not likely a result of acute pancreatitis To distinguish BP limb obstruction from pacnreatitis, the latter condition would have lipase elevated in the 1000s.

Answer 154

D Try to increase margin to ampulla to allow localized resection.

Answer 155

B Sabiston: Adenomatous polyps carry a distinct risk for the development of malignancy in the polyp. Mucosal atypia is frequent,and progression from dysplasia to carcinoma in situ has been observed. The risk for the development of carcinoma is approximately 10% to 20% and increases with increasing size of the polyp. Endoscopic removal is indicated for pedunculated lesions and is sufficient if the polyp is completely removed and there are no foci of invasive cancer on histologic examination. If the polyp is larger than 2 cm, is sessile, or has a proven focus of invasive carcinoma, operative excision is warranted. Up to Date: Gastric adenomas typically occur in a background of chronic atrophic gastritis. Gastric adenomas are much less common than fundic gland polyps in patients with FAP; they are typically isolated and located in the antrum and are associated with a relatively low but real risk of progression to cancer. Adenomas may be flat or polypoid, and are usually <2 cm in size. Adenomas are usually solitary. Most are found in the antrum, but some occur in the corpus and cardia. It is estimated that 8 to 59 percent of adenomas are associated with synchronous gastric carcinomas [53]. The presence of invasive carcinoma in an adenoma correlates with increasing size, villous contour, and the degree of dysplasia [23,54]. The risk of malignancy is lower in flat adenomas [55]. High-grade dysplasia has been identified in close proximity to a high proportion (40 to 100 percent) of early gastric cancers. In addition, as adenomatous polyps are associated with atrophic gastritis, the normal-appearing antral and corpus mucosa should be sampled to assess the stage of gastritis and, thus, cancer risk. All patients should be tested for active H. pylori infection and, if present, the infection should be treated

Answer 156

D Pyloric stenosis results in hypochloremic, hypokalemic metabolic alkalosis Need 20 KCL or more; rehydrate at 150%.

Answer 157

A HP eradication is first line. In the rare HP negative patient, RT is very effective with low recurrence. Complete response to eradication can take 12-18 months, so usually defer RT til after that. MALT with t(11:18) is unlikely to respond to eradication and is treated with RT DLBC lymphoma (high-grade MALT) is treated with upfront chemo (R-CHOP).

Answer 158

C Up to 2cm can consider endoscopic resection, but sessile is more difficult. Given size >2cm, sessile, and close to ampulla, transduodenal polypectomy would be best. Schwartz Tumors located in the duodenum, including asymptomatic lesions incidentally found during EGD, can pose the greatest therapeutic challenges. These lesions should be biopsied; symptomatic tumors and adenomas, because of their malignant potential, should be removed. In general, duodenal tumors less than 1 cm in diameter are amenable to endoscopic polypectomy. Lesions greater than 2 cm in diameter are technically difficult to remove endoscopically and may need to be removed surgically. Surgical options include transduodenal polypectomy and segmental duodenal resection. Tumors located in the second portion of the duodenum near the ampulla of Vater may require pancreaticoduodenectomy. EUS may offer utility for duodenal tumors ranging in size between 1 and 2 cm in diameter Recent studies have shown that endoscopic resection of biopsy-proven benign duodenal periampullary adenomas leads to equivalent efficacy to surgery but with lower morbidity. Adenomas can recur; therefore, surveillance endoscopy is required after these procedures.

Answer 159

A Sabiston: Patients with splenic aneurysms may report a history of left upper quadrant or epigastric pain. The term double rupture has been used to describe these aneurysms, but is relatively rare. There is initial contained bleeding in the lesser sac, followed by free hemorrhage into the peritoneal cavity, causing hypovolemic shock. Treatment should be considered in aneurysms larger than 2 cm in diameter. Because of the high mortality rate, treatment is warranted for pregnant women and those of childbearing age. Simple ligation or excision of the aneurysm is preferred to splenectomy. Endovascular repair is emerging as the treatment of choice.

Answer 160

D Sabiston: endo, then angio, then wedge Dieulafoy's lesion: current trends in diagnosis and management. Ann R Coll Surg Engl. 2010 Oct; 92(7): 548–554. There is no consensus on the treatment of Dieulafoy's lesions. Therapeutic endoscopy can control the bleeding in 90% of patients while angiography is being accepted as a valuable alternative to endoscopy for inaccessible lesions. Currently, surgical intervention is kept for failure of therapeutic endoscopic or angiographic interventions and it should be guided by pre-operative localisation

Answer 161

B in answer key though D seems like a reasonable choice. If type I, no vagotomy required

Answer 162

C | Primary repair if small (usual case), otherwise resect portion and do D-J.

Answer 163

A C if previously had been on steroids

Answer 164

A Forrest IIa; dual methods of control is superior.

Answer 165

B Etiology is hiatus hernia. Organoaxial associated with HH; mesoaxial is not, so treatment for mesoaxial volvulus is gastropexy.

Answer 166

A Dieulafoy’s lesion. 1st line is endoscopic management.

Answer 167

B Sabiston: If these maneuvers fail, high gastrotomy and suturing of the mucosal tear is indicated. It is important to rule out the diagnosis of variceal bleeding in cases of failed endoscopic therapy by a thorough examination of the gastroesophageal junction.

Answer 168

A Acute gastric remnant distension. - Usually after RYGB - Due to edema or obstruction of enteroenterostomy site. - Dx within first few days post op. - N/V, LUQ pain, bloating, hiccups - Tx-- perc decompression or reoperation - NG tube controversial and will not decompress the remnant stomach

Answer 169

B Afferent limb syndrome; revise to R-Y or Braun Sabiston: Upper endoscopy demonstrates friable, beefy red mucosa. Most patients suffering from alkaline reflux gastritis have had gastric resection performed with a Billroth II anastomosis. Although bile reflux appears to be the inciting event, a number of issues remain unanswered with respect to the role of bile in its pathogenesis. For example, many patients have reflux of bile into the stomach following gastrectomy without any symptoms. Moreover, there is no clear correlation between the volume or composition of bile and the subsequent development of alkaline reflux gastritis. Although it is clear the syndrome does exist, caution needs to be exercised to ensure that it is not overdiagnosed. After a diagnosis is made, therapy is directed at relief of symptoms. Unfortunately, most medical therapies that have been tried to treat alkaline reflux gastritis have not shown any consistent benefit. Thus, for patients with intractable symptoms, the surgical procedure of choice is conversion of the Billroth II anastomosis into a Roux-en-Y gastrojejunostomy, in which the Roux limb has been lengthened to more than 40 cm. SCNA (Postgastrectomy Syndromes) Another possible solution to afferent loop syndrome is an afferent to efferent loop bypass. This bypass procedure, originally described by Braun, is particularly useful when dissection of the original gastrojejunal anastomosis is not required or technically difficult.

Answer 170

D SCNA (Postgastrectomy Syndromes) Although bile reflux and gastritis are more common after B-I and B-II reconstruction than after Roux-Y, debilitating symptoms are infrequent. For the few patients with severe bile reflux gastritis after partial or subtotal distal gastrectomy with B-I or B-II reconstruction, the best solution is to reoperate and convert to Roux-Y anatomy.

Answer 171

C Intestinal metaplasia is a risk factor for adenocarcinoma, but we don’t really know how to follow or treat these patients. Up to Date says surveillance is recommended, eradicate H. pylori, and no data to support chemoprevention.

Answer 172

B Shaw – no operation unless obstructing or cholangitic.

Answer 173

B Most sources say treat when>2cm. If you’re already there for the ulcer, just ligate the thing and spare him the contrast.

Answer 174

B Endoscopic resection – 1st line; if recurrence then open polypectomy Uptodate Endoscopically visible duodenal adenomas are identified in more than half of FAP patients. Approximately half of duodenal cancers are ampullary or periampullary. Complete polypectomy or sampling of duodenal polyps should be performed at the time of initial discovery and on each subsequent examination. An abnormal-appearing papilla should be biopsied. Adenomas identified at the ampulla of Vater should be removed endoscopically if possible. Management of high-grade dysplasia in the periampullary region (surgery/ablative therapy versus more frequent surveillance) is controversial and should be individualized based on the patient’s age and the number of duodenal adenomas. The resection margins should be free of neoplastic tissue. A study that included 26 FAP patients who underwent endoscopic ampullectomy demonstrated the procedure can be performed safely, but ongoing surveillance is required because recurrences were common. The severity of duodenal polyposis, as determined by the Spigelman stage (0 to IV), is used to guide subsequent surveillance (table 1). Surgery (duodenectomy) is reserved for patients with stage IV polyposis.

Answer 175

B in answer key <12cm, HM; 12-25cm Finney appropriate. Maybe this patient is at risk for short bowel syndrome. Don’t do if longer than 25cm as creates a blind loop diverticulum. But A is also a reasonable choice if no concerns about short gut cause there is a risk of malignancy with stricture

Answer 176

C Depends on age. If >70, increased M&M with laparoscopic repair, so do open.

Answer 177

C Enteropathy Assoc T cell Lymphoma

Answer 178

C If stable, resect b/c of risk of malignancy. If unstable, oversew but needs repeat scopes.

Answer 179

C Gastric remnant distension — Gastric remnant distension is a rare but potentially lethal complication following gastric bypass [12,13]. The gastric remnant is a blind pouch and may become distended if paralytic ileus or distal mechanical obstruction occurs postoperatively. Iatrogenic injury to vagal fibers along the lesser curvature may also contribute, possibly by leading to impaired emptying of the bypassed stomach. Progressive distension can ultimately lead to rupture, spillage of massive gastric contents, and subsequent severe peritonitis [14]. The combination of the large size of inoculum (liters) and the injurious contents (acid, bile, pancreatic enzymes, and bacteria) makes this complication much more serious than leakage occurring at the gastrojejunostomy. Clinical features include pain, hiccups, left upper quadrant tympany, shoulder pain, abdominal distension, tachycardia, or shortness of breath. Radiographic assessment may demonstrate a large gastric air bubble. Treatment consists of emergent operative decompression with a gastrostomy tube or percutaneous gastrostomy [15]. Immediate oative exploration and decompression are required if percutaneous drainage is not feasible, or if perforation is suspected. Although gastrostomy is not performed routinely by most surgeons at the initial gastric bypass operation, drainage of the gastric remnant can prevent this rare but sometimes fatal complication. Routine gastrostomy should be considered in the elderly, super-obese patients, patients with diabetic gastropathy and as part of revisional surgeries where gastric emptying may be delayed.

Answer 180

C UGI contrast swallow – leak, also to assess distal stomach for outflow obstruction Several points (based on ASMBS paper): 1) Unstable patients should not have imaging studies but go to the OR for exploration 2) CT with oral and IV contrast is more sensitive 3) For GB, early exploration and repair of leak with remnant gastrostomy 4) For GS, early leaks (within 48 hrs) can be managed with operative repair, drainage, and feeding access, but beyond 48 hrs don’t try to repair the leak, just drain and feed.

Answer 181

A <2cm, not ulcerated, clinically node negative is candidate for EMR. Up to Date: Standard and expanded criteria for endoscopic resection — The general guidelines for the selection of patients with EGC who are appropriate for endoscopic resection with EMR or ESD are outlined below [1-4]: ``` ●High probability of en bloc resection ●Tumor histology •Intestinal type adenocarcinoma •Tumor confined to the mucosa •Absence of venous or lymphatic invasion ●Tumor size and morphology •Less than 20 mm in diameter, without ulceration •Less than 10 mm in diameter if Paris classification IIb or Iic ``` Studies have shown high survival and cure rates in patients with EGC who undergo EMR: Sabiston Endoscopic therapy for gastric cancer is well established in Eastern countries. Endoscopic resection is a safe and effective technique for patients who meet the criteria and will continue to play an increasing role in the treatment of this disease. As a matter of standard practice, patients with tumors larger than 2 cm, with ulceration or with any submucosal invasion, should be referred for gastrectomy with lymph node dissection if not part of a clinical trial.

Answer 182

A Controversial; NCCN says chemorads, but surgeons say in fit patient, R0 resection is only chance for cure and can get wider margins so re-resect to negative margins. Different if esophageal margin is positive. If there is metastatic or N2 disease, probably little benefit from re-resection and treatment should be chemorads (or chemo), but if N0 or N1 in a young person, there is survival advantage. Some evidence that positive margins re-resected is equivalent to initially negative margins.

Answer 183

D Standard textbook answer, although Toronto manual 2015 says staging laparoscopy for T2 and higher.

Answer 184

D Up to Date: Many families with HDGC have germline mutations in the E-cadherin (CDH1) gene that are inherited in an autosomal dominant pattern. The lifetime cumulative risk for clinically significant gastric cancer in individuals from these families is >80 percent in both men and women by age 80; the median age at diagnosis is 38. Because these early gastric cancers are located beneath an intact mucosal surface, early detection is extremely difficult, and prophylactic total gastrectomy is usually advised after age 20, and before the age of 40. Modified criteria for selection of patients for genetic testing for HDGC have been proposed based upon the experience of the British Columbia Cancer Agency Hereditary Diffuse Gastric Cancer Program: ●Families with two or more documented cases of gastric cancer in first or second degree relatives, with at least one diffuse gastric cancer diagnosed before age 50 years ●Families with multiple lobular breast cancers with or without diffuse gastric cancer in first or second degree relatives ●Individual diagnosed with diffuse gastric cancer before 35 years of age from a low incidence population ●Potential additional criteria which need additional validation in clinical studies include: •Three or more cases of gastric cancer in first or second degree relatives, diagnosed at any age, one or more of which is a documented case of diffuse gastric cancer (3 percent mutation rate; 1 positive/30 tested) •Family with one or more cases of both diffuse gastric cancer and signet ring colon cancer (33 percent mutation rate; 1 positive/3 tested). •Personal history but no family history of diffuse gastric cancer or lobular breast cancer (mutation rate unknown)

Answer 185

D Antrectomy – diagnosis, therapy, risk of CA, deals with obstruction Endoscopic dilation – also reasonable, but doesn’t mention deeper biopsy; need to exclude deeper invasive Dilate, PPI, rescope and rebiopsy. LGD has low rate of progression to invasive, and given age just dilate. Gastric Preneoplastic Lesions and Epithelial Dysplasia,Gastroenterology Clinics of NA (2007) Given the low rate of malignant transformation of low-grade dysplasia, annual endoscopic surveillance with rebiopsy typically is performed, and surgical resection is usually not necessary [99] and [100]. It also must be emphasized that low-grade dysplasia occurring in a background of extensive intestinal metaplasia may be associated with a higher risk of malignancy [101]. Patients who have high-grade dysplasia, large adenomatous polyps, or well-differentiated adenocarcinomas no more than 2 cm should undergo definitive therapy. Complete excision of mucosal-based lesions may be performed by endoscopic mucosal resection, obviating the need for surgical resection in many cases [102]. Mucosal lesions that are not amenable to endoscopic resection, and those with a submucosal component, are managed best with surgical resection.

Answer 186

D Prophylactic gastrectomy between ages 20-40 (peak incidence age 38). Mammography is not useful as young and dense breasts, and lobular carcinoma not detected on mammo. MRI would be good option.

Answer 187

B Sabiston: Adenomatous polyps carry a distinct risk for the development of malignancy in the polyp. Mucosal atypia is frequent,and progression from dysplasia to carcinoma in situ has been observed. The risk for the development of carcinoma is approximately 10% to 20% and increases with increasing size of the polyp. Endoscopic removal is indicated for pedunculated lesions and is sufficient if the polyp is completely removed and there are no foci of invasive cancer on histologic examination. If the polyp is larger than 2 cm, is sessile, or has a proven focus of invasive carcinoma, operative excision is warranted.

Answer 188

A SBO is contraindication to chemo. This patient has very short life expectanct (weeks) so medical management is optimal, as even with surgery likely wont survive to discharge. Surgery for MBO is contraindicated with ascites. NCCN specifically included steroids and octreotide for medical management of MBO. Multifocal recurrence, incomplete SBO. May be a role for palliative surgery, but overall is not clear exactly what that is. Midline recurrence would require abdominal wall resection otherwise would not heal. Don’t operate for MSBO if generalized carcinomatosis or ascites.

Answer 189

Both A and B in answer key Deeper biopsy – reasonable -exclude lymphoma

Answer 190

C Not Siewerts III as does not invade EGJ, but even if it were: Patients with Siewert type II and III tumors should undergo a total gastrectomy with a transhiatal resection of the distal esophagus with lymphadenectomy of the lower mediastinum and an extended lymph node dissection including nodes along the hepatic, left gastric, celiac, and splenic arteries as well as those in the splenic hilum. (UTD)

Answer 191

D TYPE III , so resection and lymphadenectomy. Regardless, resect all 2cm or greater. ``` Up to Date: Type 3 (sporadic) gastric carcinoids are treated by partial or total gastrectomy with local lymph node resection. The risk of nodal metastases is dependent on tumor size and depth, and some have suggested that endoscopic resection alone may represent adequate therapy for intraepithelial tumors <2 cm and perhaps for tumors <1 cm invading the lamina propria or submucosa. However, this is not a standard approach. For type 1 and 2 gastric carcinoids smaller than 1 to 2 cm, endoscopic resection represents adequate therapy. Subsequent endoscopic surveillance is needed every 6 to 12 months since these patients continue to exhibit mucosal changes and hyperplasia of enterochromaffin-like cells (ECL) due to sustained hypergastrinemia. ```

Answer 192

D in answer key but maybe A based on uptodate UTD Type I gastric ulcer — Type I gastric ulcers are the most common type of gastric ulcer. These occur along the lesser curvature near the junction of fundic and antral mucosa and occur in the setting of acid hyposecretion. For most patients with type I gastric ulcer, distal gastrectomy with Billroth I or Billroth II reconstruction is recommended since this approach removes the ulcer and the diseased antrum. It also treats an occult malignancy. Although type I gastric ulcer has classically been considered the consequence of inadequate gastric mucosal defense, as opposed to increased acid secretion, many advocate the addition of some form of vagotomy to the gastric resection. Although most prefer distal gastrectomy, highly selective vagotomy has been used for type I gastric ulcer. The value of highly selective vagotomy in gastric ulcer may derive from its ability to decrease acid secretion while maintaining adequate gastric emptying and minimizing postoperative duodenogastric reflux. The procedure is performed as for duodenal ulcer, with the addition of a gastrotomy to resect or biopsy the ulcer bed.

Answer 193

A Siewert classification — subclassification scheme for EGJ adenocarcinomas - Type I tumor (located between 5 and 1 cm proximal to the anatomical squamocolumnar junction or Z-line (figure 2)) [16] – Adenocarcinoma of the distal esophagus that usually arises from an area with specialized intestinal metaplasia of the esophagus (ie, Barrett's esophagus) and that may infiltrate the EGJ from above. - Type II tumor (located between 1 cm proximal and 2 cm distal to the anatomical Z-line) – True carcinoma of the cardia arising from the cardiac epithelium or short segments with intestinal metaplasia at the EGJ; this entity is also often referred to as "junctional carcinoma." - Type III tumor (located between 2 and 5 cm distal to the anatomical Z-line) – Subcardial gastric carcinoma that infiltrates the EGJ and distal esophagus from below. In general, type I cancers more frequently involve lymph nodes in the upper mediastinum (tracheal bifurcation and above) [28]. Patients with type I tumors are not appropriate candidates for a purely transabdominal approach to resection. The standard surgical approach is a transthoracic en bloc esophagectomy combined with resection of the upper part of the stomach and two-field lymphadenectomy. On the other hand, for type II and III carcinomas, nodal metastases are more frequently found in the lower mediastinum and around the celiac trunk (table 4) [29]. The standard surgical approach is a transhiatally extended total gastrectomy with distal esophageal resection and systemic lymphadenectomy of nodes that drain the stomach.

Answer 194

B Perioperative chemo for T3 and higher, N1 and higher. UTD For most patients with potentially resectable, histologically proven noncardia gastric adenocarcinoma with invasion beyond the submucosa (clinical stage T2N0 or higher (table 1)) on preoperative staging evaluation, we recommend combined modality therapy over surgery alone. We generally prefer neoadjuvant therapy over initial surgery, especially for those with a high likelihood of developing distant metastases (ie, those with bulky T3/T4 tumors, visible perigastric nodes by preoperative imaging studies, a linitis plastica appearance, or positive peritoneal cytology in the absence of visible peritoneal disease). There are no randomized trials demonstrating better outcomes from neoadjuvant therapy versus initial surgery followed by any form of adjuvant therapy. However, given the greater chance of delivering therapy in the preoperative setting and the fact that patients who are at high risk of developing distant metastases may be spared the morbidity of unnecessary gastrectomy if evidence of distant metastases emerges after chemotherapy, we favor this approach. However, upfront surgery remains an accepted approach, especially for patients with clinically staged, nonbulky, T2 or T3 tumors with no visible perigastric nodes.

Answer 195

A D1 vs D2, Dutch and British trials did not show survival benefit to D2. Morbidity is related to pancreatectomy and splenectomy, so don’t do it. Current standard of care in Canada is D2

Answer 196

D Palliative resection for bleeding, do not resect met!

Answer 197

C MAGIC: perioperative ECF for stage II-IVa; improved 5-yr survival, DFS, recurrence rates. Up to Date: Lymphadenectomy: The Dutch trial has been updated with 15-year follow-up [64]. The survival curves have continued to separate, although the difference in overall survival is still not statistically significant (22 versus 28 percent in the D1 and D2 arms, respectively, p = 0.34). However, the gastric cancer-related death rate is significantly higher in the D1 arm (48 versus 37 percent) while death rates due to other causes were not different. This supports the concept that if the D2 dissection can be done with low operative mortality, similar to that of a D1 dissection (as occurs in high volume centers), there will be a positive survival impact. This mirrors the conclusion of the latest Dutch trial paper, which is that D2 dissection is recommended in patients with potentially curable gastric cancer. Given the apparent impact of D2 lymphadenectomy on disease-specific survival, most major cancer centers are performing a D2 as compared to a D1 dissection. Treatment guidelines published by the National Comprehensive Cancer Network (NCCN) recommend that D2 lymph node dissection is preferred over a D1 dissection. However, in view of the higher reported rates of operative mortality when this procedure has been performed in randomized trials, this recommendation this should be tempered by where and by whom the operation is being performed Perioperative Chemotherapy: A meta-analysis of these three trials [3,22,23] plus two other trials comparing preoperative oral fluoropyrimidine versus surgery alone [24,25] and seven other smaller trials comparing a variety of preoperative chemotherapy regimens versus surgery alone concluded that neoadjuvant chemotherapy was associated with a statistically significant benefit in terms of both overall survival (odds ratio [OR] 1.32, 95% CI 1.07-1.64) and PFS (OR 1.85, 95% CI 1.39-2.46) [27]. Furthermore, neoadjuvant chemotherapy was associated with a significantly higher complete (R0) tumor resection rate (OR 1.38, 95% CI 1.08-1.78), and did not significantly worsen rates of operative complications, perioperative mortality, or grade 3 or 4 adverse effects. In terms of patient selection for this approach, it is reasonable to utilize the eligibility criteria for the MAGIC trial (patients of any age with a performance status of 0 or 1, a histologically proven adenocarcinoma of the stomach that was considered to invade through the submucosa [stage T2 or higher, with no evidence of distant metastases or locally advanced inoperable disease, as evaluated by CT, ultrasonography, or laparoscopy) SCNA: In summary, based on the trials mentioned earlier, the retrospective studies suggest improved survival in patients undergoing ELND, but this is not confirmed in prospective studies. With an experienced surgeon, a D2 lymphadenectomy can be performed safely and provides more accurate staging information

Answer 198

C Endoscopic therapy as 1st line is reasonable, even if unstable. We routinely scope unstable UGIB patients for hemostasis. Mastery (6th ed, p 993). Postoperative intragastric hemorrhage should always be managed first with endoscopy. If bleeding is ongoing after 4U of blood in 24hrs and it is not possible to control endoscopically, reoperation is needed. At relook, should make transverse gastrostomy 3-5cm above the anastomosis and obtain hemostasis. Closure is in horizontal direction

Answer 199

D Perforation of the esophagus is a surgical emergency. Early detection and surgical repair within the first 24 hours results in 80% to 90% survival; after 24 hours, survival decreases to less than 50%.

Answer 200

E Common cause of intermittent dysphagia, associated with HH, treatment is dilation or endoscopic forcep disruption of mucosal ring.

Answer 201

B Splenic cysts are categorized as parasitic, usually from Echinococcus infection, or nonparasitic. Nonparasitic cysts, can be further subdivided into primary (congenital) or secondary (pseudocysts). Primary cysts are relatively rare entities. Symptoms are generally vague left upper-quadrant discomfort, although many cysts are completely asymptomatic and are discovered when imaging is done for other purposes. Indications for surgical intervention include symptoms and cysts larger than 5 cm (figure 1). Percutaneous aspiration of the cyst contents leads to poor results, with reaccumulation of the cystic fluid being the norm. Therefore, a variety of sclerosing agents added to percutaneous aspiration are used. Although success rates for eradicating the cyst have improved, recurrence rates remain high. Unroofing of the cyst still leaves behind a portion of the cyst lining on the spleen. Therefore, recurrences are still possible. Splenectomy would be an effective treatment of the cyst, and, in fact, was previously considered the standard of care. However, with splenectomy, all of the functioning splenic parenchyma is removed, with the subsequent short- and long-term complication associated with the asplenic state. The newer technique of partial splenectomy offers the best management option of eliminating the entire cyst wall, thereby minimizing recurrences, yet maximizing the remaining functional splenic parenchyma. This can be done either through an open laparotomy incision or laparoscopically. It is also less technically demanding if the cyst is located at a splenic pole.

Answer 202

C Although uncommon, splenic abscesses can be lethal if not treated appropriately. The most common etiology of a splenic abscess is hematogenous spread to the spleen from another septic focus, such as endocarditis, diverticulitis, or directly from intravenous drug abuse. Trauma to the spleen can make the organ more susceptible to infection if there is a devascularized segment of splenic parenchyma. Patients present with fever, elevated white blood cell count, and left upper-quadrant pain. Diagnosis is made by CT scan Intravenous antibiotics and splenectomy provide the best means of source control. Aspiration or percutaneous drainage may occasionally be successful; they are associated with increased rates of abscess recurrence (50–60. Park AE, Godinez CD Jr. Spleen. In: Brunicardi FC, Andersen DK, Billiar TR, eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill;2010:1245–1265. UTD: Splenic abscess is usually managed by a combination of antibiotic therapy and splenectomy [44-46,49]. CT-guided percutaneous aspiration is occasionally successful, but this approach has not replaced splenectomy as the standard of care.

Answer 203

A UTD: Optimizing the preoperative platelet count – If the platelet count needs to be increased for splenectomy, intravenous immune globulin (IVIG) is often administered several days to a week prior to the procedure (table 2). We prefer to perform splenectomy with a platelet count of ≥50,000/microL; however, some patients with ITP are able to undergo splenectomy safely in the setting of more severe thrombocytopenia with platelets available for transfusion if urgently needed because of intraoperative bleeding

Answer 204

A Observe if asymptomatic, <5cm.

Answer 205

B and D First determine functionality. If nonfunctional, observe if <5cm. Tests -Pheo: 24-hour urine fractionated metanephrines and catecholamines -For patients with symptoms of Cushing's syndrome: 24-hour urinary free cortisol -For patients lacking symptoms of Cushing's syndrome: 1 mg overnight dexamethasone suppression test -Primary Aldosteronism: Plasma aldosterone concentration, plasma renin activity -For adrenocortical carcinoma: Serum DHEAS

Answer 206

C Splenectomy may be useful in cirrhotics with thrombocytopenia preventing antiviral therapy. IFN 2-a is effective antiviral but can cause thrombocytopenia precluding use. UTD: splenectomy almost never necessary for thrombocytopenia in cirrhosis unless <10 which is extremely rare. Clear evidence of portal hypertension; not an indication for splenectomy.

Answer 207

A and B both highlighted in answer key

Answer 208

B Ectopic spleen (accessory spleen)- more common in ITP than splenosis

Answer 209

B Mucous membrane bleeding is considered significant bleeding., so 2nd line therapy is indicated. Splenectomy is the preferred 2nd line therapy, as IVIG only transiently improves counts. Question is odd, however, as clinical bleeding with plts >50 is exceptionally uncommon. Sabiston Splenectomy is also the treatment of choice for patients with incomplete response to glucocorticoid treatment and for pregnant women in the second trimester of pregnancy who have also failed steroid treatment or IV Ig therapy with platelet counts less than 10,000/mm3 without symptoms or less than 30,000/mm3 with bleeding problems. It is not necessary to proceed to splenectomy for patients who have platelet counts higher than 50,000/mm3, have had ITP for longer than 6 months, are not experiencing bleeding symptoms, and who are not engaged in high-risk activities. A recent review of short-term and long-term failure of laparoscopic splenectomy has reported an overall approximate failure rate of 28% at 5 years after splenectomy.9 UTD The goal of ITP therapy is to provide a safe platelet count to prevent clinically important bleeding, rather than to normalize the platelet count [1-4]. We often initiate second-line therapy at a slightly lower platelet count than used for initiating initial therapy (ie, <20,000/microL rather than 30,000/microL that is used for initial therapy) We consider intravenous immune globulin (IVIG) to be rescue treatment in ITP rather than routine therapy. It is important for patients with clinically important bleeding and for patients in whom a more rapid response is required [5]. Second-line therapy is generally reserved for patients with thrombocytopenia that is associated with significant bleeding symptoms (eg, mucosal purpura, more serious bleeding) or for severe, persistent or recurrent thrombocytopenia (eg, platelet count <20,000/microL), following glucocorticoid-based treatments. For second-line therapies, we recommend splenectomy or rituximab rather than observation or chronic glucocorticoids For patients who require additional treatment beyond initial therapy with glucocorticoids, we suggest splenectomy, provided the patient can tolerate surgery. This practice is based on greater response rates and longer sustained responses to splenectomy compared with rituximab If the platelet count needs to be increased for splenectomy, intravenous immune globulin (IVIG) is often administered several days to a week prior to the procedure (table 2). We prefer to perform splenectomy with a platelet count of ≥50,000/microL; however, some patients with ITP are able to undergo splenectomy safely in the setting of more severe thrombocytopenia with platelets available for transfusion if urgently needed because of intraoperative bleeding

Answer 210

C Patient needs urgent OR for diverticulitis due to peritonitis.

Answer 211

B Mild elevation in metanephrines expected with antihypertensives, TCA’s, antipsychotics. CT if first line, non-contrast to evaluate densite (obviously can’t assess washout). MRI would be indicated d/t CT being contraindicated. MIBG non-contributory as a routine test, used if pt has pheo and concern for multifocality. ●With CT, there is some exposure to radiation but no risk of exacerbation of hypertension if current radiographic contrast agents are given. CT with low-osmolar contrast is safe for patients with pheochromocytoma even without alpha or beta blocker pretreatment, as illustrated in a report of 22 such patients [56]. After intravenous (IV) low-osmolar contrast administration for CT scan, there was a significant increase in diastolic blood pressure but no increase in plasma catecholamine levels or episodes of hypertensive crises. ●With MRI, there is neither radiation nor dye. This more expensive test can distinguish pheochromocytoma from other adrenal masses; on T2-weighted images, pheochromocytomas appear hyperintense and other adrenal tumors isointense, as compared with the liver (image 1) [18]. However, MRI lacks the superior spatial resolution of CT. • If abdominal and pelvic CT or MRI is negative in the presence of clinical and biochemical evidence of pheochromocytoma, one ought first to reconsider the diagnosis. If it is still considered likely, then iodine-123 (123-I) metaiodobenzylguanidine (MIBG) scintigraphy may be done. MIBG is a compound resembling norepinephrine that is taken up by adrenergic tissue. A MIBG scan can detect tumors not detected by CT or MRI or multiple tumors when CT or MRI is positive [6]. ●MIBG scintigraphy is superfluous in patients with sporadic solitary adrenal pheochromocytoma identified on CT/MRI [57]. ●MIBG scintigraphy is indicated in patients with large (eg, >10 cm) adrenal pheochromocytomas (increased risk of malignancy) or paraganglioma (increased risk of multiple tumors and malignancy) (image 2) [25]

Answer 212

B Mild elevation in metanephrines expected with antihypertensives, TCA’s, antipsychotics. CT if first line, non-contrast to evaluate densite (obviously can’t assess washout). MRI would be indicated d/t CT being contraindicated. MIBG non-contributory as a routine test, used if pt has pheo and concern for multifocality. CT and MRI are equivalent; MRI better for extraadrenal; IV contrast can also precipitate catecholamine crisis. Non-contrast CT would be best. ●With CT, there is some exposure to radiation but no risk of exacerbation of hypertension if current radiographic contrast agents are given. CT with low-osmolar contrast is safe for patients with pheochromocytoma even without alpha or beta blocker pretreatment, as illustrated in a report of 22 such patients [56]. After intravenous (IV) low-osmolar contrast administration for CT scan, there was a significant increase in diastolic blood pressure but no increase in plasma catecholamine levels or episodes of hypertensive crises. ●With MRI, there is neither radiation nor dye. This more expensive test can distinguish pheochromocytoma from other adrenal masses; on T2-weighted images, pheochromocytomas appear hyperintense and other adrenal tumors isointense, as compared with the liver (image 1) [18]. However, MRI lacks the superior spatial resolution of CT. • If abdominal and pelvic CT or MRI is negative in the presence of clinical and biochemical evidence of pheochromocytoma, one ought first to reconsider the diagnosis. If it is still considered likely, then iodine-123 (123-I) metaiodobenzylguanidine (MIBG) scintigraphy may be done. MIBG is a compound resembling norepinephrine that is taken up by adrenergic tissue. A MIBG scan can detect tumors not detected by CT or MRI or multiple tumors when CT or MRI is positive [6]. ●MIBG scintigraphy is superfluous in patients with sporadic solitary adrenal pheochromocytoma identified on CT/MRI [57]. ●MIBG scintigraphy is indicated in patients with large (eg, >10 cm) adrenal pheochromocytomas (increased risk of malignancy) or paraganglioma (increased risk of multiple tumors and malignancy) (image 2) [25]

Answer 213

A Treatment of splenic abscesses depends on whether the abscess is unilocular or multilocular. In one third of adult patients, the abscess is multilocular. In one third of children, the abscess is unilocular. Unilocular abscesses are often amenable to percutaneous drainage, along with antibiotics, with success rates reported at 75% to 90% for unilocular lesions. Multilocular lesions, however, are usually treated with splenectomy, drainage of the left upper quadrant, and antibiotics. Laparoscopic splenectomy for abscess has been reported.3 Gold standard is actually splenectomy, but better efficacy of perc drain if unilocular.

Answer 214

A Severe congenital hemolytic anemia – antibody mediated; must removal all splenic tissue Myeloid metaplasia – only for relieving mass effect

Answer 215

Both A and E

Answer 216

C Splenic Arterial Interventions: Anatomy, Indications, Technical Considerations, and Potential Complications, 2005. Splenic artery aneurysms are the most common visceral artery aneurysms, with a reported prevalence of 0.8% at arteriography and 0.04%–0.10% at autopsy. Most aneurysms are small (<2 cm in diameter), saccular, and located at a bifurcation in a middle or distal segment of the splenic artery. Splenic artery aneurysms are multiple in 20% of cases. Splenic artery aneurysms are found most often in multiparous women: Double rupture phenomenon: aneurysm first ruptures into the lesser sac with mild clinical symptoms then the blood overflows into peritoneal cavity through the Winslow foramen with hemorrhagic shock.

Answer 217

D Grade IV injury, embolization improves succes of NOM. Stable patient.

Answer 218

A Decreased red cell life span – lengthened RBC life span Properdin and tuftsin are opsonins produced in spleen, Howell-Jolly bodies present post-splenectomy. RBC life span is increased.

Answer 219

C Decr IgM but IgG stays same Decr WCC Incr RBC lifespan, especially in HS

Answer 220

G and now H based on recent literature a. CLL – yes, maybe b. autoimmune hemolytic anemia – yes, if warm c. SLE with hypersplenism d. Feltys syndrome – yes, good response to splenectomy e. SC anemia f. hereditary spherocytosis g. cirrhosis with splenomegaly h. trauma i. Hairy cell leukemia – SESAP: used to be an indication, but newer medical treatment obviated splenectomy j. Polycytemia rubra vera (yes, if painful or splenic infarctions) Basically, splenectomy useful if symptomatic splenomegaly.

Answer 221

A Staph, Salmonella, E. coli (Clinical Infectious Disease) Sabiston: Staph, Strep, Salmonella, Enterococcus Candida possible in neutropenic/immunosuppressed, but seems like still less common than bacterial. Fungal in 25% of immunosuppressed splenic abscescc patients. (Shackleford’s) Candida – more common then in immunocompetent, but still < staph.

Answer 222

D | Sepsis 1-5%

Answer 223

C | Accessory spleens – actually quite common, probably more than trauma

Answer 224

C Hypertension, +/- hypokalemia, hypernatremia, metabolic alkalosis, muscle weakness, hypomagnesemia, CV risk

Answer 225

A Urine with low sg and resistant to ADH (should be high SG) Alkalosis – not a key feature but may be present

Answer 226

A Sabiston – 75% caused by pituitary adenoma. UTD: 1) iatrogenic 2) ectopic ACTH (SCLC) 3) Cushings disease 4) adrenal tumours SESAP says pituitary source in 80-85%, ectopic in 15%. UTD says ectopic, but qualifies that it is “probably” the 2nd most common (after iatrogenic) although often undiagnosed. Traditional answer is adenoma (pituitary) so Cushing’s disease.

Answer 227

C or D in answer key IVIG is 2nd line, provides temp support if pts <5 or bleeding. IVIG lasts for days to weeks. Indications for splenectomy: Duration 3-6 months, ongoing thrombocytopenia, Splenectomy only for plts <30, or 30-50 and inability to wean from steroids; steroid dosing is 1-1.5mg/kg/d/ 6 weeks is too early to consider splenectomy; should wait 6 months as possibility of spontaneous regression. Goal is 50,000, so should start to taper. Splenectomy only after 6 months and if unable to maintain plts 50 or higher. UTD: In practice, we often wait at least six months from diagnosis of ITP to splenectomy, to allow for late spontaneous remissions; this practice is consistent with a 2010 consensus report [6]. However, many patients with persistently severe and symptomatic thrombocytopenia in spite of first-line therapy may require splenectomy much sooner (eg, within weeks).

Answer 228

D HIPEC is not offered to pts with distant mets. Methods for HIPEC vary between centres. Difficult to standardize surgical technique between surgeons. Other variables include timing of intraperitoneal therapy with regard to surgical anast; thoroughness of extirpation; and the doses, timing and choice of chemo. R0 resections may not be possible. Disease specific survival compared with standard systemic therapy options is improved. Improvement is on the order of months or occasionally years. Trade off is mortality rates approaching 20% in worst cases but closer to 6% in high volume centres. Major morbidity ranges from 12-52% in high volume centres and can lead to prolongs hosp stays and high costs

Answer 229

A Low or high dose aspirin reduces both polyps and advanced lesions in men and women. At least 4 RCTs provided evidence in at risk pts, with good colonoscopy FU regimens. Adverse events were uncommon with no difference between groups for death, MI, bleeding or invasive cancers. Incidence of invasive cancer of the colon was low with this level of surveillance but high risk lesions (e.g. High grade dysplasia, a known precursor to cancer) were seen less freq with aspirin in some studies. Others showed a decr in invasive cancer risk. Latency period from aspirin prevention to benefit appears to be approx 10 yrs; apparent only after at least 5 yrs of therapy. Concurrent statin therapy does not appear to have an effect on polyp or cancer prevention

Answer 230

E CRC liver mets can be resected for long term survival and even cure. Approx 5-10% of 50,000 cases of CRC liver mets each yrs in US are candidates for curative resection. Long term survival can occur in up to 50% of pts. 5 preop factors most affecting outcomes in pts presenting for liver resection of CRC mets: 1) Size >5 cm, 2) disease free interval <1 year, 3) Node positive primary, 4) Greater than 1 tumor, 5) CEA >200 Traditional contradindications to hepatectomy for met CRC were presence of extrahepatic diseases at least 4 hepatic mets, close margins and inability to resect all disease. Hepatectomy for at least 4 mets is assoc with a 5 yr survival rate of 33% and recurrence rate of 80%. Pts w/ close or involved margins have long term survival, and resection of extrahepatic mets presenting concomitantly with liver mets results in long term survival of selected pts. Extrahep met sites most favourable for resection are lung mets, local recurrence of original tumor, and portal LNs. After resection for hepatic CRC mets, recurrence rates at least 80%, with half of recurrences isolated to the liver. Pts whose disease is amenable and who undergo second liver resection for removal of all disease have 5 yr survival for 30-40%

Answer 231

B Pt has large mediastinal mass. Radio growth of mediastinal masses, such as lymphomas, may distort airway, causing resp distress, wheezing and orthopnea. Imaging depicts enlargement of mediastinum with involvement of airway. At times, pleural or pericardial fluid can be obtained for cytologic analysis. If neither peripheral LNs nor fluids are available for bx or puncture, CT guided needle bx for cytologic analysis is generally next step. If this is still not diagnostic, bx by thoracoscopy or anterior Chamberlain may be necessary. Chamberlain procedure is an anterior mediastinoscopy used to bx a mass or LNs in the center of the chest, which is done through a small transverse incision in an intercostal space. Mediastinal disease compressing the airway poses a significant risk. In pts with tracheal compression, sedation and anesthesia should be avoided. These pts may prove impossible to ventilate, even with intubation, b/c of distal tracheal or bronchial obstruction. For pts with severe airway obstruction, dx by alternate methods needs to be considered. In this pt, a Chamberlain procedure using local anesth is the safest approach. Radiotherapy or chemo is inappropriate until a dx is made.

Answer 232

D Anti vascular growth factors (VEGF) recombinant humanized monoclonal antibody. New blood vessel formation is a fundamental event in the process of tumor growth and met dissemination. VEGF and its receptors play a role in tumor proliferation. Approaches to limit VEGF activity include monoclonal antibodies and small molecules, incl the corresponding receptor tyrosine kinase activity. FDA removed met breast ca indication from bevacizumab labelling, citing a lack of demonstrated safety and efficacy in breast cancer. Does not prolong OS and does not provide sufficient benefit in slowing disease progression to outweigh significant risks assoc with treatment. Indications include colon, kidney, brain and lung cancers. Assoc with incr incidence of hypersensitivity reactions in combo with chemo compared with chemo alone. Incidence of anaphylactic/anaphylactoid reactions was 5% in clinical trials. Patients have significantly incr risk of GI perf with a positive correlation with higher doses of bevacizumab and CRC. Extended used can incr long term risk of wound healing complications for up to 6 mos after cessation

Answer 233

D Most common tumor of appendix is carcinoid, a neuroendocrine tumor that is found in 0.3-0.9% of pts who undergo appy. Appendiceal tumors including carcinoid, are usually found incidentally on pathologic exam of an inflamed appendix. Size of tumor determines tx and ppx with tumors >2 cm having the greatest met potential. Formal R hemi is indicated. Other indications for R hemi include mesoappendiceal invasion, tumors at base of appendix with positive margins, high grade malignant tumors with a high mitotic index, and goblet cell adenocarcinoid tumors. R hemi also may be considered for 1-2 cm tumors at the base of appendix; however this remains controversial. Simple appy reserved for tumors <1.5 cm in diameter, b/c chance of lymphatic or distant mets is minimal. Observation and radiation have no role and chemo may be considered in mgmt of met tumors, although it has limited efficacy.

Answer 234

A MALT lymphoma aka extranodal marginal zone lymphomas MALT type. Indolent B cell lymphomas that develop secondary to chronic inflamm from either infection or autoimmune process. Any tissue that has mucosa assoc lymphoid tissue can develop this tumor, including salivary glands, resp tract, bladder and small intestine. Most commonly seen in stomach. Gastric MALT lymphomas are typically identified during endoscopy being performed for non specific gastric symptoms. Discrete masses are rare, with the most common endoscopic finding beating erythema, ulcer or erosions. Most are seen in the Antrum and multifocal disease is common. Dx made by bx of area All patients with gastric MALT need to be evaluated for H pylori. Regardless of H pylori status, all pts with local disease should be tx with eradication therapy b/c of risk of false neg test. Of pts with local disease positive for H pylori, 50-70% will have a favourable response to tx. Complete response can take a several months, and serial endoscopy is needed to evaluate tx response. Once gastric MALT lymphoma is identified, a staging evaluation is undertaken to determine whether more than mucosal involvement is present. Gastric staging is done with endoscopic U/S. Further staging includes CT chest/abdo/pelvis, bone marrow evaluation and a PET CT scan. Unique to MALT lymphoma is the evaluation of other potential sites of disease including bronchoscopy, colonoscopy and small bowel evaluation If the patient fails to response, follow up radiation can be used. Chemo is not used if only local disease is present. Resectional therapy is rarely necessary and quality of life is better with gastric preservation. Disseminated disease is tx as any other lymphoma with chemo or antibody based approaches. However, b/c these are indolent tumors, watchful waiting is also reasonable.

Answer 235

B Lung is most common site of mets for soft tissue sarcoma. Similar to the primary tumor, resection of pulm mets is performed to control local diseases. Resection confers a survival advantage and should be performed, if possible, before considering any other tx modality. Criteria need to be applied to planned resection: Minimal amt of lung should be removed with each specimen. Stapled metastasectomy is procedure of choice. Multiple unilateral resections can be performed, again with lung preservation being of utmost importance. If multiple lesions are present in a single lobe, precluding separate excision, especially if thoracoscopic approach is undertaken. If a patient has recurrent pulmonary disease that can be resected safely, sx should be undertaken using the these same principles. Soft tissue sarcomas do not met to LNs. Lymphadenectomy would not be part of sx. Neoadjuvant therapy before surgical resection has no benefit.

Answer 236

C Firm symptomatic anal lesions require path exam to exclude malignancy. Reassurance and observation are contraindicated. Laser ablation does not provide tissue for dx. B/c of anatomical position of this lesion, seen only through the anoscope, office excision would be technically difficult and likely very uncomfortable for the pt. Transanal excision in the OR allows for complete excision with margins under optimal conditions. This lesion is an anal melanoma. By contrast, with cutaneous melanoma, anal melanomas are often amelanotic

Answer 237

C Lymphedema is accumulation of protein rich fluid in regions where lympahtic system cannot transport interstitial fluid. Occurs most often as a complication of LN dissection for cancer tx. Most commonly assoc with breast cancer mgmt, overall 16% incidence in pts tx for melanoma; sarcoma; H&N; urologic and gyne cancer. Tx remains suboptimal and usually palliative, focus is on several measures to prevent it, although many measures are anecdotal and no evidence based. Conflicting lower level data regarding needle stick avoidance, no data to support bp measurement avoidance, and level 1 data refuting the notions of avoiding extremes of temp or vigourous exercise. RCT of wt loss after LN surgery shows less lymphedema in intervention group. Findings support a large amt of evidence linking obesity to the development of cancer related lymphedema.

Answer 238

D GIST, the most common sarcoma of the GI tract, arises from interstitial cells of cajal and possesses unique kinase mutations that can serve as targets for medical therapy, either in the adjuvant setting or when gross tumor is present. Most common mutations at exon 11 of c kit (CD117), a tyrosine kinase. Imatinib is a tyrosine kinase inhibitor specific for such mutations is commonly used as medical therapy for GIST. Drug stopped right before planned operation does not increase complications over the expected rate. OS at 2 yrs was 91-93%. Given to pts with advanced but possible operable disease, approx 25% converted to resectable tumors and long term survival was documented. Whether given in the adjuvant, neoadjuvant or palliative setting, imatinib, an oral agent is generally well tolerated. Major side effects include fever, H/A, fluid retention, GI side effects, anemia and elevated LFTs One of the hallmarks of imatinib therapy of measurable tumors is delayed response. Avg time of overall response in the multi center trial was 13 weeks. Centres using imatinib for advanced GIST in hope of rendering pts resectable generally follow reponding patients for at least 6 months before considering surgical exploration. Soon after starting therapy, some tumors actually swell, giving the false impression of CT that the tumors are progressing. Dynamic studies such as MRI, contrast enhanced CT or PET/CT may show decr intensity in these swollen tumors, indicating a metabolic response. Accordingly the Choi criteria, which include a dynamic measure of response, may be more accurate for assessing response to imatinib than the standard guidelines that rely on size alone.

Answer 239

D Systemic chemo is palliative and generally provides only limited improvement in survival. Over past few decades, CRS and HIPEC were developed for pts with mucin producing peritoneal surface malignancies. Studies have shown survival advantages for these approaches. CRS is an extensive procedure and incl greater omentectomy, splenectomy,. R and LUQ peritonectomy, chole, less omentectomy, pelvic peritonectomy, amd resection of the most involved parts of the bowel--often R colon, rectosigmoid and sometimes gastric antrum. Completeness of resections is scored on a standard grading scale, with the score correlating with survival. Tx plan and prognosis hinge on specific histology, which usually can't be determined by frozen section. PMP is the more rare type of mucinous intraperitoneal neoplasm, characterized by mucinous ascites, low grade neoplasm (often of appendiceal origin) and a better prognosis. PMP has almost no ability to spread by via lymphatics or hematogenous routes. Generally stays limited to peritoneal cavity where it spreads by fluid current and gravity. Repeated CRS can palliation the disease for yrs but rarely yields cure. However, the addition of appropriately timed (before adhesion formation) HIPEC has yielded 5 and 10 yr survival rates of 75-100% and 68%, respectively, although results are worse with higher grade tumors and incomplete resections. Mucinous colorectal adenocarcinoma (MCA) is essentially stage 4 colon cancer limited to the abdo. MCA is assoc with the ability to spread to lymphatics and a poorer outcome. In selected patients with MCA limited to the peritoneal cavity, CRS and HIPEC can 5 yr survival rates of 27-31%. Role of systemic therapy and bio therapy for MCA remains under study Although CRS and HIPEC are therefore considered the next step in the otherwise healthy pt presented; such pts may be best tx at centres of expertise and only after exact histology has been determined on permanent pathology. Even a recent report of CRS and HIPEC done at nonspecialized hospitals involved surgeons with special expertise operating at carefully chosen institutions.

Answer 240

E Regardless of disease stage at presentation and extent of sx, prognosis for anal melanoma is poor, with overall 5 yr survival rates of 10-20%. Although 20% of pts have inguinal node met disease at presentation, it is unclear that groin dissection has any effect on mgmt or prognosis. Survival after WLE is similar to APR, which has prompted recommendation of transanal excision over radical sx in most cases. Results of systemic therapy are disappointing. Radiation alone provides the options of sphincter preservation but does not incr survival. Chemorads with Nigro protocol is 1st line tx for scc of the anus not melanoma. For a pt whose anal melanoma has already been completely excised, observation is best recommendation.

Answer 241

A Carcinoid of the appendix is the most commonly type of primary malignant lesion of the appendix. Often asymp and found incidentally during appy. Incidence 0.3-0.9% undergoing appy and they are commonly located at the tip of the appendix Major of incidental carcinoid cured by appy. Current recommendations of additional sx include inadequate resection margins, tumor >2 cm, goblet type morphology. Complete R hemi is required. In tumors >2 cm, 30-60% will have met spread. Met rate for tumors <2 cm is no higher than 3%. Controversy regarding tx of lesions in 1-2 cm range. In such cases, evidence of mesoappendiceal invasion, vasc invasion, incr mitosis, or presence of proliferation markers must be evaluated and careful pt risk assessment undertaken. Goblet cell carcinoids have features resembling both carcinoid and adenoca and they all require R hemi. In this pt, tumor size 1.5 cm at the tip with clear margins, surveillance by CT abdo is indicated. Nether has evaluation by colonoscopy nor R hemi is indicated. Octreotide scan is useful for making a dx b/c it can image carcinoids expressing somatostatin receptors, particularly those with receptor subtypes 2 and 5 for which octreotide has high affinity. Urine 5 HIAA is a useful lab marker to make the dx of carcinoid, b/c it provides a summation of tumor secretory activity. Neither of these studies are indicated in this pt, however, b/c a pathologic dx has been made.

Answer 242

1. C 2. B 3. B 4. C 5. D 20% of Americans over lifetime will develop some type of skin cancer. Divided into nonmelanoma skin cancers and cutaneous melanoma. Nonmelanoma skin cancers account for ~90% of all cutaneous malignancies. Of these tumors, BCC is the most common (75% of all nonmelanoma lesions), followed by SCC (20%) and rare skin lesions (fibrohistiocytic and adnexal cancer 5%). Cutaneous melanoma is the deadliest skin cancer, accounting for 75% of all skin cancer related deaths. UV radiation from sun exposure is a major RF for all skin cancers, accounting for 90% of all nonmelanoma skin cancers and 65% of all CM. Both UVA (320-400 nm) and UVB (280-320 nm) radiation lead to skin cancer formation. UVA radiation approx 95% of all UV exposure to the skin, causes indirect cutaneous damage via oxygen radical formation and depletion of Langerhands cells in the skin. UVB, the remaining 5% of UV exposure, directly damages DNA within the skin cell. For both BCC and CM, fair complexion, blond or red hair, and blue eyes constitute risk factors. Whereas cumulative UV exposure incr risk of SCC, intermittent UV exposure is assoc with CM and BCC. Hx of sunburn at an early age incr CM risk. Although smoking is not a RF in either BCC or CM, it does incr risk of developed SCC by 3x. BCC typically raised, pearl color nodule; SCC tends to be a small, scaly, white or red lesion with friable base; CM is characterized by ABCDEs. Care must be taken b/c pigmented BCCs can exist and nonpigmented CM does occur. Depth of invasion is an important prognostic factor in both CM and SCC due to strong assoc between mets and tumors >1 mm thick. CM tends to met to regional LNs first. Distant mets can arise throughout the body, incl the liver, brain, bone, lung, skin and GI tract. Although rare (<0.03%), BCC can met as well and its risk is assoc with depth of invasion. Other RF for BCC mets include large/recurrent tumor, prev irradiated tumors and immunosuppression. Common sites of mets for BCC are bone and lung. For lesions requiring surgical excision, recommended margin is predicted on lesion and in certain cases, its size. For CM, 1 cm margin is required for lesions 1 mm or less in depth, whereas 2 cm margin is needed for lesions >1 mm. In BCC, surgical excision with 0.5-1 cm margins is often adequate. SCC lesions usually require margins of at least 2 cm. Other tx options include topical chemo with imiquimod (BCC or CM) or 5FU (SCC), photodynamic therapy (BCC and SCC), radiotherapy (BCC, SCC, and met CM), immunotherapy (interferon alpha 2b or IL2 in met CM), curettage and dissection (BCC), MOHs (BCC) and systemic chemo (BCC, SCC, CM)

Answer 243

1. C 2. A 3. A Resection of mets may provide a small but real disease free survival. Further, new agents that tx met melanoma may render more pts resectable. Some of the newer agents target either the pt's T cell receptors or a specific tumor mutation Ipilimumab is a fully human monoclonal antibody against cytotoxic T lymphocyte antigen 4 (CTLA 4). Causes activated T cells to survive and incr the pool of anti tumor T cells. Adverse events assoc with the drug are mostly immune related and include colitis, rash and elevated LFTs. RCT phase III study of stage IV melanoma pts tx with ipilimumab vs a peptide vaccine showed 3 yr survival rates of 21% and 12%, respectively, and led to FDA approval Approx 40-60% of CM carry mutations in tyrosine kinase protein BRAF and 90% of those mutations are a substitution of glutamic acid for valine at codon 600 (V600E). Vemurafenib is an inhibitory molecule selective for the V600E mutation. In a large RCT phase III study of stage IV melanoma pts tx with either vemurafenib or dacarbazine, responses rates were 48% and 5% respectively. Led to FDA approval of vemurafenib for stage IV melanoma in pts with V600E mutation. Adverse effects are mostly cutaneous and include appearance of SCC and kerathoacanthomas. Exact mechanism is undergoing study. May be related to activation of alternative pathways, such as mitogen activated protein kinase pathway, and thus it may be assoc with drug resistance.

Answer 244

1. D 2. A 3. B Several modalities exist and therapy chose depends on type of lesion, number present, anatomical locations, size, patient comorbidities, degree of liver dysfunction (i.e. Cirrhosis, portal HTN), and presence of extrahepatic disease. Accurate preop radiologic and functional assessment of liver is essential. Multidetectoy CT with 3D reconstruction and MRI with MRCP are recommended to determine morphologic characteristics of tumor, vascular or biliary involvement, presence of satellite lesions, and presence of chronic liver disease. Determine liver functional status with Child Pugh or MELD score. Liver volumetry can also be performed. Complete surgical removal of tumor remains mainstay for acheving cure in pts with hepatic involvement. Type of resection (anatomical vs wedge) and width of margin required is based on lesion type. Major vasc resection when necessary and regional lymphadenectomy should be undertaken. Criteria for resectability vary with type of malignancy. In HCC, pts with early cirrhosis (CP A/early B) meeting Milan criteria (1 lesion =5 cm or 3 or fewer lesions with larger = 3 cm) and this without cirrhosis are candidates. In CRC liver met, criteria include =4 lesions, favourable anatomy for resection (ie. proximity to vasc structures, ability to obtain adequate margin), and lack of extrahepatic disease. Both RFA and TACE are tx options in the setting of unresectable disease. Successfully used to downstage tumors, allowing their resection. In addition,they can serve as bridging therapies in pts who are transplant candidates. RFA uses direct application of high freq alternating current to cause thermally induced coagulation necrosis of tumor cells. Depending on temp generated, this necrosis occurs over a short time interval (50-52) or is immediate (>60). For large tumors, multiple applications are necessary. An advantage of RFA is that it may be used in near large vascular structures b/c they can serve as a heat sink to prevent endothelial damage. Pts with multiple bilateral lesions, central lesions not amenable to anatomic resection, contralat nodules after undergoing hemihepatectomy, and severe liver disease/comorbidities are candidates for RFA. TACE involves administration of cytotoxic drugs via hepatic artery with subsequent embolization. Direct intra-arterial infusion of chemo drugs is more effective than IV infusion and maximizes local effects while minimizing systemic complications. Often used in the setting of unresectable HCC. In CRC liver met, direct hepatic artery infusion can be used by means of a surgically placed pump. Contraindications to TACE include Child C cirrhosis, severe leukopenia/thrombocytopenia, cardiac/renal insufficiency, ascites, PV occlusion, and atypical hepatic artery anatomy. Orthotopic liver transplant is preferred therapy for Child Pugh B and C pts with HCC satisfying Milan criteria. In this setting, OLT results are similar to those found in OLT for other cases. 4 yr survival approaches 75% and recurrence free survival 83% In CRC liver met, new chemo agents such as oxaliplatin, iron ore an and bevacizumab have improves response rates compared with traditional 5FU/leucovorin therapy, allowing for neoadj downstaging of prev unresectable met lesions 75F pt with central CRC liver met abutting portal vein is candidate for RFA b/c she is a poor surgical candidate for major hepatic resection

Answer 245

1. E 2. A 3. C Classic appearance of Ewing sarcoma on XR is an onion skin appearance. Osteosarcoma has an appearance of a starburst. Most common cytogenetic changes in Ewing sarcoma is a translocation (11:22). Burkitt lymphoma has cytogenetic change, translocation <8:14). EBV is implicated in multiple types of cancers, including Burkitt lymphoma. Giant cell tumors are usually lyric lucent lesions that are rarely malignant. Account for approx 20% of benign tumors. AML is assoc with bone pain caused by buildup of leukaemia cells and is sometimes assoc with pathologic #s. It is assoc with translocations that are different from Ewing sarcoma and Burkitt lymphoma.

Answer 246

1. B 2. A 3. D 4. C 5. E Familial susceptibility to breast ca accounts for <25% of all breast ca cases. BRCA 1 and BRCA 2 are high penetrance breast cancer predisposition genes identified by genetic studies. Germaine mutations found in all cells within the body; peripheral monocytes are used for testing. Clinical criteria for referral for BRCA testing include 1) at least 3 breast or ovarian cancer cases, at least 1 in the same family when the pts is <50 yrs, 2) breast can cases when pt is <40 yrs in same family, 3) male breast ca and family member with either ovarian cancer early or early onset female breast ca, 4) pt <60 yrs with breast ca in a family of Ashkenazi Jewish descent, 5) pt < 40 yrs with bilat breast ca, and 6) breast ca and ovarian ca in same pt. Historically GISTs were through to be of smooth muscle or neural origin. Mid 1990s KIT was recognized to play a key role in development of interstitial cells of Cajal and cells of origin for GISTs. KIT is commonly expressed in GISTs and is a tyrosine kinase whose activity is normally regulated by binding of endogenous ligand, stem cell factor. Binding of stem cell factor to KIT results in receptor homodimerization and activation of its tyrosine kinase activity. In >80% of GISTs, mutation in KIT gene occurs, leading to constitutive activation. Imatinib is a small molecule that is a specific inhibitor of a number of tyrosine kinase enzymes, including c-kit. It inhibits c-kit by occupying the TK active site, leading to decr in activity. HNPCC is a common, autosomal dominant syndrome characterized by early onset of cancer (avg age <45 y.o.), development of neoplasticism lesions in a variety of tissues (e.g. Endometrial, gastric, renal, ovarian, and skin) and microsatellite instability (MSI). Tumors should be tested for MSI in the following situations: 1) CRC dx in pt <50 yrs, 2) presence of synchronous, metachronous CRC or other HNPCC assoc tumors regardless of age, 3) aCRC with MSI-H histology dx in of <60 yrs old 4) CRC dx in at least 1 first degree relative with an HNPCC related tumor, with 1 of the cancer being dx at <50 y.o, 5) CRC dx in at least 2 first or second degree relatives with HNPCC related tumors, regardless of age ERBB encodes a tyrosine kinase inhibitor involved in growth signaling and belongs to the epidermal growth factor receptor family. Overexpression secondary to gene amplification is the most common mechanism or ERBB2 (HER2/neu) protein overexpression and can lead to oncogenic transformation. Overexpression in 18-20% of invasive breast carcinomas and is an independent marker for poor clinical outcome in newly dx pts, who usually have ER neg phenotype. From a therapeutic point of view, pts with breast ca and incr Her2 have a good therapeutic response to traztuzumab, a human monoclonal antibody. Patients also have relative resistance to endocrine therapies, especially SERMs (e.g. Tamoxifen) EGFR encodes a cell membrane receptors with protein tyrosine kinase activity and downstream mitogenic effects. Nearly 90% of lung ca specific EGFR mutations consist of point mutations that lead to constitutive action of protein tyrosine kinases. Testing for EGFR mutations in lung ca has become widespread b/c pts with non small cell lung cancer carrying mutations respond more often to PTK inhibitors such as gefitinib. Trials show mutation status to be an independent predictor of response, progression free survival and OS in pts with NSCLC tx with gefitinib. Mutations are more common in adenocas of female pts who never smoked and are of Asian descent

Answer 247

1. C 2. A. 3. B 4. C Papillary thyroid cancer can be accurately dx by FNA based on presence of hyper cellular aspirate containing nuclear overcrowding, grooves or inclusions. Total thyroidectomy is tx of choice for papillary thyroid cancers >1 cm in diameter. RET gene trans locations are present in some as somatic genetic changes. Should not be confused with RET gene codon mutations, which are assoc with medullary thyroid cancer Follicular thyroid cancer cannot be dx by FNA. Follicular cancer can be distinguished from benign follicular Adenoma by capsular or vascular invasion, which can be determines reliably only on permanent histology. Follicular cancers or adenomas have an identical appearance on FNA and are collectively called follicular neoplasms. Definitive tx is total thyroidectomy Huerthle cell cancers consist of oxyphilic cells that appear pink and are filled with mitochondria. Cannot be dx by FNA. Can be distinguished from benign Huerthle cell Adenoma by capsular or vascular invasion., which can be determined reliably only on permanent histology. Huerthle cell cancers and adenomas have identical appearance on FNA and are collectively called Huertle cell neoplasms. Definitive tx is total thyroidectomy Medullary thyroid cancer is characterized by presence of stromatolites amyloid and absence of thyroid follicles; can be dx by FNA. Amyloid stains strongly with Congo red staining. FNA can't always distinguish MTC on bases of appearance of cells alone, immunohistochemistry staining of FNA sample for chromogranin A, CEA or calcitonin can confirm neuroendocrine origin of MTC from parafollicluar C cells. Serum calcitonin of CEA elevations also confirm dx. Total thyroidectomy and bill central neck dissection is OR of choice for pts with clinically evidence disease. Ipsilateral lateral neck dissection is indicated for pts who have large primary tumors or who have enlarged LNs in the lateral compartment FNA is typically sufficient to dx anaplastic thyroid cancer. Immunohistochem can be used to verify cytologic dx. Mgmt is difficult b/c of rapid progression of disease and uniformly fatal outcome. Although surgical resection with aggressive adjuvant chemorads may be considered for rare small tumors confined to the thyroid, almost all pts with anaplastic thyroid cancer will have unresectable disease and should be offered non surgical tx under investigation

Answer 248

D Pseudoangiomatous stromal hyperplasia (PASH) is a benign stromal proliferation that simulates a vascular lesion. PASH may present as a mass or thickening on physical examination. The most common appearance on mammography and ultrasound is a solid, well-defined, noncalcified mass. The characteristic histologic appearance is a pattern of slit-like spaces in the stroma between glandular units. PASH can be confused with mammary angiosarcoma. If there are any suspicious features on imaging, the diagnosis of PASH on a core biopsy should not be accepted as a final diagnosis, and excisional biopsy should be performed. However, in the absence of suspicious imaging characteristics, a diagnosis of PASH at core biopsy is considered sufficient, and surgical excision is not always necessary. There is no increased risk of subsequent breast cancer associated with PASH.

Answer 249

A From feliciano trauma, head injury is a relative reason to operate

Answer 250

B Posterior and superior to nerve Dorsal and lateral to the RLN.

Answer 251

C? (B/c old question?) NCCN says consider total vs lobectomy if no prior rads, no distant mets, no cervical LN mets, no extrathyroidal extension or tumor <4 cm

Answer 252

B Feliciano recommends primary repair for injuries less than 50% of the airway with minimal devitalization.

Answer 253

D Rule out tracheoinominate fistula is bleeding >48 hrs. If bleeding <48 hrs likely skin bleed and can do A.

Answer 254

D? Old answer key says A. This is a T1b tumor. NCCN says surgery alone vs neoadjuvant then surgery

Answer 255

A? Terrible question. Patient has metastatic gastric cancer. In real life, would try endoscopy or IR to stop bleeding

Answer 256

C R en Y is treatment for bile reflux and afferent loop syndrome

Answer 257

C Alkaline Reflux Gastritis: patient dosent feel better after vomiting, usuall fails to respond to medical therapy although Urosdeoxycholic acid might be promising. Surgical Options are: Braun(enteroenterostomy),distal enteroenterostomy , Roux-en-Y , Henley Loop. (C)

Answer 258

B Type 1, which represent 70 to 80 percent of all gastric carcinoids, are associated with chronic atrophic gastritis. In this condition, serum gastrin rises in response to gastric achlorhydria. The elevated gastrin, in turn, simulates neuroendocrine cell hyperplasia in the stomach and development of multifocal polypoid carcinoid tumors. The clinical behavior of these tumors is usually indolent. Type 2, which represent approximately 5 percent of gastric carcinoid tumors, also occur as a result of elevated serum gastrin levels stimulating multifocal gastric carcinoid tumors. The underlying cause of type 2 gastric carcinoids is a pancreatic or duodenal gastrinoma (Zollinger-Ellison syndrome). The clinical behavior is usually indolent. Type 3 gastric carcinoids (sporadic carcinoids) occur in the absence of atrophic gastritis or the Zollinger-Ellison syndrome. They account for 20 percent of gastric carcinoids and are the most aggressive; local or hepatic metastases are present in up to 65 percent of patients who come to resection. Type 3 (sporadic) gastric carcinoids are treated by partial or total gastrectomy with local lymph node resection. The risk of nodal metastases is dependent on tumor size and depth, and some have suggested that endoscopic resection alone may represent adequate therapy for intraepithelial tumors <2 cm and perhaps for tumors <1 cm invading the lamina propria or submucosa. However, this is not a standard approach. For type 1 and 2 gastric carcinoids smaller than 1 to 2 cm, endoscopic resection represents adequate therapy. Subsequent endoscopic surveillance is needed every 6 to 12 months since these patients continue to exhibit mucosal changes and hyperplasia of enterochromaffin-like cells (ECL) due to sustained hypergastrinemia. Progression to a malignant phenotype or disease-related death is rare with small tumors. Metastases occur in less than 10 percent of tumors ≤2 cm. Antrectomy is a reasonable option for type 1 gastric carcinoids if there are numerous progressive tumors. Antrectomy reduces hypergastrinemia by reducing the gastrin-producing cell mass in the antrum of the stomach; in most cases, this leads to tumor regression. The success of this approach was shown in a series of 51 patients with type I carcinoids, 10 of whom had antrectomy (eight in conjunction with endoscopic removal of the largest tumor)]. Seven of the eight with residual disease became endoscopically tumor-free, and one progressed and died of metastatic disease. In all, 9 of the 10 patients treated with antrectomy remained tumor-free for an average of 65 months. More aggressive surgical therapy is rarely needed for type 1 gastric carcinoids, unless there is extensive tumor involvement of the gastric wall (which increases the risk for a coexisting adenocarcinoma, tumor size >2 cm (which increases the risk for metastases, poorly differentiated histology, or for emergent bleeding .

Answer 259

C Small (<2 cm) diverticula can be suspended from the vertebral fascia and need not be excised. In patients with severe chest pain, dysphagia, or a documented motor abnormality, a long esophagomyotomy is indicated. If a diverticulopexy is performed, the myotomy is begun at the neck of the diverticulum and extended onto the LES. If a diverticulectomy is pursued, a vertical stapling device is placed across the neck, and the diverticulum is excised. The muscle is closed over the excision site, and a long myotomy is performed on the opposite esophageal wall, extending from the level of the diverticulum onto the LES. If a large hiatal hernia is also present, the diverticulum is excised, a myotomy performed, and the hiatal hernia repaired. Failure to repair the hernia results in a high incidence of postoperative reflux. Schwartz: In patients selected for surgery, preoperative manometry is essential to determine the proximal extent of the esophageal myotomy. Most surgeons extend the myotomy distally across the LES to reduce outflow resistance. Consequently, some form of antireflux protection is needed to avoid gastroesophageal reflux.

Answer 260

B cervical goes to cervical nodes; mid esoph to mediastinal; distal to abd. Crus is a T4a lesion. Bad nodes are defined as beyond one nodal station, therefore for a distal cancer, b is ok. (B)

Answer 261

D? You want to trach below but 4th is pretty low...

Answer 262

B For DCIS, can omit radiation if margin >10 mm. Don't need to do anything further for the LCIS

Answer 263

B? Wide excision with intention of obtaining surgical margins >/=1 cm. Narrow margins are assoc with heightened local recurrence but are not an absolute indication for mastectomy No prospective RCT for use of radiation with phyllodes. In the setting where additional recurrence would create significant morbiditiy (i.e. chest wall), radiation may be considered following the same principle as applied to sarcoma

Answer 264

B Excisional biopsy is recommended only for small cutaneous or subcutaneous tumors, usually smaller than 5 cm, in which a wide reexcision (if required) is usually straightforward.

Answer 265

A According to a lit review in the surgical annals of vascular surgery, accessible lesions should have an open repair. (A)

Answer 266

C Indications for repair are failure to wean from the vent. uncontrollable pain despite maximal therapy, major deformity, non-union # and already there for something else.

Answer 267

B Operative management should include resection of the affected segment of the colon involved with diverticulitis (usually with a primary anastomosis) and simple repair of the secondarily involved organ. Suspicion of carcinoma may mandate a wider, en bloc resection.

Answer 268

A Contra-indications to re-resection: Nerve root involvement above the level of L1-2 Proximal (S1,2) sacral invasion extending to the sacral promontory Involvement of the paraaortic lymph nodes Tumor encasement of the iliac vessels Extension of tumor through the greater sciatic notch Bilateral ureteral obstruction Unresectable extrapelvic disease Circumferential involvement of the pelvic wall

Answer 269

B? Old answer key said A

Answer 270

A Review course--controversy re excision of radial scars but there is a mass here which requires further work up

Answer 271

A Post-mastectomy radiation improves OS and DFS. Indicated in large primary, 4 or more nodes +.

Answer 272

B Adjuvant endorine is preferred. Can trial 2nd line endocrine if no response to AI. Also needs bisphosphonate.

Answer 273

C Cardiac dysfunction due to chemo. Echo will evaluate cardiac function (cardiotoxic chemo?), pericardial effusion, PE. Evaluate cause prior to treatment.

Answer 274

A vs C Up to Date: Either MRM or ALND with WBI is acceptable with equivalent outcomes. MRM is standard therapy, and there are no prospective trials validating WBI as an alternative. Systemic therapy for stage II disease.

Answer 275

B Doesn't specify timing of RT in answers--needs to be post partum. Since end of 1st trimester (like 1 week away!) and palp nodes would consider neoadjuvant then surgery then radiation post partum If early in 1st trimester then mastectomy

Answer 276

A Margin is negative; goal is minimum 2mm margins. If postive, radiate bed. NO data on post-mastectomy RT for DCIS! However, do need to treat the contralateral breast with surveillance and tamoxifen or AI depending on menopausal status.

Answer 277

A AIs not studied in men.

Answer 278

A Very controversial. Observe if option, as many resolve with time. Ralph George (Toronto breast surgeon) says steroids. Meiers say steroids are also reasonable, but better current answer is methotrexate; treat for long courses, up to 1 year before maximal response expected. Up to Date: Management — IGM is a self-limiting inflammatory condition but commonly takes 9 to 12 months to resolve. IGM associated with a localized infection usually resolves with antibiotics and drainage [8,21,27,29]. The approach to antibiotic therapy is as outlined above for periductal mastitis. Surgical excision for IGM is often followed by slow wound healing and is not advocated. (See 'Periductal mastitis' above.) There is no role for steroid use; systemic glucocorticoid therapy and local depot steroid injections have been used for treatment of IGM based on the hypothesis that it is an autoimmune disease, although there are no randomized controlled trials that demonstrate efficacy for steroids in the treatment of IGM [27,39,43,44]. Methotrexate for treatment of IGM has been described [45-47]. Discontinuation of these drugs has been associated with rebound inflammation.

Answer 279

A MRI – higher mastectomy rate

Answer 280

A Some say with no chemo? ACC is a favourable histology with low risk of LN mets (<1%). It is a breast carcinoma, so safe answer is to do SLNB. Clear that BCS is adequate, and there is survival advantage to RT. No data on chemo, but NCCN recommends adjuvant endocrine for favourable histology >3cm, and chemo for >1cm. However, adjuvant chemo has not been studied specifically for ACC. Clinical role of sentinel-lymph-node biopsy in breast cancer. The Lancet Oncology. Volume 3, Issue 2, February 2002, Pages 105–110 Pts with ACC benefit from SLNB d/t low risk of LN mets. Adjuvant radiation therapy is associated with improved survival for adenoid cystic carcinoma of the breast. J Surg Onc, 2010. “RT after local surgical therapy for ACC of the breast improved both cause-specific and overall survival. Use of RT in this rare tumor should be considered in patients otherwise eligible for RT.” <1% chance of LN mets Adenoid cystic carcinoma of breast: Recent advances. World J Clin Cases. 2014 Dec 16; 2(12): 732–741. a. have t (9:22) translocation b. luminal and basal features c. low grade, usually indolent, excellent prognosis vs other TNBC d. usually cured with BCS +/- RT

Answer 281

C NCCN factors micromets into adjuvant decision, but ITC probably has no prognostic significance. For small tumours (<5mm) where chemo would not normally be given, it will be considered if Nmi+

Answer 282

D! (Although in this question A and D are the same answer!) Herceptin never given alone. Options really are NACT+Herceptin then ACT + Herceptin, or NACT + Herceptin

Answer 283

D Definitely no ALND for micromets, but MA.20 may apply: high-risk node – or + patients treated with axillary radiation had less recurrence but same OS. CTX is definitely indicated, so any answer must include chemo.

Answer 284

C Locally advanced breast cancer meeting criteria for NACT; axilla needs staging; SLNB is relatively contraindicted in locally advanced (T4) as has a high probability of nodal involvement. Pectoralis adherence does not equal T4a. Ulceration is T4b. UTD Although there have been no randomized trials, most men with early-stage disease (T1 to T2, N0 to N1) undergo a simple mastectomy rather than a mastectomy with pectoral muscle removal. The data to support less extensive chest wall resection (originally as a modified radical mastectomy rather than radical mastectomy) come from retrospective studies that consistently show the procedures result in an equivalent local recurrence rate and survival outcomes. Locally advanced disease — Men who present with locally advanced disease (T3N0 or stage III disease) or inflammatory breast cancer are treated similarly to women who present in this way. We offer these patients neoadjuvant chemotherapy because randomized trials of neoadjuvant chemotherapy followed by surgery versus primary surgery followed by adjuvant chemotherapy, which have been predominantly performed in women, show it is associated with high rates of clinical response and a higher likelihood for allowing cosmetically acceptable surgery without compromising survival outcomes. Following completion of chemotherapy, we proceed with a mastectomy in most patients, provided they have a sufficient response to make surgery feasible. For patients who do not have a sufficient response, an alternative regimen should be administered Management of the regional nodes — Assessment of the regional nodes is an important aspect of surgical breast cancer management, as it is in women. We agree with an expert panel convened by the American Society of Clinical Oncology (ASCO) and feel that sentinel lymph node (SLN) biopsy for men with clinically node-negative breast cancer is "acceptable" Although the role of SLN biopsy is established in women with clinically node-negative breast cancer, its proven role in men is less robust due to the rarity of male breast cancer. Most studies have restricted SLNB to T1 or T2 breast cancers <5 cm in size, since larger tumors have a higher likelihood of positive axillary nodes. However, some studies have shown that SLNB is accurate in patients with T3 tumors and clinically negative axillae [87,88]. Thus, many clinicians do not recognize large breast tumors as a contraindication to SLNB, as long as the axilla is clinically negative. However, patients with T4 tumors (locally advanced) or inflammatory breast cancer are not considered candidates for SLNB. The false-negative rate is high in patients with inflammatory breast cancer, presumably because of the presence of partially obstructed, functionally abnormal subdermal lymphatics.

Answer 285

B Ralph George: don’t need to excise mass-associated PASH; excise ALL if postmenopausal women (if not on HRT), as PASH is estrogen-related lesion. 2 reasons to excise: mass-associated PASH, and ADH

Answer 286

B NCCN: if no response, consider 2nd line chemo and/or RT. UTD: RT, no 2nd line chemo. IBC is systemic disease so treat systemically.

Answer 287

C Prev years say A Want to ensure that lesion is responsive and isolated before considering resection per HPB fellow and surg onc staff

Answer 288

C UTD Paracentesis is mainstay of management in 90% of patients

Answer 289

A NCCN: ER + HER2 – T1-2 without LN mets: Oncotype DX to determine RS: If low (<18,), endocrine alone. Intermediate risk (18-31) consider ACT; High (>31) ACT + endocrine ER + HER2 tumours always get ACT with herceptin if >1cm, considered for >0.6cm Not entirely clear whether Oncotype is useful for premenopausal; Although TAILORx study showed no difference in recurrence for younger vs older women with low RS.

Answer 290

B Chemo has slightly higher response rates than endocrine alone, but actually no difference in OS. Endocrine therapy versus chemotherapy — It is commonly thought that chemotherapy results in higher response rates and more rapid responses than endocrine therapy, and it is often used as the initial treatment for patients with hormone receptor-positive metastatic breast cancer with a poor prognosis, especially those with visceral metastases. A meta-analysis that included eight small randomized trials, all published prior to 1995, compared the response rates for chemotherapy alone with those of endocrine therapy alone [44]. The pooled estimate of response rates showed an advantage for chemotherapy over endocrine therapy (relative risk 1.25, 95% CI 1.01-1.54), although the two largest trials had opposite findings [45,46]. No significant difference was seen in overall survival (OS) (hazard ratio [HR], 0.94, 95% CI 0.79-1.12), and on subset analysis, there was no obvious trend to suggest an effect of age, menopausal status, or pattern of metastatic disease on the efficacy of either therapy. ASCO Guidelines: Bone-modifying agent therapy is only recommended for patients with breast cancer with evidence of bone metastases.

Answer 291

A Meiers: MDE should not be mass associated, so discordant therefore excise. MDE: Mammary duct ectasia (MDE) is a benign abnormality characterized by dilatation of the mammary ducts (1). The frequency of MDE may range from 1.1% (2) to 75% (3), according to the diagnostic method used, which might be clinical, histopathological or necropsy-based (2–4). MDE occurs most often in women around menopause (5,6), also being able to occur in younger women (5), children (7), and men (8). Some degree of dilatation of the ducts occurs with aging, and this can be considered as a normal involution of the breast tissue (3,9). MDE is benign. Squamous metaplasia is non-proliferative breast lesion

Answer 292

A Breast angiosarcoma is often multicentric with wider involvement than appreciated, so mastectomy is standard of care. Other primary sarcomas mayb be treated with WLE. Up to Date: Surgery represents the only potentially curative modality for breast sarcomas. The type and extent of the operation is based upon both the size of the tumor and the size of the breast, as well as histology: An adequate resection margin is the single most important determinant of long-term survival with breast sarcomas For larger tumors (ie, those >5 cm), the overall cosmetic result is often better with a mastectomy and reconstruction than with lumpectomy. Deep seated tumors, which are close to or involve the chest wall, may require en bloc resection of the chest wall.With the exception of angiosarcomas, the majority of primary breast sarcomas are not multicentric and negative surgical margins are more important than the extent of surgical resection. Breast angiosarcomas (primary or therapy-related) often affect a much larger field of the breast or chest wall than anticipated, and mastectomy is the standard treatment

Answer 293

B Groot: 2cm margin; don’t compromise oncology for cosmesis. Meiers agrees. Orient incision in a wedge so as to close NAC with good cosmesis.

Answer 294

C Probably fibrocystic changes; ibuprofen is first line. NSAIDs are 1st line.

Answer 295

C Up to Date: Medical management of gynecomastia: 1) tamoxifen 2) testosterone replacement (if hypogonadic). First line is tamoxifen in adolescents and men, with 3-6 month trial. Usually partial response.

Answer 296

A See above. RT is probably indicated, reducing local recurrence. There is a very low incidence of LN mets (1-5%), and some argue that this means women will benefit from SLNB. This is a low-grade, favourable histology T3 carcinoma, so the safe answer is RT + SLNB, accepting overtreatment.

Answer 297

D Infraclavicular is local disease, surgery is first line. Resection indicated when possible. NCCN has surgery first, then RT. If unresectable, NACT.

Answer 298

B? NCCN says tx supraclav with radiation if possible an d consider systemic therapy Patient had prev lumpectomy and therefore would likely have had radiation before Surgery has no role in supraclavicular recurrent disease

Answer 299

B UTD Second-line treatment — For patients with disease progression following first-line endocrine therapy, second-line treatment is a reasonable option, provided they are appropriate candidates for endocrine therapy. (See Patients who develop rapidly progressive metastatic disease should be treated with chemotherapy. Premenopausal women — For premenopausal women who progress following first-line treatment, ovarian ablation should be offered, which would allow the administration of endocrine agents only approved for postmenopausal women. However, for women with disease progression on ovarian suppression agents, serum estradiol levels should be checked to ensure menopausal status was achieved. If high estradiol levels are noted despite ovarian suppression, ovarian ablation should be pursued. Once menopause is induced (or confirmed by laboratory testing), the treatment approach for postmenopausal women is used. For premenopausal women who refuse ovarian suppression or ablation, we recommend chemotherapy. Postmenopausal women — There is a lack of clinical trials to address the optimal sequence of therapy in second-line and subsequent-line settings. The available options include the administration of a non-cross-resistant AI, tamoxifen, fulvestrant, fulvestrant plus palbociclib, or endocrine therapy plus the mammalian target of rapamycin (mTOR) inhibitor, everolimus, in the second-line setting.

Answer 300

A | Risk of associated cancer

Answer 301

A SLNB not successful; axillary staging then is ALND which can be done later IF path shows a cancer in specimen.

Answer 302

A T1-2, ER +, Her2 -, LN – is indication for Oncotype to determine benefit of chemo

Answer 303

A per NCCN Insufficient information to declare high-risk (5yr >1.66%, lifetime >20%). No guidelines support routine use of MRI for LCIS surveillance. Gail model not applicable in LCIS so can’t use it to stratify as high-risk. The NCCN Breast Cancer Screening and Diagnosis Clinical Practice Guidelines for women with LCIS include annual mammography and clinical breast examination (CBE) every 6 to 12months, with consideration of annual MRI.68 However, the American Cancer Society (ACS) guidelines do not support routine use of MRI in this setting, stating that there is not enough evidence to recommend for or against MRI screening in women at increased risk from LCIS.69 The ACS guidelines are based on the increased sensitivity of MRI in women at high risk because of an inherited predisposition or strong family history of breast cancer; however, the biology of the breast cancers that develop in women with LCIS differs from those that develop in women at risk from BRCA mutations, and a recent longitudinal cohort study of women in surveillance for a diagnosisof LCIS suggests that routine MRI screening is not warranted in these patients.

Answer 304

B Upgrade of 8-17%.

Answer 305

B UTD 5-year survival rate with local and regional recurrence following MRM is 7%. If only SC nodes, 28%. Postmastectomy locoregional recurrence: • complete restaging • complete resection of local chest wall recurrence when possible • NACT considered if might downsize resection required • RT is also given if not previously • ALND for axillary recurrence • SC recurrence: systemic therapy followed by local therapy (surgery or RT may be used alone depending on prior nodal irradiation. )

Answer 306

Prev years said C If certain of dx/no suspicious features, can observe

Answer 307

A >1% of tumour cells expressing ER/PR is considered positive, and response to endocrine therapy can be expected. However, historically a cutoff of 10% was used; in patients with 1-9% who don’t tolerate endocrine therapy, it is reasonable to discontinue.

Answer 308

A Still need to stage the axilla. Possible that tumour replacement is reason can’t localize SLN. Internal mammary nodes — The surgical management of the internal mammary (IM) nodes remains controversial. There is no consensus on the need for IM nodal dissection in women with detection of an IM SLN. The IM nodes are not routinely dissected in patients undergoing breast-conserving therapy or mastectomy with axillary lymph node dissection (ALND). Thus, in the absence of definitive data, dissection of the IM nodes with sentinel lymph node biopsy (SLNB) should be considered investigational.

Answer 309

B Diabetic mastopathy — Diabetic mastopathy, also known as lymphocytic mastitis or lymphocytic mastopathy, is seen occasionally in premenopausal women who have longstanding type 1 diabetes mellitus. The typical presentation is a suspicious breast mass with a dense mammographic pattern. Core biopsy is recommended for diagnostic confirmation. Pathology shows dense keloid-like fibrosis and periductal, lobular, or perivascular lymphocytic infiltration [72-74]. The pathogenesis is unknown, but it may represent an autoimmune reaction as the histologic features are similar to those seen in other autoimmune diseases [75]. Once the diagnosis is established, excision is not necessary and there is no increased risk of subsequent breast cancer.

Answer 310

B Her2 + has high likelihood of PCR, NACT indicated; Herceptin given for 1 year.

Answer 311

B At one year following surgery, women with pedicled TRAM flaps, free TRAM flaps, and expander/implants had similar levels of general satisfaction [56], but autologous tissue reconstructions (TRAM procedures) were associated with greater aesthetic satisfaction than expander/implant techniques. At year two, these procedural differences had diminished, but patients continued to be more aesthetically satisfied with autologous tissue compared with expander/implant reconstructions [106].

Answer 312

C Toronto Manual There is some evidence, however, that radiotherapy may be safely omitted in some cases of DCIS: 1. Tumour less than 2 cm 2. Margins greater than 10 mm 3. Low or intermediate grade DCIS (grade 1 or 2)19 With wide margins (>10mm), there is little benefit to RT. Tamoxifen effectively reduces risk for both DCIS and LCIS in both breasts. Perfect patient to treat without RT: wide margin, small foci, low grade, LCIS requiring chemoprevention.

Answer 313

C No ALND for micromets; would get chemo based on young age and ER negative.

Answer 314

A UDH Usual ductal hyperplasia — Ductal hyperplasia without atypia is a pathologic diagnosis, usually found as an incidental finding on biopsy of mammographic abnormalities or breast masses, characterized by an increased number of cells within the ductal space. Although the cells vary in size and shape, they retain the cytological features of benign cells [5,6]. No additional treatment is needed for ductal hyperplasia. The risk of subsequent breast cancer in women with usual ductal hyperplasia is small and chemoprevention is not indicated.

Answer 315

B Doesn’t meet criteria for locally advanced. AJCC specifies dermal invasion alone is not T4, must have ulceration.

Answer 316

C B is – reasonable but also needs RT to be complete tx (2B evidence, is last of 3 options in NCCN)

Answer 317

B Anthracycline-based chemo; if inadequate reponse, taxane-based chemo

Answer 318

Prev years picked D--we don't excise supraclav LNs. A if possible then consider B

Answer 319

B Prev years picked A but we don't do this test

Answer 320

A ``` Luminal A -Er/Pr +, Her2- Luminal B -Triple pos Basal -Triple neg Her 2 enriched -Er/Pr -, Her2+ ```

Answer 321

C vs A? Neurological symptoms and signs, which suggest the possibility of spinal cord compression, must be investigated as a matter of urgency. This requires a full radiological assessment of potentially affected area as well as adjacent areas of the spine. MRI is the method of choice. An emergency surgical opinion (neurosurgical or orthopaedic) may be required for surgical decompression. If no decompression/stabilization is feasible, emergency radiotherapy is the treatment of choice and vertebroplasty is also an option. MRI best method to differentiate mets vs fragility fracture.

Answer 322

A | Prev years picked B but we don't do this

Answer 323

D This is non pathological INITIAL APPROACH TO PATHOLOGIC NIPPLE DISCHARGE — Women presenting with pathologic nipple discharge should undergo a focused ultrasound. In addition, a mammogram should be performed for women ≥30 years of age [3-5]. Any concerning imaging abnormality, including an intraductal mass on ultrasound (US) or mammogram, warrants surgical evaluation. In patients with spontaneous nipple discharge that is unilateral and/or bloody, surgical evaluation is required even if initial imaging results are negative Normal ultrasound and mammogram — In patients with spontaneous nipple discharge that is unilateral and/or bloody, further evaluation is required even if initial imaging results are negative. Unilateral discharge (bloody or nonbloody) — Unilateral, particularly uniductal, nipple discharge requires additional work-up to rule out malignancy, regardless of whether the discharge is bloody or not. If the patient has undergone ultrasound and mammogram, and both are negative, s/he should be referred for either galactography or ductoscopy evaluation, depending upon local expertise. Patients who are found to have intraductal masses by either galactography or ductoscopy are candidates for surgical excision of the involved duct to rule out malignancy.

Answer 324

B Prev years picked A. If only one margin A is reasonable but stem says multiple

Answer 325

D Never take to OR without a biopsy. Intraductal papillomas — Intraductal papillomas consist of a monotonous array of papillary cells that grow from the wall of a cyst into its lumen. Although they are not concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision, particularly if atypical cells are identified [14,16-21]. In a meta-analysis of 34 studies that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were upgraded to malignancy following a surgical excision [21]. Because of a risk of malignancy, these require surgical excision. Once the diagnosis of solitary papilloma is confirmed by excisional biopsy, no additional treatment is needed in most patients, unless there is evidence of associated atypia, in whom discussion about endocrine therapy for breast cancer prevention is indicated Solitary intraductal papillomas may be identified as a mass on a mammogram, ultrasound, magnetic resonance imaging (MRI), ductogram, or they can be found incidentally [23]. Nipple discharge, particularly bloody nipple discharge, is a frequent clinical presentation. For a solitary papilloma without biopsy evidence of atypia, the need for surgical excision is not clear. Examples in the literature include the following:

Answer 326

Prev year said B because – probably a cyst which may improve/resolve with aspiration, followed by mammo A seems also very reasonable

Answer 327

A first and then C? depends if recurred while on tamoxifen

Answer 328

A Either RT or antiestrogen therapy, but tamoxifen probably lowest risk. This is unresectable disease. AI more effective, but contraindicated given osteoporosis.

Answer 329

A Clinically positive nodes, so no SLNB; defer chemo til 2nd TM, RT until after delivery.

Answer 330

A UTD Taken together, these data suggest that central lumpectomy or complete resection of the nipple-areola complex followed by whole breast RT is a reasonable alternative to mastectomy for women with PDB and no palpable mass or mammographic abnormality as long as a good cosmetic outcome and negative margins can be achieved. Patients with in situ disease do not require axillary investigation unless the disease is extensive enough to merit mastectomy. If mastectomy is planned, SLN biopsy is often (and appropriately) done preemptively in order to avoid complete axillary lymph node dissection in case an invasive component is identified at final pathology. = ●If invasive disease has been identified, patients with clinically node-negative disease should undergo SLN biopsy at the time of wide excision. An SLN can be successfully identified in 97 percent of patients with PDB [56]. Management of a positive SLN is discussed in detail elsewhere. ●For patients with pure PDB, no underlying palpable mass and clinically negative axillary nodes, there is some controversy as to the need for axillary evaluation. Given the high incidence of DCIS alone in patients with PDB and no evidence of an underlying breast mass, SLN biopsy is recommended only if invasive disease is identified or mastectomy is planned

Answer 331

A May have capsular fibrosis with radiation with an implant but this can be managed later by plastics

Answer 332

C Paget's disease

Answer 333

C Tubular>mucinous>medullary

Answer 334

B Treat like DCIS

Answer 335

A For all: H&P, LFT’s, CBC, mammo, u/s Bone Scan, CT CAP if stage 3, symptoms ?nodes.

Answer 336

A is closest Breast 70%, Ovarian 20% in BRCA 2 Breast 70%, Ovairan 40% in BRCA !

Answer 337

C? A is wrong. Autosomal dominant B it's ~ 70% D Bilat oophorectomies recommended in patient whol have completed child bearing

Answer 338

B because option A doesn't include radiation Tx options - Central lumpectomy with radiation - Simplet mastectomy with SLNB

Answer 339

B Neither HCTZ or ramipril cause gynecomastia. Captopril and enalopril can. This is classic senescent gynecomastia.

Answer 340

E 2nd trimester requires too long a delay before RT can be given. Breast RT should be given within 12 weeks in order to be effective. UTD opinion is that SLNB has not yet been proven safe in pregnancy, so ALND is standard of care, however most institutions will utilize SLNB without blue dye. SCNA, Schwarz concur: MRM in 1st & 2nd trimesters

Answer 341

A – because of age. Most are <35 yrs.

Answer 342

C Herceptin based chemo for all HER + tumors node + or >1cm. For tumors <1cm no trials, UTD suggests Herceptin based regimen.

Answer 343

B Treat like DCIS Noninvasive, but based on young age (<50) RT is probably indicated. Normally adjuvant treatment is based on associated pathology, not IPC (eg. DCIS, LCIS, etc). RT is controversial but may improve survival.

Answer 344

C Discordant. LH should not be mass-forming.

Answer 345

A in prev years. I would probably pick this as iniitial mgmt. Question asks best mgmt which would probably be B

Answer 346

C No atypia so f/u adequate.

Answer 347

B Depends on operability; if operable then yes. If inflammatory, 2nd line + RT, this doesn’t sound like inflammatory.

Answer 348

B Supraclav nodes = N3c Locally advanced

Answer 349

D Anthracyclines then taxane as 2nd line.

Answer 350

C Lumpectomy + radiation = package deal Also tamoxifen

Answer 351

B Ranitidine, cimetidine, omeprazole, captopril. Not related to ramipril.

Answer 352

D T4 – Tumor of any size with direct extension to the chest wall and/or the skin (ulceration or skin nodules)

Answer 353

Last year said A. This is a small cancer but it is Her2 positive. Would at least have a discussion re: chemo and herceptin

Answer 354

B | Discordant path

Answer 355

B according to prev years – probably fibrocystic changes; US best modality for that, also needs mammo

Answer 356

C In a 2015 observational study that included over 100,000 patients who received a diagnosis of DCIS in the Surveillance, Epidemiology, and End Results (SEER) database, when compared with lumpectomy (with or without radiotherapy), mastectomy resulted in [2]: ●A similar 10-year breast cancer-specific mortality (multivariate hazard ratio [HR] for mastectomy versus lumpectomy 1.2, 95% CI 0.96-1.50) ●Lower rates of ipsilateral invasive recurrence (1.3 versus 3.3 percent)

Answer 357

A vs B Tamoxifen – for contralateral RR There are no studies evaluating post-mastectomy RT for DCIS.

Answer 358

A Not tx surgically Prev had radiation

Answer 359

C AI only in post menopausal AI worsen osteoporosis 45 yo post TAH BSO with DVT -possibly, as is now postmenopausal and AI have less DVT risk than tam

Answer 360

C B also possible since >80% ER +

Answer 361

B in old answers. | Core bx is probably better

Answer 362

A in prev years | B seems like a better answer since you need to rule out cord compression or edema

Answer 363

A In reality, B is also included in staging work up

Answer 364

C Follow up in 6 months – shouldn’t have a new cyst in postmenopausal

Answer 365

A This is non proliferative

Answer 366

Prev year said A If this is inflammatory breast cancer, needs chemo before surgery.

Answer 367

Prev year said C but D is best

Answer 368

A in prev years | We do give C for risk reduction for the contralateral breast

Answer 369

B Frequent variations on this question; if CA 19-9 above 130, then oncologic resection. On oral exam, need to get tissue diagnosis before doing surgery. Some HPB surgeons would do the Whipple based on this. However, in this scenario, CA19-9 is below cutoff for malignancy. UTD & AASLD specify endoscopic therapy first with good success. Spyglass with biopsy and FISH for polysomy are best to evaluate. Sabiston - Cholangiocarcinoma Tissue diagnosis prior to resection in operative patients is unnecessary. With obstructive jaundice, bile cytology and brushings are unreliable, and thus a negative cytology report does not exclude malignancy. Therefore, invasive attempts to establish a diagnosis prior to resection carry risk but do not alter subsequent management. Establishing a tissue diagnosis is only important when the patient is not a surgical candidate. Up to Date The optimal cutoff value that best discriminates between benign or malignant biliary tract disease is influenced by the presence of cholangitis (suggested by the presence of fever, leukocytosis, and right upper quadrant pain) and/or cholestasis (defined as a serum bilirubin >3 mg/dL [51.3 micromol/L]). In one report, a CA 19-9 cutoff value of ≥37 U/mL was 78 percent sensitive and 83 percent specific for malignant disease in patients who did not have cholangitis or cholestasis. By contrast, if the patient had cholangitis or cholestasis, the sensitivity dropped to 74 percent and the specificity to 42 percent when a cutoff of ≥37 U/mL was used. In patients with cholestasis or cholangitis, increasing the cutoff value to ≥300 U/mL was optimal for increasing specificity (87 percent), but at the expense of reduced sensitivity (approximately 40 percent). CA 19-9 is an established serum marker for the diagnosis of cholangiocarcinoma, although it is reported to have a wide variation in sensitivity (50 to 90 percent) and specificity (54 to 98 percent) Serum levels of CA 19-9 are widely used for detecting cholangiocarcinoma in patients with PSC. CA 19-9 concentrations >1000 U/mL are consistent with advanced disease, often involving the peritoneum. If initially elevated, serum CA 19-9 levels may be useful for following the effect of treatment and to detect disease recurrence. We typically use a CA 19-9 value ≥129 U/mL to increase suspicion for a cholangiocarcinoma in patients with PSC, especially in the presence of a dominant hilar stricture, though the current United Network for Organ Sharing policy for transplantation for cholangiocarcinoma uses a cutoff of ≥100 U/mL

Answer 370

A There is some recent discussion of pancreatic enucleation for malignancy, but should not be considered standard. First, it may be technically very difficult to enucleate an invasive lesion. Second, there is very high morbidity with leaks, etc. Formal resection should currently be considered standard of care for malignant lesions. Total pancreatectomy for RCC mets to pancreas is well described. Lastly, you won’t be able to do a LAPAROSCOPIC enucleation; would be more feasible if open. Annals of Surgical Oncology January 2006, Volume 13, Issue 1, pp 75-85 Standardized pancreatic resection adapted to the location of the tumor in terms of partial pancreaticoduodenectomy,distal pancreatectomy, and total pancreatectomy was generally recommended for the management of isPMs (Fig. 1). Because of the high recurrence rate, atypical local resection was confined to some exceptional cases. Omission of radical resection was reserved for a few exceptional cases. Ten of the 13 pertinent reports of nonresected isPMs specified the survival times. Two of the patients documented underwent what is now known to be an ineffective chemotherapeutic regimen, and another eight went without treatment. The survival data of these 10 patients with nonresected disease were compared with the data of 139 patients who underwent radical resection. The actuarial 3- and 5-year survival rates of 21% and 0% for nonresected metastases were significantly (P = .0383) poorer than those for resected lesions (78% and 72%). Surgical treatment of isPMs from neoplasms other than renal cell cancer carry a poor prognosis, because they often signal the onset of disseminated metastatic disease. However, a recent retrospective study demonstrated that in a highly selected group of patients with distant pancreatic melanoma metastases, complete resection of the metastases may improve survival. By contrast, the outcome of surgery for isPMs from clear cell renal carcinoma is clearly superior, with a mean survival time of 4 years and actuarial 5-year survival rates of 43% to 75%, and is even better than the outcome of surgery for primary adenocarcinoma of the pancreas. Because multiple metastases do not have a significantly poorer outcome, omitting or decidedly rejecting radical surgery, if possible, is unfounded. Radical resection for multiple metastases is just as beneficial as it is for solitary metastases. The only difference found was in the type of operation: as would be expected, total pancreatectomy was more often performed in patients with multiple metastases (Table 4).

Answer 371

A vs B vs C Toronto Manual: neoadjuvant is not standard of care, only true way to assess resectability NCCN: Sequence of events for borderline resectable: neoadjuvant therapy, restage, laparoscopy, definitive surgery. NACT is usually FOLFIRINOX, may include radiation but that is +/- Sabiston For patients who appear resectable on imaging studies alone, laparoscopy identifies additional unresectable disease in up to 30% of cases. Others have argued that with current imaging used properly, the benefit of additional laparoscopy only rarely alters surgical planning. Recently, there has been some consensus on a more selective use of laparoscopy for those at particularly high risk for occult disease, including those with large tumors (>3 cm), significantly elevated CA19-9 level (>100 U/mL), uncertain findings on CT, or body or tail tumors. It may be clinically prudent also to consider laparoscopy for patients with clinical indicators of widespread disease, including significant weight loss, malnutrition, or pain. There are no level 1 data available. In select patients, the role of neoadjuvant therapy is clearer, particularly those with significant venous or limited arterial involvement who are classified as borderline resectable. In these patients, where up-front surgical exploration has a significant risk of exposing patients to nontherapeutic laparotomy, the argument for neoadjuvant therapy is strengthened. For individuals with significant SMV–portal vein involvement(>180 degrees or short-segment encasement), or hepatic arterial or SMA abutment (<180 degrees) who have been traditionally considered unresectable, neoadjuvant therapy may play an important role in identifying the subset of patients most likely to derive benefit from aggressive multimodality therapy, including surgical resection with vascular reconstruction.51 This type of aggressive treatment should be undertaken only by an experienced multidisciplinary team in the setting of a clinical trial

Answer 372

A Childs A not contraindication to PH; however concen about 3 lesions indicating multifocality, in which case PH has a very high recurrence rate. The accumulation of outcomes data has clearly established LT as the gold standard for early-stage HCC in the setting of cirrhosis, BUT: PH acceptable for limited disease. Multiple studies have demonstrated that a normal serum bilirubin level and the absence of clinically significant portal hypertension (ie, hepatic vein pressure gradient <10 mm Hg) are the best available indicators of acceptably low risk of postoperative liver failure after PH. In the absence of an elevated serum bilirubin and portal hypertension, survival after PH can exceed 70% at 5 years. Sabiston Patients with advanced cirrhosis (Child class B and C) and early-stage HCC should be considered for transplantation whereas those with Child class A cirrhosis have similar results with transplantation and resection and should probably be resected.

Answer 373

A PanIN 1&2 do PanIN 3 reresect.

Answer 374

B Likely hepatic adenoma. Cameron: Formal resection at the time of acute hemorrhage is generally not recommended, although if the patient has life-threatening hemorrhage or if the lesion is refractory to transarterial interventions, then laparotomy may be necessary to achieve hemostasis. In these instances, the operation is analogous to a trauma laparotomy in which use of inflow occlusion (Pringle's maneuver), packing and pressure, topical hemostatic agents, and selective hepatic arterial ligation are potentially useful maneuvers.

Answer 375

C as initial. A if no mass. D if mass a. HJ – if no mass or pain b. Frey – decompresses PD not BD c. ERCP/stent – only if cholangitic or malnourished as temporizing measure, high failure rate if pancreatic head calcs present d. Whipple – if mass present or cannot R/O malignancy; only option to deal with pain and obstruction

Answer 376

Transplant is the preferred surgical therapy for MOST surgical disease in PSC; the only exception is focal extrahepatic stricture OR complications in early histologic stage disease. Transplant can be considered for peripheral and hilar cholangiocarcinoma as part of a trial – not for extrahepatic/distal CCA. CCA arising in PSC setting raises possibility of transplant. Overall, transplant is the treatment of choice, particularly as most are intrahepatic or proximal. Frozen section on bile duct should be done and pancreatiocoduodenectomy performed AT THE TIME OF TRANSPLANT if margins are positive. This patient has advanced liver disease (pruritus, jaundice), which is indication for transplant. D.J. Rea, C.B. Rosen, D.M. Nagorney, et al. Transplantation for cholangiocarcinoma: when and for whom? Surg Oncol Clin N Am, 18 (2009) UTD SURGICAL THERAPY — Surgical options for primary sclerosing cholangitis (PSC) include biliary reconstructive procedures, proctocolectomy (in patients with ulcerative colitis), and liver transplantation [74]. Biliary reconstruction — Studies using various methods of biliary-enteric drainage, with or without intraoperative stent insertion, have reported excellent outcomes (free of jaundice and cholangitis) for several years after the procedure [75-77]. However, there may be significant morbidity and mortality, particularly in patients with cirrhosis. In addition, surgery carries a risk of postoperative infection and increases scarring in the porta hepatis, potentially complicating future liver transplantation [75]. The enthusiasm for biliary surgery declined further after a retrospective study found liver transplantation to be superior to biliary surgical procedures [78]. The actuarial symptom-free survival rate in 23 patients treated by nontransplantation biliary surgery was 35 percent at 10 years; the actuarial survival rate from the onset of PSC (56 percent at 10 years) was identical to that expected from the prognostic model. In comparison, the actuarial patient survival rate five years after transplantation in 28 patients was greater than that expected from prognostic models (89 versus 31 percent). Thus, surgical therapies other than transplantation should generally be avoided in patients with PSC. The only exception may be in patients with isolated focal extrahepatic strictures and early histologic stage disease [79].

Answer 377

D In this patient would observe. Enucleation of PNET in elderly patients is reasonable. Some centers observe PNETS <2cm.

Answer 378

C Exceeds Milan criteria so no tranplant

Answer 379

A If the injury occurs to a larger duct, but is not caused by electrocautery and involves less than 50% of the circumference of the wall, a T tube placed through the injury, which is effectively a choledochotomy, usually will allow healing without the need for subsequent biliary enteric anastomosis. Any cautery based injury, in which the extent of thermal damage may not manifest immediately, or an injury involving more than 50% of the duct circumference requires resection of the injured segment with anastomosis to reestablish biliary enteric continuity. When the defect is smaller than 1 cm and not near the hepatic duct bifurcation, mobilization with end-to-end anastomosis of the bile duct can provide acceptable reconstruction. This approach should be accompanied with transanastomotic T tube placement. The tube should be inserted through a separate choledochotomy, and not exit the bile duct though the anastomosis. To ensure a tension-free anastomosis, a generous Kocher maneuver, mobilizing the duodenum and the head of the pancreas out of the retroperitoneum, is necessary. When the defect is smaller than 1 cm and not near the hepatic duct bifurcation, mobilization with end-to-end anastomosis of the bile duct can provide acceptable reconstruction. This approach should be accompanied with transanastomotic T tube placement.The tube should be inserted through a separate choledochotomy, and not exit the bile duct though the anastomosis. To ensure a tension-free anastomosis, a generous Kocher maneuver, mobilizing the duodenum and the head of the pancreas out of the retroperitoneum, is necessary. Injuries adjacent to the bifurcation or involving more than a 1-cm defect between the ends of the bile duct require reanastomosis to the gastrointestinal tract

Answer 380

B NCCN: Sequence of events for borderline resectable: neoadjuvant therapy, restage, laparoscopy, definitive surgery. NACT is usually FOLFIRINOX, may include radiation but that is +/- There is good evidence for benefit of staging laparoscopy; up to 23% are converted to unresectable. Currently NACT or NACRT are being used (NACT more commonly), but there is insufficient evidence to recommend one over the other (ie with or without radiation).

Answer 381

A on prev years but they were no sure

Answer 382

C Due to debris, A may not work well. B for infected pseudocysts with sepsis or <6 weeks

Answer 383

B Liver transplant – only used after liver failure, percutaneous treatments first

Answer 384

B Resect >5cm, as increased risk of HCC and rupture.

Answer 385

A Up to Date: In general, resection appears to benefit responding patients (ie, those who have a partial response, stable disease, or focal progression, and possibly those with isolated sites of progression) but has little to offer those who experience generalized disease progression while receiving a TKI. Furthermore, resection, even if complete, does not eliminate the need for continued treatment with TKI therapy. Progression-free survival is significantly shorter in patients who discontinue treatment as compared to those who continue the drug after resection Hepatic resection for liver metastases — The liver is the site of recurrence in as many as 67 percent of patients with relapsed GIST. Prior to the imatinib era, these patients were treated like other soft tissue sarcomas metastatic to the liver, with resection when technically feasible. The available data on GIST liver metastases suggest five-year survival rates from 27 to 34 percent in patients undergoing resection alone. For patients with isolated liver metastases, hepatic resection combined with imatinib provides the greatest opportunity for long-term disease control. A course of preoperative therapy (ie, three to nine months) is preferred in most cases, as it not only has the potential to reduce the extent of needed surgery, but it also permits the "biologic selection" of the best candidates for surgery, particularly if extensive procedures are planned.

Answer 386

A Gavin says do preop MRCP. Really depends on how choledocholithiasis was managed. Shaw says MRCP is appropriate if trying to avoid cholecystectomy. Patient needs a cholecystectomy; no harm to postoperative ERCP if stones present on IOC.

Answer 387

B Per Karanicolas @ review course & Shaw & Canada consensus

Answer 388

C in this answer key D in other questions Cameron: Fibrolamellar HCC represents nodal metastases in 15% to 30% of cases. Thus the lymph nodes in the porta hepatis, celiac region, and peripancreatic areas should be examined and, if suspect, either sampled or dissected. In cases of nodal recurrence after previous liver resection, exploration and dissection of the recurrent lymph nodes represent rational therapy.

Answer 389

A Management — Initial management of pancreatic fistulas and resultant complications of pancreatic ascites and pleural effusion include reduction of pancreatic stimulation and octreotide (a long-acting somatostatin analogue) to decrease pancreatic secretion. However, the long-term success of these approaches is limited, and only 50 to 65 percent of fistulas close over four to six weeks [4]. Patients with persistent symptoms require endoscopic stents, preferably bridging the ductal disruption. Surgery for a persistent pancreatic fistula is indicated when endoscopic management fails or is technically unfeasible. The management of pancreatic fistulas is discussed in detail separately.

Answer 390

B Up to Date Complex fluid collections and pancreatic necrosis — It is important to identify complex (ie, thick, debris-filled) pancreatic fluid collections since these may require intensive management with several endoscopic procedures. Complex collections are more likely in patients with pancreatic necrosis, which is best identified using MRI. The decision to proceed with an endoscopic transmural drainage approach depends on how well-organized the necrosis appears. Although post-drainage infectious complications can be managed by expert endoscopists, failure to recognize underlying necrosis may result in inadequate drainage/irrigation and subsequent infection. Endoscopic drainage is less likely to be successful in patients with pancreatic necrosis compared with patients with uncomplicated pancreatic fluid collections. However, endoscopic treatment is a reasonable alternative to surgery in carefully selected patients if an endoscopist skilled in endoscopic necrosectomy is available.

Answer 391

B Need to drain duct; if attempt ERCP and unable to drain, you’ve introduced infection into a static system; PTC more reliable and can later be internalized.

Answer 392

D If rebleeds could rescope or angio

Answer 393

B Sentinel bleed, suspect GDA stump leak, can be managed with endovascular or surgery. Surgery is gold standard, however increasing role for endovascular therapies so not sure.

Answer 394

Prev years said A Replaced R hepatic from SMA 12.5% Accessory R hepatic from SMA 4%

Answer 395

Prev year said D but review course said C Keith says sphincterotomy is the best answer – can extend by 2cm, and should be able to get the stone out. Shaw says transduodenal sphincterotomy is part of the open CBDE, to push it retrograde to deliver also that choledochoduodenostomy is reasonable. Stones impacted in the ampulla may be difficult for both endoscopic ductal clearance as well as common bile duct exploration (open or laparoscopic). In these cases the common bile duct is usually quite dilated (about 2 cm in diameter). A choledochoduodenostomy or a Roux-en-Y choledochojejunostomy may be the best option under this circumstance.

Answer 396

D SCNA – PNETS Central pancreatectomy is another parenchyma-sparing procedure that can be considered for small benign lesions. For even smaller tumors less than 2 cm, surgical resection may not necessarily be mandated. The ENETS’ guidelines state “no data exist with respect to a positive effect of surgery on overall survival in small (<2 cm), possibly benign or intermediate-risk pancreatic endocrine tumors” and advocate careful balancing of surgical risk before proceeding to resection over observation. Lee and colleagues described a cohort of 67 patients with small (median size 1 cm), incidentally found nonfunctional PanNETs who were observed for a median of 45 months. There were no cases of disease progression over this observation period. Therefore, for small tumors less than 2 cm with a low proliferative index (Ki-67), observation may be an appropriate option.

Answer 397

B in prev years But I would be reluctant to do this with varcies. I would probably go with A

Answer 398

C (prev year said A) This is T1a = invades lamina propria. Can tx with lap chole. T1b = Invades muscle layer which requires further resection

Answer 399

This is a tricky question. The reference to travel makes you think hydatid but her cysts are simple B? C?

Answer 400

B Replaces is more common than accessory

Answer 401

A ? cystadenoma Multiloculated and mural thickening are all things that make you want to resect

Answer 402

A In Barcelona algorithm, presence of portal HTN determines if resect vs transplant for solitary HCC

Answer 403

Last year picked B but this seems early b/c your tract is not mature yet and patient is stable/not septic. I would probably go with C.

Answer 404

B If mass--> whipple If no mass--> HJ

Answer 405

C Solid pseudopapillary neoplasms — The malignant potential of solid pseudopapillary neoplasms (SPNs) has not been well studied. In a series of 62 patients, nine (15 percent) had malignant SPNs [46]. No factors were identified that predicted malignancy. In a second series with 106 patients who underwent surgery for SPN, 17 patients had high-grade malignant SPN [47]. Tumor size ≥5 cm was associated with an increased risk of high-grade malignancy. Malignant solid pseudopapillary neoplasms (SPNs) can be cured when completely excised [48], and prolonged survival can be seen even in the presence of metastatic disease with surgical debulking [49,50]. Given the lesion's malignant potential, combined with its good prognosis if resected, the finding of a pancreatic mixed solid and cystic lesion in a young woman on CT or MRI should lead to resection in most cases.

Answer 406

A Patient does need imaging follow up

Answer 407

A Patient has Gilbert's (indirect hyperbilirubinemia)

Answer 408

B. Seems asymp

Answer 409

A Type IV ERCP perforation Type I Lateral duodenal wall Type II Periampullary Type III CBD perforation Type IV RP air alone

Answer 410

A Shaw – urgent operation only for incarceration. Medically manage. Leak not a big deal. Urgent surgery for rupture or incarceration. If ulcerated, eschar, or weeping fluid, medically manage ascites then elective repair. , Schwartz Patients with advanced liver disease, ascites, and umbilical hernia require special consideration. Enlargement of the umbilical ring usually occurs in this clinical situation as a result of increased intra-abdominal pressure from uncontrolled ascites. First line of therapy is aggressive medical correction of the ascites and paracentesis for tense ascites with respiratory compromise. These hernias are usually filled with ascitic fluid, but omentum or bowel may enter the defect after large-volume paracentesis. Uncontrolled ascites may lead to skin breakdown on the protuberant hernia and eventual ascitic leak, which can predispose the patient to bacterial peritonitis. Patients with refractory ascites may be candidates for transjugular intrahepatic portocaval shunt (TIPS) or eventual liver transplantation. Umbilical hernia repair should be deferred until after the ascites is controlled.

Answer 411

A is best. C is initial

Answer 412

A Sabiston 1st line is TPN, octreotide, drainage; 60% respond with this. If continued drainage, ERCP stent across ductal disruption.

Answer 413

A Serous cystadenoma. Vague discomfort is not convincing for symptoms from this small cyst. Resect if >4cm, symptomatic, growth >0.6cm/year.

Answer 414

A Up to Date TREATMENT — The treatment of established mesenteric venous thrombosis (acute and subacute) is predominantly conservative, consisting of systemic anticoagulation to minimize extension of thrombus, bowel rest, and careful, serial observation for any signs of clinical deterioration. Must also asses for hypercoagulability.

Answer 415

C Autoimmune pancreatitis can develop a mass which is confused for carcinoma, but often responds to steroids. Sausage-like dilation is pathognomonic for autoimmune. Steroids then rituximab. Type 1 AIP has elevated IgG4; Type 2 AIP does not have elevated levels, more commonly associated with IBD. Can have mass, ductal dilation, ductal stenosis, jaundice. Also some overlap with IgG4-associated cholangitis (IAC). Always need to have a strong suspicion for pancreatic CA and rule it out, rather than rule in AIP. This patient, based on age and intermittent symptoms, is very unlikely to have PDAC, so trial of steroids is worthwhile. Sausage-like dilation is characteristic of AIP.

Answer 416

C Shaw: usually 2/2 cryptosporidum; treat AIDS and etiology. Multifocal less amenable to endoscopic therapy. Antibiotics alone ineffective; often have papillary stenosis which is responsive to papillotomy.

Answer 417

C Surgical resection is the mainstay of therapy for patients who present with locoregional disease. Complete tumor extirpation offers the only opportunity for cure and provides symptomatic relief for patients with functional PNETs. With the exception of most insulinomas, most PNETs are malignant7,8,27 and resection for these neoplasms should follow sound oncologic principles, including formal pancreatectomy and regional lymphadenectomy. 28,29 Depending on tumor location, pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy is typically performed. For patients with benign insulinomas, laparoscopic or open enucleation is the procedure of choice.

Answer 418

B Elderly, diabetes, cholangitis, instrumentation, recent biliary colic.

Answer 419

B MCN – lipase N, CEA high IPMN – lipase and CEA high Pseudocyst – lipase high Serous cystadenoma

Answer 420

B Choledochal cyst

Answer 421

D CBD stricture in CP is usually fibrotic. Endoscopic therapy has reasonable short-term efficacy, but not great in long term. Most recurrences after endoscopic therapy occur within 1 year. Presence of pancreatic head calcification predicts failure of endoscopic therapy: Risk factors for failure of endoscopic stenting of biliary strictures in chronic pancreatitis: a prospective follow-up study." The American journal of gastroenterology 98.11 (2003): 2448-2453. CONCLUSIONS: Endoscopic drainage of biliary obstruction provides excellent short term but only moderate long term results. Patients without calcifications of the pancreatic head benefit from biliary stenting. Patients with calcifications were identified to have a 17-fold (95% CI = 4–74) increased risk of failure of a 12 month course of endoscopic stenting. Table IV. Indications for biliary drainage (Frey et al. [28]) 1. Symptomatic cholangitis or infected bile. 2. Biliary cirrhosis (biopsy proven). 3. CBD stones in association with common bile duct stricture. 4. Inability to rule out cancer of the pancreas. 5. Progression of the common bile duct stricture based on radiological assessment of increased dilatation of the common and intrahepatic bile ducts. 6. Persistent jaundice for over a month. 7. Persistently elevated alkaline phosphatase (> 3 × normal levels > 1 month).

Answer 422

C Femoral due to incarceration risk

Answer 423

A I think there have been variations of this question where B is the answere but A was not an option

Answer 424

B | Tissue based repair

Answer 425

Prev year picked B. I think D is the right answer Prev year based their answer that UTD says that delivery is curative and the only effective tx for HELLP and indicated after maternal stabilization in pregnancies >= 34 weeks gestation. But how they describe the patient makes it seem that she is still tachy UTD: The management of a contained hematoma is to support the patient with volume replacement and blood transfusion, as needed. If the size of the hematoma remains stable and her laboratory abnormalities are resolving, the patient may be discharged home with outpatient follow-up. It may take months for the hematoma to resolve completely [42,47]. Percutaneous embolization of the hepatic arteries is a reasonable first-line therapy of hepatic rupture in women who are hemodynamically stable [48,49]. Surgical intervention is indicated if there is hemodynamic instability, persistent bleeding, increasing pain, or continued expansion of the hematoma [50]. A team experienced in liver trauma surgery should be consulted [51]. Operative management includes packing, drainage, hepatic artery ligation, and/or resection of affected areas of the liver. For patients with intractable hemorrhage despite these interventions, administration of recombinant factor VIIa [52] and liver transplantation [53-56] have been successful in case reports. Patients who survive have no hepatic sequelae.

Answer 426

A vs B Typical management of ruptured hepatic adenoma is angio with elective resection however the fact that she is tachy and hypotensive makes it seem like they want you to lap her

Answer 427

C Hepatic adenoma A FNH B FNH D Hemangioma

Answer 428

B Shaw: only intervene if complications of hemorrhage or cholangitis.

Answer 429

B Too early to drain; acute fluid collection; 60-80% will improve with time

Answer 430

B The risk factors for acute pancreatitis include sphincter of Oddi dysfunction, female sex, young age, prior history of post-ERCP pancreatitis, history of recurrent acute pancreatitis, difficult cannulation, pancreatic duct injection, pancreatic sphincterotomy, failed attempts at placing a pancreatic duct stent, precut sphincterotomy, and low endoscopy volume.

Answer 431

D Up to Date American Association for Study of Liver Diseases (AASLD) recommendes surveillance in patients at risk for HCC (cirrhosis, chronic HBV) with US q6 months; no recommendation for AFP alone – poor sensitivity and specificity.

Answer 432

A If ulceration considered high-risk for bleeding and banding should be done. Banding superior to medical therapy for primary prophylaxis, though with procedural complications. Recommend primary prophylaxis with beta blockers unless doesn’t tolerate, in which case EVL is used.

Answer 433

C Based on Barcelona algorithm.

Answer 434

A (but want to know more about the lesion like whether there is enhancing mural nodules or duct diln)

Answer 435

D Cystadenoma Some ppl would advocate for formal resection

Answer 436

B 50/50 rule: 50% INR, 50 bili @ 5 days.

Answer 437

C NACT indicated in borderline resectable disease, short DFI (<12mths). Bevacizumab is commonly given in metastatic CRC; it always requires a chemo backbone (usually FOLFOX or FOLFIRI), despite little evidence of benefit in those regimens; useful as conversion therapy (cetuxumab not effective for conversion). BCZMB contraindicated if recent arterial thromboembolic events. In the absence of validated predictive factors for treatment benefit, the default position in the palliative management of mCRC (intentionally neglecting financial considerations) is to add bevacizumab to the chemotherapy backbone chosen for the individual patient. For those who are at high risk for serious toxicity, in particular arterial thromboembolic events, where benefit from the addition of bevacizumab has to be balanced against a perceived risk for potentially life-threatening adverse events, a non-bevacizumab containing first-line regimen such as FOLFOX or FOLFIRI with or without cetuximab or panitumumab (if RAS wild-type) may be preferred. When added to cytotoxic FU-based chemotherapy for mCRC, bevacizumab routinely improves outcomes, regardless of the specific chemotherapy backbone that is chosen. However, in some trials, bevacizumab appears to provide greater incremental gain in PFS when it is added to "weaker" chemotherapy regimens such as FU/LV or bolus IFL than to more active regimens such as FOLFOX A major issue is whether to withhold bevacizumab from elderly patients who have a history of an arterial thromboembolic event (ATE) within the past 6 to 12 months. Bevacizumab increases the risk of an ATE. In one meta-analysis, the risk appeared to be higher in those over the age of 65 and in those with a prior history of an ATE Cetuximab + irinotecan has benefit; cetuxumab + FOLFOX does not seem to add benefit.

Answer 438

B Sabiston Treatment of acalculous cholecystitis is similar to that for calculous cholecystitis, with cholecystectomy being therapeutic. Given the substantial inflammation and high risk of gallbladder gangrene, an open procedure is generally preferred. However, many of these patients are critically ill and would not tolerate the physiologic insult of a laparotomy, explaining why the mortality rate of cholecystectomy for acalculous cholecystitis is up to 40%. Accordingly, percutaneous drainage of the distended and inflamed gallbladder is carried out in patients unable to tolerate a laparotomy. The cholecystostomy tube used to drain the gallbladder can be placed by ultrasound or CT guidance. Approximately 90% of patients will improve with percutaneous drainage and the tube can eventually be removed. If follow-upimaging continues to demonstrate no stones, interval cholecystectomy is generally unnecessary.

Answer 439

B MRCP is preferred for many patients because it is noninvasive. However, the sensitivity of MRCP may be lower for small stones (<6 mm, (image 3)) [35], and biliary sludge can be detected by EUS, but generally not by MRCP. As a result, EUS should be considered in patients in whom the suspicion for choledocholithiasis remains moderate to high despite a negative MRCP. (See 'Intermediate-risk patients' above.)

Answer 440

A Elective hepatic resection once stable

Answer 441

C A and D are both FNH B is hemangioma

Answer 442

A Would try ERCP and stent first given her age. HJ is best management

Answer 443

A Observe, glucagon, try to flush out. Stones that small should pass. If larger than 5mm, options are LCBDE or ERCP, with equivalent success, choice depends on local expertise.

Answer 444

C Adenomyomatosis is not an indication for resection but sounds like patient is symptomatic from gb

Answer 445

C Malignant hyperthermia: are due to a hypercatabolic state, which presents as a very high temperature, an increased heart rate and breathing rate, increased carbon dioxide production, increased oxygen consumption, acidosis, rigid muscles, and rhabdomyolysis

Answer 446

B Immediately following the approval of bevacizumab in the US in 2004, FOLFOX plus bevacizumab (table 7) emerged as the most commonly used combination regimen for palliative front-line therapy of mCRC despite the absence of phase II or phase III data confirming the superiority of this regimen over any other. BCZ never given alone, always with a chemo backbone. Marginal benefit when added to FOLFOX, more when added to 5-FU. Can be used as conversion therapy to achieve resectability.

Answer 447

B Percutaneous palliation is more effective, and preferred. The problem with endoscopy is that you may attempt ERCP, push bacteria beyond the obstruction, and then not be able to drain that system, leaving the patient cholangitic. For distal, ERCP with metal stents would be preferred. SCNA – Proximal Biliary Tumours Percutaneous drainage is more effective than endoscopic approaches due to technical and mechanical limitations of the latter; initial percutaneous drainage can be followed by self-expanding metallic stent placement. Although 2 or 3 stents may be necessary to drain all ducts, partial decompression can offer symptom relief.

Answer 448

E Small, (<15mm), free floating, funcitonal GB, not pigment stones, minimally symptomatic. Efficacy is 30-50%, but will reform.

Answer 449

B Bile acids work by reducing biliary cholesterol secretion, increasing biliary bile acid concentrations, and as a result, reducing the cholesterol saturation index. Studies using strict inclusion criteria have found dissolution rates of between 50 to 60 percent, and a meta-analysis found a 37 percent dissolution rate with UDCA, with the best results occurring in patients with small, buoyant stones.

Answer 450

E to drain collection then B

Answer 451

D Lap Pringle

Answer 452

D? to assess for hepatitis or cirrhosis Prev year said C

Answer 453

C Small stones should pass, especially as should have dilated sphincter in CBDE.

Answer 454

Last year said A. I think B is a better answer

Answer 455

C first to control the sepsis then B

Answer 456

D ERCP sphincterotomy is treatment for divisum

Answer 457

A Santorini/Minor = dorsal = most of panc Wirsung /Major= ventral = head of panc

Answer 458

C but also A Necrolytic migratory erythema present in 80% of patients.

Answer 459

Answer key says C. That seems a bit extreme if EUS was an option I'd probably pic that. Of these answers, B?

Answer 460

A Thrombosis — A history of venous or arterial thromboses is common in PV. These complications were noted in 7 and 16 percent, respectively, in the WHO-defined PV patients. Although the mechanisms involved in this hypercoagulable state are unclear, abnormalities in blood viscosity, platelets, and leukocytes have been implicated (Uptodate)

Answer 461

D | Testicles drain into systemic circulation

Answer 462

C Biliary triads – at corner, with artery and portal v Hepatic vein at the centre

Answer 463

A in answer key UptoDate: Three clinical features suggest the possibility of a pseudoaneurysm: ●Unexplained gastrointestinal bleeding ●Sudden expansion of a walled-off pancreatic fluid collection ●An unexplained drop in hematocrit Management: angioembolization, then surgery(distal pancreatectomy and closure of proximal pancreatic stump) Persistent collection after cystgastrostomy, you should be concerned about: 1. Pseudoanyerysm (drop in Hb, HCT, need angioembolization or OR) 2. Ductal disruption (need MRCP/ERCP for anatomic delineation) a. Type 1 - no disruption, endoscopic or percutaneous drain b. Type 2 - stricture, OR c. Type 3 - complete occlusion, OR: pancreaticojejunostomy, or distal pancreatectomy+closure of proximal stump

Answer 464

A UTD The enthusiasm for biliary surgery declined further after a retrospective study found liver transplantation to be superior to biliary surgical procedures [78]. The actuarial symptom-free survival rate in 23 patients treated by nontransplantation biliary surgery was 35 percent at 10 years; the actuarial survival rate from the onset of PSC (56 percent at 10 years) was identical to that expected from the prognostic model. In comparison, the actuarial patient survival rate five years after transplantation in 28 patients was greater than that expected from prognostic models (89 versus 31 percent). Thus, surgical therapies other than transplantation should generally be avoided in patients with PSC. The only exception may be in patients with isolated focal extrahepatic strictures and early histologic stage disease Liver transplantation is the treatment of choice for patients with advanced liver disease due to PSC, and patients should generally be referred for liver transplantation once their Model for End-stage Liver Disease (MELD) score is ≥15

Answer 465

D UTD The incidence of primary carcinoma of the thyroglossal duct is less than 1 percent in all age groups Article: Article Navigation Thyroid Cancer in Thyroglossal Duct Cysts Requires a Specific Approach due to Its Unpredictable Extension Thyroglossal duct cyst cancer histotype was papillary in 23 of 26 patients (88.5%) and follicular-Hurthle in 3 of 26 cases (11.5%)

Answer 466

C The RLN on both sides pass deep to the lower border of the inferior constrictor muscle and enter the larynx posterior to the cricothyroid articulation.

Answer 467

B Injury to the hypoglossal nerve (CN XII) and lingual nerve (CN V3) are much less common (<1% of patients) than injury to the marginal mandibular nerve (branch of facial nerve--CN VII) (probably 5-10%).

Answer 468

A and B Injury to the hypoglossal nerve (CN XII) and lingual nerve (CN V3) are much less common (<1% of patients) than injury to the marginal mandibular nerve (branch of facial nerve--CN VII) (probably 5-10%).

Answer 469

B Marginal mandibular Lingula is deep to mylohyoid

Answer 470

C | http://practicalneurology.com/2015/10/spinal-accessory-nerve-injury/

Answer 471

D Elevate the cyst off the deep structures i.e. Xn, XIn, XIIn, descendens hypoglossi, internal jugular vein and carotid vessels take care not to traumatise the ranine/lingualveins where the tract crosses the XIIn

Answer 472

B Tip of tongue--submental Anterior 2/3 Lateral--Ipsilateral submandibular Anterior 2/3 Central--Bilat Submandibular Posterior 1/3--Upper Deep Cervical

Answer 473

C Ranula -type of mucocele found on the floor of the mouth. Ranulas present as a swelling of connective tissue consisting of collected mucin from a ruptured salivary gland caused by local trauma. Granular cell tumors can affect all parts of the body; however, the head and neck areas are affected 45% to 65% of the time. Of the head and neck cases 70% of lesions are located intraorally (tongue, oral mucosa, hard palate). The next most common location that lesions are found in the head and neck area is the larynx (10%)

Answer 474

Both seem like contraindications Radiation to mandible can lead to osteoradionecrosis of the jaw

Answer 475

A Image result for malignant parotid tumor children Salivary gland neoplasms are rare in children. Most tumors (65%) are benign, with hemangiomas being the most common, followed by pleomorphic adenomas. In children, 35% of salivary gland neoplasms are malignant. Mucoepidermoid carcinoma is the most common salivary gland malignancy in children.

Answer 476

A ``` C = jugular foramen D = phrenic nerve ```

Answer 477

B in prev answers. A is reasonable.

Answer 478

``` D Total thyroidectomy -Known distant mets Extrathyroidal extension Tumor >4 cm Cervical LN mets Poorly differentiated Prior radiation Bilateral nodularity ```

Answer 479

B in prev answer but I think D is right. | You can't dx follicular or huerthle cell neoplasm on FNA. Need to look at architecture

Answer 480

A First branchial cleft cysts - Type I cysts- external auditory canal. Inferior and posterior to the tragus , but may also be in the parotid. - Type II cysts-angle of the mandible and may involve the submandibular gland Second branchial cleft cysts - 95% - Anterior border of the upper third of the SCM and adjacent --Anywhere along the course of a second branchial fistula: skin of the lateral neck, between the internal and external carotid arteries, and into the palatine tonsil Third branchial cleft cyst - Rare - Same skin location as a second branchial fistula - Courses posterior to the carotid arteries and pierces the thyrohyoid membrane to enter the larynx, terminating on the lateral aspect of the pyriform sinus. - (eg, inside the larynx), but they are characteristically located deep to SCM Fourth branchial cleft - Extremely rare. - From the lateral neck and parallels the course of the recurrent laryngeal nerve (around the aorta on the left and around the subclavian artery on the right), terminating in the apex of the pyriform sinus - Cysts arise in various locations, including the thyroid gland and mediastinum.

Answer 481

A then Sistrunk electively

Answer 482

A based on NCCN

Answer 483

A Subacute lymphocytic thyroiditis (also known as silent sporadic thyroiditis or painless sporadic thyroiditis) is clinically and pathologically similar to postpartum thyroiditis but occurs in the absence of pregnancy. It appears to be autoimmune in origin; the thyroid contains a lymphocytic infiltrate partially resembling Hashimoto's disease but without the fibrosis, Askanazy cells, and extensive lymphoid follicle formation. Between 5 and 20 percent of patients exhibit hyperthyroidism from release of pre-formed T4 and T3, which may be followed by hypothyroidism and then a return to normal in the majority of patients. RAIU low/absent Riedel thyroiditis, or Riedel's thyroiditis (RT), is a rare, chronic inflammatory disease of the thyroid gland characterized by a dense fibrosis that replaces normal thyroid parenchyma. The fibrotic process invades adjacent structures of the neck and extends beyond the thyroid capsule. RAIU N/low Hashimoto's disease (also known as chronic lymphocytic thyroiditis or chronic auto-immune thyroiditis) is an autoimmune condition characterized by the infiltration of the thyroid by lymphocytes and the formation of Askanazy (Hürthle) cells. It is the most common inflammatory disorder of the thyroid in the United States. Patients may have normal thyroid function, frank clinical primary hypothyroidism associated with low free T4 and high TSH concentrations, or subclinical hypothyroidism with normal free T4 and elevated TSH levels. Circulating levels of antithyroid peroxidase antibodies, usually in high titers, are a hallmark of Hashimoto's disease. RAIU N/low Graves' disease, also known as toxic diffuse goiter, is an autoimmune disease that affects the thyroid.[1] It frequently results in and is the most common cause of hyperthyroidism.RAIU is high.

Answer 484

C in old answers. I would pick D cause patient has cervical LN mets which is an indication for RAIU per NCCN

Answer 485

C Cytokeratin = adenoca Vimentin = sarcoma HMB45 = melanoma

Answer 486

D? vs B? NCCN states periodic neck U?S Local practice, we typically do one at 1 yr for follow up

Answer 487

D Surgery first. If unresectable, radiated per NCCN

Answer 488

D? We never do it for A, B or C

Answer 489

B Prev radiation is one of the indications for total/subtotal

Answer 490

C https://www.ncbi.nlm.nih.gov/pubmed/9790290 Suspensory ligament of Berry: its relationship to recurrent laryngeal nerve and anatomic examination of 24 autopsies.

Answer 491

B In parathyroid carcinoma, calcium >3.5 typically

Answer 492

DC | ricothyroid is SLN

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